Citation Nr: 1332435 Decision Date: 10/18/13 Archive Date: 10/24/13 DOCKET NO. 10-01 870 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease of the lumbar spine and the cervical spine. 2. Entitlement to an initial rating in excess of 10 percent for posttraumatic stress disorder (PTSD) prior to December 4, 2008, in excess of 30 percent for the period from December 4, 2008, to June 5, 2012, and in excess of 50 percent thereafter. 3. Entitlement to an initial compensable rating for left (minor) shoulder strain with history of compression arthralgia prior to January 6, 2012, and in excess of 10 percent thereafter. 4. Entitlement to an initial compensable rating for hemorrhoids. REPRESENTATION Veteran represented by: Tennessee Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Andrew Ahlberg, Counsel INTRODUCTION The Veteran served on active duty from February 2005 to June 2008. His awards and decorations include the Combat Action Badge. This matter was previously before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs Regional Office (RO) in Nashville, Tennessee. The Board remanded the claims for additional development in September 2011 and February 2013. The Veteran was afforded a video-conference hearing before the undersigned Veterans Law Judge in February 2011. A written transcript of the hearing has been associated with the record. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file reveals VA treatment records dated through June 2013, which were considered in the July 2013 supplemental statement of the case. The issue of entitlement to a higher initial rating for the Veteran's lumbar and cervical spine disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. Resolving doubt in favor of the Veteran, for the entire appeal period, his PTSD has been manifested by difficulty in establishing and maintaining effective work and social relationships without more severe symptomatology indicative of occupational and social impairment with deficiencies in most areas and an inability to establish and maintain effective relationships, or total occupational and social impairment. 2. Resolving doubt in favor of the Veteran, for the entire appeal period, his left (minor) shoulder strain with history of compression arthralgia has been manifested by painful limited motion without ankylosis, motion limited to midway between the side and shoulder level, flail shoulder, nonunion, fibrous union, dislocation, malunion, or nonunion. 3. At no time during the appeal period have hemorrhoids been large or thrombotic, irreducible, with excessive redundant tissue evidencing frequent occurrences. CONCLUSIONS OF LAW 1. For the entire appeal period, the criteria for an initial rating of 50 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, DC 9411 (2013). 2. For the entire appeal period, the criteria for an initial rating of 10 percent, but no higher, for left (minor) shoulder strain with history of compression arthralgia have been. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5201, 5019 (2013). 3. For the entire appeal period, the criteria for an initial compensable rating for hemorrhoids have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.114, DC 7338 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice must inform the claimant of any information and evidence not of record: (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. 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 Board observes that the Veteran has appealed with respect to the propriety of the initially assigned ratings for his PTSD, left shoulder disability, and hemorrhoids from the original grant of service connection. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess, supra, 19 Vet. App. 473, 490 (2006). In this case, the Veteran's claims for service connection for PTSD and left shoulder strain were granted and initial ratings assigned by a September 2008 rating decision on appeal. Service connection for hemorrhoids was granted, and an initial rating assigned, by a November 2008 rating decision on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned ratings for the service-connected disabilities at issue, no additional 38 U.S.C.A. § 5103(a) notice is required with respect to these issues because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Relevant to the duty to assist, the Veteran's service treatment records (STRs) and post-service treatment VA and private treatment records have been obtained, and the development requested in the September 2011 and February 2013 remands has been accomplished to the extent possible. In this regard, the VA examinations requested in the September 2011 remanded were accomplished in January and June 2012, and the reports from these examinations reflect compliance with the instructions of this remand. The VA medical records requested in this remand were obtained, and a September 2011 letter mailed to the Veteran asked him to provide the proper authorization to obtain any additional pertinent records, to include, as requested in the September 2011 remand, those from a chiropractor with the initials T.D. No such authorization was received from the Veteran, and as the duty to assist is not a "one way street," when, as in the instant case with respect to supplying the proper authorization to obtain the records in question, it is the Veteran that has the "information that is essential in obtaining the putative evidence," the Veteran cannot "passively wait" for the assistance of the VA. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Thus, no further development to obtain the records from T.D. is indicated. With respect to the development requested in the February 2013 remand, the VA outpatient treatment reports requested therein were associated with the Virtual VA file and the requested documentation listing the dates of the Veteran's military service were obtained. Also obtained were the requested additional treatment records, to include reports of psychiatric treatment, from the Irwin Army Hospital and other military facilities. With respect to the reference in the February 2013 remand to pre deployment examinations, the reports from treatment at military facilities appear to be complete, and include reference to other pre-deployment examinations, the reports from which, to include from such examinations conducted in October 2005, May 2006, and August 2006, were previously of record. With respect to the records from the Rutherford County Sherriff's Department, Health4 Life Chiropractic, and Riverview Family Chiropractic referenced in the most recent remand, a Febrary2013 letter mailed to the Veteran (at his current address as requested) asked the Veteran to provide the proper authorization to obtain these and any additional pertinent records. There being no response to this request, no further development with respect to obtaining these records is indicated. Wood, supra. Finally with respect to the shoulder examination requested in the February 2013 Board remand, such an examination was scheduled for June 2013 but the Veteran failed to report to the examination, despite being informed of date and time of this examination in writing and by telephone. (See June 2013, electronic mail messages documenting the efforts made to inform the Veteran of this examination.). As such, no further development to schedule the Veteran for a VA shoulder examination is indicated. Wood, supra. In short, the Board finds that there has been substantial compliance with the instructions of its remands. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). The Board finds that the VA examinations are adequate because, as discussed below, they were based upon consideration of the Veteran's pertinent medical history and his lay assertions and current complaints, and because they provide sufficient detail to allow the Board to make fully informed determinations. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). All necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) (2013) requires that any Veterans Law Judge who chairs a hearing fulfill two duties to comply with the VCAA. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant, 23 Vet. App. at 488. Here, during the February 2011 hearing, the undersigned Veterans Law Judge adequately explained the claims on appeal and suggested evidence that may support these claims. The Board accordingly concludes that the notice requirements under Bryant were effectively satisfied. To the extent any such notice may have been inadequate, this was effectively cured both by actual knowledge as evidenced by statements of record from the Veteran, and well as by the Board providing such explanation of the issues and suggesting submission of evidence in the subsequent remands the Board issued to develop the claims. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose with respect to the matters adjudicated in this decision. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case with respect to the claims adjudicated herein, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claims adjudicated herein. 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). II. Analysis The Board has reviewed all of the evidence of record, to include in the Veteran's claims file and the Virtual VA file with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims adjudicated herein. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Ratings Schedule) found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the appellant's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating an appellant's service-connected disabilities. 38 C.F.R. § 4.14. 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). Staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007) Fenderson v. West, 12 Vet. App. 119, 126 (1999). A. PTSD The Veteran's service-connected PTSD has been rated under DC 9411, and the criteria for rating such psychiatric disability are set forth in the General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. Under the General Rating Formula, a 10 percent rating is assigned when there is occupational and social impairment due to mild or transient symptoms which decreases work efficiency and ability to perform occupational tasks only during periods of significant stress, or, symptoms controlled by continuous medication. 38 C.F.R. § 4.130. A 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned for 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 affecting 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); inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for 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 symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the "American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders" (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." 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 v. Brown, 8 Vet. App. 240 (1995). 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; rather, 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). With the above criteria in mind, the relevant evidence will be summarized. As previously noted, the Veteran has been awarded the Combat Action Badge and his DD Form 214 reflects service in Kuwait/Iraq in support of Operation Iraqi Freedom. His Military Occupational Specialty was listed therein as an Indirect Fire Infantryman. At an August 2008 VA examination, the Veteran reported stressors associated with his duty as a gunner with the infantry during his service in Iraq, and PTSD was diagnosed at this examination. Following the August 2008 VA examination, service connection for PTSD was granted by a September 2008 rating decision. A 10 percent rating was assigned effective from June 15, 2008, the day following the Veteran's separation from active duty. Subsequent rating decisions increased the rating for PTSD to 30 percent from December 4, 2008, and 50 percent from June 5, 2012. As the 30 and 50 percent ratings were not assigned effective from the date of the grant of service connection, there is for consideration, as the issue it listed on the Title Page, entitlement to a rating in excess of 10 percent for PTSD prior to December 4, 2008, in excess of 30 percent for the period from December 4, 2008, to June 5, 2012, and in excess of 50 percent thereafter. AB v. Brown, 6 Vet. App. 35 (1993). Turning first to the issue of entitlement to rating in excess of 10 percent for PTSD prior to December 4, 2008, the Board finds that, as there is evidence of record that that Veteran has had difficulty in establishing and maintaining effective work and social relationships from the date service connection was granted, a 50 percent rating is warranted for the entire appeal period, i.e., beginning June 15, 2008. See 38 C.F.R. § 4.130. As support for this determination, reports from psychiatric treatment during service in December 2007 reveal psychiatric symptoms severe enough to warrant the prescription of medication to alleviate psychiatric symptoms. It was indicated at that time that the Veteran had separated from his wife and the psychological symptoms were said to include "[i]nterpersonal relationship problems." Moreover, at the August 2008 VA examination, the Veteran reported that he did not like to be around other people in crowds, that he had divorced his wife, and that he was living with his father as a result of a having an argument with his girlfriend. He also reported anxiety when riding in a car with other people, and the GAF score following the examination of 65 is associated with some difficulty in occupational and social functioning. See Carpenter, supra. In making the determination that a 50 percent rating is warranted from the date of service connection of June 15, 2008, although review of the clinical evidence from that date does not reveal clinical evidence documenting the majority of the symptoms for a 50 percent rating listed in the General Rating Formula, the symptoms listed in the criteria are meant not as an exhaustive list of symptoms, but rather, as examples of the type and degree of the symptoms or effects that would justify a particular rating. See, e.g., Mauerhan. It is the impact of a Veteran's psychiatric symptoms on occupational and social functioning that is of primary importance, and from the clinical evidence and Veteran's statements, to include those in sworn testimony to the undersigned with respect to the "social distance from other people" his PTSD has caused (February 9, 2011, Hearing Transcript, Page 6) attesting to his problems with PTSD due to his service in a hostile theater of operations from immediately after separation from service, it cannot be said that the preponderance of the evidence is against a conclusion that the criteria for a 50 percent rating were met from June 15, 2008. Unless the preponderance of the evidence is against the Veteran's claim, it cannot be denied, and when a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. As such, and without finding error in the assignment of the ratings for such disability by the RO and consistent with Mauerhan, the Board will exercise its discretion to find that the evidence is in relative equipoise and conclude that the criteria for an initial 50 percent rating for PTSD have been met from June 15, 2008, the effective date of the grant of service connection. Id. As for whether a rating in excess of 50 percent (70 percent) may be assigned, considering the pertinent evidence of record set forth above, the Board finds that the criteria for a rating in excess of 50 percent for PTSD are not met at any time since the grant of service connection. First with regard to whether the criteria for such a rating are not demonstrated, while not dispositive of the matter, the examiner who conducted the August 2008 VA examination, in reporting what best summarized the level of occupational and social impairment resulting solely from psychiatric disability as set forth in the rating criteria, selected the level of disability characterized by a 10 percent rating as codified under 38 C.F.R. § 4.130. The same exercise performed at the January 2012 VA psychiatric examination showed the examiner selecting the level of disability characterized by a 50 percent rating as codified under 38 C.F.R. § 4.130. While the examiner who conducted the January 2009 VA examination found deficiencies due to PTSD in the areas of thinking, family relations, work, and mood, the GAF score following this examination of 68 would not be consistent with a 70 percent rating, as a such a GAF score approaches mere "mild" symptoms with some occupational impairment in an individual otherwise functioning "pretty well." Carpenter, supra. A 70 percent rating would also not be consistent with the fact, as set forth in the reports from the January 2009 VA examination and elsewhere, the Veteran is able to work full time as a sheriff's deputy. Moreover, the January 2009 VA examination did not demonstrate any of the types of symptoms listed for a 70 percent rating; namely, suicidal ideation; obsessional rituals, abnormal speech, near-continuous panic or depression (only one or two panic attacks were reported), impaired impulse control, spatial disorientation, neglect of personal appearance and hygiene, or the complete inability to establish and maintain effective relationships. In addition, none of types of symptoms listed for a 70 percent rating were demonstrated at the August 2008 VA examinations or at the most recent VA examination in January 2012. Finally, the GAF score of 60 assigned at the January 2012 VA examination, which demonstrate only "moderate" difficulty in social or occupational functioning, would not be consistent with a 70 percent rating. VA outpatient treatment reports, to include from the time of the examinations set forth above, do not reflect a level of disability associated with PTSD that differs from that shown at the time of these VA examinations. In short therefore, the Board finds that the criteria for 70 percent rating for PTSD are not met at any time since the grant of service connection. 38 C.F.R. § 4.130, DC 9411. Moreover, the Board finds that the criteria for a 100 percent rating under the General Rating Formula are not met. In this regard, the evidence does not show that the Veteran has 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. Moreover, the Veteran is still employed full-time and, thus, is not totally occupationally impaired. As such rating criteria requires that there be total occupational and social impairment, the Veteran does not meet the requirements for a 100 percent rating for his PTSD. In determining that the criteria for a rating in excess of 50 percent for the Veteran's PTSD are not met, it is again emphasized that it has considered the applicable rating criteria not as an exhaustive list of symptoms, but rather, as examples of the type and degree of the symptoms or effects that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule in determining that a rating in excess of 50 percent is not for assignment. See supra, Mauerhan. B. Left Shoulder Disability Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. Normal forward elevation of the shoulder is from 0 to 180 degrees, normal abduction is from 0 to 180 degrees, normal external rotation is from 0 to 90 degrees, and normal internal rotation is from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. The Veteran is right handed. See eg. January 2009 VA examination. Thus, as the service-connected disability involves the left shoulder, such disability involves the minor extremity. Limitation of motion of the minor arm to the shoulder level is evaluated 20 percent disabling, the minimal rating under 38 C.F.R. § 4.71a, DC 5201. Limitation of motion of the minor arm midway between side and shoulder level is also 20 percent disabling, and limitation of motion of the minor arm to 25 degrees from the side is evaluated as 30 percent disabling under 38 C.F.R. § 4.71a, DC 5201. The March 2008 separation examination is negative for a shoulder disability but STRs reflects complaints of left shoulder pain. Following separation from service, June 2008 radiographic testing of the left shoulder was normal. A September 2008 VA examination showed limitation of flexion of the shoulder to 150 degrees and limitation of abduction to 170 degrees. The Veteran described discomfort in the left shoulder of a "buzzing" or vibrating sensation. It was noted that the "DeLuca" criteria were negative, and the diagnosis was left shoulder strain. Thereafter, service connection for left shoulder strain with history of compression arthralgia was granted by a September 2008 rating decision. A noncompensable rating was assigned under DC 5201 effective from June 15, 2008. This rating was continued until August 2012, at which time a rating decision increased the rating to 10 percent under DCs 5201-5019 (bursitis, rated as for arthritis) effective from January 6, 2012. The basis for this 10 percent rating as stated in the August 2012 rating decision was that a January 6, 2012, VA examination demonstrated painful motion of the arm at the shoulder so as to warrant a 10 percent rating under 38 C.F.R. § 4.59 on the basis of functional loss to due painful motion. As the 10 percent rating for the left shoulder disability was not assigned effective from the grant of service connection, there is for consideration, as the issue is listed on the Title Page, entitlement to a compensable rating for such disability prior to January 6, 2012, and in excess of 10 percent thereafter. AB v. Brown, supra. Turning first to the issue of whether a compensable rating may be assigned prior to January 6, 2012, the Board finds that as the Veteran had pain and limited flexion and abduction in the left shoulder from as early as the September 2008 VA examination, a 10 percent rating is warranted on the basis of painful limited of motion in the left shoulder for the entire appeal period, i.e., from June 15, 2008. See 38 C.F.R. §§ 4.59, 4.71a, DCs 5003, 5201-5019; Burton, supra. As for whether a rating in excess of 10 percent may be assigned, an increased (20 percent) rating under DC 5201 would require limitation of motion of the left arm to at least the shoulder level. Motion in the arm, as indicated, was shown from well beyond the shoulder level to 150 degrees of flexion and 170 degrees of abduction at the September 2008 VA examination. At the January 2009 VA examination, flexion in the left shoulder was to 162 degrees, abduction to 160 degrees, internal rotation to 90 degrees, and external rotation to 80 degrees; as such, the motion shown at this examination is also well beyond that required for a 20 percent rating under DC 5201. At the January 2012 VA examination, motion in the left shoulder was to full flexion and 170 degrees of abduction, thereby not warranting increased compensation under DC 5201. Review of the VA outpatient treatment report do not reflect range of motion findings in the left shoulder that would warrant increased compensation. As for other potentially applicable diagnostic codes under which a rating in excess of 10 percent could be assigned for disabilities of the arm or shoulder, such a rating would require ankylosis (DC 5200) flail shoulder (DC 5202), nonunion (DCs 5202, 5203), fibrous union (DC 5202), or dislocation, nonunion, or malunion (DCs 5202, 5203). Such manifestations were not shown at any of the VA examinations set forth above or any other clinical evidence of record. With regard to giving proper consideration to the effects of pain in assigning a disability rating, as well as the provisions of 38 C.F.R. § 4.45 and the holdings in DeLuca and Mitchell, supra, the reports from the examinations conducted above document consideration of these principles, and there is no indication that increased compensation would be warranted under these principles. In short and based on the analysis above, the rating criteria for compensation in excess of 10 percent for minor shoulder strain with history of compression arthralgia are not met at any time since the date of the grant of service connection, June 15, 2008. 38 C.F.R. § 4.71a, DCs 5003, 5201-5219. C. Hemorrhoids Under 38 C.F.R. § 4.114, DC 7336, a 10 percent rating is warranted when there is evidence of external or internal hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent rating, which is the maximum disability rating available under DC 7336, is warranted when there is evidence of external or internal hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. The medical history collected at separation from service demonstrated complaints of hemorrhoids, and a November 2008 VA examination resulted in a diagnosis of internal hemorrhoids. The Veteran reported at that time that his hemorrhoids were internal but "puff out" sometimes and resolve "within an hour or so" with the use of cream. He reported a history of occasional bleeding and described current symptoms at that time as anal itching and burning with no diarrhea, difficulty with passing stool, pain, tenesmus, or swelling. The Veteran reported no history of thrombosis and a history of recurrent hemorrhoids without thrombosis of 4 or more episodes per year with no history of fecal incontinence or perianal discharge. The physical examination showed no hemorrhoids, fistulas, stricture, or prolapse. The sphincter was not impaired. The examiner stated that the Veteran's hemorrhoids resulted in no significant occupational effects and moderate effects on toileting. Following the November 2008 VA examination, a rating decision in that that month granted service connection for hemorrhoids. A noncompensable rating was assigned effective from June 15, 2008. Thereafter, the pertinent evidence includes reports from a January 2012 VA examination to asses the severity of the Veteran's hemorrhoids. The physical examination was normal and revealed no external hemorrhoids, anal fissures, or other abnormalities. Signs or symptoms of hemorrhoids that were large or thrombotic, irreducible, with excessive redundant tissue were not reported. The examiner stated that the Veteran's hemorrhoids did not impact his ability to work. Review of the VA outpatient treatment reports included reports from emergency room treatment for rectal bleeding and hemorrhoids in August 2011 but does not reflect a level of disability that differs in significant degree from that shown at the VA examinations described above. Applying the pertinent criteria to the facts summarized above, a compensable rating for hemorrhoids under DC 7336 requires evidence of external or internal hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. Such manifestations are simply not demonstrated by the clinical evidence of record as summarized above. As such, the Board finds that the rating criteria for compensable rating for hemorrhoids are not met at any time since the date of the grant of service connection, June 15, 2008. 38 C.F.R. § 4.114, DC 7336. D. Other Considerations The Board emphasizes that in making the above determinations, staged ratings for the Veteran's disabilities beyond those already assigned or granted herein are not warranted as the Veteran's symptomatology has otherwise remained stable throughout each time period during the appeal. See Fenderson, Hart, supra. In making its determinations in this case, the Board has carefully considered the Veteran's contentions with respect to the nature of his service-connected disabilities at issue and notes that his lay testimony is competent to describe certain symptoms associated with these disabilities. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and have been contemplated by the disability ratings that have been assigned. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disabilities at issue. As such, while the Board accepts the Veteran's testimony with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected conditions at issue. The Board has also contemplated whether the case should be referred for extra-schedular consideration for the disabilities at issue. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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 claimant's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected disabilities at issue with the established criteria found in the rating schedule. The Board finds that the disabilities at issue are fully addressed by the rating criteria under which each such disability is rated. In this regard, the specific diagnostic criteria adequately address the whole of the Veteran's symptoms referable to his service-connected spine and shoulder disabilities, PTSD, and hemorrhoids. There are no additional symptoms of the service-connected disabilities at issue. In this regard, a wide range of signs and symptoms are contemplated in the applicable rating criteria for the Veteran's disabilities. Specifically, the service-connected left shoulder disability requires application of the holding in Deluca, supra, and Mitchell, supra, which, in turn, requires consideration of 38 C.F.R. §§ 4.40 and 4.45. 38 C.F.R. § 4.40 requires consideration of functional loss, including the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, pain, weakness, and atrophy. Likewise, 38 C.F.R. § 4.45 requires consideration of, in part, incoordination, impaired ability to execute skilled movements, painful motion, swelling, deformity, disuse atrophy, instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing. Also, 38 C.F.R. § 4.59 requires consideration of such matters as unstable or mal-aligned joints, and crepitation as well as any painful arthritic motion. Furthermore, in evaluating the Veteran's PTSD, all relevant symptomatology, to include those not enumerated in the rating criteria, are considered. See Mauerhan, supra. Finally, with respect to the Veteran's hemorrhoids, the rating criteria specifically contemplates all symptomatology associated with such disability. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology associated with the service-connected disabilities addressed above. As such, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating for either of the service-connected disabilities addressed above is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). "Because the VA disability rating schedule is designed to consider the disabling effect of disabilities separately, no single DC provision will adequately assess the variety of symptoms involved with multiple service-connected disabilities." Johnson v. Shinseki, 26 Vet.App. 237 (2013) (en banc). Thus, as to the question of "whether [38 C.F.R.] § 3.321(b)(1) requires VA to consider multiple service-connected disabilities on a collective basis" the Court held that it did not. Id. (noting that a concurring opinion in Brambley v. Principi, 17 Vet. App. 20, 27 (2003) that there should have been a determination of "whether the appellant's service-connected disabilities as a whole [sic] entitled [a Veteran] to [an extraschedular rating] under § 3.321(b)(1)" had never been adopted by the Court and concurring opinions are not binding on the Court" (citing Maryland v. Wilson, 519 U.S. 408, 412-13). Stated in other terms, an extraschedular rating may not be assigned for the cumulative impact of the service-connected disabilities herein at issue. Finally, the Board acknowledges the holding in Rice v. Shinseki, 22 Vet. App. 447 (2009) that a total rating based on individual unemployability due to service-connected disability (TDIU) claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. In this case, the Veteran has been shown to be working full time as a sheriff's assistant, and there is otherwise no evidence or allegation that the Veteran is unemployable due to any of the service-connected disabilities at issue. Therefore, the issue of entitlement to a TDIU is not raised in the instant appeal and further consideration of such is not necessary. In sum, while entitlement to a 50 percent rating for PTSD and 10 percent for minor shoulder strain with history of compression arthralgia for the entire appeal period is warranted, the preponderance of the evidence is against a rating in excess of 50 percent for PTSD, 10 percent for minor shoulder strain with history of compression arthralgia, and a compensable rating for hemorrhoids at any time since the grants of service connection for these disabilities. Therefore, the benefit of the doubt doctrine is not applicable with respect to claims for ratings in excess of 50 percent for PTSD, 10 percent for left shoulder strain with history of compression arthralgia, and a compensable rating for hemorrhoids, and these claims must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7; Gilbert, supra. ORDER For the entire appeal period, an initial 50 percent rating, but no higher, for PTSD is granted, subject to regulations governing the payment of monetary awards. For the entire appeal period, an initial 10 percent rating, but no higher, for left shoulder strain with history of compression arthralgia is granted, subject to regulations governing the payment of monetary awards. An initial compensable rating for hemorrhoids is denied. REMAND Regarding the Veteran's claims of entitlement to an initial rating in excess of 10 percent for degenerative joint disease of the lumbar spine and the cervical spine, the Board finds that a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide his claim so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Following the issuance of the July 2013 supplemental statement of the case, the Veteran submitted a VA Form 21-4142 (Authorization and Consent to Release Information to VA) identifying treatment records from Dr. M. Hazel in Murfreesboro, Tennessee, dated to July 27, 2013, for his spine disability. Therefore, a remand is necessary in order for the AOJ to attempt to obtain such private treatment records. After obtaining such outstanding treatment records, the AOJ should review the newly received records and then conduct any additionally indicated development, to include affording the Veteran any examinations deemed necessary for the adjudication of the claim. The Board also notes that the Veteran's service-connected cervical and lumbar spine disability is currently evaluated pursuant to DCs 5003-5242 (degenerative arthritis of the spine). Such disability is rated under the General Rating Formula for Diseases and Injuries of the Spine. A Note to such rating criteria provides that disability of the thoracolumbar and cervical spine segments should be separately evaluated, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. See Note (6). Currently, the Veteran is assigned a single 10 percent rating for his cervical and lumbar spine disability. Therefore, in the readjudication of the claim, the AOJ should specifically consider whether he is entitled to separate ratings for his lumbar and cervical spine disabilities pursuant to Note (6) of the General Rating Formula for Diseases and Injuries of the Spine. Accordingly, the case is REMANDED for the following action: 1. Request records from Dr. Hazel using the VA Form 21-4142 submitted by the Veteran in July 2013. If such form has expired, provide the Veteran with the necessary authorization for the release of such private treatment records. After obtaining any necessary authorization, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. 2. Thereafter, the AOJ should review the newly received records and then conduct any additionally indicated development, to include affording the Veteran any examinations deemed necessary for the adjudication of the claim. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. In the readjudication of the Veteran's claim, the AOJ should specifically consider whether he is entitled to separate ratings for his lumbar and cervical spine disabilities pursuant to Note (6) of the General Rating Formula for Diseases and Injuries of the Spine. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs