Citation Nr: 1332690 Decision Date: 10/21/13 Archive Date: 10/24/13 DOCKET NO. 07-36 961 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) from March 4, 2004. 2. Entitlement to an initial compensable disability rating for removal of the right testicle due to atrophy 3. Entitlement to an initial disability rating in excess of 10 percent for the residuals of a right ankle chip fracture. 4. Entitlement to an initial disability rating in excess of 10 percent for a left shoulder strain. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Crohe, Counsel INTRODUCTION The Veteran had active service from July 1967 to July 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs Regional Office (RO) in St. Petersburg, Florida, denying the claims currently on appeal. The Veteran was afforded a video conference hearing before the undersigned Veterans Law Judge in July 2010. A written transcript of this hearing has been prepared and incorporated into the evidence of record. In November 2010, the Board, in relevant part, remanded the claims for further development. In a March 2012 rating decision, the Appeals Management Center (AMC) increased the evaluation assigned for PTSD to 100 percent, effective January 19, 2011. Because the AMC did not grant the maximum rating for the entire period of the appeal, it cannot be said that the Veteran has been granted the maximum available benefit. See AB v. Brown, 6 Vet. App. 35, 38 (1993) [when a Veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated]. Indeed, in the representative's most recent written argument, it was noted that the Veteran feels he is entitled to a 100 percent rating from the date of the original claim, or March 4, 2004. Accordingly, the issue of an initial rating in excess of 50 percent prior to January 19, 2011, is still in appellate status. The issue of entitlement to service connection for scars of the left leg was raised during the July 2010 hearing and in the prior November 2010 Board decision, but it has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over this issue, and it is referred to the AOJ for appropriate action. The issue of entitlement to a separate TDIU rating for consideration of an award of special monthly compensation is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Since March 04, 2004, the Veteran's PTSD has been manifested by total occupational and near total social impairment. 2. The residuals of the Veteran's removal of right testicle are manifested by benign prostatic hyperplasia (BPH) and urinary frequency requiring daytime voiding between two and three hours, or awakening to void two times per night. 3. The Veteran's residuals of a right ankle chip fracture are productive of marked limitation of motion; ankylosis has not been shown. 4. The Veteran's left shoulder strain is manifested by mild arthritis and at its most restrictive, the flexion and abduction were limited midway between the side and the shoulder level; ankylosis of the scapulohumeral articulation or impairment of the humerus have not been shown. CONCLUSIONS OF LAW 1. The criteria for a 100 percent rating for PTSD have been met since March 4, 2004. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411 (2013). 2. The criteria for an initial rating of 10 percent, but no more, for urinary frequency as residual to BPH and removal of the right testicle due to atrophy have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.115a, 4.115b, Diagnostic Codes 7524,7527 (2013). 3. The criteria for an initial rating of 20 percent for residuals of a right ankle chip fracture have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.7, 4.71(a), Diagnostic Code 5271 (2013). 4. The criteria for a 20 percent rating for left shoulder strain with arthritis are met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5024, 5201 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify & Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012) redefined VA's duty to assist the Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). In regards to the Veteran's increased rating claim for PTSD, given that this decision grants the full benefit sought, the claim is substantiated and further notice or development is not required. See 38 U.S.C.A. § 5103A(a)(2) (Secretary not required to provide assistance "if no reasonable possibility exists that such assistance would aid in substantiating the claim"). The appeal for higher initial ratings left shoulder and right ankle disabilities, and residuals of right testicle removal arises from the Veteran's disagreement with the rating assigned pursuant to the grant of service connection. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or address prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (2003). The Court has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as initial rating) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105. Goodwin v. Peake, 22 Vet. App. 128 (2008). Where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements. Id. There has been no allegation of such error in this case. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA obtained all of the Veteran's service treatment records as well as identified relevant post-service VA and private treatment records. The Veteran was provided with multiple VA examinations. In November 2010, the Board remanded the claims, in part, to provide contemporaneous VA examinations to determine the severity of the left shoulder and right ankle disabilities, and residuals of right testicle removal. In regards to residuals of the removal of the right testis, the October 2011 disability benefits questionnaire combined with the January 2011 VA examination are adequate for the purposes of adjudication and reflect substantial compliance with the Board's November 2010 remand instructions. See Barr v. Nicholson, 21 Vet. App. 303 (2007); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Additionally, the January and October 2011 VA examination reports are adequate for the purposes of adjudication and reflect substantial compliance with the Board's November 2010 remand instructions. Id. There is no indication that the service-connected disabilities on appeal have worsened since the date of the most recent examination, and hence an additional examination is not required. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995); cf. Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The United States Court of Appeals for Veterans Claims has held that the provisions of 38 C.F.R. § 3.103(c)(2) (2013) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam). At the Board hearing the undersigned identified the issues, inquired as to how the disabilities were effecting his employment, and asked about his treatment providers in order to ascertain whether there was additional evidence he could submit. Hence, the Bryant duties were met. Additionally, based on the Veteran's testimony regarding treatment, the Board remand also requested a copy of the private medical report from Dr. "Piazz" described by the Veteran during his July 2010 hearing. In December 2010, the Veteran submitted a copy of the medical report from Dr. M.R. Piazza. The submission of this record reflects compliance with the Board's November 2010 remand instructions. See D'Aries, supra. The appeal is thus ready to be considered on the merits. II. Legal Criteria Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the disability. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. Post Traumatic Stress Disorder When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA will also consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The schedular criteria for rating psychiatric disabilities incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). See 38 C.F.R. §§ 4.125, 4.130. PTSD is rated under 38 C.F.R. § 4.130, DC 9411, according to the General Rating Formula for Mental Disorders. Under the General Rating Formula, a 50 percent disability rating is warranted when there is 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is warranted when there is 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); and inability to establish and maintain effective relationships. A 100 percent disability rating is warranted 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; and memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Id. at 443. The United States Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The Board has considered the GAF scores assigned during the appeal period. The GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). GAF 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). GAF scores ranging from 51-60 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). Id. Where an examiner is unable to distinguish the symptoms of a service connected disability from non-service connected manifestations, all the manifestations will be considered part of the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996)). For the appeal period from March 4, 2004, the Veteran has been diagnosed as having PTSD and alcohol dependence. On November 2005 VA examination report, the examiner indicated that the Veteran claimed that he used alcohol to self-medicate for his symptoms of nightmares and flashbacks from Vietnam. The examiner appeared to assign a GAF score of 45 for both disabilities. In light of this evidence and the fact that there is no evidence to clearly distinguish the symptoms of the Veteran's PTSD from his alcohol dependence, the Board will also attribute all of his psychiatric and alcohol related symptoms to PTSD for the purposes of assessing the severity of his PTSD. Id. A review of the evidence of record shows that the Veteran experienced symptoms of chronic sleep impairment, relationship difficulties, depressed mood, and alcohol dependence. See VA Outpatient treatment records dated from November 2000 to August 2012. On November 2005 VA PTSD examination, the Veteran reported that he has not worked since 1999, because "the stress became so great." On mental status examination, the Veteran's appearance was clean and he was casually dressed; he had the ability to maintain personal hygiene. There was psychomotor agitation; his speech was unremarkable and spontaneous. His attitude was guarded towards the examiner. His affect was very inappropriate in that he laughed and smiled constantly at times when he was discussing very difficult topics. He was oriented to person, time, and place. His mood was anxious. His thought process included rambling, but the content was unremarkable. He did not have delusions or hallucinations. His judgment was partially impaired. He had poor sleep. He did not exhibit inappropriate or obsessive/ritualistic behavior. He did not have panic attacks, episodes of violence, or suicidal/homicidal ideations. He had good impulse control and his memory was normal. The examiner reported that the Veteran basically stopped functioning outside of the house and that he stayed away form anything that reminded him of war. The examiner noted that the Veteran's wife was divorcing him and he had no friends. On January 2010 VA examination for a disability other than PTSD, the examiner reported that the Veteran stopped working related to a psychiatric problem and anxiety. On January 19, 2011 VA examination, the Veteran reported that his relationship with his two sons went downhill recently. He reported that he had no friends and spent the vast majority of his time at home either watching television or reading. He reported that he routinely had problems such as road rage and impatience in line at stores to the extent that he often opts to stay at home. The examiner summarized the Veteran's current psychological function status as a very isolative existence that was constant with both chronic PTSD and chronic alcoholism. On mental status examination, the Veteran appeared appropriately and casually dressed, but was disheveled in appearance. His psychomotor activity was restless and tense. His attitude was suspicious, irritable, and guarded. His affect was constricted and his mood was depressed and dysphoric. He did not understand the outcome of his behavior, but partially understood that he had a problem. He described a very restless sleep pattern that was routinely disrupted by combat-related nightmares. He was very isolative and drank to manage these symptoms. He had episodes of violence, but was aware of his low frustration tolerance such that he generally remained at home rather than going out into society. There was severe impairment in engaging in sports and exercise, traveling, shopping, and other recreational activities; a moderate impairment in diving; and a slight impairment in household chores. The examiner assigned a GAF sore of 60. The examiner specifically noted the Veteran's admission of having serious problems with homicidal ideations and plans towards his ex-boss in 1999 and his ex-wife as she was divorcing him in 2007. The examiner reported that the Veteran appeared to be a good historian, despite his excessive daily drinking. The examiner commended that since the Veteran's last VA PTSD examination, the Veteran continued to struggle with severe symptoms of PTD as well as chronic alcoholism that had negatively impacted his family relations (especially with his two sons). He had no friends or leisure pursuits (other than watching television or reading alone at home) and had a notably poor support system. He recently applied for several jobs, but did not get any feedback. The examiner stated that given the severity of the Veteran's PTSD and alcoholism, he was a very poor candidate for returning to the workforce and would have great trouble obtaining a job and maintaining any kind of employment. The examiner specifically reported that these problems became rather static since the Veteran last worked in 1999. The examiner added that the Veteran had total occupational and social impairment due to PTSD signs and symptoms. Additionally, a February 2011 psychodiagnostic interview from Dr.G.K. noted that the Veteran's PTSD and alcohol were the primary factors in the Veteran's two divorces and inability to work. Here, the evidence reflects that he was assigned a GAF score of 45 on the November 2005 VA examination, which was indicative of serious symptoms or serious impairment in social, occupational, or school functioning. The evidence reflects that the Veteran has been unemployed since 1999, which has been reported as due to stress, psychological problems, or anxiety. Additionally, the evidence reflects that he has essentially been unable to function socially. Although the January 2011 VA examination reported a GAF score of 60, which was indicative of only moderate impairment, the examiner found that there was total occupational and social impairment, and more significantly that the Veteran's PTSD related problems have been static since he last worked in 1999. Overall the evidence reflects that the Veteran's symptoms have remained consistent with those symptoms that were reported at the time of the January 19, 2011 VA examination and the combination of his occupational and social impairment most closely approximates the criteria for a 100 percent rating from the time he filed his increased rating claim on March 4, 2004. Resolving reasonable doubt in the Veteran's favor, a 100 percent rating is granted for the entire appeal period from March 4, 2004. Hence, the full benefit sought on appeal during this period is granted. 38 C.F.R. §§ 4.7, 4.21, 4.130, DC 9411. B. Total Disability Rating Based on Individual Unemployability Although the Veteran did not formally file a claim for TDIU until February 2009, the Court has held that a TDIU is an element of all claims for an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to a TDIU is raised where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); see Jackson v. Shinseki, 587 F.3d 1106, 1109-10 (2009) (holding that an inferred claim for a TDIU is raised as part of an increased rating claim only when the Roberson requirements are met). Therefore, the issue of unemployability was raised prior to his February 2009 formal claim for TDIU. A TDIU is granted where a veteran's service-connected disabilities are rated less than total, but they prevent him from securing or following all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16(a) (2013). VA will grant a TDIU when the evidence shows that a veteran is precluded, by reason of his service connected disabilities, from obtaining or maintaining "substantially gainful employment" consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). A TDIU is provided where the combined schedular evaluation for service-connected diseases and disabilities is less than total, or 100 percent. 38 C.F.R. § 4.16(a). By way of this decision, the Board granted a 100 percent schedular disability rating for the Veteran's service-connected PTSD and alcohol dependence. The grant of a 100 percent schedular disability rating was specifically based upon the evidence which showed that the Veteran's PTSD caused serious impairment in his occupational functioning and most closely approximated the criteria for a 100 percent disability evaluation, or total occupational impairment. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9413-9411. Accordingly, the Veteran's unemployability has already been considered in the 100 percent schedular disability rating assigned. As a TDIU is considered a lesser benefit than the 100 percent rating assigned for the Veteran's PTSD, and the grant of a 100 percent rating renders moot the issue of entitlement to a TDIU (based on PTSD and under Rice) for the period when the 100 percent rating is in effect. VAOPGCPREC 6-99; 64 Fed. Reg. 52,375 (1999). The issue regarding a separate TDIU rating based on the Veteran's service-connected disabilities other than PTSD for consideration of an award of special monthly compensation has been addressed in the remand below. C. Removal of Right Testicle Due to Atrophy The Veteran currently has a noncompensable disability rating for removal of the right testicle due to atrophy under 38 C.F.R. § 4.115b, Diagnostic Code 7524 (2013). Diagnostic Code 7524 provides a 0 percent evaluation when there is the removal of one testis and a 30 percent evaluation for removal of both testes. Diagnostic Code 7523 provides a 0 percent evaluation when there is complete atrophy of one testis. A 20 percent rating is for assignment when there is complete atrophy of both testes. 38 C.F.R. § 4.115b, Diagnostic Code 7523 (2013). A note to these diagnostic codes provides that, in cases of the removal of one testis as the result of a service-incurred injury or disease, other than an undescended or congenitally undeveloped testis, with the absence or nonfunctioning of the other testis unrelated to service, a rating of 30 percent will be assigned for the service-connected testicular loss. VA outpatient treatment records, dated November 2000 to August 2012 included an August 2004 treatment record that revealed an atrophic right testicle with discomfort. In February 2005, the Veteran had the atrophic right testicle removed. A February 2011 treatment record noted the Veteran's complaints of lack of libido. The Veteran was diagnosed with hypogonadism. The record reported that because the Veteran had elevated gonadotropins, it may appear that his remaining testicle was underfunctioning. The February 2011 lab results revealed that the Veteran had low free testosterone and elevated gonadotropin levels, which were indicative of primary hypogonadism. An August 2012 dental record noted a history of hypertrophy (benign) of the prostate without urinary obstruction. On January 2011 VA examination, the examiner noted that the physical examination was limited due to the Veteran being unable to step onto the examining table and was examined in the sitting position. The Veteran reported that he continued to have episodic discomfort in the scrotal area. There were no urinary symptoms, leakage, obstructed voiding, recurrent urinary tract infections or stones, renal dysfunction, acute nephritis, hydronephrosis, or cardiovascular symptoms. There was erectile dysfunction with an absence of ejaculation of unknown etiology. An examination of the penis was normal. On examination, the left testicle was of normal size and tender. There was a normal epididymitis/spermatic cord/scrotum examination. There were no significant effects on occupation or usual daily activities. The examiner noted that the Veteran had a normal serum testosterone level in August 2010. Consequently, he had a functioning left testicle. There was evidence of mild left testicular atrophy on physical examination. It was not secondary to the right orchiectomy. An ultrasound of the scrotum in May 2003 revealed an essentially normal left testicular size. The examiner found that the Veteran's erectile dysfunction was not secondary to the right orchiectomy. The Veteran did not have hypogonadism. A VA disability benefits questionnaire (DBQ), dated May 25, 2012, noted that the Veteran had BPH that was diagnosed in August 2009 and an atrophic testicle removed in 2005. The examiner reported that the Veteran had voiding dysfunction related to BPH; however, he did not require wearing absorbent material or the use of an appliance. His urinary frequency increased in that he had daytime voiding interval between 2 and 3 hours and night time awakening to void 2 times. The examiner noted that the voiding dysfunction caused signs or symptoms of obstructed voiding such as slow or weak stream (that was not markedly slow or weak) and decreased force of stream (that was no markedly decreased force of stream). The Veteran had erectile dysfunction that was related to vascular problems. The examiner indicated that it was not likely attributable to the Veteran's testis atrophy, BPH, or removal. A physical examination of the penis was normal, the right testis was removed, and the left testis was normal in size. The epididymis was normal, but his prostate was slightly enlarged. The examiner indicated that prior studies revealed increased luteinizing hormone (LH) and follicle-stimulating hormone (FSH) as well as decreased testosterone levels. The functional impact resulted in hypogonadism. His testicular problems did not impact his ability to work. As reflected above, the Veteran's left testicle is not nonfunctioning, but it is under-functioning, which is manifested by a low testosterone level. Additionally, there was no evidence of complete atrophy of the left testicle, but rather there was evidence of mild left testicular atrophy that was unrelated to the Veteran's right testicle removal on January 2011 VA examination. Additionally, on subsequent VA examination, the left testicle was reported as normal in size. Thus, the criteria for a 30 percent rating under Diagnostic Code 7524 or a 20 percent rating under Diagnostic Code 7523 are not satisfied. In short, a compensable rating for the Veteran's removal of right testicle due to atrophy is not warranted. The Board notes, however, that the Veteran is not uncompensated for removal of the right testicle. Rather, the Veteran is already in receipt of special monthly compensation for loss of use with subsequent anatomical loss of a creative organ. 38 U.S.C.A. § 1114(k) (West 2002); 38 C.F.R. § 3.350 (2013). The Board has considered whether a compensable schedular evaluation is warranted for the Veteran's erectile dysfunction. However, the January 2011 and May 2012 VA examination reports revealed that the Veteran's erectile dysfunction was unrelated to the removal of his right testicle, but rather was related to a vascular problem. Regardless, the Board notes that there is no specific disability rating for erectile dysfunction. The closest analogous code appears to be 38 C.F.R. § 4.115b, Diagnostic Code 7522 (2013), which rates deformity of the penis with loss of erectile power. The Board can find no other diagnostic code provision that would be more appropriate in rating the Veteran's disability. There is no evidence that he has had removal of half or more of his penis, or that glans have been removed, such that would warrant consideration under Diagnostic Codes 7520 or 7521, respectively. Therefore, Diagnostic Code 7522 would be the most appropriate to rate this disability. Pursuant to Diagnostic Code 7522, two distinct elements are required for a compensable, 20 percent, disability rating: penile deformity and loss of erectile power. Dorland's Medical Dictionary defines deformity as 'distortion of any part or general disfigurement of the body; malformation.' Dorland's Illustrated Medical Dictionary 481 (30th ed. 2003). As noted above, the Veteran's penis was found to be normal on physical examinations in January 2011 and May 2012. Thus, as the Veteran is not shown to have penile deformity, the Board finds that a separate compensable evaluation for erectile dysfunction is not warranted. Consequently, while the condition meets the requirements for special monthly compensation for loss of use of a creative organ under 38 U.S.C. § 1114, subsection (k), 38 C.F.R. § 3.350(a), for which the Veteran is already being compensated for, it does not approximate the applicable criteria for a compensable evaluation under the rating schedule. Therefore, a separate compensable evaluation for erectile dysfunction with deformity of the penis is not warranted. Finally, the Board will address whether the Veteran's BPH warrants a compensable disability rating. The Board will evaluate this disability as prostate gland injuries, infections, hypertrophy, postoperative residuals 38 C.F.R. § 4.115b, Diagnostic Code 7527 (2013). This diagnostic code directs that the disability be rated as voiding dysfunction or urinary tract infection, whichever is predominant. Here, the evidence shows that the Veteran does not have a history of urinary tract infections; however, as voiding dysfunction has been identified on the May 2012 DBQ, the Board will consider the voiding dysfunction as the predominant disability for rating purposes. Voiding dysfunction is rated under the three subcategories of urine leakage or incontinence, urinary frequency, and obstructed voiding, and only the predominant area of dysfunction is to be considered for rating purposes. 38 C.F.R. § 4.115a. Continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence requiring the wearing of absorbent materials that must be changed less than twice a day warrants a 20 percent rating. Required wearing of absorbent materials, which must be changed 2 to 4 times daily, warrants a 40 percent evaluation. A 60 percent rating is contemplated in cases requiring use of an appliance or wearing of absorbent materials that must be changed more than 4 times a day. Id. Urinary frequency producing daytime voiding interval between two and three hours, or; awakening to void two times per night is rated 10 percent disabling. Daytime voiding interval between one and two hours, or; awakening to void three to four times per night is rated 20 percent disabling. Daytime voiding interval of less than one hour, or awakening to void five or more times per night, is rated 40 percent disabling. Id. Finally, obstructed voiding entails ratings ranging from noncompensable to 30 percent. A noncompensable evaluation is warranted for obstructive symptomatology with or without stricture disease requiring dilatation 1 to 2 times per year. A 10 percent rating is warranted for marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or a combination of the following: (1) post-void residuals greater than 150 cubic centimeters (cc's); (2) uroflowmetry; markedly diminished peak flow rate (less than 10 cc's per second); (3) recurrent urinary tract infections secondary to obstruction; (4) stricture disease requiring periodic dilatation every 2 to 3 months. A 30 percent rating contemplates urinary retention requiring intermittent or continuous catheterization. Id. The Board finds that the Veteran's BPH warrants a 10 percent rating based on urinary incontinence. Specifically, the Board notes that the May 2012 DBQ specifically reported daytime voiding interval between two and three hours, or; awakening to void two times per night. Based upon this information, the Board finds that the competent evidence of record reflects that a 10 percent disability rating for urinary frequency is warranted. The Board finds that the preponderance of the competent evidence does not establish entitlement in excess of 20 percent as daytime voiding between 1 and 2 hours or less or night time awakening to void 3 to 4 times or more has not been alleged or shown. The Board finds that a rating in excess of 20 percent is not warranted based on voiding dysfunction requiring the use of absorbent materials or an appliance; or obstructed voiding with urinary retention requiring intermittent or continuous catheterization or marked obstructive symptomatology, as these conditions have neither been alleged by the Veteran nor shown by the evidence of record. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his residuals of the right testicle removal. Lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. In summary, the Board finds that a disability rating of 10 percent is warranted under Diagnostic Code 7527 for BPH as residual to the Veteran's right testicle removal. To this extent, the Veteran's claim is granted. A rating in excess of 10 percent is not warranted at any point since the effective date of the grant of service connection, so the Board cannot "stage" this rating under Fenderson. The Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against assigning a rating in excess of 10 percent for these disabilities, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To this extent, the claim must be denied. D. Residuals of Right Ankle Chipped Fracture The Veteran's service-connected right ankle disability has been rated as 10 percent disabling by the RO under the provisions of Diagnostic Code 5271, which applies to limitation of motion of the ankle. A 10 percent rating is warranted when the ankle has moderate limitation of motion and a 20 percent rating is warranted when the ankle has marked limitation of motion. Full range of motion of the ankle is from zero to 20 degrees dorsiflexion and from zero to 40 degrees plantar flexion. 38 C.F.R. § 4.71a , Plate II. In the present case, it should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet.App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. VA outpatient treatment records, dated November 2000 to August 2012, noted persistent right ankle pain. On November 2005 VA examination of the joints, the Veteran reported that his right ankle hurt 4 or 10 times a month. He did not use a brace and did not have a history of having surgery on his ankle. He reported that it effected his daily activities and that he had problems with standing for long periods of time. The inspection of the right ankle showed no instability, tenderness or swelling. Plantar flexion was from zero to 20 degrees and dorsiflexion was from zero to 5 degrees. There was no pain. There was no additional range of motion loss due to pain, fatigue, weakness, lack of endurance following repetitive use in the ankle. He was diagnosed with right ankle chip fracture. X-rays revealed no acute findings, and remote avulsion injury of the lateral malleolus as well as possibly the posterior tibial plafond. A February 2006 treatment record from Dr. M.R. Piazza of Orthopeadic Specialists reported a normal range of motion in the lower extremities. Deep tendon reflexes in the patella and Achilles were 0, bilaterally. Pathologic reflexes were normal, bilaterally. On January 2010 VA examination of the spine, sensory, reflex, and motor examinations of the lower extremities, including the ankle, were normal. During the July 2010 video conference hearing, the Veteran contended that his ankle was stiff and hurt from time to time, however, the pain was not constant. He had limited motion in his ankle. He reported that he could only walk a limited distance then would have to stop due to increased pain. He had difficulty with walking up the stairs. He reported that he used a cane for both his ankle and his back. On January 2011 VA examination, the Veteran reported that right ankle pain has become constant over the last 10 years. There were reports of pain, stiffness, and decreased speed of joint motion. There was no evidence of right ankle deformity, giving way, instability, weakness, incoordination, episodes of dislocation or subluxation, locking episodes, effusion, or other symptoms. The Veteran reported that he had severe flare ups every two months for a duration of one to two weeks. He could stand for 5 minutes and walk 150 yards. He did not use assistive devices or aids. On physical examination, his gait was antalgic; there was no evidence of abnormal weight bearing. There was right ankle tenderness with no evidence of instability, or tendon abnormality. There was no objective evidence of pain with motion. Dorsiflexion was from 0 to 10 degrees and plantar flexion was 0 to 15 degrees. There was no objective evidence of pain following repetitive motion and no additional limitations after three repetitions. The examiner noted, however, that the Veteran reported that he had pain at the upper limits of range of motion testing. The examiner indicated that the Veteran's right ankle disability would impact occupational activities in that it caused decreased mobility and pain. The disability severely effected the Veteran's chores, shopping, exercise, sports, and recreation activities; moderately effected traveling dressing, and driving; and had a mild effect on bathing, toileting, and grooming. On October 2011 VA examination, the Veteran reported increasing pain, stiffness, and swelling in the right ankle. He walked with a cane and took Tramadol for pain. He did not wear a brace. He did not report flare-ups that impacted the function of the ankle. Range of motion attesting revealed 45 degrees of plantar flexion with pain at 0 degrees and 20 degrees dorsiflexion with pain at 0 degrees. Repetitive motion testing revealed plantar flexion to 45 degrees and dorsiflexion to 20 degrees. Repetitive testing did not result in additional limitation in range of motion. There was functional loss and/or impairment of the ankle manifested by pain on movement. There was localized tenderness or pain on palpation of joints/soft tissue. Muscle strength testing was normal. Anterior drawer and talar tilt testing revealed that there was no laxity. The examiner responded know when asked if the Veteran had ankylosis. The Veteran did not have :shin splints', stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneous (os calcis), or talus (astragalus), or talectomy (astragalectomy). He did not have a total ankle joint replacement or other ankle surgery. The examiner reported that the Veteran's ankle disability did not impact his ability to work. The examiner noted that the only abnormality present was the Veteran's subjective report of pain. A February 2012 VA podiatry consult revealed that the Veteran had complaints of right ankle pain and was seeking treatment options. He reported that his ankle bothered him with walking and exercise. Physical examination revealed normal muscle strength and sensation. The anterior drawer sign was not present, bilaterally. There was pain on palpation on the lateral gutter, and ATF and CF ankle ligaments, as well as on the medial malleolus. There was pain ion dorsiflexion, plantar flexion, and rearfoot eversion. The podiatrist included the findings of a November 2011 MRI report, which revealed a likely remote tear. The report also noted that the calcaneofibular ligament may be torn. The podiatrist included an assessment of right traumatic ankle arthropathy with lateral gutter osteophytes and right lateral ankle instability. The Veteran was prescribed an ASO ankle Brace. After reviewing the overall evidence of record, the Board finds that a rating 20 percent rating for the Veteran's service-connected right ankle disability is warranted. At its worst, dorsiflexion was limited from 0 to 5 degrees and plantar flexion was limited to 20 degrees on November 2005 VA examination. Comparing these ranges of motion to the normal ranges of motion, it appears that at its most restrictive, the Veteran's dorsiflexion is limited to a quarter of what is considered normal range of motion and plantar flexion is limited to half of what is considered normal range of motion. The Board views this as falling within the realm of overall marked limitation of motion. The Board also finds that a disability rating in excess of 20 percent is not warranted based on functional loss due to pain, weakness, fatigability, or incoordination of the right ankle. See 38 C.F.R. §§ 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 204 -08 (1995). Although the Veteran complained of ankle pain during all examinations, he is already in receipt of the maximum schedular rating based on limitation of motion, so he cannot receive a higher rating based on the DeLuca factors. See Johnston v. Brown, 10 Vet. App. 80 (1997). The only other Diagnostic Code allowing for a higher evaluation for an ankle disability is Diagnostic Code 5270. This regulatory provision requires ankylosis of the ankle. A 30 percent rating is warranted with ankylosis between 30 degrees and 40 degrees in plantar flexion or between 0 degrees to 10 degrees in dorsiflexion. A 40 percent rating is warranted with ankylosis more than 40 degrees plantar flexion, more than 10 degrees dorsiflexion, or with abduction, adduction, inversion or eversion deformity. Ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Shipwash v. Brown, 8 Vet.App. 218, 221 (1995) (citing DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (27th ed. 1988) at 91). A higher rating is not warranted under Diagnostic Code 5270 as there is no clinical evidence demonstrating the presence of any ankylosis of the ankle. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his right ankle. Lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau, supra; see Buchanan, supra. (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. Resolving all doubt in the Veteran's favor a 20 percent disability rating is warranted for the right ankle disability. However, the preponderance of the evidence is against a rating in excess of 20 percent for the Veteran's service-connected residuals of a right ankle chipped fracture at any point since the effective date of the grant of service connection, so "staged" ratings are not warranted. See Fenderson, supra. As the preponderance of the evidence weighs against a rating in excess of 20 percent, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b). E. Left Shoulder Strain with Arthritis In this case, the Veteran's left shoulder disability has been evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5024. Pursuant to 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; unlisted disabilities requiring rating by analogy will be coded first with the numbers of the most closely related body part and "99." Hence, the Veteran's left shoulder disability is rated by analogy, using the criteria for tenosynovitis under Diagnostic Code 5024. Tenosynovitis, in turn, is rated based on limitation of motion of the affected part, as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5024. Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. In the absence of limitation of motion, a 10 percent rating is assigned when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is assigned when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Arthritis due to trauma under Diagnostic Code 5010 substantiated by x-ray findings is rated as degenerative arthritis under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2013). Normal shoulder motion is defined as 0 to 180 degrees of forward elevation (flexion), 0 to 180 degrees of abduction, and 0 to 90 degrees of internal and external rotation. See 38 C.F.R. § 4.71, Plate I. Disabilities of the shoulder and arm are rated under 38 C.F.R. § 4.71a (2013), Diagnostic Codes 5200 through 5203. A distinction is made between major (dominant) and minor musculoskeletal groups for rating purposes. In the instant case, as the Veteran is right-handed, his left shoulder is considered the minor upper extremity. Under Diagnostic Code 5201, a higher rating of 20 percent is assigned for limitation of motion at shoulder level for the minor upper extremity. Limitation of shoulder motion to midway between the Veteran's side and shoulder level warrants a 20 percent rating for the minor upper extremity. When there is limitation of motion to 25 degrees from the Veteran's side, a maximum 30 percent rating is warranted for the minor upper extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5201. A 20 percent rating also may be assigned under Diagnostic Code 5203 for dislocation of the clavicle or scapula of the major or minor extremity. A 20 percent rating may be assigned as well for nonunion of the clavicle or scapula with loose movement. Without loose movement, a 10 percent rating is assignable. A 10 percent rating additionally may be assigned for malunion of the clavicle or scapula. 38 C.F.R. § 4.71a, Diagnostic Code 5203. VA outpatient treatment records, dated November 2000 to August 2012, noted left shoulder pain. An October 2011 VA x-ray reported revealed mild degenerative arthritis of the shoulder joint. On November 2005 VA examination of the joints, the examiner reported that the Veteran initially reported that he did not have major complaint from the left shoulder, but then later said that he had pain in the left shoulder 10 times a month. He also has a complaint of numbness in both arms and this appeared to be related to his neck. In terms of effect on occupation, there was no effect on occupation. In terms of daily activity he said that it bothered him when he reached out with his left arm above his head. He did not use any devices. The inspection of the left shoulder showed no tenderness or instability. The range of movement of the left shoulder was from zero to 170 degrees on abduction and from zero to 160 degrees on flexion. He complained of pain at 170 on abduction and 160 on flexion. There was no additional range of motion loss due to pain, fatigue, weakness, lack or endurance following repetitive use. He was diagnosed with a left shoulder strain. X-rays were unremarkable. VA treatment records included a December 2005 treatment record that noted the Veteran's history of a left shoulder injury in Vietnam with continued left thumb numbness. Active range of motion on the left side revealed that flexion was to 115 degrees, abduction was to 110 degrees, and extension was to 30 degrees. A January 2006 MRI report that was unremarkable. Upper extremity reflexes were unresponsive in the biceps and brachioradialis, but were 1+ in the triceps. A February 2006 treatment record from Dr. M.R. Piazza of Orthopaedic Specialists reported a normal range of motion in the upper extremities. Deep tendon reflexes in the biceps, brachioradialis, and triceps were 1, bilaterally. Pathologic reflexes were normal, bilaterally. On January 2010 VA spine examination, sensory, reflex, and motor examinations of the upper extremities were normal. During his July 2010 video conference hearing, the Veteran contended that he had trouble with movement in his shoulder and always had left thumb numbness. He indicated that there was nerve involvement with his left shoulder. At the time of the hearing, the Veteran demonstrated that he was not able to lift over his head and was only able to move to approximately the shoulder level. He reported pain with movement. On January 2011 VA examination, the Veteran reported that left shoulder pain had become constant over the last 10 years. There were reports of pain and stiffness. There was no evidence of left shoulder deformity, giving way, instability, weakness, incoordination, episodes of dislocation or subluxation, locking episodes, effusion, or other symptoms. The Veteran indicated that he had severe flare ups three to four times per year for a duration of 10-14 days. There was no objective evidence of pain with motion. Flexion was from 0 to 30 degrees, abduction was from 0 to 20 degrees, internal rotation was from 0 to 5 degrees, and external rotation was from 0 to 10 degrees. There was no objective evidence of pain following repetitive motion and no additional limitations after three repetitions. The examiner noted, however, that the Veteran reported that he had pain at the upper limits of range of motion testing. The examiner indicated that the Veteran's left shoulder disability would impact occupational activities as a result of pain. The disability severely effected the Veteran's chores, shopping, exercise, sports, and recreation activities; moderately effected bathing, and mildly effected grooming and driving. On October 2011 VA examination, the examiner diagnosed the Veteran with left shoulder strain. The Veteran reported increasing pain and stiffness in the left shoulder. He reported numbness in the left thumb since his left shoulder injury. He took Tramadol for pain. The Veteran was right hand dominant. The Veteran indicated that he did not have flare-ups that impacted the function of the shoulder. Left shoulder flexion was to 180 degrees with pain at 0 degrees, and left shoulder abduction was to 180 degrees with pain at 0 degrees. After repetition, left shoulder flexion and abduction was to 180 degrees. The examiner indicated that the Veteran did not have additional limitation in the range of motion of the shoulder and arm following repetitive testing. The Veteran had functional loss/functional impairment of the shoulder after repetitive motion due to pain on movement. There was localized tenderness or pain on palpation. The Veteran guarded the left shoulder. Muscle strength testing was normal. There was no ankylosis. Hawkins' impingement test, empty-can test, an external rotation/infraspinatus strength test, lift-off subscapularis test, cross-body abduction test, and crank apprehension and relocation test were each negative. There was no history of mechanical symptoms (clicking, catching, etc.) There was no history of recurrent dislocation (subluxation, of the glenohumeral (scapulohumeral) joint. The Veteran did not have an AC joint condition or any other impairment of the clavicle or scapula. There was no tenderness no palpation of the AC joint. He did not have a total shoulder replacement or any other surgery. The examiner reported that imaging studies were available and degenerative or traumatic arthritis was not documented. The examiner determined that the left shoulder disability did not impact the Veteran's ability to work. The examiner noted that the examination results were grossly inconsistent. The Veteran initially was unable to provide more than 10 degrees of flexion or abduction; however, when the examiner asked the Veteran to take off his shirt, he demonstrated 180 degrees of such motion without discomfort. The examiner noted that the only abnormality found were subjective reports of pain. After reviewing the overall evidence of record, the Board finds that a rating 20 percent rating for the Veteran's service-connected left shoulder disability is warranted. At its worst, flexion was from 0 to 30 degrees, abduction was from 0 to 20 degrees, internal rotation was from 0 to 5 degrees, and external rotation was from 0 to 10 degrees on January 2011 VA examination. Comparing these ranges of motion to the normal ranges of motion, it appears that at its most restrictive, the Veteran's forward flexion and abduction were limited midway between the side and the shoulder level. The Board views these findings as falling within the realm of overall limitation of motion midway between the side and the shoulder level of the minor arm warranting a 20 percent disability. At no point throughout the appeal period was the arm limited to motion of 25 degrees from the side. A higher initial rating is not warranted on the basis of functional loss due to pain or alternatively due to weakness, premature or excess fatigability, incoordination, or pain on movement of the left shoulder. See 38 C.F.R. §§ 4.40, 4.45, 4.59. As observed, his pain and these other considerations have not had any consequent effect on his range of motion in terms of causing any further restriction, including over and above that shown. This includes no suggestions of additional limitation of motion on repetitive-use testing. The Board notes that the Veteran did have functional loss/functional impairment of the shoulder after repetitive motion due to pain on movement on October 2011 VA examination. However, the medical evidence of record did not show functional limitation of the severity needed to show entitlement to a rating higher than 20 percent at any point since the effective date of the grant of service connection, so the Board cannot "stage" this rating under Fenderson, either. The only other Diagnostic Codes allowing for a higher evaluation for a left (minor) shoulder disability are Diagnostic Codes 5200 (ankylosis of the scapulohumeral articulation) and 5202 (impairment of the humerus). The Veteran, however, does not have ankylosis or other impairment of the humerus. Therefore, a rating in excess of 20 percent is not available under these Codes, either. In addition to the medical evidence, the Board has considered the Veteran's testimony and his lay statements. He has reported left shoulder pain with movement as well as interference with activities of daily living. The Veteran is certainly competent to describe the symptoms that he observes pertaining to his left shoulder. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. Resolving all doubt in the Veteran's favor a 20 percent disability rating is warranted for the left shoulder disability. However, the preponderance of the evidence is against a rating in excess of 20 percent for the Veteran's service-connected left shoulder strain. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b). F. Other Considerations Consideration has also been given by the Board as to whether the schedular evaluations are inadequate, requiring that the RO refer the claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extra-schedular evaluation. Such a referral is warranted where a service-connected disability presents an exceptional or unusual disability picture that renders impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a claimant's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this regard, the analysis must include a discussion of whether the rating criteria adequately address all of the claimant's symptomatology. Also, extra-schedular ratings under 38 C.F.R. § 3.321 are awarded on a disability-by-disability basis for each individual disability being considered and not on the combined effect of all of a claimant's service-connected disabilities. See Johnson v. Shinseki, No. 10-1785 (Vet. App. Mar. 27, 2013). Here, during the course of the appeal period the Veteran's residuals of right testicle removal have been manifested by BPH and urinary frequency requiring daytime voiding between two and three hours, or awakening to void two times per night have been shown. Otherwise, the Veteran has not reported or describe symptomatology not contemplated by the rating schedule under 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Codes 7524, 7527. Thus, the Board finds Diagnostic Codes 7524 and 7527 adequately addresses the Veteran's symptoms. Additionally, residuals of a right ankle chip fracture is productive of marked limitation of motion and his left shoulder strain with arthritis reflects limitation of motion midway between the side and the shoulder level. The Veteran has not described or reported symptomatology not contemplated by the rating schedule under 38 C.F.R. §§ 4.71a, Diagnostic Codes 5271 (for his right ankle) as well as 5024 and 5201 (for his left shoulder). Thus, the Board finds Diagnostic Codes 5271, 5024 and 5201 adequately addresses the Veteran's symptoms. Thus, the first step of the Thun analysis for left shoulder and ankle disabilities, and residuals of the removal of the right testis, whether the rating criteria adequately address all of the claimant's symptomatology, have been met. As such, the Board's extra-schedular analysis for each disability ends, and consideration of the second step-whether the claimant's exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization-is not warranted. Therefore, without sufficient evidence reflecting that the Veteran's disability picture for PTSD, left shoulder and ankle disabilities, and residuals of the removal of the right testis is not contemplated by the rating schedule, referral for a determination of whether the Veteran's disability picture related to left shoulder and ankle disabilities, and residuals of the removal of the right testis requires the assignment of an extra-schedular rating is not warranted. 38 C.F.R. § 3.321(b)(1); Thun, supra. ORDER From March 4, 2004, entitlement to an initial rating of 100 percent for PTSD, is granted subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an initial rating of 10 percent, but no more, for BPH and removal of the right testicle due to atrophy, is granted subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an initial rating of 20 percent, but no more, for residuals of right ankle chipped fracture, is granted subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an initial rating of 20 percent, but no more, for left shoulder strain with arthritis, is granted subject to the laws and regulations governing the payment of monetary benefits REMAND A review of the record discloses further development is necessary prior to the adjudication of the Veteran's formal claim of entitlement to a TDIU due to service-connected disability. It is acknowledged that the Court has held that the receipt of a 100 percent schedular rating for a service-connected disability does not necessarily render moot any pending claim for a TDIU. Bradley v. Peake, 22 Vet. App. 280 (2008). Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, the Court's decision in Bradley recognizes that a separate award of a TDIU predicated on a single disability may form the basis for an award of special monthly compensation. In Bradley, the Court found that TDIU was warranted in addition to a schedular 100 percent evaluation where the TDIU had been granted for a disability other than the disability for which a 100 percent rating was in effect. Under those circumstances, there was no "duplicate counting of disabilities." Bradley, 22 Vet. App. at 293. Here, the Veteran's service-connected PTSD is rated at a 100 percent schedular disability rating. However, on his February 2009 application for increased compensation based on unemployability, the Veteran reported that in addition to his PTSD, the pain in his back, shoulder and ankle prevented him from securing or following any substantially gainful occupation. In a February 2010 rating decision, the RO denied entitlement to a TDIU. In July 2010, the Veteran indicated that he disagreed with the denial of a TDIU. However, a statement of the case has not been issued in regards to whether the Veteran is entitled to a separate TDIU rating based on his service-connected disabilities other than PTSD. See Manlicon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: Issue a statement of the case regarding entitlement to a separated TDIU rating based on the Veteran's service connected disabilities other than PTSD. Only if the Veteran perfects an appeal should the claims be certified to the Board and after any necessary development has been completed. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ J.A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs