Citation Nr: 1336749 Decision Date: 11/12/13 Archive Date: 11/22/13 DOCKET NO. 07-24 121A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a cervical spine disability on a direct basis. 2. Entitlement to service connection for a cervical spine disability as secondary to service-connected disability. 3. Entitlement to an evaluation in excess of 10 percent for right hip bursitis. 4. Entitlement to an initial evaluation in excess of 20 percent for lumbosacral spondylosis. 5. Entitlement to an effective date earlier than September 29, 2006, for the grant of service connection for lumbosacral spondylosis. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD P. Olson, Counsel INTRODUCTION The Veteran had active military service from April 1971 to April 1991. The issues of entitlement to service connection for a cervical spine disability and entitlement to an evaluation in excess of 10 percent for right hip bursitis come back before the Board of Veterans' Appeals (Board) on Remand from the United States Court of Appeals for Veterans Claims (Court) regarding a Board decision rendered in June 2012. These matters were originally on appeal from a June 2008 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Columbia, South Carolina. In August 2013, the Board remanded the case for additional development. The United States Court of Appeals for Veterans Claims (the Court) indicated that there are some circumstances in which it is appropriate for the Board to deny a claim under one theory of entitlement and remand the claim under a different theory of entitlement, essentially bifurcating the claim. See Roebuck v. Nicholson, 20 Vet. App. 307, 315(2006). As such, the issue of entitlement to service connection for a cervical spine disability has been bifurcated into a direct claim and a claim on a secondary basis as reflected above. The issue of entitlement to service connection for erectile dysfunction has been raised by the Veteran's representative, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issues of entitlement to service connection for a cervical spine disability as secondary to service-connected disability, entitlement to an initial evaluation in excess of 20 percent for lumbosacral spondylosis, and entitlement to an effective date earlier than September 29, 2006, for the grant of service connection for lumbosacral spondylosis 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. The preponderance of the evidence is against finding that the Veteran has a current cervical spine disability due to a disease or injury in-service; and there is no competent evidence that arthritis was manifested to a compensable degree within one year following discharge from active duty. 2. The Veteran's right hip bursitis has not been shown at any time during the appeal period to cause flexion limited to 30, 20, or 10 degrees or abduction limited such that motion is lost beyond 10 degrees. CONCLUSIONS OF LAW 1. A cervical spine disability, variously diagnosed, was not incurred in or aggravated by service, and cervical arthritis may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for an evaluation in excess of 10 percent for right hip bursitis have not been met. 38 U.S.C.A. §§ 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010-5019, 5250--5253 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matter Pursuant to the Board's August 2013 Remand, the Appeals Management Center (AMC) scheduled VA examinations to determine the current severity of right hip bursitis and etiology of current cervical spine disorders, readjudicated the Veteran's claim under provision of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), and issued a Supplemental Statement of the Case. Based on the foregoing actions, the Board finds that there has been compliance with the Board's August 2013 Remand. Stegall v. West, 11 Vet. App. 268 (1998). Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (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 requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in March 2008, July 2008, August 2008, and August 2009 of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. The case was most recently readjudicated in September 2013. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. The Virtual VA eFolder has been reviewed. There is no evidence that additional records have yet to be requested, or that additional examinations are in order. Service Connection The Veteran seeks service connection for a cervical spine disability which he contends started during his active service and worsened over the years. Post-service medical records include numerous diagnoses relating to the Veteran's cervical spine including cervical stenosis, myelopathy, radiculitis, cervicalgia, and spondylosis. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be warranted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Arthritis, if manifest to a degree of 10 percent within one year after separation from active duty, may be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The Board has reviewed all service treatment records, all VA medical records, Social Security Administration records, as well as private medical records from Tuomey Medical Professionals, Cedars Medical Clinic, and Pee Dee Orthopaedic. The Veteran's service treatment records indicate that in May 1983, the Veteran presented with complaints of pain in right shoulder and side of neck for two days. Physical examination demonstrated tender right trapezius. He was given medication and sent to physical therapy. There are not recorded follow-up visits or complaints. Despite the isolated complaint in service of neck pain, Board cannot conclude a "chronic" cervical spine condition was incurred during service. Treatment for a disorder in service cannot be considered treatment for a chronic disorder unless there is some indication that a chronic disorder exists. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. For a showing of chronic disability in service there is required a combination of manifestations sufficient to identify the disorder, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." In this case, there is no evidence of a chronic neck disorder during service, on the clinical examination for retirement in October 1990, the Veteran's neck and spine were evaluated as normal. Moreover, the first showing of cervical arthritis was not until 2007, years after the appellant's discharge from service. It is not shown by any competent evidence to be related to service. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by evidence of continuity of symptomatology. Although the appellant reports continuity of post-service symptoms, the Board finds his allegations to be of limited probative value. As noted above, entitlement to service connection for a cervical spine disability was denied by a June 2012 Board decision. The Veteran appealed the Board's decision to the Court. In March 2013, VA and the Veteran filed a Joint Motion for Partial Remand (JMR). The JMR moved for the parties to vacate and remand the June 2012 decision with respect to, inter alia, the claim for service connection for a cervical spine disability as the parties determined that a remand was necessary to allow the Board to revisit the credibility of the Veteran's allegations as well as reassess the probative value of the 2009 private physician's statement. In adjudicating a claim, including as to continuity of symptomatology, the Board must assess the competence and credibility of the veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board also has a duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). In this case, the Veteran is competent to give evidence about what he experienced; for example, he is competent to report that he engaged in certain activities in service and currently experiences certain symptomatology. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). Competency, however, must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Board acknowledges that it cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). However, such lack of contemporaneous evidence is for consideration in determining credibility. In this regard, the Board notes that the record is devoid of objective evidence of cervical spine complaints until 2007, years after service. The Board notes that the Veteran was seen at VA community based outpatient clinic in January 2002 at which time he noted occasional hip and low back pain; there was no mention of any neck pain. In addition, in September 2004, the Veteran filed a claim with VA for compensation benefits evidencing his awareness that he could apply for VA benefits for service related disabilities. At that time he did not file a claim for service connection for a neck disorder. This is inconsistent with his assertion that he has experienced neck pain since service because it is reasonable to conclude that if he believed that he neck pain in 2004 that was related to service, he would have claimed service connection for it at that time. As such, the Board finds that any assertions by the Veteran as to the continuity of symptomatology of his cervical spine disorders since service to be less than credible. The remaining question, therefore, is whether there is medical evidence of a relationship between the current disability and military service. In April 2007, a private physical therapist noted that the Veteran was presented with back and neck pain with onset approximately 30 years ago. In addition, the Veteran's private physician noted in treatment records dated in 2009 that the cervical stenosis and degenerative joint disease had an onset of January 1991. The Veteran underwent VA examination in August 2013 at which time he reported onset of persistent neck problems around 2006 but stated that he had off and on problems with his neck in the 1980s during active duty. After a review of the claims file and physical examination of the Veteran, the VA examiner opined that cervical stenosis and spondylosis status post C2-C6 surgical decompression and fusion were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran's service treatment records showed a single treatment for neck pain of two days duration and that there was no mention of trauma or any records in the service treatment records to show chronic or recurrent neck problems. The Board notes that there is a difference of opinion among the medical professionals. In deciding whether a current cervical spine disorder had its onset in service, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Evans v. West, 12 Vet. App. 22, 30 (1998). That responsibility is particularly onerous where medical opinions diverge. At the same time, the Board is mindful that it cannot make its own independent medical determinations and that there must be plausible reasons for favoring one medical opinion over another. Id. Here, there are legitimate reasons for accepting the August 2013 VA examiner's unfavorable medical opinion over the statements made by the Veteran's treating providers that the Veteran's neck pain started in service. With regard to medical evidence, an assessment or opinion by a health care provider is never conclusive and is not entitled to absolute deference. Indeed, the courts have provided guidance for weighing medical evidence. They have held, for example, that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). In addition, an examination that does not take into account the records of prior medical treatment is neither thorough nor fully informed. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). A bare transcription of lay history, unenhanced by additional comment by the transcriber, is not competent medical evidence merely because the transcriber is a health care professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). A medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). Also, a medical opinion is inadequate when unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). Finally, a medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). In sum, the weight to be accorded the various items of medical evidence in this case must be determined by the quality of the evidence and not necessarily by its quantity or source. In this case, the August 2013 VA examiner offered a medical opinion after a review of the claims file and physical examination of the Veteran. The examiner noted the Veteran's report of onset of persistent neck problems around 2006 and problems off and on with his neck in the 1980s. The examiner also offered a rationale for his opinion that the current cervical spine disorders did not have their onset during service and noted that there was only a single treatment for neck pain of two days during service and no mention of trauma or any evidence of chronic or recurrent neck problems. The Veteran's treatment providers who noted the onset of cervical spine stenosis and arthritis in January 1991 and neck pain for 30 years did not provide a rationale for these determinations. Specifically, neither provider mentioned normal neck and spine examination on retirement or the lack of any complaints related to his neck for more than 15 years after service. Thus, the Board finds that the August 2013 reasoned medical opinion that the current cervical spine disorders are less likely related to his active duty service is more probative than the statements made by the Veteran's treating professionals that the cervical spine disorders had their onset during service. Thus, the record is absent evidence of in-service incurrence of a chronic cervical spine disorder, evidence of cervical spine arthritis within a year following service, and credible evidence of continuity of symptomatology. Further, the more probative evidence of record is against a nexus between currently diagnosed cervical spine disorders and the Veteran's active duty service. The Board acknowledges the Veteran contention that his current cervical spine disorders are related to his service. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the etiology of the Veteran's current cervical spine disorders falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection on a direct basis, and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. Increase Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When, as here, the Veteran is requesting a higher rating for an already established service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "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) The Veteran was initially granted service connection for right hip bursitis by a March 2006 Decision Review Officer decision which assigned a 10 percent evaluation effective December 2, 2004. The Veteran filed his claim for an increased evaluation in October 2007. The Veteran's service-connected right hip bursitis has been evaluated as 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5019. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned; the additional code is shown after a hyphen. 38 C.F.R. § 4.27 (2012). Diagnostic Code 5010 provides that traumatic arthritis will be rated as degenerative arthritis under Diagnostic Code 5003. See 38 C.F.R. § 4.71a. Under Diagnostic Code 5003, degenerative arthritis, when 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 limitation of motion of the specific joint or joints involved is noncompensable under the appropriate Diagnostic Codes, a rating of 10 percent 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. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. Bursitis is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5019, which is to be rated on limitation of motion of the affected parts, as degenerative arthritis. Disabilities of the hip and thigh are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5250 through 5255. Diagnostic Code 5250 requires ankylosis of the hip. Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Colayong v. West, 12 Vet App 524 (1999) (citing DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (28TH Ed. 1994) at 86). Diagnostic Code 5251 provides a maximum rating of 10 percent for limitation of extension of the thigh to 5 degrees. Diagnostic Code 5252 provides a 10 percent rating for limitation of flexion of the thigh to 45 degrees; a 20 percent rating where flexion is limited to 30 degrees; a 30 percent rating where flexion is limited to 20 degrees; and a 40 percent rating where flexion is limited to 10 degrees. Diagnostic Code 5253 provides a 10 percent evaluation when there is limitation of abduction of the thigh such that the legs cannot be crossed or there is limitation of rotation such that it is not possible to toe out more than 15 degrees. A 20 percent rating requires limitation of abduction with motion lost beyond 10 degrees. According to VA standards, full hip range of motion is defined as 0 to 125 degrees hip flexion and zero to 45 degrees hip abduction. See 38 C.F.R. § 4.71, Plate II (2012). The Veteran underwent VA examination in December 2007 at which time he reported pain on the right hip occurring approximately every other day. The Veteran reported that his right hip limited his standing to less than one hour but that he could walk a mile on level ground. The Veteran reported that he had to curtail his sporting activities. He reported flare ups two to three times a week, primarily in the morning lasting up to three hours and characterized by increased pain and stiffness. Physical examination demonstrated that the Veteran appeared to be in moderate degree of pain getting on and off the examination table. He could extend the right hip to 5 degrees with end-range pain. Flexion was to 95 degrees, abduction to 45 degrees, and adduction to 10 degrees. Internal rotation was to 20 degrees and external rotation was to 30 degrees. These were characterized by end-range pain but were not additionally limited following repetitive use. The greater trochanter was nontender, but he was tender over the anterior aspect of the hip joint and in the right flanks superior to his hip. On VA examination in September 2009, the Veteran reported right hip pain of an intensity of 5 out of 10 which was present all the time. He reported that his job was occasionally affected by his hip as it affected his ambulation. Physical examination showed right hip flexion to 87 degrees, extension to 30 degrees, abduction to 40 degrees, adduction to 25 degrees, external rotation to 45 degrees, and internal rotation to 30 degrees. There was pain throughout all movement, and the pain was more severe at end point with abduction and flexion. The Veteran was able to repetitively range the right hip without changes in his range of motion or level of pain following repetitive use. He had significant tenderness to palpation over the trochanteric region, but no significant joint warmth, redness, swelling or crepitus. The right hip was stable. The Veteran underwent VA examination in August 2013 at which time he reported flares occurring once or twice a week aggravated by pushing the lawnmower, heavy lifting, going up steps, and leaning over to pick something up. The Veteran rated the pain as a 6 on a scale from zero to 10. He also reported that when his hip pain flared up, he would lie down and rest and that Naproxen helped a little. Physical examination demonstrated flexion to 100 degrees with pain beginning at 65; extension to 15 degrees with pain at 10 degrees; abduction to 40 degrees with pain at 35 degrees; adduction to 20 degrees with pain at 20 degrees; internal rotation to 20 degrees with pain at 20 degrees; and external rotation to 25 degrees with pain at 15 degrees. The examiner noted that abduction was not lost beyond 10 degrees, that adduction was not limited such that he could not cross his legs, and that rotation was not limited such that he could not toe-out more than 15 degrees. There was no additional limitation in range of motion of the hip and thigh following repetitive use testing. Muscle strength testing was normal in hip flexion, abduction and extension. The examiner also determined that the Veteran did not have ankylosis of the hip joint, malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. In this case, there is no evidence of record of right hip ankylosis to support the application of Diagnostic Code 5250; no evidence of limitation of right thigh flexion to 30 degrees or less and no limitation of right thigh abduction lost beyond 10 degrees to support a higher evaluation pursuant to Diagnostic Codes 5252 or 5253; no evidence of flail joint to support the application of Diagnostic Code 5254; and no evidence of malunion or fracture of the femur to support the application of Diagnostic Code 5255. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant on motion. Disability of the musculoskeletal system is the inability to perform normal working movement with normal excursion, strength, speed, coordination, and endurance, and that weakness is as important as limitation of motion, and that a part that becomes disabled on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, through atrophy, for example. 38 C.F.R. § 4.40 (2012). The provisions of 38 C.F.R. §§ 4.45 and 4.59 also contemplate inquiry into whether there is limitation of motion, weakness, excess fatigability, incoordination, and impaired ability to execute skilled movements smoothly, and pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing, and weight-bearing are also related considerations. The Court has held that diagnostic codes predicated on limitation of motion require consideration of a higher rating based on functional loss due to pain on use or due to flare-ups. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); Johnson v. Brown, 9 Vet. App. 7 (1997); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). The March 2013 JMR moved for the parties to vacate and remand the June 2012 decision with respect to claim for increased rating for right hip bursitis as the parties determined that a remand was necessary as the Board did not provide an adequate discussion as to the impact, if any, of the factors under 38 C.F.R. §§ 4.40 and 4.45 with regard to the Veteran's entitlement to a higher rating under the diagnostic codes involving limitation of motion, especially given its express acknowledgement. Even when taking into account the Veteran's complaints of pain and stiffness and reports of flare ups, the Board finds that the Veteran's right hip disability does not warrant an evaluation in excess of 10 percent. See 38 C.F.R. §§ 4.40 and 4.45. The September 2007 VA examiner specifically noted that on examination, the Veteran was able to flex and abduct pain free. The September 2009 VA examiner noted that the Veteran denied flare ups and that on range of motion examination, he had pain which was more severe at the end of flexion and abduction but that range of motion was unchanged following repetitive use. The August 2013 VA examiner noted that the Veteran had pain on flexion at 65 degrees and on abduction at 35 degrees; however, he specifically noted that the Veteran did not have additional limitation in range of motion of the right hip and thigh after repetitive testing. Thus, the Board cannot find that the Veteran demonstrated additional limitation of motion which approximated flexion limited to 30 degrees or limitation of abduction with motion lost beyond 10 degrees. The Board has found no medical evidence of record that would warrant a staged rating for this increased rating claim at any time during the appeal period. There are no identifiable periods of time during which this condition has been shown to be disabling to a degree that would warrant a 20 percent disability rating, and thus higher "staged ratings" are not warranted. As the preponderance of the evidence is against an evaluation in excess of 10 percent for right hip bursitis, the benefit of the doubt doctrine is not applicable, and the claim must be denied. 38 U.S.C.A. 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board is aware that an extraschedular rating is a component of an increased rating claim. Barringer v. Peake, 22 Vet. App. 242 (2008); see Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); see Fisher v. Principi, 4 Vet. App. 57, 60 (1993); 38 C.F.R. § 3.321(b)(1). If so, factors for consideration in determining whether referral for an extraschedular rating is warranted include marked interference with employment or frequent periods of hospitalization that indicate that application of the regular schedular standards would be impracticable. Thun, citing 38 C.F.R. § 3.321(b)(1) (2008). In the present case, the Board finds no evidence that the Veteran's service-connected right hip disability presents such an unusual or exceptional disability picture at any time so as to require consideration of an extra-schedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b)(1). The criteria pertaining to hip bursitis in the Rating Schedule focus on limitation of motion of affected part. As discussed above, such symptomatology describes the Veteran's current disability picture. Thus, it appears that the schedular criteria adequately compensate for any loss in earning capacity, and referral for extraschedular consideration is not warranted. Id. ORDER Entitlement to service connection for a cervical spine disability on a direct basis is denied. Entitlement to an evaluation in excess of 10 percent for right hip bursitis is denied. REMAND With respect to service connection for a cervical spine disability as due to service-connected disability, the Veteran's representative has submitted an article published by Matthew Tull, Ph.D. which indicates that PTSD sufferers are more likely to suffer physical symptoms and conditions such as pain and arthritis. Thus, a different theory of entitlement has been raised. As noted in the introduction, bifurcation of this claim is appropriate as this theory of entitlement has not been properly developed for adjudication. In particular, a review of the claims file reveals that the Veteran has not been properly notified of the provisions of the VCAA concerning secondary claims. Therefore, it is apparent that the Board must remand this case to ensure that the Veteran is properly notified of the VCAA and to determine whether all evidence needed to consider the claim has been obtained. With respect to the remaining issues, in August 2013, the Board granted entitlement to service connection for a low back disability. In an August 2013 rating decision, the RO assigned a 20 percent disability evaluation effective September 29, 2006. In September 2013, VA received the Veteran's disagreement with the 20 percent rating as well as with the effective date. Therefore, the appropriate Board action is to remand the issue for the issuance of a Statement of the Case. Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: 1. Development contemplated by the VCAA should be undertaken, including, but not limited to, informing the Veteran of the information and evidence not of record (1) that is necessary to substantiate s claim for entitlement to service connection for a cervical spine disability as secondary to service-connected disability; (2) that VA will seek to obtain; and (3) that the claimant is expected to provide. In addition, the Veteran should be informed of how VA determines disability ratings and effective dates. 2. The issue of entitlement to service connection for a cervical spine disability as secondary to service-connected disability should be reviewed on the basis of the additional evidence. Such review should include consideration of whether an examination and nexus opinion is needed. If so, such exam should be conducted. If the benefit sought is not granted in full, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 3. After ensuring that any actions needed to comply with the VCAA, the Veteran and his representative should be provided a Statement of the Case as to the issues of entitlement to an initial evaluation in excess of 20 percent for lumbosacral spondylosis and entitlement to an effective date earlier than September 29, 2006, for the grant of service connection for lumbosacral spondylosis. The Veteran should be informed that he must file a timely and adequate substantive appeal in order to perfect an appeal of these issues to the Board. If a timely substantive appeal is not filed, the claim should not be certified to the Board. If so, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs