Citation Nr: 1333387 Decision Date: 10/23/13 Archive Date: 10/24/13 DOCKET NO. 05-31 602 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Honolulu, Hawaii THE ISSUES 1. Entitlement to service connection for diabetes mellitus, type II. 2. Entitlement to a rating in excess of 10 percent for left shoulder bursitis. 3. Entitlement to service connection for white matter in the brain. 4. Entitlement to service connection for mini-strokes. 5. Entitlement to service connection for a heart condition, to include left ventricular hypertrophy, to include as secondary to diabetes mellitus, type II. ATTORNEY FOR THE BOARD Arif Syed, Associate Counsel INTRODUCTION The Veteran had active service in the United States Navy from February 1975 to February 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2003 rating decision on behalf of the Honolulu, Hawaii, Regional Office (RO) of the Department of Veterans Affairs (VA). The case has been before the Board on prior occasions, and was remanded in July 2010, September 2012, and May 2013 for procedural and evidentiary development. It is additionally noted that the Veteran has submitted multiple recent statements indicating that he intended to pursue a claim of entitlement to service connection for high blood pressure which he believed to be included in his heart condition claim. See, e.g., a statement from the Veteran dated August 2012. However, it does not appear that his blood pressure has been considered in the adjudication of his heart condition claim. Indeed, in a November 2007 rating decision, the RO declined to reopen a previously denied claim of entitlement to service connection for high blood pressure. The Veteran did not file a timely notice of disagreement as to this rating decision. However, as the Veteran has raised a claim of entitlement to service connection for high blood pressure, the Board will refer the issue of whether new and material evidence has been received sufficient to reopen a previously denied claim of entitlement to service connection for high blood pressure to the agency of original jurisdiction (AOJ) for appropriate action. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of the Veteran's case should take into consideration the existence of this electronic record. The Board has reviewed the Veteran's claims folder and the record maintained in the Virtual VA paperless claims processing system. The issues of entitlement to service connection for white matter in the brain, mini-strokes, and a heart condition are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. The competent and probative evidence of record serves to link the Veteran's currently diagnosed diabetes mellitus to his military service. 2. The evidence of record shows that the Veteran's service-connected left shoulder disability is manifested by symptoms consistent with pain and limitation of motion; neither limitation of motion at the shoulder level or below nor ankylosis is shown. 3. The evidence of record does not show that the Veteran's service-connected left shoulder disability is so exceptional or unusual that referral for extraschedular consideration by a designated authority is required. CONCLUSIONS OF LAW 1. The Veteran's currently diagnosed diabetes mellitus was incurred in military service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 2. The criteria for a disability rating in excess of 10 percent for the service-connected left shoulder bursitis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5019, 5201 (2013). 3. Application of the extraschedular rating provisions is not warranted for the Veteran's service-connected left shoulder bursitis. 38 C.F.R. § 3.321(b) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks entitlement to service connection for diabetes mellitus, type II, as well as entitlement to an increased disability rating for his service-connected left shoulder bursitis. In the interest of clarity, the Board will discuss certain preliminary matters. The issues on appeal will then be analyzed and a decision rendered. Stegall concerns As alluded to above, in July 2010, September 2012, and May 2013, the Board remanded these claims and ordered either the AOJ or Appeals Management Center (AMC) to obtain outstanding VA and private treatment records as well as afford the Veteran VA examinations for his diabetes and left shoulder bursitis. The Veteran's claims were then to be readjudicated. Pursuant to the Board's remand instructions, the AOJ obtained outstanding VA and private treatment records and associated these records with the Veteran's claims folder. Moreover, the Veteran was afforded a VA examination for his diabetes in May 2012 as well as a VA examination for his left shoulder bursitis in October 2012. The Veteran's diabetes and left shoulder claims were readjudicated via an August 2013 supplemental statement of the case (SSOC). Accordingly, the Board's remand instructions have been complied with regarding the Veteran's diabetes and left shoulder claims. See Stegall v. West, 11 Vet. App. 268, 271 (1998) [where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance]. The Veterans Claims Assistance Act of 2000 The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA). The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also defines the obligations of VA with respect to its statutory duty to assist a claimant in the development of his claim. See 38 U.S.C.A. §§ 5103, 5103A (West 2002). Notice The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2013), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). In the case at hand, the record reflects that the originating agency provided the Veteran with the required notice by a letter mailed in October 2002, and notice with respect to the disability rating and effective-date elements of the claim, by a letter mailed in March 2006. Although the March 2006 letter pertaining to the disability rating and effective-date elements of the claim was provided after the initial adjudication of the claims, the Board finds that the Veteran has not been prejudiced by the timing of this letter. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the AMC readjudicated the Veteran's claims in the August 2013 SSOC. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). There is no indication or reason to believe that the ultimate decision of the originating agency on the merits of the claim would have been different had complete VCAA notice been provided at an earlier time. Duty to assist In general, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim for VA benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. The law affords that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). In the instant case, the Board finds reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claims. There is no reasonable possibility that further assistance would aid in substantiating the claims. The pertinent evidence of record includes the Veteran's statements, service treatment records, as well as VA and private treatment records. The Veteran was afforded VA examinations for his left shoulder bursitis in June 2003, August 2006, and October 2012. The examination reports reflect that the examiners interviewed and examined the Veteran, reviewed his past medical history, documented his current medical conditions, and rendered appropriate diagnoses consistent with the remainder of the evidence of record. Furthermore, these examination reports contain sufficient information to rate the Veteran's left shoulder bursitis under the appropriate diagnostic criteria. The Board therefore concludes that the VA examination reports are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2013); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) [holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate]. The Board notes that although the Veteran's claims folder was available during the August 2006 and October 2012 VA examinations, it is unclear as to whether it was available during the June 2003 VA examinations. However, even if the claims folder was not available during the June 2003 VA examination, such did not have an adverse effect on the adequacy of the examination. Notably, as previously indicated, the examiners fully considered the Veteran's complaints, to include his complaints of functional impairment and pain with respect to his left shoulder bursitis. A physical examination was then performed that addressed all the relevant rating criteria. The Board finds that under the circumstances of this case, VA has satisfied the notification and duty to assist provisions of the law and that no further action pursuant to the VCAA need be undertaken on the Veteran's behalf. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2013). The Veteran has been accorded the opportunity to present evidence and argument in support of his claims. In his September 2005 substantive appeal [VA Form 9], he declined the option of testifying at a personal hearing. Accordingly, the Board will proceed to a decision as to the issues of entitlement to service connection for diabetes mellitus and entitlement to an increased disability rating for left shoulder bursitis. Service connection for diabetes mellitus Generally, service connection may be granted for disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2013). Service connection may also be granted on a presumptive basis for certain chronic disabilities, including diabetes mellitus, when such are manifested to a compensable degree within the initial post-service year. See 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2013). In order to establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact or chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2013). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2013). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Veteran is claiming entitlement to service connection for diabetes, which he contends is due to his military service. See, e.g., the Veteran's notice of disagreement dated August 2004. As noted above, in order for service connection to be granted, three elements must be present: (1) a current disability; (2) in-service incurrence of disease or injury; and (3) nexus. See Hickson, supra. It is undisputed that the Veteran currently suffers from diabetes. See, e.g., a private treatment record from C.T., M.D. dated September 2013. Hickson element (1) is, therefore, satisfied. Turning to Hickson element (2), in-service incurrence of an injury or disease, the Veteran's service treatment records document several instances of elevated blood glucose levels. Notably, treatment records dated October 1987, November 1987, and June 1990 indicate a blood glucose level of 117. Based on the documentation of elevated glucose levels, the Board finds that Hickson element (2) is arguably satisfied. Turning to Hickson element (3), nexus, the competent and probative evidence demonstrates that the Veteran's currently diagnosed diabetes is related to his military service. Specifically, Dr. C.T. noted in a letters dated June and September 2013 that the Veteran is currently diagnosed with diabetes. She further noted the Veteran's elevated blood glucose levels during service in 1987. Although she only discussed a blood glucose level reading in March 1987 which does not appear to be of record, the Veteran's service treatment records discussed above document blood glucose levels of 117 on multiple occasions. Dr. C.T. thereafter reported that the elevated blood glucose level of 117 documented in service indicated a diagnosis of pre-diabetes. She therefore concluded that the diagnosis of pre-diabetes in service progressed to the diagnosis of diabetes mellitus, type II, for which the Veteran is currently being treated. Dr. C.T.'s rationale for her conclusion was based on her treatment of the Veteran as well as her review of his medical history and medical reports documenting elevated blood glucose levels. The report of Dr. C.T. is based upon thorough examination of the Veteran and thoughtful analysis of the Veteran's entire history and current medical condition. See Bloom v. West, 12 Vet. App. 185, 187 (1999) [the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"]. While a VA examination conducted in May 2012 contains a negative nexus opinion, the Board observes that in finding that the Veteran's diabetes was not related to his military service, the VA examiner did not discuss in his rationale any of the elevated blood glucose levels noted in the Veteran's service treatment records. Indeed, although the VA examiner indicated a review of the Veteran's service treatment records, it is unclear as to whether he reviewed the Veteran's service treatment records documenting elevated blood glucose levels. On the contrary, Dr. C.T. specifically addressed the Veteran's elevated blood glucose level noted in service and concluded that this was the onset of the Veteran's diabetes mellitus, type II. As such, the Board finds that the May 2012 VA examination report is of no probative value in evaluating the Veteran's claim. In short, based on the total record, the Board finds that there is sufficient competent medical evidence to indicate a positive nexus between the Veteran's current disability and his military service. Hickson element (3), and therefore all elements, is satisfied. In summary, the Veteran has met all requirements needed to establish service connection for diabetes mellitus, type II. The benefit sought on appeal is therefore granted. Higher evaluation for left shoulder bursitis Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2013). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4 (2013). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2013). A request for an increased rating must be viewed in light of the entire relevant medical history. See 38 C.F.R. § 4.1 (2013); see also Peyton v. Derwinski, 1 Vet. App. 282, 287 (1991). However, where entitlement to compensation has already been established and increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court held that "staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." The evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. See 38 C.F.R. § 4.10 (2013). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. See 38 C.F.R. § 4.40 (2013). Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. See 38 C.F.R. § 4.45 (2013). The Veteran is currently assigned a 10 percent disability rating for left shoulder bursitis, under Diagnostic Code 5019 [bursitis]. Diagnostic Code 5019 provides that bursitis will be rated based on limitation of motion of the affected part, as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5019 (2013). Diagnostic Code 5201, for limitation of the arm, provides for a 20 percent rating when limitation of the minor arm is at shoulder level or midway between the side and shoulder level and a maximum 30 percent evaluation when limitation of motion of the minor arm is to 25 degrees from the side. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 degrees to 180 degrees, abduction from 0 degrees to 180 degrees, external rotation from 0 degrees to 90 degrees, and internal rotation from 0 degrees to 90 degrees. 38 C.F.R. § 4.71, Plate I. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The evidence of record does not show tenosynovitis or ankylosis of the left shoulder. Accordingly, Diagnostic Codes 5024 and 5200 are not applicable. Additionally, the evidence does not show impairment of the humerous such as recurrent dislocation at the scapulohumeral joint or malunion, fibrous union, or nonunion of the humerous; nor does the evidence show impairment of the clavicle or scapula such as malunion, nonunion, or dislocation. Accordingly, Diagnostic Codes 5202 and 5203 are not applicable. In short, the Board finds that the Veteran's left shoulder disability is appropriately rated under Diagnostic Code 5019 with further consideration of Diagnostic Code 5201. An initial matter, the Board observes that the Veteran is right handed. See, e.g., the October 2012 VA examination report. Thus, his right shoulder is his major (or dominant) shoulder, and his left shoulder is his minor (non-dominant) shoulder. As indicated above, the Veteran is currently rated as 10 percent disabling under Diagnostic Code 5019 with consideration of Diagnostic Code 5201. In order to warrant a 20 percent rating under Diagnostic Code 5201, the evidence must demonstrate limitation of motion at the shoulder level or midway between the side and shoulder level. See 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2013). The Veteran was afforded a VA examination in June 2003. He reported pain in his left shoulder when working in the yard or doing heavy lifting, especially above shoulder level. There were no flare-ups, and no episodes of dislocation or recurrent subluxation, and no effect on his job because he was engaged in office work. He did not use assistive devices. Upon physical examination, the examiner noted the absence of tenderness or crepitus in the left shoulder. Range of motion testing showed forward flexion to 102 degrees, abduction to 100 degrees, external rotation to 77 degrees, and internal rotation to 90 degrees. The examiner diagnosed the Veteran with bursitis of the left shoulder. The Board notes that a VA treatment record dated July 2005 documents the Veteran's report that his left shoulder was "pain free" and that he had full range of motion. The Veteran was provided a subsequent VA examination in August 2006. He reported left shoulder bursitis since 1980, for which he used analgesic balm. He did not experience constant pain, or any effect on his work, but did have flare-ups of pain when reaching overhead, and he was not able to engage in daily activities such as chores requiring a sustained overhead reach. Upon physical examination, the Veteran's range of motion findings were normal; repetition of motion did not result in reduced range of motion or joint function. There was no tenderness to palpation and shoulder X-rays showed no significant bony abnormalities. In August 2006, shortly after the VA examination, the Veteran was seen for increased left shoulder pain over the past two days. There was no pain without movement, but pain made him unable to raise his arm above his shoulder. On physical examination, there was no point tenderness, and he had normal range of motion. A subsequent VA treatment record dated September 2006 documented active range of motion to be within normal limits, although the Veteran had difficulty in accomplishing activities of daily living independently. He thereafter received physical therapy, including hot packs and ultrasound treatments, and regained full function of his shoulder and experienced a significant decrease in his pain. See VA treatment records dated September and October 2006. The Board further notes that a VA treatment record dated June 2010 documents minimal tenderness over the left shoulder with deltoid range of motion and strength intact. An August 2010 VA treatment record notes the Veteran's complaints of left shoulder pain. The Veteran was provided a VA examination in October 2012. He reported flare-ups when reaching over his head and that the left shoulder disability affected his ability to do chores. He also reported that the left shoulder disability did not affect his work. Upon examination, the VA examiner recorded normal range of motion testing with no objective evidence of painful motion. The Veteran did not have additional loss of range of motion of the shoulder following repetitive-motion testing. The examiner further noted the absence of functional loss or functional impairment of the arm. Furthermore, the Veteran did not have localized tenderness or pain or palpation of the joints, soft tissue, biceps, or tendon of the left shoulder, nor did he have guarding of the left shoulder. Muscle strength testing was 5/5 for shoulder flexion and abduction. The examiner also reported that ankylosis of the left shoulder joint was not identified. Specific tests for rotator cuff conditions, including Hawkins' Impingement Test, empty-can test, external rotation/infraspinatus strength test, and lift-off subscalpularis test were negative. The examiner noted an absence of a history of mechanical symptoms and recurrent dislocation of the glenohumeral (scapulohumeral) joint as well as a negative crank apprehension and relocation test. The examiner reported no acromioclavicular joint condition or other impairment of the clavicle or scapula or tenderness on palpation of the acromioclavicular joint. Cross-body adduction test was negative. The examiner further noted that the Veteran did not have any other physical pertinent physical findings, complications, condition, signs and/or symptoms related to the diagnosis of bursitis. After review of the record, because the competent and probative evidence of record demonstrates left arm motion to a level which is above the shoulder level (90 degrees), the Board finds that the Veteran is not entitled to a higher 20 percent disability rating under Diagnostic Code 5201. The examination reports documenting range of motion testing indicate that both flexion and abduction of the left shoulder exceed 90 degrees even when considering the impact of pain on motion. Indeed, the range of motion testing documented during the period under consideration, to include the June 2003, August 2006, and October 2012 VA examinations as well as the July 2005 and June 2010 VA treatment records indicate full range of motion. The Board concludes that the evidence of limited to normal range of motion of the left shoulder is more appropriately assigned a 10 percent disability rating under Diagnostic Code 5201. Therefore, the Veteran's service-connected left shoulder bursitis does not warrant an increased disability rating under Diagnostic Code 5201 at any time during the period under consideration. The Board has also considered the provisions of 38 C.F.R. § 4.40 and 4.45 (2013). See DeLuca, supra. In this regard, the Board notes the Veteran's report that he experiences pain in his shoulder as well as flare-ups. However, functional loss due to pain or weakness must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. As noted above, the October 2012 VA examiner recorded normal range of motion testing with no objective evidence of painful motion. The Veteran did not have additional loss of range of motion of the shoulder following repetitive-motion testing. The examiner further noted the absence of functional loss or functional impairment of the arm. Any loss of function due to pain for this Veteran has predominantly occurred at a level well above 90 degrees, which is congruent with the assigned 10 percent rating. Accordingly, the Board is unable to identify any clinical findings that would warrant an increased evaluation under 38 C.F.R. § 4.40 and 4.45 at any time during the period under consideration. The current 10 percent rating adequately compensates the Veteran for any functional impairment attributable to his left shoulder disability. See 38 C.F.R. §§ 4.41, 4.10 (2013). In evaluating the severity of his service-connected disability, the Board also has considered whether the Veteran is entitled to a greater level of compensation for the disability at issue on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2013). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disability, with the established criteria shows that the rating criteria reasonably describe the level and symptomatology thereof. The criteria specifically provide for evaluation of the disability based upon impairment of the shoulder and associated symptomatology, and they practicably represent the average impairment in earning capacity resulting from the Veteran's service-connected disability. See 38 C.F.R. § 4.1. In denying the Veteran's claim for an increased rating, the Board observes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims (Court) held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the evidence of record does not show, and the Veteran has not asserted, that his left shoulder bursitis prevents him from securing and following substantially gainful employment. On the contrary, the Veteran has stated that the left shoulder disability does not affect his work. See, e.g., the October 2012 VA examination report. There is no competent and probative evidence to the contrary. Accordingly, the Board concludes that the issue of TDIU has not been raised in this case. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for diabetes mellitus, type II is granted. Entitlement to a rating in excess of 10 percent for left shoulder bursitis is denied. REMAND Service connection for white matter of the brain and mini-strokes The Veteran contends that he has disabilities manifested by white matter in the brain and mini-strokes that are related to headaches he experienced during military service. See the Veteran's claim for VA benefits dated December 2002. The Veteran's service treatment records show that he was seen in November 1975, April 1977, and October 1988 for complaints of headaches in conjunction with other symptoms, including nasal congestion and cough. On each occasion, he was treated for an upper respiratory infection or virus and the condition apparently resolved. On the medical history questionnaire completed for the periodic examinations in November 1988 and July 1993, he reported a history of severe headache, but all periodic physical examinations and the November 1994 retirement physical examination were reported as normal. Following the Veteran's discharge from service, he underwent an MRI in August 2002 at the Tripler Army Medical Center which revealed an impression of "multiple T2 signal abnormalities diffusely throughout the subcortical white matter and also involving the left thalamus and posterior mid brain ... These findings likely represent chronic ischemic white matter disease given age of the patient, however, demyelinating process cannot be excluded with signal abnormalities in these locations." A subsequent private MRI in November 2002 from Dr. J.P. revealed an impression of anosmia, subjective with intact sense of taste. Although Dr. J.P. reported that the Veteran did not have clinical symptoms of a stroke, he advised the Veteran to get an echocardiogram and quad duplex scan to look for risk factors of a stroke. The Veteran was afforded a VA examination for his claimed disabilities manifested by white matter of the brain and mini-strokes in May 2012. The VA examiner noted the findings of the August and November 2002 MRI reports. After examination of the Veteran and consideration of his medical history, the VA examiner declined to diagnose the Veteran with a disability manifested by white matter of the brain or mini-strokes. Specifically, the examiner reported that numerous neurology examinations subsequent to the 2002 MRI reports were absent any diagnosis of white matter disease or stroke. He thereafter reported that the nature and etiology of the Veteran's white matter changes seen on the 2002 MRI are unknown and no diagnosis of stroke or disease has been documented by any Neurology consult. Typically, in the absence of proof of present disability there can be no valid claim. To be present as a current disability, there must be evidence of the condition at some time during the appeals period. However, the Board recognizes the Court's decision in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), which held that a claimant satisfies the current disability threshold when a disability exists at the time his or her claim was filed, even if the disability resolves prior to VA's adjudication of the claim. In this case, although a disability manifested by white matter of the brain was not rendered during the May 2012 VA examination, the Board reiterates that the August 2002 MRI from Tripler Army Medical Center indicated an impression of white matter disease. Although the November 2002 MRI from Dr. J.P. did not reveal an impression of white matter disease, the evidence of record is unclear as to whether the Veteran's white matter of the brain disease existed at the time he filed service connection for this claim in December 2002. In light of the Court's decision in Romanowsky, the Board is of the opinion that a clarifying medical opinion would be probative in ascertaining whether the Veteran's previously diagnosed white matter of the brain disease resolved prior to the filing of his claim in December 2002, and if not, whether such disability is related to his military service, to include treatment for headaches. See Charles v. Principi, 16 Vet. App. 370 (2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 C.F.R. § 3.159(c)(4) (2013) (holding a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient medical evidence to decide the claim). The Board further notes that the Veteran has indicated that his mini-strokes are related to his white matter of the brain disease. See the Veteran's claim for VA benefits dated December 2002. As such, his mini-strokes claim is inextricably intertwined with his white matter of the brain disease claim. In other words, development of the Veteran's claim for entitlement to service connection for white matter of the brain may impact his claim for entitlement to service connection for mini-strokes. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) [two or more issues are inextricably intertwined if one claim could have significant impact on the other]. Service connection for a heart condition In a statement dated August 2013, the Veteran indicated that his heart condition, in addition to being related to his military service, is alternatively secondary to his service-connected diabetes mellitus. Although he was afforded a VA examination in May 2012 in order to determine whether his heart condition is related to his military service, there is no probative medical opinion of record which discusses a possible relationship between his heart condition and his service-connected diabetes mellitus. In light of the foregoing, the Board is of the opinion that a clarifying medical opinion would be probative in ascertaining whether the Veteran's heart condition is related to his service-connected diabetes mellitus. See Charles and McLendon, both supra; see also 38 C.F.R. § 3.159(c)(4), supra. Accordingly, the case is REMANDED for the following action: 1. Provide appropriate VCAA notice to the Veteran with respect to filing a secondary service connection claim. 2. Return the claims folder to the VA examiner who examined the Veteran in May 2012 for his claimed white matter of the brain disease as well as his heart condition. The VBMS claims folder must be reviewed by the examiner. The examiner is requested to address the following: a) Identify any current disability manifested by white matter of the brain. b) If a disability manifested by white matter of the brain is not identified, provide an opinion as to when the white matter of the brain disease identified on the August 2002 MRI from the Tripler Army Medical Center resolved, in particular if it resolved prior to December 2002 when the Veteran filed his claim for VA benefits. c) If a disability manifested by white matter of the brain is identified at any time during the course of the appeal period (from December 2002), provide an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that the disability is related to the Veteran's period of military service, to include treatment for headaches in November 1975, April 1977, October 1988, November 1988, and July 1993. d) whether it is at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran's current heart condition is either (1) caused or (2) aggravated (i.e. permanently worsened beyond the normal progression of the disability) by his service-connected diabetes mellitus, type II. If the examiner finds that the heart condition is aggravated by the service-connected diabetes mellitus, then he should quantify the degree of aggravation, if possible. The examiner must provide a thorough, detailed, and non-conclusory clinical rational for all opinions expressed. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. In the extraordinary situation that the examiner is of the opinion that an opinion cannot be provided without resorting to speculation, then he must provide a detailed medical explanation as to why this is so. If the examiner indicates that he cannot respond to the Board's questions without examination of the Veteran, such should be afforded to the Veteran. 3. After completing the above action, the claims should be readjudicated. If the claims remain denied, a supplemental statement of the case should be provided to the Veteran. After the Veteran has had an adequate opportunity to respond, the appeal should be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ Bethany L. Buck Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs