Citation Nr: 1335171 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 10-11 160 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for lumbar spine disorder, to include as due to service-connected disabilities. 2. Entitlement to a rating in excess of 20 percent for osteoarthritis of the left acromioclavicular joint with rotator cuff tear of the left shoulder, post-operative. 3. Entitlement to a separate rating for neurologic impairment associated with osteoarthritis of the left acromioclavicular joint with rotator cuff tear of the left shoulder, post-operative, and/or another service-connected disability. 4. Entitlement to a total disability rating due to individual unemployability as a result of service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from October 1966 to October 1968, had subsequent service in the reserves, and served on active duty from June 1981 to November 2001. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas.. In December 2010, the Veteran testified at a hearing before the undersigned Veterans Law Judge sitting at the RO; a transcript of the hearing has been associated with the claims folder. In January 2012, the Board remanded the claims, as well as the issue of entitlement to service connection for an acquired psychiatric disorder, for further development. Thereafter, a March 2013 rating decision granted service connection for depression and assigned an initial 30 percent rating, effective February 12, 2008. As the award of service connection for such disability is a full grant of the benefit sought on appeal, such issue is no longer before the Board. As relevant to the Veteran's claim for an increased rating for his left shoulder disability, the January 2012 remand noted that additional development was necessary in order to determine whether such disability resulted in neurological impairment. As will be discussed further herein, the Board finds that the record has been fully developed as to the Veteran's claim for an increased rating for his left shoulder disability with the exception of whether such results in neurological impairment. In this regard, the record is still unclear whether the Veteran is entitled to a separate rating for neurologic impairment associated with his left shoulder disability. Therefore, the Board has bifurcated the claim as shown on the first page of this decision. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA paperless claims processing system reflects VA outpatient treatment records dated through December 2012 that were of record, but not specifically cited by the agency of original jurisdiction (AOJ), in a December 2012 supplemental statement of the case. Upon review, the Board finds that the additional outpatient treatment records are cumulative of evidence already considered and thus not pertinent. Therefore, a remand so as to allow the AOJ to specifically consider such records is not necessary. 38 C.F.R. § 19.31 (2013). Virtual VA also includes the Veteran's representative's September 2013 Appellant's Post-Remand Brief. As noted by the Board in the January 2012 decision, with respect to the Veteran's claim for a dental disorder, the Board observes that a claim for service connection is also considered to be a claim for VA outpatient dental treatment. See Mays v. Brown, 5 Vet. App. 302 (1993). In this regard, the December 2007 rating decision denied service connection for a dental disorder for compensation purposes and a March 2008 letter from the Central Arkansas Veterans Healthcare System denied the Veteran's claim for dental treatment purposes. In the Veteran's June 2008 notice of disagreement submitted via his representative, he specifically indicated that he was in disagreement with the December 2007 rating decision and intended to appeal the issue of service connection for loss of teeth and periodontitis for dental care only. However, despite the March 2008 letter from the Central Arkansas Veterans Healthcare System, such issue has never been adjudicated by the RO. Therefore, the issue of entitlement to service connection for loss of teeth and periodontitis for dental treatment purposes has been raised by the record, but has not been adjudicated by the AOJ. Therefore, the Board does not have jurisdiction over it, and it is again referred to the AOJ for appropriate action. The issues of entitlement to service connection for a lumbar spine disorder, a separate rating for neurological impairment associated with the Veteran's left shoulder disability, and for a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. The Veteran is right hand dominant. 2. For the entire appeal period, the Veteran's osteoarthritis of the acromioclavicular joint with rotator cuff tear of the left shoulder, post-operative, is manifested by pain with less movement than normal, weakened movement, excess fatigability, and pain on movement following flare-up, exertion, and repetitive use, but does not result in functional loss that more nearly approximates limitation of the arm to 25 degrees from the side, without evidence of ankylosis of the shoulder, impairment of the humerus, or impairment of the clavicle. CONCLUSION OF LAW The criteria for rating in excess of 20 percent for osteoarthritis of the left acromioclavicular joint with rotator cuff tear of the left shoulder, post-operative, are not met at any time during the period covered by this appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.25, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5201 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, February 2008 and September 2008 letters, sent prior to the initial unfavorable decision issued in January 2009, advised the Veteran of the evidence and information necessary to substantiate his increased rating claim as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, such letters advised him of the information and evidence necessary to establish an effective date in accordance with Dingess/Hartman, supra. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claims and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of any notice. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The Board also finds that VA has complied with all assistance provisions of the VCAA. The evidence of record contains the Veteran's service treatment records, post-service VA and private medical records, records from the Social Security Administration (SSA), and lay statements and testimony of the Veteran. Moreover, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional evidence that is necessary for a fair adjudication of the claim that has not been requested or obtained. Additionally, the Veteran was afforded VA examinations so as to adjudicate his claim for an increased rating for his left shoulder disability in February 2008 and March 2012. Neither the Veteran nor his representative has alleged that such are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected left shoulder disability as they include an interview with the Veteran, a review of the record, and a full physical examination, addressing the relevant rating criteria. Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's increased rating claim and no further examination is necessary. The Veteran was also afforded the opportunity to set forth his contentions during a hearing before the undersigned Veterans Law Judge in December 2010. In Bryant v. Shinseki, 23 Vet.App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the December 2010 hearing, the undersigned Veterans Law Judge noted the issue on appeal. The hearing focused on the elements necessary to substantiate the Veteran's claim for an increased rating for his left shoulder disability. Specifically, he testified regarding the nature, severity, and frequency of his symptoms, and the impact of the disability on his daily life and occupation. Moreover, to the extent that the hearing discussion revealed additional, outstanding VA treatment records and suggested a possible increase in the severity of the Veteran's left shoulder disability, the Board remanded the issue in January 2012 so as to obtain such records and afford the Veteran a contemporaneous VA examination. Additionally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may adjudicate the claim based on the current record. In January 2012, the Board remanded the case for additional development. As discussed in the preceding paragraphs, VA treatment records dated through December 2012 have been obtained and the Veteran was afforded a VA examination in March 2012 so as to determine the current severity of his left shoulder disability in accordance with the January 2012 remand directives. Therefore, the Board finds that the AOJ has substantially complied with the January 2012 remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In this regard, while the March 2012 VA examiner did not fully address whether the Veteran's left shoulder disability results in neurological impairment, the Board is remanding such aspect o f his claim for further development. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis The Veteran served as a U.S. Army infantryman and communications technician during his first period of service that included a tour of duty in Germany. He later served as an active duty supply specialist in a one-man office at an Army Reserve Center during the second period of active service. He reported that his supply duties included both physical and administrative tasks. He contended in written statements and at his Board hearing that his left shoulder disability is more severe than is contemplated by the current rating and precludes him from continuing work as a school bus driver. The Veteran is service-connected for left shoulder osteoarthritis with post-operative repair of a rotator cuff tear, currently evaluated as 20 percent disabling. This disability is rated under the criteria of a hyphenated diagnostic code, 38 C.F.R. § 4.71a , Diagnostic Code 5003-5201. The hyphenated diagnostic code in this case indicates that the service-connected disability is considered to be degenerative arthritis (5003) associated with a residual condition of limitation of motion of the arm (5201). See 38 C.F.R. § 4.27. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. When 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for 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. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X- ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of motion of the non-dominant arm at the shoulder warrants a 20 percent rating if motion is to the shoulder level or if to midway between the side and the shoulder, and a 30 percent rating if to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The normal range of motion of the shoulder is from zero degrees at the side to 180 degrees overhead in both forward elevation and abduction. Normal internal and external rotation is from zero to 90 degrees. 38 C.F.R. § 4.71a, Plate I. As there is no evidence of ankylosis of the shoulder, impairment of the humerus, or impairment of the clavicle, the Diagnostic Codes pertaining to such impairments are not applicable. 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202, 5203 (2013). Service treatment records and a March 2012 VA examination show that the Veteran is right-handed. Therefore, he is considered right hand dominant. Consequently, his left shoulder is considered his non-dominant upper extremity. In December 2006, a private physician noted the Veteran's report of left shoulder pain and numbness in the median distribution of the left hand. A magnetic resonance image of the shoulder showed significant acromioclavicular joint arthritis and a partial or possibly full thickness rotator cuff tear. An image of the cervical spine showed spondylosis and foraminal narrowing at several levels. The physician planned to perform surgery in June 2011 after the Veteran completed seasonal work as a school bus driver. The physician diagnosed the neurologic symptoms as possible carpal tunnel syndrome. In March 2007, A VA physician noted the Veteran's report of left shoulder pain without any specific traumatic injury and the inability to completely elevate and abduct the shoulder. He also reported some numbness and tingling in the lateral and posterior side of the left arm from the shoulder to the tips of the fingers. The Veteran reported difficulty turning the steering wheel on a school bus and the use of oral medication for pain. On examination, forward elevation and abduction was limited to 110 and 90 degrees respectively. Internal rotation and forearm pronation and suppination were normal and external rotation was slightly less than normal. There was no additional loss of function or range of motion on four repetitions and no report of flare-up episodes. There was no tenderness or muscle atrophy. A concurrent X-ray showed minimal spurring. The physician did not indicate an awareness of the private physician's diagnosis or the results of the December 2006 magnetic resonance image. In a March 2007 rating decision, the RO granted an increased rating of 20 percent. In June 2007, the private physician performed left shoulder surgery that included a debridement of a partial rotator cuff tear, subacromial decompression, and distal clavical resection. In a September 2007 letter, the physician advised that three month convalescence was required. In August 2007, another VA physician accurately summarized the Veteran's pre-surgery symptoms and the corrective surgical procedure. The Veteran reported that he did not undergo any physical therapy and continued to experience pain for which he used oral medication. He reported that he was unable to lift or perform any overhead activities with his left arm and was unable to lift himself from a bathtub or perform household chores. Repetitive use of the shoulder caused additional pain. The Veteran did not experience flare-ups because he avoided use of the left arm. On examination forward elevation and abduction was 120 and 80 degrees respectively. Internal and external rotation was 40 and 20 degrees respectively and reduced to 20 degrees in both directions on repetition. There was no additional loss of elevation or abduction on repetition. X-rays continued to show minimal spurring and calcific tendinitis. In a December 2007 rating decision, the RO granted a temporary total rating for convalescence from June 11, 2007 to October 1, 2007 and a 20 percent rating thereafter. Thereafter, in February 2008, VA received the Veteran's current claim for an increased rating. While additional VA treatment records and a February 2008 VA examination report were associated with the claims file within one year of the issuance of the December 2007 rating decision, such do not reflect complaints or findings demonstrating an increase in the severity of the Veteran's left shoulder disability. 38 C.F.R. § 3.156(b) (when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period); Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011). Therefore, the Veteran's current claim has been pending since February 2008. In February 2008, the Veteran underwent another VA examination. The physician noted a review of the claims file and the Veteran's report that he was unable to return to his job as a school bus driver because he could not lift or rotated his arm enough to steer the bus. The Veteran reported flare-up pain on activity. As a result, he limited daily activities and experienced a loss of sleep because of pain. On examination, the physician noted that the surgical portals were well healed with no atrophy and only a slight loss of strength. Reflexes and sensation were intact. Forward elevation and abduction were 55 degrees and 40 degrees respectively. Internal rotation was normal but external rotation was 45 degrees. There was no additional loss of function but increased pain on repetition. In August 2008 and November 2008, the Veteran was evaluated in a VA rheumatology clinic for symptoms of multiple joint pains in the knees, hips, shoulders, and lower back. Clinicians noted myalgia and inflammatory markers, diagnosed polymyalgia rheumatica, and prescribed steroid medication. However, the clinicians continued to assess the reduced mobility of the left shoulder as associated with the rotator cuff tear. In the January 2009 rating decision on appeal, the RO denied a rating in excess of 20 percent for the Veteran's left shoulder disability, citing the results of the February 2008 examination. In July 2009, the Social Security Administration granted disability benefits for degenerative joint and disc disease starting in April 2007. Medical records used in the determination were obtained and are duplicates of the VA and private treatment records already of record. Also included are functional reports submitted by the Veteran and his spouse, who reported generally that the Veteran was not working and performed few household chores because of multiple disabilities. The Veteran and his spouse did not specifically address limitations imposed by the left shoulder but did report that he was able to shop and drive an automobile. In a December 2010 Board hearing, the Veteran stated that he continued to experience left shoulder pain, left arm and hand numbness, and loss of grip strength. He described himself as a "one handed person" because of limitation of motion of the shoulder, loss of feeling in the hands, and reduction of grip strength. In March 2012, the VA physician who performed the 2008 examination noted a review of the claims file and examined the Veteran's bilateral shoulders, elbows, and wrists. The physician noted the previous diagnoses of rotator cuff syndrome, degenerative joint disease, and tendinitis of the left shoulder. The Veteran continued to report left shoulder pain with use and the inability to lift anything above the shoulder level with unspecified flare-ups that also prevented overhead activities. On examination, forward elevation and abduction were 75 degrees and 110 degrees respectively limited by pain at the end of the range of motion. Following repetitive use, it was noted that the Veteran had less movement than normal, weakened movement, excess fatigability, and pain on movement; however, no additional limitation of motion was demonstrated. The physician noted localized tenderness, guarding, and mild loss of muscle strength (expressed as a four on a scale of one to five). Tests for weakness impingement and a rotator cuff tear were positive. A clinical test and imaging was also positive for joint pathology. Additional VA and private treatment records do not the findings required for an increased rating for the Veteran's left shoulder disability. Therefore, in consideration of the evidence of record, the Board finds that, for the entire appeal period, the Veteran's left shoulder disability is manifested by pain with less movement than normal, weakened movement, excess fatigability, and pain on movement following flare-up, exertion, and repetitive use, but does not result in functional loss that more nearly approximates limitation of the arm to 25 degrees from the side, without evidence of ankylosis of the shoulder, impairment of the humerus, or impairment of the clavicle. Consequently, the Board concludes that he is not entitled to a rating in excess of 20 percent for such disability. In reaching this determination, the Board finds that the Veteran is both competent and credible to report on his observed symptoms of pain, left arm weakness, and inability to lift objects or perform activities with the arm above the shoulder. His reports have been consistent, accepted without challenge by examiners, and consistent with clinical observations. The Board further finds that the Veteran's range of motion in forward elevation and abduction was not 25 degrees or less from the side at any time during the period covered by this appeal. Although the Veteran reported flare-up pain, and following repetitive use at the March 2012 VA examination, it was noted that the Veteran had less movement than normal, weakened movement, excess fatigability, and pain on movement; however, he did not report nor has a clinician observed a reduction in the range of motion to 25 degrees or less during a flare-up or after repetitive use. The Veteran is unable to perform overhead lifting and is unable to continue his work as a bus driver. However, he did report to SSA that he was able to drive an automobile and go shopping. There is no history of fractures and no observations of dislocations or bone malunion or misalignment. The Veteran's activities are limited only in avoidance of heavy overhead lifting. He does receive regular VA primary care with medication for pain but neither the Veteran nor the record identified recommendations for therapy or surgical intervention. A higher schedular rating is not warranted without more severe limitation of motion of the shoulder. In this regard, the Board finds that such rating contemplates the Veteran's subjective complaints referable to his left shoulder, to include less movement than normal, weakened movement, excess fatigability, and pain on movement on flare-ups and repetitive use; however, no additional limitation of motion is demonstrated, as it includes consideration of functional loss resulting from such symptomatology. See DeLuca, supra; Mitchell, supra. The Board has considered whether staged ratings under Hart, supra, are appropriate for the Veteran's service-connected left shoulder disability; however, the Board finds that his symptomatology has been relatively stable throughout the appeal period, with even some improvement in range of motion in the most recent examination. Therefore, assigning staged ratings for such disabilities is not warranted. Additionally, the Board has considered whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected left shoulder degenerative joint disease and rotator cuff tear with the established criteria found in the rating schedule. The Board finds that the Veteran's symptomatology is fully addressed by the rating criteria under which such disabilities are rated. The rating criteria contemplates the functional loss he experiences as a result of pain, repetitive use, and flare-ups, to include loss of range of motion. The additional neurologic symptoms of the left arm require further evaluation but do not preclude adjudication of a schedular rating under the adequate orthopedic criteria. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a TDIU is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. While the Veteran asserts that he is unable to continue work as a bus driver because of his left shoulder, such issue has been independently appealed and will be addressed in the Remand secion. Therefore, further discussion of such issue at this time is unnecessary. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims for a rating in excess of 20 percent for his left should disability. Therefore, the benefit of the doubt doctrine is not applicable in the instant appeal and his increased rating claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. ORDER A rating in excess of 20 percent for osteoarthritis of the left acromioclavicular joint with rotator cuff tear of the left shoulder, post-operative, is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Lumbar Spine Disorder In the Board's January 2012 remand, it was noted that the Veteran has testified that he experienced low back symptomatology during service, but denied seeking treatment and denied sustaining an injury to the spine. Service treatment records do not reflect any complaints or diagnoses related to the lumbar spine. The Veteran asserts that his lumbar spine disability is due to or aggravated by his service-connected disabilities, to include his left shoulder disability. Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a nonservice-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Initially, the Board notes that a July 2002 radiology interpretation of the abdomen and pelvis reflect evidence of degenerative changes in the lumbar spine with no other abnormality seen within the abdomen or pelvis. The Board notes that for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if manifested to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1133; 38 C.F.R. §§ 3.307, 3.309. Otherwise, VA outpatient treatment records reflect complaints of low back pain beginning in or about December 2003. The Board notes, however, that the specific VA outpatient treatment record that diagnosed a back condition in December 2003 is not of record. Thus, the AOJ should ensure that the entirety of the Veteran's VA outpatient treatment records are associated with the claims folder. A May 2004 private treatment record reflects complaints of low back pain. The Veteran stated that the onset of low back pain was acute and had been occurring in a persistent pattern for months. The course had been gradually worsening. The examiner diagnosed lumbar/lumbosacral intervertebral disc degeneration (established diagnosis). Based on the foregoing, the Board remanded the issue in order to afford the Veteran a VA examination so as to determine the nature and etiology of his lumbar spine disorder. Thereafter, in March 2012, a VA physician noted a review of the claims file and performed an examination. The physician concluded that the Veteran's current degenerative disc disease of the lumbar spine was as likely as not due to aging because there was a lack of evidence of any symptoms or disease prior to November 2002. However, the physician did not acknowledge awareness of the July 2002 imaging evidence or comment on whether the imaging was sufficient to show the onset of degenerative disc disease to a compensable level within one year of active duty service. The March 2012 VA examiner further opined that the Veteran's lumbar spine disorder is in no way aggravated by, related to, secondary to, or the result of his other service-connected conditions as there was no evidence to establish a nexus or connection. However, the examiner did not completely explain his rationale for such opinion. VA must ensure that any medical opinion is based on sufficient facts or data. Jones v. Shinseki, 23 Vet. App. 382 (2010). Neives-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (Neither a VA medical examination report nor a private medical opinion is entitled to any weight in a service connection or rating context if it contains only data and conclusions without reasoning or rationale.) Therefore, the Board concludes that an addendum to the report or an additional examination is necessary to provide sufficient medical evidence for a decision on the claim. Neurological Impairment Associated with Left Shoulder Disability At the December 2010 Board hearing, the Veteran testified to his continued left shoulder symptoms, and stated that that he experienced neurological impairment to include numbness, tingling, and loss of grip strength. He stated that he had a significant loss of function of the entire arm. In the Board's January 2012 remand, the Board requested that the Veteran undergo a VA examination of his left shoulder so as to determine whether the Veteran's left shoulder disability resulted in neurologic impairment, to include numbness, tingling, and loss of grip strength. If so, the examiner was to specifically indicate the nature and severity of the impairment. As indicated previously, the Veteran underwent an examination in March 2012; however, the examiner did not address the Veteran's neurologic symptoms in the shoulder examination. In the elbow examination, he noted a diagnosis of bilateral ulnar neuralgia and positive tinel sign associated with the ulnar nerves, but did not indicate whether such was related to the Veteran's left shoulder disability, or any other service-connected disability. Parenthetically, the Board notes that the Veteran is also service-connected for left elbow and left elbow disabilities. Therefore, the Board finds that a remand is necessary in order to obtain an opinion regarding the etiology of any neurological impairment in the Veteran's upper left extremity. TDIU As the outcome of the Veteran's aforementioned remanded claims will impact his TDIU claim, the latter claim is inextricably intertwined with the former claims. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a Veteran's claim for the second issue). Therefore, consideration of the Veteran's TDIU claim should be deferred pending the readjudication of the aforementioned remanded claims. Accordingly, the case is REMANDED for the following action: 1. Return the claims file to the VA examiner who conducted the Veteran's March 2012 spine examination. The claims file and a copy of this Remand must be made available to the examiner. The examiner shall note in the examination report that the claims folder and the Remand have been reviewed. If the March 2012 VA examiner is not available, the claims file should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the full record, please offer an opinion on the following: a) Did arthritis (degenerative joint disease) of the lumbar spine manifest November 30, 2002? In offering such opinion, the examiner should specifically consider, and explain the significance of, the July 2002 radiology interpretation of the abdomen and pelvis reflect evidence of degenerative changes in the lumbar spine with no other abnormality seen within the abdomen or pelvis. If so, please describe the manifestations of such disease. b) Does the Veteran have any disability of the lumbar spine that is at least as likely as not (a 50 percent or higher degree of probability) related to his military service? c) Does the Veteran have any disability of the lumbar spine that is at least as likely as not (a 50 percent or higher degree of probability) proximately due to a service-connected disability, to include left shoulder disability, right shoulder disability, left elbow disability, left wrist disability, right wrist disability, left heel spur, residuals of nodule removal, left foot, or depression? If not, has any lumbar spine disorder at least as likely as not (a 50 percent or higher degree of probability) undergone a permanent increase in its severity due to the Veteran's service-connected left shoulder disability, right shoulder disability, left elbow disability, left wrist disability, right wrist disability, left heel spur, residuals of nodule removal, left foot, or depression, and if so, what measurable degree of lumbar spine disability is due to service-connected disability(ies)? In offering his opinion, the examiner is requested to fully review the claims file, to include the medical records as well as the Veteran's lay statements regarding incurrence and continuity of symptomatology of his lumbar spine disorder. The rationale for any opinion offered should be provided. 2. Return the claims file to the VA examiner who conducted the Veteran's March 2012 left shoulder VA examination. The claims file and a copy of this Remand must be made available to the examiner. The examiner shall note in the examination report that the claims folder and the Remand have been reviewed. If the March 2012 VA examiner is not available, the claims file should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the full record, please offer an opinion on the following: Does the Veteran have any neurologic disability of the left upper extremity, to include numbness, tingling, and/or loss of grip strength, that is at least as likely as not (a 50 percent or higher degree of probability) proximately due to his service-connected left shoulder disability, left elbow disability, and/or left wrist disability? If not, has any neurologic disability of the left upper extremity at least as likely as not (a 50 percent or higher degree of probability) undergone a permanent increase in its severity due to the Veteran's service-connected left shoulder disability, left elbow disability, and/or left wrist disability, and if so, what measurable degree of left upper extremity neurologic disability is due to service-connected disability(ies)? In offering the opinion, the examiner is requested to fully review the claims file, to include the medical records as well as the Veteran's lay statements regarding incurrence and continuity of his left upper extremity neurologic symptoms. The rationale for any opinion offered should be provided. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the 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 or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs