Citation Nr: 1333713 Decision Date: 10/25/13 Archive Date: 11/06/13 DOCKET NO. 09-25 209 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for a right knee disability. 3. Entitlement to service connection for bilateral hand arthritis. 4. Entitlement to service connection for bilateral foot arthritis. 5. Entitlement to service connection for a disability manifested by loss of hair. 6. Entitlement to service connection for a gynecological disability. 7. Entitlement to service connection for neurological gravis of the chest. 8. Entitlement to service connection for residuals of Gulf War Syndrome. 9. Entitlement to an initial disability rating in excess of 30 percent for ocular myasthenia gravis. 10. Entitlement to a higher initial disability rating for major depression, currently evaluated as 50 percent disabling. 11. Entitlement to an initial disability rating in excess of 10 percent for degenerative joint disease of the neck. 12. Entitlement to an initial disability rating in excess of 10 percent for degenerative joint disease of the left shoulder. 13. Entitlement to an initial disability rating in excess of 10 percent for residual scar, status-post repair of left rotator cuff. 14. Entitlement to an initial disability rating in excess of 10 percent for carpal tunnel syndrome of the right hand. 15. Entitlement to an initial disability rating in excess of 10 percent for strain of the lumbar spine. 16. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESSES AT HEARING ON APPEAL The Veteran and her daughter ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The Veteran served on active duty from October 1980 to October 1983, July 1991 to January 1992, and January 2003 to July 2006. These matters come to the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating decision that, in pertinent part, denied service connection for bilateral hearing loss, for a right knee disability, for bilateral hand arthritis, for bilateral foot arthritis, for a disability manifested by loss of hair, for a gynecological disability, for neurological gravis of the chest, and for residuals of Gulf War Syndrome; and that granted service connection for ocular myasthenia gravis evaluated as 30 percent disabling, for major depression evaluated as 30 percent disabling, for degenerative joint disease of the neck evaluated as 10 percent disabling in January 2007, for degenerative joint disease of the left shoulder evaluated as 10 percent disabling, for scar residual of status-post repair of left rotator cuff evaluated as 10 percent disabling, for carpal tunnel syndrome of the right hand evaluated as 10 percent disabling, and for strain of the lumbar spine evaluated as 10 percent disabling-each effective on July 22, 2006, unless otherwise stated. The Veteran timely appealed the denials of service connection, and appealed for higher initial ratings. In May 2012, the RO increased the disability evaluation to 50 percent for major depression, effective on July 22, 2006, the effective date of the grant of service connection. Because higher evaluations are available for major depression, and the Veteran is presumed to seek the maximum available benefit for a disability, the claim remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In June 2013, the Veteran and her daughter testified during a hearing before the undersigned at the RO. Following the hearing, the Veteran submitted additional evidence and waived initial consideration of the evidence by the RO. In the case of Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans' Claims (Court) held, in substance, that every claim for a higher evaluation includes a claim for TDIU where the Veteran claims that her service-connected disabilities prevent her from working. In this case, the Board notes that the Veteran has put forth statements indicating that she believes her service-connected disabilities render her unemployable. Accordingly, in light of the holding in Rice, the Board has characterized the issues on appeal so as to include a claim for entitlement to TDIU. Lastly, in addition to reviewing the Veteran's paper claims file, the Board has surveyed the contents of her Virtual VA file. The issues of higher initial ratings for ocular myasthenia gravis, major depression, degenerative joint disease of the neck, and strain of the lumbar spine are addressed in the REMAND portion of the decision below; and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. Prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran in June 2013, that a withdrawal of the appeals for service connection for bilateral hearing loss; a right knee disability; bilateral hand arthritis; bilateral foot arthritis; a disability manifested by loss of hair; a gynecological disability; neurological gravis of the chest; and residuals of Gulf War Syndrome, is requested. 2. For the period prior to August 18, 2009, the Veteran's left shoulder disability has been manifested by X-ray evidence of degenerative changes, and functional impairment due to painful motion; neither flexion nor abduction limited to shoulder level, nor functional impairment with overhead activities are demonstrated. 3. For the period from August 18, 2009, the Veteran's left shoulder disability has been manifested by constant pain and functional loss of the left (minor) arm which more nearly approximates limited arm motion to shoulder level; arm motion limited to midway between side and shoulder level and ankylosis have not been demonstrated. 4. Throughout the rating period, the Veteran's residual scar, status-post repair of left rotator cuff, has been tender and painful; three or more scars that are unstable or painful, or loss of function of the body part affected have not been demonstrated. 5. Throughout the rating period, the Veteran's carpal tunnel syndrome of the right hand has been manifested by night pain, numbness, tingling of the fingers, and swelling-productive of no more than mild incomplete paralysis of the median nerve. 6. The Veteran has not worked full-time since September 2008, and has not worked at all since July 2009; she reportedly has completed four years of high school, and has no additional training; she last worked in food service. 7. Service connection is in effect for a depressive disorder, rated as 50 percent disabling; for ocular myasthenia gravis, rated as 30 percent disabling; for degenerative joint disease of the neck, rated as 10 percent disabling; for strain of the lumbar spine, rated as 10 percent disabling; for a left shoulder disability with degenerative joint disease, now rated as 20 percent disabling; for residual scar, status-post repair of left rotator cuff, rated as 10 percent disabling; and for carpal tunnel syndrome of the right hand, rated as 10 percent disabling. The combined disability rating is 80 percent. 8. The Veteran's service-connected disabilities are shown to be of such a nature or severity to prevent her from obtaining or retaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeals for service connection for bilateral hearing loss; a right knee disability; bilateral hand arthritis; bilateral foot arthritis; a disability manifested by loss of hair; a gynecological disability; neurological gravis of the chest; and residuals of Gulf War Syndrome, have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2013). 2. For the period prior to August 18, 2009, the criteria for an initial disability rating in excess of 10 percent for a left shoulder disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5201 (2013). 3. For the period from August 18, 2009, the criteria for a 20 percent disability rating for a left shoulder disability have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (2013). 4. The criteria for an initial disability evaluation in excess of 10 percent for residual scar, status-post repair of left rotator cuff, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.20, 4.118, Diagnostic Code 7804 (2007). 5. The criteria for an initial disability evaluation in excess of 10 percent for carpal tunnel syndrome of the right hand have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.124, 4.124a, Diagnostic Codes 8515, 8615, 8715 (2013). 6. The criteria for a TDIU have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.15, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The Veteran's claims, decided below, arise from her disagreement with the initial evaluations assigned following the grants of service connection. Courts have held that once service connection is granted, the claim is substantiated; additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Board concludes that VA's duty to assist has been satisfied. All available records identified by the Veteran as relating to the claims decided for higher initial disability ratings have been obtained, to the extent possible. The RO provided the Veteran with appropriate VA (contract) examinations; and there is no evidence indicating that there has been a material change in the severity of the Veteran's left shoulder disability with degenerative joint disease, scar residual of status-post repair of left rotator cuff, or carpal tunnel syndrome of the right hand since she was last examined. The Board finds the examination reports to be thorough and adequate upon which to base a decision with regard to these claims. In Bryant v. Shinseki, 23 Vet App 488 (2010), the United States Court of Appeals for Veterans Claims (Court) recently held that the Veterans Law Judge who chairs a Board hearing fulfill two duties to comply with 38 C.F.R. § 3.103(c)(2). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. Here, during the hearing, the undersigned Veterans Law Judge sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked, or was outstanding that might substantiate the claims. Neither the Veteran nor her representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2); and no prejudice has been identified in the conduct of the Board hearing. Given these facts, it appears that all available records have been obtained. There is no further assistance that would be reasonably likely to assist the Veteran in substantiating the claims. 38 U.S.C.A. § 5103A(a)(2). II. Service Connection Claims Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2012). Withdrawal may be made by the Veteran or by her authorized representative. 38 C.F.R. § 20.204. In the present case, the Veteran withdrew the appeals for service connection for bilateral hearing loss; a right knee disability; bilateral hand arthritis; bilateral foot arthritis; a disability manifested by loss of hair; a gynecological disability; neurological gravis of the chest; and residuals of Gulf War Syndrome in writing-during her hearing before the undersigned and via correspondence submitted in June 2013. There remain no allegations of errors of fact or law for appellate consideration as to those issues. Accordingly, the Board does not have jurisdiction to review each of the appeals for service connection, and the claims are dismissed. III. Higher Initial Disability Ratings Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. If feasible, these determinations are to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a 10 percent evaluation is assignable each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. 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. Here, the Veteran is competent to testify on factual matters of which she has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). She is also competent to report symptoms of pain, numbness, and tingling. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe her symptoms and their effects on employment or daily activities. A. Degenerative Joint Disease of the Left Shoulder Service connection has been established for degenerative joint disease of the left shoulder. The RO evaluated the Veteran's disability as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5099-5010, based on painful motion of the left shoulder and degenerative changes, following rotator cuff surgery. A hyphenated diagnostic code generally reflects a rating by analogy (see 38 C.F.R. §§ 4.20 and 4.27). For rating purposes, a distinction is made between major (dominant) and minor musculoskeletal groups. In the instant case, the Veteran is right-handed; hence, her left shoulder is considered her minor upper extremity. Traumatic arthritis will be rated as degenerative arthritis, as shown above. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Under Diagnostic Code 5201, a 20 percent evaluation is warranted for motion of the minor arm limited to shoulder level, or limited to midway between the side and shoulder level. A maximum 30 percent rating is assignable for the minor upper extremity, when motion is limited to within 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The standard ranges of motion for shoulder abduction and forward elevation (flexion) are 180 degrees. 38 C.F.R. § 4.71, Plate I. Shoulder level is 90 degrees. Historically, the Veteran had fallen in February 2004 and injured her left shoulder. At that time there was severe pain with range of motion, a positive Hawkins' impingement sign, and weakness of the rotator cuff. Records show that the Veteran tried physical therapy, anti-inflammatories, and injections without getting better; and that she elected to undergo left shoulder arthroscopy with a subacromial decompression in February 2005. Following surgery, the Veteran underwent physical therapy. Records dated in June 2005 show that she had full range of motion and much less pain, and some weakness of the rotator cuff. In January 2006, the Veteran had full range of motion and fairly good strength; she reported a little bit of weakness, but was doing well. She reported occasional pains. X-rays taken of the left shoulder in January 2007 revealed mild degenerative joint disease with evidence of a prior surgery; no fracture or other significant abnormality was evident. The report of a January 2007 VA (contract) examination shows complaints of pain located at left arm and shoulder, occurring four times per week and lasting for one hour. The pain came by itself, and was relieved by itself or with medication. At the time of pain the Veteran reportedly can function with medication. She described the pain level as a 7 on a 10-point scale. She reported no incapacitation, and was not receiving any treatment for her disability; and had no prosthetic implants of the joint. Her functional impairment was not being able to lift during exacerbation. Examination of the left shoulder in January 2007 showed signs of tenderness. Range of motion was normal, with limitation to 180 degrees on flexion; to 180 degrees on abduction; to 90 degrees on external rotation; and to 60 degrees on internal rotation. Pain was noted at the extremes of motion on external rotation and internal rotation. The examiner also noted that left joint function was additionally limited by pain after repetitive use; the additional limitation was estimated at 0 degrees. The diagnosis was degenerative joint disease of the left shoulder; subjective factors included residual pain, and X-rays showed degenerative changes. The examiner noted decreased internal rotation with pain limitation. Examination of the left shoulder on August 18, 2009, revealed instability, weakness, tenderness, and guarding of movement. There were no signs of edema, abnormal movement, effusion, redness, heat, deformity, malalignment, and drainage. There was no subluxation. Range of motion of the left shoulder was to 120 degrees on flexion, with pain from 100 degrees; to 120 degrees on abduction, with pain from 100 degrees; to 60 degrees on external rotation; and to 60 degrees on internal rotation. Pain was also noted at the extremes of motion on external rotation and internal rotation. There was no additional limitation of motion after repetitive use. The examiner noted that the left joint function was additionally limited by pain, fatigue, weakness, and lack of endurance after repetitive use; and that pain had the major functional impact. In June 2013, the Veteran testified that she had pain in the left shoulder, and had swelling on top of the shoulder; and that she sometimes had a hard time lifting her arm over her head. She testified that it would be "very stiff." The Veteran testified that she had let her doctors know when she started having problems with her shoulder; and was told that she would have problems off and on, and to be careful. In this case, prior to the August 18, 2009 examination, the evidence shows that the Veteran's motion of the left arm was nearly full; and that she could function at the time of pain with medication. The evidence does not reflect that limited motion of the Veteran's left shoulder met the criteria for a compensable disability rating under Diagnostic Code 5201. The currently assigned 10 percent disability rating already compensates the Veteran for significant functional impairment due to degenerative joint disease of the left shoulder, based on painful motion. Given the findings of the January 2007 examiner, the Board finds that the overall evidence warrants no more than the currently assigned 10 percent disability rating for service-connected degenerative joint disease of the left shoulder prior to August 18, 2009. 38 C.F.R. §§ 4.71a, Diagnostic Codes 5010, 5201. A clear preponderance of the evidence is against a higher initial disability rating based on functional loss due to pain on use or due to flare-ups, as the Veteran's complaints of pain and dysfunction are not supported by adequate pathology prior to August 18, 2009. Specifically, the examiner noted that there was no actual additional loss on repetition (noting zero degrees of difference). As of the August 18, 2009 examination, the evidence shows that the Veteran's motion of the left arm has been limited by pain and weakness, resulting in some functional impairment with overhead activities. The Veteran also has reported that the left arm was stiff, and that pain limited her movement. Taking into account her lay assertions, particularly with respect to functional loss resulting from pain and other symptoms as contemplated by Deluca, the Board concludes that these symptoms approximate the criteria for a 20 percent disability rating under 38 C.F.R. § 4.71a, Diagnostic Code 5201. The disability has been symptomatic and results in some dysfunction at shoulder level. Accordingly, staged ratings, pursuant to Fenderson, supra, are indicated. The evidence has not shown at any time that the Veteran's motion of the left arm is limited to 25 degrees from her side during any examination. 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2012). Nor is there evidence of ankylosis of the left shoulder or arm. The Veteran can still move her left shoulder and arm, although limited by pain. Even with consideration of functional factors, the Board finds that the Veteran's left shoulder disability with degenerative joint disease has not met or approximated the criteria for a disability evaluation in excess of 20 percent under Diagnostic Code 5201 at any time. For the foregoing reasons, a 20 percent disability evaluation for the Veteran's left shoulder disability with degenerative joint disease is warranted for the period from August 18, 2009 forward. B. Residual Scar, Status-Post Repair of Left Rotator Cuff Service connection has been established for residual scar, status-post repair of left rotator cuff, based on evidence showing a superficial scar that is painful on examination. The RO has evaluated the Veteran's residual scar, status-post repair of left rotator cuff, as 10 percent disabling under Diagnostic Code 7804, pertaining to scars. A deep scar is one that is associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (2). A scar at a location other than the head, face, or neck that is deep or that causes limitation of motion would have to have an area exceeding 6 square inches (39 square centimeters) to warrant a 10 percent rating, 12 square inches (77 square centimeters) to warrant a 20 percent rating, 72 square inches (465 square centimeters) to warrant a 30 percent rating, or 144 square inches (929 square centimeters) to warrant a 40 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7801. A superficial scar is one that is not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802, Note (2). A scar at a location other than the head, face, or neck that is superficial and that does not cause limitation of motion would have to have an area exceeding 144 square inches (929 square centimeters) to warrant a 10 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7802. A 10 percent evaluation is provided for superficial scars that are poorly nourished with repeated ulcerations under 38 C.F.R. § 4.118, Diagnostic Code 7803; or for superficial scars that are tender or painful on objective demonstration under 38 C.F.R. § 4.118, Diagnostic Code 7804 (2007). Disabling effects are to be rated either as scars or as impairment of function, whichever results in the higher rating. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2007). Although, no more than one of these ratings may be assigned without violating the rule against the pyramiding of disabilities. 38 C.F.R. § 4.14. During the course of this appeal, VA revised the criteria for evaluation of scars, effective on October 23, 2008. 73 Fed. Reg. 54708 (September 23, 2008) (codified at 38 C.F.R. § 4.118 (2009)). Initially, the revised criteria were applicable only to claims received by VA on or after October 23, 2008; and, hence, were inapplicable in this case. Since then, VA published a correcting amendment to allow Veterans whose scars were rated by VA under the former criteria (versions in effect prior to October 23, 2008) to request evaluation review under the revised criteria. See 77 Fed. Reg. 2909 (January 20, 2012). The correction amendment specifically encompasses claims that have received an initial rating, and are still pending in the appeals process. Id. The correction is effective January 20, 2012. The revised criteria for Diagnostic Code 7804 provide that one or two scars that are unstable or painful warrant a 10 percent rating; three or four scars that are unstable or painful warrant a 20 percent rating; and five or more scars that are unstable or painful warrant a 30 percent rating. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. See 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (1) (October 23, 2008). Alternatively, the revised criteria provide that disabling effects not considered in a rating provided under Diagnostic Codes 7801, 7802, and 7804 are to be rated as impairment of function. 38 C.F.R. § 4.118, Diagnostic Code 7805 (October 23, 2008). Historically, as noted above, the Veteran underwent left shoulder surgery in February 2005. Records show that she still had some pain over the scar in June 2005; and at follow-up treatment in January 2006, the examiner noted that most of the Veteran's pain was about the scar. During the January 2007 VA (contract) examination, the Veteran reported pain located at her left arm and shoulder for two years. Examination revealed an elevated scar present at the left shoulder, measuring about 3.7 centimeters by 1.2 centimeters, with tenderness and hyperpigmentation of less than six square inches. There was no disfigurement, ulceration, adherence, instability, tissue loss, inflammation, edema, keloid formation, hypopigmentation, or abnormal texture. The examiner noted a tender scar. Examination of the Veteran's residual scar, status-post repair of left rotator cuff, in August 2009 revealed no changes. In June 2013, the Veteran testified that she had soreness on her shoulder. In this case, the objective evidence supports the currently assigned 10 percent disability rating on the basis of scars under the former criteria. Ten percent is the maximum rating for any superficial scar. The evidence does not reflect a deep scar or one that causes limitation of motion and exceeds 12 square inches to warrant a higher initial rating. Nor does the evidence reflect any functional impairment from the residual scar, status-post repair of left rotator cuff. The Board notes that the Veteran's service-connected left shoulder disability with degenerative joint disease has been evaluated separately, and is not for consideration in evaluating the Veteran's residual scar, status-post repair of left rotator cuff. 38 C.F.R. § 4.14. There is no evidence of three or more scars that are unstable or painful to warrant a higher rating under the revised criteria. Solely on the basis of tenderness and pain on objective examination, the evidence does not meet either the former or revised criteria for a disability rating in excess of 10 percent under any diagnostic code. 38 C.F.R. § 4.7. The objective clinical findings outweigh the Veteran's lay assertions regarding severity. Thus, the weight of the evidence is against the grant of an initial disability rating in excess of 10 percent for residual scar, status-post repair of left rotator cuff. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. C. Carpal Tunnel Syndrome of the Right Hand Service connection has been established for carpal tunnel syndrome of the right hand, based on evidence showing recurrent numbness and pain following surgical intervention. The RO has evaluated the Veteran's carpal tunnel syndrome of the right hand as 10 percent disabling under Diagnostic Code 8515, pertaining to incomplete paralysis of the median nerve. The Veteran is right-hand dominant. A 10 percent evaluation is warranted for mild incomplete paralysis of the median nerve of the major upper extremity. A 30 percent evaluation is warranted for moderate incomplete paralysis of the median nerve of the major upper extremity. A 50 percent evaluation is warranted for severe incomplete paralysis of the median nerve of the major upper extremity. 38 C.F.R. § 4.124a, Diagnostic Codes 8515, 8615, 8715. The term "incomplete paralysis" indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Complete paralysis of the median nerve is indicated by the following: hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances. 38 C.F.R. § 4.124a, Diagnostic Codes 8515, 8615, 8715. During a January 2007 VA (contract) examination, the Veteran reported having numbness to fingers while sleeping; and that the symptoms awaken her. She described the symptoms as occurring constantly, and not causing any pain. The Veteran reportedly did not receive any treatment for her symptoms, and reported no functional impairment. Examination in January 2007 revealed that the right hand was dominant; the Veteran used it to write, eat, and comb her hair. Range of motion of the right wrist was normal, with 70 degrees on dorsiflexion; 80 degrees on palmar flexion; 20 degrees on radial deviation; and 45 degrees on ulnar deviation. The joint function of the right wrist was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The examiner noted a positive right Tinel's sign, and a history of intermittent numbness of right fingers. During an August 2009 VA (contract) examination, the Veteran reported tingling and numbness of her fingers; and weakness of the last two fingers of the right hand. The symptoms still occurred while sleeping; and sometimes the Veteran was unable to place lids on containers or turn the tops of jars, due to swelling or pain in the hand. The Veteran reportedly took over-the-counter medications, and reported occasional swelling of the right hand while sleeping. Examination in August 2009 revealed that the range of motion of the right wrist was to 60 degrees on dorsiflexion, with pain at 40 degrees; to 60 degrees on palmar flexion, with pain at 60 degrees; to 20 degrees on radial deviation, with pain at 15 degrees; and to 40 degrees on ulnar deviation, with pain at 30 degrees. The joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The examiner noted decreased range of motion, tenderness with movement, and abnormal sensation. In June 2013, the Veteran testified that she sort of felt pins and needles in her hands while sleeping; and that her hands swell while sleeping. She did not recall having problems grasping things, or picking up things. Here, throughout the rating period, the evidence reflects no more than mild incomplete paralysis of the median nerve of the right wrist. There have been no reports of loss of reflexes, muscle atrophy, or constant pain at any time. 38 C.F.R. §§ 4.123, 4.124. While the August 2009 examiner had noted decreased range of motion and tenderness with movement, significant functional loss due to pain or weakness has not been demonstrated to warrant an initial disability rating in excess of 10 percent at any time. Though she has minimal limitation of motion, her primary symptom remains sensory in nature. In light of all evidence of record, the Board finds that the Veteran's present level of disability and functional loss due to pain results in no more than mild incomplete paralysis of the median nerve under Diagnostic Code 8515. The evidence does not show atrophy of the muscles, or neurological deficits producing more than mild incomplete paralysis. Hence, an initial disability rating in excess of 10 percent for carpal tunnel syndrome of the right hand is not warranted. D. Extraschedular Consideration Finally, an extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that the schedular evaluations assigned for the Veteran's service-connected degenerative joint disease of the left shoulder, scar residual of status-post repair of left rotator cuff, and carpal tunnel syndrome of the right hand are adequate in this case. Specifically, the diagnostic criteria adequately describe the severity and symptomatology, as well as functional impairment, of the Veteran's service-connected disabilities. She is not experiencing symptoms that are not contemplated by the applicable rating criteria. Therefore, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). IV. TDIU Total disability ratings for compensation based upon individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. For the purpose of one 60 percent disability, or one 40 percent disability in combination, disabilities resulting from a common etiology or a single accident will be considered as one disability; and disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, will be considered as one disability. 38 C.F.R. §§ 3.340, 3.34l, 4.16(a). In determining whether the Veteran is entitled to TDIU, neither his non-service-connected disabilities nor his age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993); 38 C.F.R. § 3.341(a). In this case, the Veteran has completed four years of high school education, and has had no additional education and training. She reportedly last worked full time in food services in September 2008. Service connection is currently in effect for a depressive disorder, rated as 50 percent disabling; for ocular myasthenia gravis, rated as 30 percent disabling; for degenerative joint disease of the neck, rated as 10 percent disabling; for strain of the lumbar spine, rated as 10 percent disabling; for a left shoulder disability with degenerative joint disease, now rated as 20 percent disabling; for residual scar, status-post repair of left rotator cuff, rated as 10 percent disabling; and for carpal tunnel syndrome of the right hand, rated as 10 percent disabling. The combined disability rating is 80 percent. Hence, the Veteran meets the threshold percentage requirements for consideration of a TDIU. The remaining question, then, is whether the Veteran's service-connected disabilities render her unemployable. The sole fact that a Veteran is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether she can find employment. Van Hoose, 4 Vet App. at 363. A May 2011 statement from one of the Veteran's former employers indicates that the Veteran had worked from April 2008 to July 2009, approximately 30 to 50 hours weekly in food production and packing; and that the reason for termination of employment was "lack of work." A July 2011 statement from another of the Veteran's former employers indicates that the Veteran had worked from December 1998 to February 2003, approximately 30 hours weekly as a food service assistant; and that the reason for termination of employment was "military." In October 2011, a VA staff psychologist indicated that the Veteran suffers from major depressive disorder, recurrent, due to effects of ocular myasthenia gravis; and from an anxiety disorder, not otherwise specified, due to effects of ocular myasthenia gravis. The psychologist noted that the Veteran's current mental health functioning was significantly impaired and directly related to the effects of her medical conditions. The psychologist added that the Veteran's medical condition severely affected her day-to-day functioning, and that her mood symptoms remained a significant concern and required ongoing clinical attention. The psychologist concluded that the Veteran is severely disabled and unable to work, due to the depression and anxiety-related impairments. In November 2011, a VA staff psychiatrist indicated that the Veteran was receiving psychiatric treatment; and that her psychiatric diagnoses included dysthymic disorder, and depressive and an anxiety disorders due to her general medical condition. The psychiatrist noted that, regardless of treatment, the Veteran remained symptomatic. The psychiatrist also opined that the Veteran is unable to work or have any gainful employment due to her current health status. VA records, dated in September 2012, reflect that the Veteran was advised by her treating psychologist and psychiatrist that she should not work. In January 2013, a VA neuromuscular physician indicated that the Veteran's ocular myasthenia gravis causes diplopia (double vision), which secondarily leads to headaches and poor concentration; and that the Veteran also experiences fatigue and fluctuating weakness. The physician opined that, due to fatigue, weakness, and diplopia, it would be difficult for the Veteran to perform sedentary work; and she would be unable to perform lifting, prolonged standing, or prolonged walking. Her symptoms would cause her to be off task greater than 25 percent of time, and she likely is unable to tolerate even low-stress work based on her symptoms. The physician also noted that the Veteran's impairments do fluctuate, as is typical for ocular myasthenia gravis. If the Veteran were to attempt working, she would likely be absent greater than four days per month. The Veteran has asserted that she is unemployable due to service-connected disabilities. To this extent, her statement is of some probative value. Significantly, the Board finds that the Veteran's mental health complaints have been corroborated by her treating psychologist and psychiatrist. The Board also finds the October 2011 and November 2011 opinions to be probative in suggesting that the Veteran's service-connected depressive disorder combines with her physical limitations due to ocular myasthenia gravis to preclude employment. The January 2013 neuromuscular physician also found that it would be difficult for the Veteran to perform sedentary work. Under these circumstances, and resolving doubt in the Veteran's favor, the Board concludes that her lay assertions combined with evidence of significant physical limitations, social isolation, and the opinions by the treating psychologist and psychiatrist that the Veteran was unable to work due to her current health status strongly suggest that the Veteran is unable to obtain or maintain gainful employment. Hence, TDIU benefits are awarded. 38 U.S.C.A. § 5107(b). (CONTINUED ON NEXT PAGE) ORDER The appeals seeking service connection for bilateral hearing loss, for a right knee disability, for bilateral hand arthritis, for bilateral foot arthritis, for a disability manifested by loss of hair, for a gynecological disability, for neurological gravis of the chest, and for residuals of Gulf War Syndrome are dismissed. For the period prior to August 18, 2009, an initial disability evaluation in excess of 10 percent for degenerative joint disease of the left shoulder is denied. For the period from August 18, 2009, a 20 percent disability evaluation for a left shoulder disability with degenerative joint disease is allowed, subject to the regulations governing the award of monetary benefits. An initial disability rating in excess of 10 percent for residual scar, status-post repair of left rotator cuff, is denied. An initial disability rating in excess of 10 percent for carpal tunnel syndrome of the right hand is denied. Entitlement to a TDIU is granted, subject to the regulations governing the award of monetary benefits. REMAND The Veteran contends that each of her service-connected disabilities remaining on appeal is more severe than currently rated, and warrants a higher initial disability rating. In evaluating the Veteran's requests for higher initial disability ratings, the Board has reviewed the medical evidence of record. Adjudication of each of the claims for higher initial disability ratings should include specific consideration of whether "staged rating" (assignment of different ratings for distinct periods of time based on the facts found), pursuant to Fenderson v. West, 12 Vet. App. 119, 126 (1999), is appropriate. Records In June 2011, the Veteran indicated that she has been receiving treatment regularly from a neurologist, Dr. O., for her ocular myasthenia gravis. Earlier records have been obtained from Dr. O., but none since February 2009. VA must specifically seek the Veteran's authorization for release of these records from March 2009 to the present date. Ocular Myasthenia Gravis Records show that the Veteran was last afforded a VA (contract) examination to evaluate the severity of her service-connected ocular myasthenia gravis in August 2009. At that time, there was evidence of intermittent diplopia. A formal Goldmann Kinetic Perimetry was not performed. Since then, the Veteran has described a worsening of the disability. VA treatment records, dated in January 2013, include an assessment of persistent diplopia. Under these circumstances, VA cannot rate the service-connected ocular myasthenia gravis without further medical clarification. Hence, the Veteran is entitled to a new VA examination. See, e.g., Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). The Board notes that, while the rating criteria for diseases of the eye have been amended, the amended rating criteria are effective December 10, 2008, and applied to all applications for benefits received by VA on or after December 10, 2008. See 73 Fed. Reg. 66550 (Nov. 10, 2008). Because the Veteran's claim was received prior to that date, the amended rating criteria are inapplicable in this appeal. Major Depression Records show that the Veteran was last afforded a VA (contract) examination to evaluate the severity of her service-connected major depression in January 2007. A global assessment of functioning (GAF) score of 65 was assigned. She was hospitalized for depression from October 21, 2009, to November 1, 2009; records show that, two weeks earlier, her son at age 23 had died in his sleep. The GAF score assigned at the time of hospital discharge was 45. Records show that an examination scheduled in December 2009 was not performed. Since then, the Veteran has described a worsening of the disability. In October 2011, a VA psychologist opined that the Veteran was severely disabled and unable to work due to the depression and anxiety-related impairments. In June 2013, the Veteran testified that she always stayed home and did nothing; and sometimes she felt withdrawal and stayed in bed. Accordingly, the Board finds that the evidence of record is inadequate to properly evaluate the service-connected major depression; and that a new VA examination, with more contemporaneous medical findings, is needed. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Degenerative Joint Disease of the Neck, and Strain of the Lumbar Spine In June 2013, the Veteran testified that her currently diagnosed neck and back disabilities were worsening. She testified that the disabilities cause a fair amount of pain, and that she currently wore a back brace. The Veteran also testified that she had fallen last year, and had some therapy; and that she continues to take lots of medication for pain, though reported no radiating pain. Records show that the Veteran was last afforded a VA (contract) examination to evaluate the severity of her service-connected neck and back disabilities in January 2007. While X-rays at that time revealed degenerative disc space narrowing of the cervical spine from C4 through C7, multiple views of the lumbar spine showed good alignment. Accordingly, the Board finds that the evidence of record is inadequate to properly evaluate the service-connected degenerative joint disease of the neck, and strain of the lumbar spine; and that a new VA examination, with more contemporaneous medical findings, is needed. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. While the further delay of this case is regrettable, due process considerations require such action. Accordingly, the case is REMANDED for the following action: 1. After obtaining any necessary contact information and authorization from the Veteran, please request records that pertain to ocular myasthenia gravis and treatment from Dr. O., from March 2009 to the present date; and associate them with the Veteran's claims file (physical or electronic). 2. Obtain recent VA treatment records for ocular myasthenia gravis, for major depression, for degenerative joint disease of the neck, and for strain of the lumbar spine-dated from March 2013 to the present date; and associate them with the Veteran's claims file (physical or electronic). 3. If, after making reasonable efforts to obtain records identified by the Veteran; and if VA is unable to secure such records, VA must notify the Veteran and (a) identify the specific records VA is unable to obtain; (b) briefly explain the efforts that VA made to obtain those records; (c) describe any further action to be taken by VA with respect to the claims; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 4. Afford the Veteran an appropriate VA examination, for evaluation of the service-connected ocular myasthenia gravis. All appropriate tests should be conducted. The entire claims file, to include a complete copy of this REMAND, must be made available to the examiner, and the examination report should note review of the file. All indicated studies should be conducted. The Veteran's field of vision should be tested according to Goldmann Perimeter testing. A Goldmann Perimeter Chart should be included with the examination report. The chart will be made part of the examination report and not less than two recordings should be made. The examiner should set forth in the examination report for the degree of remaining visual field in each of the following eight principal meridians: temporally, down temporally, down, down nasally, nasally, up nasally, up, and up temporally. The examiner should chart the areas in which diplopia exists; and should indicate whether the diplopia is persistent, occasional, or correctable. Uncorrected and corrected central visual acuity for distance and near vision of both of the Veteran's eyes should also be provided. The examiner should render specific findings as to the extent to which the service-connected ocular myasthenia gravis is disfiguring (e.g., with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, including eyes, eyelids, nose, forehead, and cheeks). These specific findings are needed to rate the Veteran's disability in accordance with the rating schedule. It is therefore important that the examiner furnish the requested information. 5. Accord the Veteran an appropriate VA examination, for evaluation of the service-connected major depression. All appropriate tests should be conducted. The entire claims file, to include a complete copy of this REMAND, must be made available to the examiner, and the examination report should note review of the file. All pertinent findings shown on evaluation should be noted in the examination report. In addition, the examiner should render a multi-axial diagnosis, including assignment of a Global Assessment of Functioning (GAF) scale score representing the level of impairment due to the Veteran's major depression, and an explanation of the meaning of the score. In providing the above-noted findings, the examiner should, to the extent possible, distinguish the symptoms attributable to service-connected major depression from those of other psychiatric conditions. However, if it is not medically possible to do so, the examiner should clearly so state, and indicate that the findings are with respect to the Veteran's overall psychiatric impairment. The examiner should set forth a rationale for the conclusions reached. These specific findings are needed to rate the Veteran's disability in accordance with the rating schedule. It is important that the examiner furnish the requested data. 6. Afford the Veteran a VA examination, for evaluation of the service-connected degenerative joint disease of the neck, and strain of the lumbar spine. The entire claims file, to include a complete copy of this REMAND, must be made available to the examiner(s), and the report of the examination(s) should note review of the file. The examiner should identify all current neurological symptoms associated with the Veteran's cervical and lumbar spine disabilities. The examiner should specify the nerves involved, note whether there is associated atrophy, weakness, or other impairment, and express an opinion as to the severity of the disability for each nerve involved. The examiner should specifically report the ranges of motion of the cervical spine and thoracolumbar spine, or whether any segment of the spine is ankylosed. If ankylosed, the examiner should report whether the spine is held in flexion or extension with any of the following: difficulty walking because of a limited line of vision, breathing limited to diaphragmatic respiration, gastrointestinal symptoms due to pressure of the costal margin on the abdomen, dyspnea or dysphagia, atlantoaxial subluxation, or neurologic symptoms due to nerve stretching. The examiner should comment upon the existence, and frequency, of any incapacitating episodes (i.e., a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician); specifically, whether, over the last 12-month period, the Veteran's incapacitating episodes had a total duration of (a) at least two weeks but less than four weeks; (b) at least four weeks but less than six weeks; or (c) at least six weeks. These specific findings are needed to rate the Veteran's disabilities in accordance with the rating schedule. It is therefore important that the examiner furnish the requested information. 7. Thereafter, readjudicate the claims remaining on appeal. If the benefits sought are not fully granted, furnish the Veteran and her representative a supplemental statement of the case (SSOC), and allow the appropriate response time before the claims file is returned to the Board, if otherwise in order. No action is required of the Veteran and her representative until they are notified by VA; however, the Veteran is advised that failure to report for any scheduled examinations may result in the denial of her claims. 38 C.F.R. § 3.655 (2012). The Veteran 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). These claims 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