Citation Nr: 1331274 Decision Date: 09/27/13 Archive Date: 10/01/13 DOCKET NO. 07-26 820 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an increased disability rating for post traumatic stress disorder (PTSD) with depressive disorder, currently evaluated as 70 percent disabling. 2. Entitlement to an evaluation in excess of 10 percent for a neck disability prior to December 22, 2011, and in excess of 30 percent thereafter. 3. Entitlement to service connection for a heart disability, to include as secondary to service-connected hypertension. 4. Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected neck disability. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Arif Syed, Associate Counsel INTRODUCTION The Veteran had active military service from January 1984 to June 1994 and from December 1995 to September 1996. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2005 rating decision of the Department of Veterans Affairs Regional Office (RO) in Winston Salem, North Carolina. By that rating decision, the RO denied service connection for a right shoulder disorder and a heart disability, to include as secondary to hypertension. The RO also increased the disability rating assigned to the service-connected PTSD with depressive disorder from 30 to 70 percent, effective January 1, 2005--the date VA received the Veteran's claim for increased compensation for this disability. The RO also continued a 10 percent disability rating assigned to the service-connected neck disability. The Veteran appealed the RO's July 2005 rating action to the Board. In June 2011, the Board remanded the Veteran's claims. In a September 2012 rating decision, the Appeals Management Center (AMC) awarded the Veteran a 30 percent disability rating for his service-connected neck disability effective December 22, 2011. However, as the increase did not constitute a full grant of the benefits sought, the Veteran's claim for a higher evaluation remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). The AMC also continued the previous denial of the Veteran's PTSD, right shoulder disability, and heart disability claims in a September 2012 supplemental statement of the case (SSOC). Accordingly, the Veteran's VA claims folder has been returned to the Board for further appellate proceedings. The Board also notes that in the above-referenced September 2012 rating decision, the AMC granted a 40 percent evaluation for cervical radiculopathy of the right upper extremity effective December 22, 2011. As evidenced by the claims folder, the Veteran did not express disagreement with either the assigned disability rating or effective date. Accordingly, this issue is not in appellate status and will be discussed no further herein. See Archbold v. Brown, 9 Vet. App. 124, 130 (1996) [pursuant to 38 U.S.C.A. § 7105(a), the filing of a notice of disagreement initiates appellate review in the VA administrative adjudication process, and the request for appellate review is completed by the claimant's filing of a substantive appeal after a statement of the case is issued by VA]. Additionally, in June 2011 the Board remanded the Veteran's claim of entitlement to service connection for hypertension. In the September 2012 rating decision, the AMC granted this claim. In view of the foregoing, this issue has been resolved and is no longer before the Board. See generally Grantham v. Brown, 114 F.3d 116 (Fed. Cir. 1997); The Board has reviewed the Veteran's claims folder and the record maintained in the Virtual VA paperless claims processing system. The issue of entitlement to service connection for sarcoidosis has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran's PTSD is manifested by deficiencies in most of the areas work, family relations, judgment, thinking, or mood; but total occupational and social impairment has not been demonstrated. 2. Prior to December 22, 2011, the Veteran's neck disability was manifested by pain, limitation of motion, forward flexion of the cervical spine greater than 30 degrees, combined range of motion greater than 170 degrees, and asymptomatic postsurgical scar; muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliois, reversed lordosis, or abnormal kyphosis was not shown. 3. From December 22, 2011, the Veteran's neck disability is manifested by pain and limitation of motion as well as a postsurgical asymptomatic scar; unfavorable ankylosis of the entire cervical spine is not shown. 4. The evidence does not show that the Veteran experiences incapacitating episodes requiring bed rest prescribed by a physician and treated by a physician due to his neck disability. 5. The Veteran's currently diagnosed right shoulder disability is not related to either his military service or his service-connected neck disability. 6. The Veteran's currently diagnosed heart disability is not related to either his military service or his service-connected hypertension. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 70 percent for PTSD are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411 (2013). 2. Prior to December 22, 2011, the criteria for a disability rating in excess of 10 percent for the Veteran's neck disability are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2013). 3. From December 22, 2011, the criteria for a disability rating in excess of 30 percent for the Veteran's neck disability are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2013). 4. Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected neck disability, is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2013). 5. Entitlement to service connection for a heart disability, to include as secondary to service-connected hypertension, is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks entitlement to increased disability ratings for his service-connected PTSD and neck disability as well as entitlement to service connection for a right shoulder disability, to include as secondary to service-connected neck disability, and for a heart disability, to include as secondary to service-connected hypertension. In the interest of clarity, the Board will discuss certain preliminary matters. The issues on appeal will then be analyzed and a decision rendered. Stegall concerns As alluded to above, in June 2011, the Board remanded these claims and ordered the agency of original jurisdiction (AOJ) to provide proper notice to the Veteran under the Veterans Claims Assistance Act of 2000 (VCAA) and provide the Veteran with VA examinations for his PTSD, neck disability, and heart disability as well as obtain a VA medical opinion for his right shoulder, and associate these reports with his claims folder. The Veteran's claims were then to be readjudicated. Pursuant to the Board's remand instructions, the Veteran was provided appropriate VCAA notice. This will be discussed in greater detail below. Additionally, the Veteran was provided VA examinations as to his PTSD, neck disability and heart disability in December 2011 and reports of the examinations were associated with his claims folder. A VA medical opinion was also obtained in December 2011 pertaining to the Veteran's right shoulder disability and a report of the opinion was associated with his claims folder. The Veteran's claims were readjudicated via the September 2012 SSOC. Accordingly, the Board's remand instructions have been complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998) [where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance]. The Veterans Claims Assistance Act of 2000 The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA). The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also defines the obligations of VA with respect to its statutory duty to assist a claimant in the development of his claim. See 38 U.S.C.A. §§ 5103, 5103A (West 2002). Notice The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2013), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). In the case at hand, the record reflects that the originating agency provided the Veteran with the required notice by letters mailed in March 2005 and July 2011, and notice with respect to the effective-date element of the claim, by a January 2006 letter as well as the July 2011 letter. Although the January 2006 and July 2011 letters were provided after the initial adjudication of the claims on appeal, the Board finds that the Veteran has not been prejudiced by the timing of these letters. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the AMC readjudicated the Veteran's claims in the September 2012 SSOC. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). There is no indication or reason to believe that the ultimate decision of the originating agency on the merits of the claims would have been different had complete VCAA notice been provided at an earlier time. Duty to assist In general, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim for VA benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. The law affords that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). In the instant case, the Board finds reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claims. There is no reasonable possibility that further assistance would aid in substantiating the claims. The pertinent evidence of record includes statements from the Veteran and other individuals, service treatment records, and VA treatment records. The Veteran was afforded VA examinations for his PTSD and neck disability in May 2005 and December 2011; for his right shoulder disability in May 2005 with an opinion obtained in December 2011; and for his heart disability in December 2011. The examination reports reflect that the examiners interviewed and examined the Veteran, reviewed his claims folder, reviewed his past medical history, documented his current medical conditions, and rendered appropriate diagnoses consistent with the remainder of the evidence of record. Furthermore, these examination reports contain sufficient information to rate the Veteran's PTSD and neck disability under the appropriate diagnostic criteria. The Board therefore concludes that the VA examination reports are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2013); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) [holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate]. The Board notes that a VA nexus opinion was not obtained as to whether the Veteran's right shoulder disability is related to his military service. Under 38 C.F.R. § 3.159(c)(4) (2013), VA will provide a medical examination or opinion if the information and evidence of record does not contain sufficient medical evidence for VA to make a decision on the claim but: (1) contains competent lay or medical evidence that the claimant has a current diagnosed disability, or persistent or recurring symptoms of disability; (2) establishes that the Veteran suffered an event, injury, or disease in service; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service. See 38 U.S.C.A. § 5103A(d) (West 2002); 38 C.F.R. § 3.159(c)(4) (2013); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board further finds that there is sufficient evidence to decide this claim, and that further medical examination or opinion is not necessary to decide the claim for service connection for a right shoulder disability. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). In the present case, as discussed in further detail below, there is no competent evidence that the Veteran suffered an event, injury, or disease, in service resulting in his right shoulder disability. Specifically, the Board has found the Veteran's allegations concerning the alleged in-service manifestation of a right shoulder disability to not be credible. Furthermore, there has been no competent evidence to suggest in-service onset of a right shoulder disability. Accordingly, a VA examination is not warranted. The facts of this case are different than the facts in Charles v. Principi, 16 Vet. App. 370 (2002), in which the Court held that VA erred in failing to obtain a medical nexus opinion where evidence showed acoustic trauma in service and a current diagnosis of tinnitus. Significantly, in this case, there is no credible supporting evidence that the Veteran's claimed in-service manifestation of a right shoulder disability or manifestation of arthritis within one year following his discharge from service occurred. The Board finds that under the circumstances of this case, VA has satisfied the notification and duty to assist provisions of the law and that no further action pursuant to the VCAA need be undertaken on the Veteran's behalf. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2013). The Veteran has been accorded the opportunity to present evidence and argument in support of his claims. He has retained the services of a representative. He cancelled his request for a hearing before a Veterans Law Judge. Accordingly, the Board will proceed to a decision as to the issues on appeal. Higher evaluation for PTSD Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. To evaluate the severity of a particular disability, it is essential to consider its history. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 4.1 and 4.2 (2013). Where there is a reasonable doubt as to the degree of disability, such doubt will be resolved in favor of the claimant. See 38 C.F.R. §§ 3.102, 4.3 (2013). In addition, where there is a question as to which of two disability evaluations should 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. See 38 C.F.R. § 4.7 (2013). A request for an increased rating must be viewed in light of the entire relevant medical history. See 38 C.F.R. § 4.1 (2013); see also Peyton v. Derwinski, 1 Vet. App. 282, 287 (1991). However, where entitlement to compensation has already been established and increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court held that "staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." The Veteran is currently rated at 70 percent under Diagnostic Code 9411 for his PTSD. Under the general rating formula for mental disorders, a 70 percent rating requires occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affected the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The Board notes that in accordance with the general rating formula, a maximum 100 percent rating is applicable if the manifestations of the service-connected psychiatric disorder result in total occupational and social impairment. Although the rating formula lists specific symptoms that are indicative of total impairment, the Court has held that the symptoms listed in the rating formula are only examples, and that evidence of those specific symptoms is not required to show that the veteran is totally disabled. In rating a mental disability, VA is required to consider all symptoms that affect her social and occupational functioning, and not limit consideration to those symptoms listed in the rating formula. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In other words, the primary consideration is whether the manifestations of the service-connected psychiatric disorder result in total social and occupational impairment, regardless of whether the Veteran demonstrates the symptoms listed in the rating formula. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. One factor for consideration is the GAF score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). While the rating schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. The Veteran was afforded a VA examination for his PTSD in May 2005. He reported depression, sleep disturbance, nightmares, intrusive thoughts, anxiety, being easily startled, did not like being in large crowds, short temper, feeling hopeless, poor concentration, weight loss, fair amount of energy, and decreased interest. He did not report suicide attempts or panic attacks. He used medication for treatment. He also reported that he had not worked in four years. He further stated that he had been married twice. He lived with his family and did some chores around the house when he could. Although the Veteran did not have any friends and did not go to church, he spent a lot of time with his daughter and watched television. Upon examination, the VA examiner reported that the Veteran was alert and cooperative but was in some discomfort due to recent neck surgery. He answered questions and volunteered information. He was also dressed appropriately and exhibited no bizarre movements or tics. His mood was subdued and was somewhat uncomfortable. His affect was appropriate. The examiner noted the Veteran's nightmares and intrusive thoughts, although there was no homicidal or suicidal ideation or intent. There was also no impairment of thought processes or communication. There were no delusions, hallucinations, ideas of reference or suspiciousness. The Veteran was oriented times three, and his memory, both remote and recent, appeared to be good. Insight and judgment were adequate as was intellectual capacity. The examiner diagnosed the Veteran with PTSD and depressive disorder, not otherwise specified (NOS) and opined that the Veteran's irritability, depressed mood, sleep disturbance, and limited capacity to tolerate stress rendered him not capable of performing employment either sedentary or active. The Board notes that VA treatment records dated March 2004 through April 2008 document the Veteran's treatment for his PTSD. VA group therapy records indicate that the Veteran's PTSD symptomatology included difficulty getting along with others, frustrated mood, sleep impairment, and impaired affect. His group therapy and mental health records indicated normal affect, speech, thought process, judgment and insight as well as absence of suicidal or homicidal ideation, delusions, or hallucinations. The Veteran was afforded a VA examination in December 2011. He reported that he had been married for the third time, and was getting along well with his current wife. He also reported that he had been communicating with friends from Italy, although he stated that it was "nothing like having a true friend that I can go talk to or anything." He also reported that in October 2010, he ran into his daughter's bedroom naked with a machete, saying that they had to get out of the house as there were "people in the yard that were going to kill us." He stated that after this incident, he was in a psychiatric unit for two weeks and was diagnosed with anoxia and delirium, possibly secondary to prednisone reaction. He further reported depression, anxiety, and did not want to go out of his house. Upon examination, the VA examiner opined that the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. He also indicated that the Veteran has intrusive thoughts, markedly diminished interest or participation in significant activities, feeling of detachment or estrangement from others, restricted range of affect, difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. Symptoms associated with the Veteran's psychiatric disorder included depressed mood, anxiety, suspiciousness, panic attacks which occurred weekly or less often, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; mild memory loss; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintain effective work and social relationships; difficulty adapting to stressful circumstances; and impaired impulse control. However, the Veteran was capable of managing his financial affairs. Furthermore, the examiner reported that the Veteran's appearance and orientation were normal. Speech was noticeably slowed, hesitant, slightly soft, with a low to medium volume. Thought processes were logical and goal-directed. No delusional beliefs were noted. Auditory, visual, and olfactory hallucinations as well as suicidal homicidal ideation were denied. Attention was moderately impaired as the Veteran was unable to do serial 7's due to impaired concentration. Moreover, memory was mildly impaired on a short-term memory task with interference and self-reported problems with memory. Abstraction ability was within normal limits, and insight and judgment were fair. Notably, the examiner reported that Minnesota Multiphasic Personality Inventory-2 (MMPI-2) testing was consistent with overreporting of symptoms although the examiner found that the Veteran's reporting of symptoms was consistent compared to the past 7 years of treatment. The examiner diagnosed the Veteran with moderate to severe PTSD and moderate major depressive disorder and also reported that the Veteran's psychosocial functioning was moderate to severe. The Veteran has submitted multiple lay statements which document his PTSD symptomatology. Specifically, his mother stated that on a daily basis, his PTSD causes him to feel discouraged, emotional, irritable, and constantly fatigued and also causes sleep impairment. His wife also noted his sleep impairment and increased anger although he was a loving and caring father and husband. One of his former commanding officers, D.G., noted the Veteran's in-service combat during service in Croatia and Bosnia. Based on the evidence of record, the Board finds that the Veteran is not entitled to a rating in excess of 70 percent for his PTSD. In this regard, the Board finds that, for the entire appeal period, such disability is manifested by occupational and social impairment with deficiencies in most areas as a result of depressed mood; sleep disturbances; nightmares; impaired impulse control; difficulty adapting to stressful circumstances; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired speech; feelings of isolation; and hypervigilance without more severe manifestations that more nearly approximate total occupational and social impairment. Indeed, the Board finds that this symptomatology is contemplated in the Veteran's current 70 percent rating. As indicated previously, a 100 percent rating is warranted where there is total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The Board notes that the evidence of record indicates that the Veteran's PTSD is arguably manifested by grossly inappropriate behavior based on his incident in October 2010 when he came into his daughter's room with no clothes on with a machete and told her that they must leave their house. However, the Board finds that the Veteran's PTSD does not result in total occupational and social impairment. Specifically, the competent and probative evidence of record does not indicate gross impairment in thought processes or communication; delusions or hallucinations; persistent danger of hearing self or others; intermittent inability to perform activities of daily living; disorientation to time or place; or memory loss for names of close relatives or own name. Indeed, the competent and probative evidence indicates that the Veteran's thought processes is essentially normal and he has been oriented on examination. The Board further notes that the evidence of record reflects that the Veteran has symptomatology including nightmares, mood swings, intrusive thoughts, feelings of isolation, and hypervigilance. See Mauerhan, supra. These symptoms are fully contemplated in the assigned evaluation. However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 70 percent under the General Rating Formula as they are not of such a severity or frequency to result in total occupational and social impairment. The Board also observes that the Veteran has been assigned GAF scores between 35 and 55, which indicate moderate impairment to some impairment in reality testing or communication with a GAF of 50 at his recent VA examination. There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter, supra. However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue. The GAF score must be considered in light of the actual symptoms of the veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Given the actual psychiatric symptoms shown in this case, the Board finds that level of overall psychiatric impairment shown to be consistent with a 70 percent rating. Accordingly, for the foregoing reasons, the Board finds that the Veteran is not entitled to a rating in excess of 70 percent for PTSD. In Hart, supra, the Court held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. In reaching its conclusion, the Court observed that when a claim for an increased rating is granted, the effective date assigned may be up to one year prior to the date that the application for increase was received if it is factually ascertainable that an increase in disability had occurred within that timeframe. See 38 U.S.C.A. § 5110 (West 2002). After a careful review of the record, the Board can find no evidence to support a finding that the Veteran's PTSD was more or less severe during the appeal period. Specifically, as discussed above, the May 2005 and December 2011 VA examination reports, as well as VA treatment records, indicate that the Veteran's PTSD symptoms have remained relatively consistent throughout the period. As such, there is no basis for awarding the Veteran a disability rating other than the currently assigned 70 percent for any time from January 2004 to the present. Higher evaluation for neck disability The law and regulations pertaining generally to disability ratings have been set forth above and will not be repeated here. The evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. See 38 C.F.R. § 4.10 (2013). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. See 38 C.F.R. § 4.40 (2013). Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. See 38 C.F.R. § 4.45 (2013). The Veteran's neck disability is currently evaluated 10 percent disabling prior to December 22, 2011, and 30 percent disabling thereafter under 38 C.F.R. § 4.71a, Diagnostic Codes 5290-5243 pursuant to the General Rating Formula for Diseases and Injuries of the Spine. See 38 C.F.R. § 4.27 [hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen]. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The evidence of record indicates that the Veteran has been diagnosed with degenerative joint disease of the cervical spine. Based on reported symptomatology, and consistent with Diagnostic Code 5243, the Board will rate the Veteran under both the General Rating Formula for Diseases and Injuries of the Spine and the Formula for Rating Intervertebral Disc Syndrome. See 38 C.F.R. § 4.71a (2013). The General Rating Formula for Diseases and Injuries of the Spine provides that with or without symptoms such as pain, stiffness, or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 30 percent rating is warranted when forward flexion of the cervical spine is 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 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 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 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. Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Under the formula for rating intervertebral disc syndrome based on incapacitating episodes, the following ratings will apply. A 60 percent rating is warranted with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. A 40 percent rating is warranted with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 20 percent rating is warranted with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 10 percent rating is warranted with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. Note (1): For purposes of evaluating under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest and prescribed by a physician and treatment by a physician. The Board notes that an MRI of the Veteran's cervical spine dated November 2004 revealed an impression of large right paracentral disc herniation at C5 and C6 with extension into the neuroforamen. Additionally, a VA treatment record dated February 2005 documents the Veteran's anterior cervical discectomy and fusion. The Board observes that the Veteran's mother submitted a statement dated April 2005 which documents the Veteran's complaints of neck pain and inability to perform chores. The Veteran was afforded a VA examination in May 2005. He complained of daily pain with movement of the neck as well as the occurrence of flare-ups with strenuous activity. He did not use walking or assistive devices. He also reported that he was able to groom and bathe himself, and do his own toileting. However, he was unable to do recreational activities. Upon examination of the Veteran's neck, the VA examiner reported that the Veteran's spine and limbs were normal. Range of motion testing revealed forward flexion of the cervical spine to 35 degrees, backward extension to 35 degrees, right lateral flexion to 40 degrees, left lateral flexion to 30 degrees, right rotation to 75 degrees, and left rotation to 65 degrees. The examiner noted that the Veteran had pain with all of these movements and stopped when the pain started. He had no fatigue, weakness, or lack of endurance. Limitation was secondary to pain and repetitive motion did not increase the lost range of motion. The examiner reported that it would be mere speculation to estimate range of motion with a flare-up. The examiner further reported no spasm, tenderness, or weakness as well as no postural abnormalities or fixed deformity. The Veteran was diagnosed with status postoperative herniated nucleus pulposus cervical spine with spinal fusion and residuals. The Board notes that an MRI of the Veteran's cervical spine dated May 2007 revealed an impression of status post cervical fusion spanning C5 to C6 and mild to level degenerative disc disease without significant central canal or foraminal narrowing. Subsequent VA treatment records dated to November 2011 document his complaints of chronic neck pain. The Veteran was provided a VA examination in December 2011. He complained of continuous neck pain of varying degrees. He did not report flare-ups. He used a brace and walker for ambulation. Upon physical examination, the VA examiner documented range of motion testing which revealed forward flexion to 5 degrees with pain at zero degrees, extension to 15 degrees with pain at 10 degrees, right lateral flexion to 10 degrees with pain at 10 degrees, left lateral flexion to 5 degrees with pain at zero degrees, right lateral rotation to 35 degrees with pain at 35 degrees, and left lateral rotation to 20 degrees with pain at 10 degrees. The examiner noted that the Veteran was not able to perform repetitive-use testing with three repetitions due to too much pain. The examiner also reported functional loss which was manifested by less movement than normal, weakened movement, incoordination, and pain on movement. An X-ray report revealed an impression of arthritis of the cervical spine. The examiner diagnosed the Veteran with degenerative arthritis and degenerative disc disease of the cervical spine. Based on the evidence of record, the Board finds that entitlement to a disability rating in excess of 10 percent prior to December 22, 2011 for the Veteran's neck disability is not warranted. As discussed above, to warrant a 20 percent disability rating under the General Rating Formula for Diseases and Injuries of the Spine, the evidence must show that the Veteran's neck disability results in forward flexion of the cervical spine greater than 15 degrees but not greater than 30 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. Crucially, none of these criteria were shown prior to December 22, 2011. On the contrary, the May 2005 VA examination report indicates that the Veteran was able to maintain forward flexion to 35 degrees, combined range of motion was 280 degrees, and there was no evidence of spasm, tenderness, or weakness, as well as no postural abnormalities or fixed deformity. There is no evidence to the contrary during this period. As such, a 20 percent disability rating of the Veteran's cervical spine is not warranted prior to December 22, 2011. The Board also finds that from December 22, 2011, the Veteran is not entitled to a disability rating in excess of 30 percent for his neck disability. As discussed above, to warrant a 40 percent disability rating under the General Rating Formula for Diseases and Injuries of the Spine Review, the evidence must show unfavorable ankylosis of the entire cervical spine. With respect to unfavorable ankylosis of the entire cervical spine, the objective medical evidence of record is pertinently absent any indication that ankylosis exists. "Ankylosis" is immobility and consolidation of a joint due to a disease, injury, surgical procedure." See Lewis v. Derwinski, 3 Vet. App. 259 (1992) [citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Medicine at 68 (4th Ed. 1987)]. Neither the medical or lay evidence of record suggests that the Veteran's cervical spine is immobile. On the contrary, the record shows that the Veteran has maintained motion, albeit limited motion, in all spheres. Accordingly, a 40 percent disability rating of the Veteran's cervical spine is not warranted from December 22, 2011. In evaluating the Veteran's increased rating claim, the Board must also address the provisions of 38 C.F.R. § 4.40 and 4.45 (2013). See DeLuca, supra. The Board recognizes the Veteran's complaints of pain and functional loss as a result of his neck disability, notably his difficulty performing chores as well as walking and standing. However, the Board places greater probative value on the objective clinical findings which do not support a disability rating in excess of 10 percent prior to December 22, 2011, or a disability rating in excess of 30 percent thereafter. In this regard, the competent and probative evidence of record does not indicate significant functional loss attributed to the Veteran's neck complaints which warrant an increased disability rating. In particular, as indicated above, the May 2005 VA examiner documented forward flexion of the cervical spine to 35 degrees, backward extension to 35 degrees, right lateral flexion to 40 degrees, left lateral flexion to 30 degrees, right rotation to 75 degrees, and left rotation to 65 degrees. Pertinently, the examiner noted that the Veteran stopped movement when pain started and also reported no spasm, tenderness, or weakness as well as no postural abnormalities or fixed deformity. Moreover, the December 2011 VA examiner documented movement of the Veteran's neck, specifically noting movement in all spheres. The Board is therefore unable to identify any clinical findings that would warrant an evaluation in excess of 10 percent prior to December 22, 2011 or an evaluation in excess of 30 percent thereafter under 38 C.F.R. § 4.40 and 4.45. The Board further finds that the current 10 percent and 30 percent ratings adequately compensate the Veteran for any functional impairment attributable to his neck disability. See 38 C.F.R. §§ 4.41, 4.10 (2013). Under VA regulations, separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25 (2013); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). However, the evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14 (2013); see also Fanning v. Brown, 4 Vet. App. 225 (1993). The Board notes that the report of the December 2011 VA examiner indicates that there is a postsurgical scar across the Veteran's neck which is consistent with the Veteran's reported surgical history. The applicable rating criteria for skin disorders under 38 C.F.R. § 4.118 were amended, effective August 30, 2002 [see 67 Fed. Reg. 49490-99 (July 31, 2002)] and again in October 2008. The October 2008 revisions are applicable to claims for benefits received by VA on or after October 23, 2008. See 73 Fed. Reg. 54708 (September 23, 2008). In this case, the Veteran filed his claim in January 2005. Therefore, only the post-2002 and pre-October 2008 version of the schedular criteria is applicable. Under 38 C.F.R. § 4.118, Diagnostic Code 7800, a 10 percent rating is warranted for one characteristic of disfigurement of the head, face, or neck. Note (1) to Diagnostic Code 7800 provides that the 8 characteristics of disfigurement, for purposes of evaluation under § 4.118, are as follows: Scar 5 or more inches (13 or more cm.) in length. Scar at least one-quarter inch (0.6 cm.) wide at widest part. Surface contour of scar elevated or depressed on palpation. Scar adherent to underlying tissue. Skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.). Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.). Underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.). Skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Crucially, the competent and probative evidence of record indicates that the Veteran's scar is asymptomatic. Specifically, the December 2011 VA examiner reported that the Veteran's scar is not painful or unstable, and that the total area of the scar is not greater than 39 square cm. There is no competent and probative evidence to the contrary. Accordingly, the Board finds that a separate rating is not warranted for the Veteran's scar. The Board additionally notes that although the Veteran has been diagnosed with degenerative arthritis of the cervical spine, this disease manifests in neck pain based on identified symptomatology. Accordingly, separately rating the diagnosis would amount to prohibited pyramiding. See 38 C.F.R. § 4.14 (2013) [the evaluation of the same disability under various diagnoses is to be avoided]. Finally, the Veteran has not identified any bladder or bowel dysfunction associated with his neck disability, and none has been diagnosed. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 60 percent rating is warranted with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months; a 40 percent rating is warranted with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; a 20 percent rating is warranted with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; and, a 10 percent rating is warranted with incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months. Further, as noted in the schedular criteria, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. The Veteran has contended that his neck disability causes pain and interference in daily activities. However, the medical evidence does not indicate that he has been prescribed bed rest by a physician based on incapacitating episodes totally at least 2 weeks but less than 4 weeks during any 12 month period. Therefore, the Veteran's service-connected neck disability does not warrant an increased disability rating alternatively under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes at any time during the course of this appeal. Extraschedular consideration In evaluating the severity of his service-connected PTSD and neck disability, the Board also has considered whether referral for the disabilities at issue on an extra-schedular basis is warranted. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2013). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities, with the established criteria shows that the rating criteria reasonably describe the level and symptomatology thereof. The criteria specifically provide for evaluation of the disabilities based upon the Veteran's PTSD and neck disability with associated symptomatology, and they practicably represent the average impairment in earning capacity resulting from the Veteran's service-connected disabilities. See 38 C.F.R. § 4.1. Rice consideration Finally, the Board has considered whether a remand for consideration of total disability benefits based on individual unemployability (TDIU) is warranted. The Court has held that TDIU is an element of an increased rating claim. Rice v. Shinseki, 22 Vet. App. 447 (2009). However, the Board observes that the Veteran was awarded TDIU in the above-referenced July 2005 rating decision with an effective date of January 20, 2005 assigned. The Veteran has not appealed the assigned effective date. Therefore, further consideration of this matter is not necessary. Service connection for a right shoulder disability The Veteran contends that his current right shoulder disorder had its onset during a period of active military service (the Veteran was unable to recall the exact period of military service), and that he has experienced continuous symptoms since discharge in 1996. Postservice VA treatment records also show that the Veteran reported having right shoulder pain that stemmed from his "neck spondylosis" and that he had neck pain that radiated into his right upper extremity. (See VA treatment records, dated in February 2002 and February 2005, respectively). Thus, the Veteran has essentially argued that his right shoulder disability is secondary to his service-connected neck disability. Pertinent legal criteria Generally, service connection may be granted for disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2013). Service connection may also be granted on a presumptive basis for certain chronic disabilities, including arthritis, when such are manifested to a compensable degree within the initial post-service year. See 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2013). In order to establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact or chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2013). Service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310(a) (2013); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish service connection for a claimed disability on a secondary basis, there must be (1) evidence of a current disability; (2) a service-connected disability; and (3) evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Presumptive service connection The Board notes that the record does not reflect medical evidence showing any manifestations of arthritis of the right shoulder during the one-year presumptive period after the Veteran's separation from service. On the contrary, the record does not reflect any complaints or findings of a right shoulder disability until May 1999 (more than 2 years after the Veteran's separation from active service) that are consistent with arthritis. Accordingly, service connection is not warranted on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309. Having determined that presumptive service connection is not warranted, the Board's inquiry turns to whether service connection on a direct or secondary basis is warranted. Direct service connection In order to establish service connection on a direct basis, there must be (1) evidence of a current disability; (2) evidence of in-service incurrence of a disease or; and (3) evidence of a nexus between elements (1) and (2). See Hickson, supra. With respect to element (1), current disability, the competent medical evidence of record indicates diagnosis of torn right rotator cuff of the right shoulder with residuals. See, e.g., the May 2005 VA examination report. Accordingly, element (1), current disability, is satisfied. Turning to crucial element (2), in-service incurrence of an injury or disease, the Veteran contends that his current right shoulder disability had its onset during a period of active military service (the Veteran was unable to recall the exact period of military service) and that he has experienced continuous symptoms since discharge in 1996. However, the Board finds the Veteran's contentions to be lacking in probative value and are not credible. Crucially, his service treatment records indicate no suggestion of complaints or treatment for a right shoulder disability. Additionally, the evidence of record does not indicate suggestion of complaints or treatment for a right shoulder disability until multiple years following the Veteran's discharge from service. The earliest document showing complaint of or treatment for a right shoulder disability is in May 1999. This is more than 2 years after his separation from service. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) [contemporaneous evidence has greater probative value than history as reported by the veteran]; see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) [noting that it was proper to consider the veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition he now raised]. The Board adds that the Veteran was provided a Persian Gulf Registry Examination in February 1997. Pertinently, the Veteran did not complain of any right shoulder disability or symptoms associated therewith at that time. Indeed, the examination results were absent any right shoulder disability. The Board observes that lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person (e.g. any evidence not requiring that the proponent has specialized education, training, or experience). 38 C.F.R. § 3.159(a)(2). As such, the Veteran can competently testify about symptoms he experienced in service. However, competency must be distinguished from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Layno v. Brown, 6 Vet. App. 465, 469 (1994). In the present case, the Board finds that the Veteran's history of a right shoulder disability since service is not credible in light of both the lack of any in-service or post service treatment or complaints of a right shoulder disability until May 1999. Accordingly, the Veteran's recent unsupported and self-serving statements concerning in-service development of a right shoulder disability are at odds with the remainder of the record, which is devoid any indication that any injury or disease occurred during service or for more than 2 years thereafter. As such, the Veteran's statements are lacking credibility and probative value. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) [VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence]. In short, there is no objective indication of an in-service diagnosis of a right shoulder disability or symptomatology attributed therewith. Element (2) is therefore not met, and the Veteran's claim fails on this basis. For the sake of completeness, the Board will discuss element (3), nexus. See Luallen v. Brown, 8 Vet. App. 92, 95-6 (1995), citing Holbrook v. Brown, 8 Vet. App. 91, 92 (1995) [the Board has the fundamental authority to decide a claim in the alternative]. There is no competent evidence of record that establishes a causal relationship between the Veteran's currently diagnosed right shoulder disability and his military service. In the absence of in-service disease or injury, it would seem that such nexus opinion would be impossible. In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). "Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). The Board notes that the Veteran has submitted statements from D.G. as well as his wife and mother which appear to indicate that his right shoulder disability is related to his military service. The Board further notes that the Veteran, his wife, his mother, and D.G. are entirely competent to report his symptoms both current and past (including pain in right shoulder and neck). However, the Veteran, his wife, his mother, and D.G. as lay people, are not competent to attribute any of his claimed symptoms of his right shoulder to his military service. The Veteran, his wife, his mother, and D.G. have presented no clinical evidence of a nexus between his right shoulder disability and military service. The Board finds that an opinion as to relationship between a right shoulder disability and military service requires specific medical training and is beyond the competency of the Veteran or any other lay person. In the absence of evidence indicating that the Veteran, D.G., his wife, or his mother have the medical training to render medical opinions, the Board must find that their contentions with regard to a nexus between the Veteran's right shoulder disability and military service to be of no probative value. See also 38 C.F.R. § 3.159(a)(1) (2013) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. As such, the statements offered by the Veteran, his wife, his mother, and D.G. in support of his own claim are not competent evidence of a nexus. The Board is aware of the provisions of 38 C.F.R. § 3.303(b), discussed above, relating to chronicity and continuity of symptomatology. The Board notes that the Veteran appears to be contending that he has had a right shoulder disability continually since service. However, as mentioned above, the first postservice evidence of complaint of, or treatment for, a right shoulder disability is dated in May 1999. See a VA treatment record dated May 1999. This was more than 2 years after the Veteran left service in September 1996. The Board finds that the Veteran's current statements regarding a continuity of right shoulder symptomatology since service are not credible. In particular, the Board reiterates that a right shoulder disability or injury was not indicated in his service treatment records. His service treatment records as well as the postservice medical evidence of record contradict any current assertion that his current right shoulder disability was manifested during service. There is no competent medical evidence that the Veteran complained of or was treated for a right shoulder disability for multiple years after his separation from service. See Maxson, supra; see also see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) [affirming Board where it found that veteran failed to account for the lengthy time period after service for which there was no clinical documentation of the claimed condition]. The Board accordingly places no probative value on the assertions of the Veteran that there has been a continuity of symptomatology dating to service. Therefore, continuity of symptomatology after service is not demonstrated. Accordingly, element (3) is not met, and the Veteran's claim also fails on this basis. Secondary service connection In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) a service-connected disability; and (3) evidence of a nexus between elements (1) and (2). See Wallin, supra. As discussed above, with respect to element (1), current disability, the competent medical evidence of record indicates diagnosis of torn right rotator cuff of the right shoulder with residuals. See, e.g., the May 2005 VA examination report. Accordingly, element (1), current disability, is satisfied. Additionally, the Veteran is currently service-connected for a neck disability. Element (2) is therefore also satisfied. Turning to crucial element (3), nexus, the Board has carefully evaluated the evidence and, for reasons stated immediately below, finds that a preponderance of the competent and probative evidence of record supports a finding that the Veteran's current right shoulder disability is not related to his neck disability. Specifically, a VA medical opinion was obtained in December 2011 as to the question of nexus between the Veteran's right shoulder disability and his neck disability. In addition to the results of an examination of the Veteran's neck, the VA examiner reviewed the Veteran's medical history. After examination of the Veteran's neck and consideration of his medical history, the VA examiner opined that the Veteran's service-connected neck disability neither caused nor permanently aggravated the right shoulder disability. The examiner's rationale for his conclusion was based on his review of medical literature as well as consideration of the Veteran's medical history. Notably, he reported that "[t]he weight of medical literature failed to indicate a nexus between these two functionally and structurally unrelated conditions..." The December 2011 VA opinion was based upon thorough review of the record and thoughtful analysis of the Veteran's entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) [the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"]. The Veteran has not submitted a medical opinion to contradict the VA examiner's opinion. As was explained in the VCAA section above, the Veteran has been accorded ample opportunity to present competent medical evidence in support of his claim. He has failed to do so. See 38 U.S.C.A. § 5107(a) (West 2002) [it is the claimant's responsibility to support a claim for VA benefits]. The Board notes that the Veteran has submitted statements from D.G. as well as his wife and mother which appear to indicate that his right shoulder disability is related to his service-connected neck disability. The Board further notes that the Veteran, his wife, his mother, and D.G. are entirely competent to report his symptoms both current and past (including pain in right shoulder and neck). However, the Veteran, D.G., his wife, and his mother, as lay people, are not competent to attribute any of his claimed symptoms of his right shoulder to his service-connected neck disability. The Veteran, D.G., his wife, and his mother have presented no clinical evidence of a nexus between his right shoulder disability and service-connected neck disability. The Board finds that an opinion as to causation or aggravation of a right shoulder disability requires specific medical training and is beyond the competency of the Veteran or any other lay person. In the absence of evidence indicating that the Veteran, D.G., his wife, or his mother have the medical training to render medical opinions, the Board must find that their contentions with regard to a nexus between the Veteran's right shoulder disability and neck disability to be of no probative value. See also 38 C.F.R. § 3.159(a)(1), supra. As such, the statements offered by the Veteran, his wife, his mother, and D.G. in support of his own claim are not competent evidence of a nexus. Accordingly, the Veteran has not presented competent and probative evidence of a link between his service-connected neck disability and the symptoms of right shoulder disability. The medical opinion is entirely unfavorable to the claim. Element (3) of the required criteria for an award of service connection is not met, and the Veteran's claim fails on this basis. Conclusion For the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a right shoulder disability, to include as secondary to service-connected neck disability. The benefit sought on appeal is accordingly denied. Service connection for a heart disability The law and regulations pertaining generally to service connection have been set forth above and will not be repeated here. The Veteran contends that his current heart disability is related to his military service or alternatively, his service-connected hypertension. Specifically, in a statement received April 2005, he reported that his heart was damaged as a result of the hypertension he incurred while serving in Bosnia. Presumptive service connection The Board notes that the record does not reflect medical evidence showing any manifestations of a heart disability during the one-year presumptive period after the Veteran's separation from service. On the contrary, the record does not reflect any complaints or findings specially pertaining to a heart disability until January 2005 (more than 5 years after the Veteran's separation from active service). Accordingly, service connection is not warranted on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309. Having determined that presumptive service connection is not warranted, the Board's inquiry turns to whether service connection on a direct or secondary basis is warranted. Direct service connection As noted above, in order for service connection to be granted, three elements must be present: (1) a current disability; (2) in-service incurrence of disease or injury; and (3) medical nexus. See Hickson, supra. As to Hickson element (1), the medical evidence of record indicates a current diagnosis of a heart disability. Specifically, the Veteran has been diagnosed with ventricular arrhythmia, cardiomyopathy, and congestive heart failure. See the December 2011 VA examination report; see also a VA treatment record dated July 2006. Hickson element (1) is therefore met. With respect to Hickson element (2), evidence of an in-service incurrence of a disease or injury, the Veteran's service treatment records show that when he Veteran presented to an emergency care clinic during his initial period of military service in April 1985, he had a blood pressure reading of 124/92. An October 1994 Army Reserve enlistment examination report reflects that the Veteran's heart was evaluated as normal. On an October 1994 Report of Medical History, the Veteran denied having had high blood pressure, shortness of breath, pain or pressure in the chest, palpitation or a pounding heart, and a heart trouble or murmur. He stated that he was in "good health." When seen in the acute care medical clinic during his second period of active military service in March 1996, the Veteran stated that he thought that he had hypertension. Upon physical evaluation, his blood pressure was 125/90. The examining physician's assessment was that the Veteran was not hypertensive at that time because he only had one borderline reading. The remainder of the Veteran's service treatment records are absent any indication of a heart disability or symptoms attributed thereby. Turning to crucial element (3), nexus, the Board has carefully evaluated the evidence and, for reasons stated immediately below, finds that a preponderance of the competent and probative evidence of record is against a finding that the Veteran's current heart disability is related to his military service. Specifically, the Veteran was afforded a VA examination in December 2011. In addition to the results of a current examination, the VA examiner considered the Veteran's service treatment records, to include his treatment at the emergency care clinic in April 1985 and March 1996 as well as his October 1994 Army Reserve enlistment examination and report of medical history. After examination of the Veteran and consideration of his medical history, the VA examiner concluded that, "there is no evidence to support diagnosis of any heart disorder during service or within one year of service discharge in September 1996." The examiner's rationale for his conclusion was based on his review of the Veteran's service treatment records, to include the records dated April 1985 and March 1996 which did not indicate a heart disability as well as normal evaluation of the heart in October 1994. He also noted that the Veteran has essential hypertension, which is the most common type and as such is idiopathic, or occurs without an identifiable cause. He further reported that his heart condition is likewise idiopathic per the weight of the medical literature. The December 2011 VA examination report was based upon thorough review of the record, thorough examination of the Veteran, and thoughtful analysis of the Veteran's entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) [the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"]. Additionally, the December 2011 VA examiner's opinion is consistent with the Veteran's medical history, which is absent any symptomatology of a heart disability for several years after service and his service records which do not show complaints of or treatment for a heart disability specifically. The Veteran has not submitted a medical opinion to contradict the VA examiner's opinion. As was explained in the VCAA section above, the Veteran has been accorded ample opportunity to present competent medical evidence in support of his claim. He has failed to do so. See 38 U.S.C.A. § 5107(a) (West 2002) [it is the claimant's responsibility to support a claim for VA benefits]. The Board notes that the Veteran has submitted statements from D.G. as well as his wife and mother which appear to indicate that his heart disability is related to his military service. To the extent that the Veteran, his wife, his mother, or D.G. assert that his heart disability is related to his military service, the Board observes that lay people are competent to testify to visible or otherwise observable symptoms of disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). However, in this case, the Veteran's statements that he has a heart disability that is due to service relates to an etiological question as to an internal, not directly observable disease, unlike testimony as to a separated shoulder, varicose veins, or flat feet, which are capable of direct observation. Compare Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis) with Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr, 21 Vet. App. at 308-309 (lay testimony is competent to establish the presence of varicose veins); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (lay person competent to testify to pain and visible flatness of his feet). The lay statements of the Veteran concerning a relationship between his heart disability and military service are therefore not competent in this regard. The Board is aware of the provisions of 38 C.F.R. § 3.303(b), discussed above, relating to chronicity and continuity of symptomatology. The Board notes that the Veteran appears to be contending that he has had a heart disability continually since service. However, as mentioned above, the first postservice evidence of complaint of, or treatment for, a heart disability specifically is dated in January 2005 when the Veteran filed his claim for VA benefits. This was more than 5 years after the Veteran left service in September 1996. The Board finds that the Veteran's current statements regarding a continuity of cardiovascular symptomatology since service are not credible. In particular, the Board reiterates that a heart disability or injury was not indicated in his service treatment records. His service treatment records as well as the postservice medical evidence of record contradict any current assertion that his current heart disability was manifested during service. There is no competent medical evidence that the Veteran complained of or was treated for a heart disability for multiple years after his separation from service. See Maxson and Mense, both supra. The Board accordingly places no probative value on the assertions of the Veteran that there has been a continuity of symptomatology dating to service. Therefore, continuity of symptomatology after service is not demonstrated. Accordingly, element (3) is not met, and the Veteran's claim fails on this basis. Secondary service connection In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) a service-connected disability; and (3) evidence of a nexus between elements (1) and (2). See Wallin, supra. As discussed above, with respect to element (1), current disability, the medical evidence of record indicates a current diagnosis of a heart disability. Specifically, the Veteran has been diagnosed with ventricular arrhythmia, cardiomyopathy, and congestive heart failure. See the December 2011 VA examination report; see also a VA treatment record dated July 2006. Accordingly, element (1), current disability, is satisfied. Additionally, the Veteran is currently service-connected for hypertension. Element (2) is therefore also satisfied. Turning to crucial element (3), nexus, the Board has carefully evaluated the evidence and, for reasons stated immediately below, finds that a preponderance of the competent and probative evidence of record is against a finding that the Veteran's current heart disability is related to his hypertension. Specifically, the Veteran was afforded a VA examination in December 2011. In addition to the results of a current examination, the VA examiner considered the Veteran's treatment at the emergency care clinic in April 1985 and March 1996 pertaining to complaints of hypertension as well as his October 1994 Army Reserve enlistment examination and report of medical history. After examination of the Veteran and consideration of his medical history, the VA examiner concluded that, "there is no evidence that the [Veteran's] hypertension has caused or permanently worsened any current heart disorder." The examiner's rationale for his conclusion was based on his review of the Veteran's service treatment records, to include the records dated April 1985 and March 1996 which did not indicate a heart disability as well as normal evaluation of the heart in October 1994. He also noted that the Veteran has essential hypertension, which is the most common type and as such is idiopathic, or occurs without an identifiable cause. He further reported that his heart condition is likewise idiopathic per the weight of the medical literature. The December 2011 VA examination report was based upon thorough review of the record, thorough examination of the Veteran, and thoughtful analysis of the Veteran's entire history. See Bloom, supra. The Veteran has not submitted a medical opinion to contradict the VA examiner's opinion. As was explained in the VCAA section above, the Veteran has been accorded ample opportunity to present competent medical evidence in support of his claim. He has failed to do so. See 38 U.S.C.A. § 5107(a) (West 2002) [it is the claimant's responsibility to support a claim for VA benefits]. The Board notes that the Veteran has submitted statements from D.G. as well as his wife and mother which appear to indicate that his heart disability is related to his hypertension. To the extent that the Veteran, his wife, his mother, or D.G. assert that his heart disability is related to his service-connected hypertension, the Board observes that lay people are competent to testify to visible or otherwise observable symptoms of disability. See Jandreau and Buchanan, both supra. Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson, supra (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). However, in this case, the Veteran's statements that he has a heart disability that is due to hypertension relates to an etiological question as to an internal, not directly observable disease, unlike testimony as to a separated shoulder, varicose veins, or flat feet, which are capable of direct observation. Compare Woehlaert (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis) with Jandreau (lay witness capable of diagnosing dislocated shoulder), both supra; Barr, supra (lay testimony is competent to establish the presence of varicose veins); Falzone, supra (lay person competent to testify to pain and visible flatness of his feet). The lay statements of the Veteran concerning a relationship between his heart disability and hypertension are therefore not competent in this regard. Accordingly, the Veteran has not presented competent and probative evidence of a link between his service-connected heart disability and hypertension. The medical opinion is entirely unfavorable to the claim. Element (3) of the required criteria for an award of service connection is not met, and the Veteran's claim fails on this basis. Conclusion For the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a heart disability, to include as secondary to service-connected hypertension. The benefit sought on appeal is accordingly denied. ORDER Entitlement to an increased disability rating for PTSD with depressive disorder, currently evaluated as 70 percent disabling is denied. Entitlement to an evaluation in excess of 10 percent for a neck disability prior to December 22, 2011, and in excess of 30 percent thereafter is denied. Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected neck disability is denied. Entitlement to service connection for a heart disability, to include as secondary to service-connected hypertension is denied. ______________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs