Citation Nr: 1337110 Decision Date: 11/14/13 Archive Date: 11/26/13 DOCKET NO. 10-26 169 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent from April 1, 2009, and in excess of 70 percent from May 30, 2012 for service connected posttraumatic stress disorder (PTSD). 2. Entitlement to a disability rating in excess of 20 percent for service connected residuals of a shell fragment wound, left shoulder, with retained foreign body. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Kalisse Anderson, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1962 to June 1966 and from January 1973 to October 1980. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The Veteran testified before the undersigned Veterans Law Judge in December 2011, and a transcript of this hearing is of record. An August 12, 2009 rating decision granted a temporary rating of 100 percent (a total temporary rating) effective January 25, 2009 based on a hospitalization of more than 21 days for service connected PTSD and assigned a 30 percent rating effective April 1, 2009. See August 2009 Rating Decision. This action is not before the Board. In February 2013, the Appeals Management Center (AMC) granted a staged increase rating for the Veteran's service connected PTSD; assigning a 50 percent evaluation for that disability and effectuated the award as of April 1, 2009. Then the AMC assigned a 70 percent evaluation and effectuated the award as of May 30, 2012. See April 2013 Rating Decision. Therefore, the Board has limited its consideration accordingly. In April 2013, the Appeals Management Center (AMC) granted an increased rating for shell fragment wound, left shoulder with retained foreign body; assigning a 20 percent evaluation and effectuated the award as of March 18, 2009 (date of claim). See April 2013 Rating Decision. Therefore, the Board has limited its consideration accordingly. In April 2013, the Appeals Management Center (AMC) granted service connection for traumatic brain injury; assigning a 40 percent evaluation for that disability and effectuated the award as of March 18, 2009 (date of claim). See April 2013 Rating Decision. As a result, the appeal of this issue has been fully resolved in the Veteran's favor and is no longer before the Board. See generally AB v. Brown, 6 Vet. App. 35 (1993). In April 2012, the Board remanded for the scheduling of a VA examination. At that time, only three issues were before the Board. As a result of the development, the AMC granted a separate evaluation for a shell fragment wound scar, left shoulder, in April 2013. The Veteran has not appealed this rating decision and as such, this issue is not before the Board at this time. See April 2013 Rating Decision. FINDINGS OF FACT 1. After April 1, 2009, the Veteran's PTSD was manifested by increased social impairment and isolation, obsessive rituals, depressed mood and panic attacks; there is no evidence of total occupational and social impairment or persistent delusions or hallucinations. 2. The Veteran's dominant hand is his right hand. 3. The Veteran's residuals of a left shoulder shell fragment wound are manifested by no more than moderately severe impairment of the Muscle Group I. 4. The Veteran's residuals of a left shoulder shell fragment wound are manifested by constant pain and numbness of the left shoulder; it is not manifested by a limitation of motion of the arm to 90 degrees or less. CONCLUSIONS OF LAW 1. The criteria for an evaluation of 70 percent, but not greater, for PTSD as of April 1, 2009, have been met. 38 U.S.C.A. §§ 1155, 5107(b) (2002); 38 C.F.R. 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for an evaluation in excess of 20 percent for service-connected residuals of a left shoulder shell fragment wound, Muscle Group I, have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (2002); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.56, 4.73, Diagnostic Code 5301 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Under 38 U.S.C.A. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. In Timberlake v. Gober, 14 Vet. App. 122 (2000), the Court held that the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. The Federal Circuit has also held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378 (Fed. Cir. 2000). It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exist which does not satisfactorily prove or disprove the claim. See U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102 (2012). Disability evaluations are determined by comparing a Veteran's present symptomatology with the criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the 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 the 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement compensation has already been established and an increase in disability rating is at issue, the present level of the Veteran's current disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board has reviewed all evidence of record, as required; however, the more critical evidence consists of the evidence generated during the appeal period. The Board is required to not only to evaluate the medical evidence of record since the filing of the claim for an increased rating but also consider the appropriateness of a "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts). See Hart v. Mansfield, 21 Vet. App. 505 (2007). PTSD The Veteran's PTSD is currently evaluated as 70 percent disabled, effective as of May 30, 2012. However, the Veteran was evaluated as 50 percent disabled from April 1, 2009 through May 29, 2012, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Under this diagnostic code, a 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to symptoms such as: flattened effect; circumstantial, circumlocutory, or stereo typed speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and-long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability evaluation is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id. The classification outlined in the portion of VA's Schedule for Rating Disabilities that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). 38 C.F.R. § 4.130. The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. GAF scores included in the record are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The DSM-IV contemplates that the GAF scale will be used to gauge a person's level of functioning at the time of the evaluation (i.e., the current period) because ratings of current functioning will generally reflect the need for treatment or care. The Board notes that while GAF scores are probative of the Veteran's level of impairment, they are not to be viewed outside the context of the entire record. Therefore, they will not be relied upon as the sole basis for an increased disability evaluation. With regard to the use of the phrase "such as" in 38 C.F.R. § 4.130, ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. Treatment records indicate that, as of April 1, 2009, the Veteran's PTSD results in symptomatology that meets the criteria for an increase to a 70 percent evaluation, but not more. From January to March 2009, the Veteran voluntarily participated in a PTSD management program at the Central Arkansas VA Health Care System. The examiner at the management program reported that the Veteran had "Extreme Re-experiencing Symptoms" such as; intrusive recollections, nightmares, flashbacks, becoming upset at stressor reminders, physical symptoms in response to stressor reminders. See March 2009 VA Treatment Notes Little Rock VA HCS. There is also a report that the Veteran has "Extreme Avoidance Symptoms" such as loss of interest; feeling isolated from other people; avoidance of things/situations that could be stressor reminders, foreshortened sense of future, emotional numbing. The examiner also noted "Extreme Arousal Symptoms" evidenced by problems with concentration; irritability/anger, hyper-vigilance, exaggerated startle and problems with sleep. Id. Lastly, the Veteran's depression screening is consistent with a severe level of depression symptoms such as sadness, discouragement, low self-esteem, inferiority, guilt, indecisiveness, irritability, loss of interest in life, loss of motivation, appetite changes, sleep changes, loss of sex drive and concerns about health. Id. A Mental Diagnostic Evaluation conducted on May 21, 2009, notes the Veteran presented in a depressed mood with constant anger. He experiences manic episodes once to twice a week. See May 2009 VA Psychiatric Examination. The Veteran presented the following additional symptoms to the examiner: anxiety with frequent panic attacks; depression, insomnia and crying spells; anhedonia, nightmares and racing thoughts. Id. The examiner concluded that the Veteran's problem behaviors have to do with his anger, his irritability and his preoccupation with Vietnam. Moreover, the examiner noted that he is constantly irritated and has been physically agitated at family members. Id. The examiner diagnosed the Veteran as having PTSD with a significant mood disorder that is shown with symptoms of manic hyperactivity and virtually constant anger; nightmares once to twice a week; startle symptoms; and hypervigelence. Id. Lastly, the examiner assessed that it was at least as likely as not that the Veteran's condition is somewhat worse than had previously been measured. Id. Additionally, the Veteran submitted lay statements from his sister K.T. and his daughter M.W. In the March 2009 statement from K.T., she notes that the Veteran has extremely limited social interaction with the exception of his children and grandchildren and on occasion his mother and that he is incapable of showing emotion. See March 2009 Letter in Support of the Veteran from K.T. She also reports that he is deeply depressed and does not want anyone around him when he gets into a deep depressive state and that he will not open the door or answer the phone; "you can't talk to him, look at him, and especially touch him." Further, K.T. states that the Veteran angers quickly, he cannot be in crowds and he must always sit so he has a clear line of sight of everything going on around him. Id. The April 2009 lay statement from M.W. reports the following changes in Veteran's symptomology. She states that there are times "when he would dismiss me and ignore me for two to three months at a time." See April 2009 Letter in Support of the Veteran from M.W. She also reports that the Veteran can seem cold and distant, unresponsive to emotion and upon listening to his granddaughter cry, "her three year old cries were met by cold unblinking non-responsive eyes." Id. M.W. states that she has seen the Veteran in severe depression. On one occasion, she reports, "he refused to leave his couch in the living room, for two weeks. "For those weeks he did not talk to anyone, he did not bathe, he didn't even eat in front of me for any of his meals....He rarely cares about his physical appearance, his clothes are often tattered and stained, but they are washed." Id. M.W. states that the Veteran "has one of the fiercest tempers I have ever seen in anyone in my lifetime." Id. M.W. says that the Veteran is easily startled by loud noises such as balloons, firecrackers, sparklers, cats, or any unexpected loud noise will make him scream out and jump up. Id. Further, that Veteran suffers from unprovoked irritability, reporting that she has seen him swing at men, women and even children and that he even elbowed one lady and turned to punch her but held back at the last minute. Id. Lastly, she notices that she has never seen the Veteran sleep for more than five to six hours straight and that he is always complaining about how tired he is all the time. Id. The Veteran's GAF score was reported as 58-60, representing "moderate" symptoms at the May 2009 evaluation. See May 2009 VA Psychiatric Examination. While the Veteran was at the PTSD management study his GAF score was reported at 45, representing "severe" symptoms of PTSD. See March 2009 VA Treatment Notes Little Rock VA HCS. The Board recognizes that one of the Veteran's GAF scores does not match his other more severe PTSD symptoms. However, the Board notes that GAF scores are a picture of the Veteran's level of functioning at the time of the evaluation and are just one component of the Veteran's disability picture. The Board does not have a "formula" that it follows in assigning evaluations. Rather, the Board considers the Veteran's entire disability picture, including GAF scores. Furthermore, the Board need not accept a GAF score as probative. See Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995) (it is the responsibility of the Board to weigh the evidence, including medical evidence, and determine where to give credit and where to withhold the same). As such, in viewing the evidence of record in its entirety, the Board finds that the Veteran's overall disability picture more closely approximates that contemplated by a 70 percent evaluation, overall, after he left the hospital. The Board acknowledges that the Veteran does not meet all of the criteria for a 70 percent disability evaluation. For example, there is no evidence of suicidal ideation, impairment in judgment and spatial disorientation. However, there is evidence that he has near continuous depression, unprovoked irritability, outburst of anger and the inability to establish and maintain effective relationships even within his family. Under such circumstances and resolving any doubt in the Veteran's favor, the Board concludes that the Veteran meets the criteria for a 70 percent evaluation for this stage of the Veteran's appeal. See generally Mauheran v. Principi, 16 Vet. App. 436 (2002). Overall, the evidence discussed above supports no more than a 70 percent evaluation as of April 1, 2009. The Veteran's own statements do not indicate total occupational and social impairment, due to such symptoms as (for example only): gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. In this regard, the Veteran's own statements would provide evidence against such a finding. The evidence of record does not clearly support the 70 percent evaluation, let alone a higher evaluation, but without consideration of the Veteran's statements as a whole, this 70 percent finding can be granted, but not greater. In reaching its decision, the Board considered the benefit of the doubt rule. However, the preponderance of the evidence reflects the Veteran's symptomatology more closely approximates that contemplated by a 70 percent evaluation during this stage of the appeal. Therefore, the benefit of the doubt rule does not apply. 38 U.S.C.A. § 5107(b) (2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Left Shoulder 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. 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. 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, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). Muscle Group damage is categorized as slight, moderate, moderately severe or severe, and is evaluated accordingly under 38 C.F.R. § 4.56. In relevant part, 38 C.F.R. § 4.56(c) describes the signs and symptoms of muscle disability as loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. A "moderate" disability of the muscles involves a through-and-through or deep penetrating wound of a relatively short track by a single bullet or small shell or a shrapnel fragment, and the absence of explosive effect of high-velocity missile and of residuals of debridement or of prolonged infection. There must be evidence of in-service treatment of the wound. There must be a record in the file of consistent complaint of one or more of the cardinal symptoms of muscle disability, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. The objective findings include entrance and, if present, exit scars which are linear or relatively small, and so situated as to indicate a relatively short track of the missile through the muscle tissue, and signs of some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). A "moderately severe" disability of the muscles involves a through-and-through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. There must be evidence in the file showing hospitalization for a prolonged period for treatment of the wound. There must be a record of consistent complaint of cardinal signs and symptoms of muscle disability, and if present, evidence of inability to keep up with work requirements. The objective findings include entrance and, if present, exit scars indicating the track of missile through one or more Muscle Groups, indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side, and tests of strength and endurance compared with sound side must demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). A "severe" disability of the muscles involves a through-and-through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. There must be evidence showing hospitalization for a prolonged period for treatment of the wound. There must also be a record of consistent complaint of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries, and if present, evidence of inability to keep up with work requirements. The objective findings include ragged, depressed and adherent scars indicating wide damage to Muscle Groups in missile track, palpation showing loss of deep fascia or muscle substance, or soft flabby muscles in wound area, muscles swelling and hardening abnormally in contraction, and tests of strength, endurance, or coordinated movements compared with the corresponding muscles of uninjured side indicating severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; (B) adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; (C) diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (D) visible or measurable atrophy; (E) adaptive contraction of an opposing group of muscles; (F) atrophy of Muscle Groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; (G) induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d)(4). Muscle Group I involves the extrinsic muscles of the shoulder girdle including the (1) trapezius, (2) levator scapulae and (3) serratus magnus that govern functioning of upward rotation of the scapula and the elevation of arm above shoulder level. Moderate impairment of the non-dominant arm is evaluated as 10 percent disabling, moderately severe impairment is afforded a 20 percent evaluation, and severe impairment is evaluated as 30 percent disabling. Limitation of motion of the shoulder is evaluated under Diagnostic Codes 5200 and 5201. See 38 C.F.R. § 4.71(a). Diagnostic Code 5201 affords a 20 percent evaluation for limitation of the arm at the shoulder level (minor side), 20 percent at midway between the side and shoulder level (minor side), and 30 percent to 25 degrees from the side (minor side). Diagnostic Code 5200 provides evaluations for ankylosis of the scapulohumeral articulation (minor side). A 20 percent evaluation is warranted for favorable ankylosis with abduction to 60 degrees and ability to reach the mouth and head. A 30 percent is warranted for intermediate ankylosis between favorable and unfavorable. A 40 percent evaluation is warranted for unfavorable abduction limited to 25 degrees from the side. The normal range of motion of the shoulder is 180 degrees of forward elevation (flexion) and abduction, and 90 degrees of external rotation. 38 C.F.R. § 4.71, Plate I. Limitation of motion at the shoulder level equates to 90 degrees of either flexion or abduction. Additionally, when making a determination of the Veteran's current disability rating it is important to note the "amputation rule," set forth at 38 C.F.R. § 4.68, which provides that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at that elective level, were an amputation to be performed. Simply stated, the Board cannot give the Veteran more compensation for his disability than it would a Veteran without a left arm. As a result, the Veteran's service-connected disabilities of the left upper extremity involve the area of the Veteran's left scapula of the shoulder; his combined rating (of the left upper extremity disabilities) may not exceed 80 percent. See 38 C.F.R. § 4.71(a), Diagnostic Code 5121 (amputation of the minor arm above the insertion of the deltoid warrants a disability rating of 80 percent). Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 must be considered. DeLuca, 8 Vet. App. at 206. Under C.F.R. § 4.59, painful motion is an important factor of disability from arthritis and actually painful joints are entitled to at least the minimum compensable rating for the joint. Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80 (1997). The Veteran underwent a VA examination of his left shoulder in July 2009. At the examination in 2009, the examiner reported that the Veteran's left shoulder shell fragment wounds residuals resulted in loss of strength in the left shoulder. The Veteran reported subjective complaints of pain, especially after using both arms for a prolonged period of time. The diagnosis that the examiner offered in 2009 was that there was a 7x7 mm metallic fragment in the subcutaneous soft tissues of the back on the left. The Veteran presented with mild glenohumeral degenerative joint disease. There was no evidence of joint effusion, fractures or tendon calcification. See July 2009 VA Examination of the Muscles. Pursuant to the April 2012 Board Remand, the Veteran underwent a VA examination of his left shoulder in March 2013. At that time, the Veteran reported that he was experiencing increasing pain and near constant numbness in his left shoulder. The Veteran also reported that he was not able to pick up anything heavy with his left arm. Upon examination, the examiner confirmed the existence of shrapnel in the Veteran's left shoulder. The examiner also noted the Veteran's loss of function of the left arm due to weakness; the Veteran cannot lift more than 15 to 20 lbs. See March 2013 VA Examination of the Muscles. With respect to the Veteran's range of motion testing, the Veteran had full range of motion of the left shoulder with no objective evidence of pain on motion, providing highly probative evidence against this claim. The Veteran continued to have full range of motion after three repetitive tests. The examiner found evidence of peripheral neuropathy that led to moderate pain and numbness in the left upper extremity. There is objective evidence that the Veteran has hypoactive tendon flexes in the Veteran's biceps, triceps and brachioradialis. After evaluating the Veteran's left shoulder disabilities and based upon the March 2013 VA examination results obtained pursuant to the April 2012 Board Remand, the AMC increased the Veteran's disability evaluation of residuals of the left shoulder fragment wound, Muscle Group I minor, from 10 percent to 20 percent, effective date of claim. The Board agrees with the AMC's decision as the evidence indicates that a 20 percent, but not higher, rating is warranted. The Veteran is not entitled to a higher rating because he does not present with the symptomatology necessary for a 30 percent evaluation. There is no evidence of loss of deep fascia or muscle substance, or soft flabby muscles in contraction and no indication of severe impairment of function, all which would warrant a higher evaluation. The Board is required to look at all possible theories of entitlement and as such, the Board has considered whether the Veteran is entitled to a separate evaluation for his shoulder disability based upon limitation of motion. As noted above, the full range of motion of the shoulder equates to 180 degrees of flexion or abduction. The March 2013 VA Examination of the Muscles does not indicate any limitation of motion of the shoulder nor pain on motion. The Veteran has full range of motion both on flexion and on abduction. Under Diagnostic Code 5201, 20 percent evaluation is warranted where motion of the minor arm is limited to shoulder level (90 degrees). Motion limited to midway between side and shoulder level (45 degrees) warrants a 20 percent evaluation for the minor extremity. Finally, maximum 30 percent evaluation is warranted for the minor extremity where motion is limited to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2012). The Veteran's shoulder disability is manifested throughout the appeal period by subjective complaints of pain and numbness with objective evidence of weakness. However, there is no evidence of abduction or forward flexion of the left arm limited to shoulder level (90 degrees) or less. There was no additional limitation of motion due to pain, fatigue, weakness, lack of endurance or incoordination following repetitive use. See DeLuca, 8 Vet. App. at 206 (1995). As a result, the Board has determined that a higher evaluation is not warranted under any alternate Diagnostic Code at any point during the appeal period. There is no evidence of ankylosis of the scapulohumeral articulation, recurrent dislocation of the scapulohumeral joint or other impairment of the humerus. As such, a higher evaluation under Diagnostic Codes 5200 or 5202 is not warranted. Additional Considerations The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA rating schedule will apply unless there are exceptional or unusual factors that would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has 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 to determine whether the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disabilities is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities on appeal with the established criteria found in the rating schedule for these disabilities show that the rating criteria reasonably describes the Veteran's disability level and symptomatology. Specifically, the symptoms of his left shoulder disability, which include constant pain and numbness, are contemplated in the applicable rating criteria. Additionally, the Veteran's social impairment, obsessive rituals and nightmares are contemplated in the applicable criteria that rate his PTSD. Lastly, entitlement to a total disability rating based upon individual unemployability (TDIU) is an element of all increased rating claims. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the record is negative for evidence that the Veteran is unemployable. He is not in receipt of Social Security disability benefits and there is no medical evidence that the Veteran's disabilities have markedly interfered with employment. Additionally, the Veteran has stated that he is currently in retirement. Simply stated, he own statements do not indicate that this issue is being raised by the record. Therefore, remand or referral of a claim for TDIU is not necessary, as there is no evidence of unemployability due to his service-connected disabilities. The Board does note that the Veteran previously applied for TDIU benefits and was denied by the RO in a May 2008 rating decision. The Veteran did not appeal that decision. Therefore, a review of the Veteran's TDIU application is not before the Board at this time. See AB, 6 Vet. App. at 37 (1993). Duties to Assist and Notify When VA receives a complete or substantially complete application for benefits, it must notify the claimant of (1) the information and evidence not of record that is necessary to substantiate a claim, (2) which information and evidence VA will obtain, and (3) which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002). See Pelegrini v. Principi, 18 Vet. App. 112 (2004). For increased-rating claims, 38 U.S.C.A. § 5103(a) requires the Secretary "to notify the claimant that to substantiate such a claim the claimant should provide or ask the Secretary to obtain medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment." Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102-103 (2010) (Vazquez-Flores II) (citing Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1279-80 (Fed. Cir. 2009) and Vazquez-Flores v. Peake, 22 Vet. App. 37, 43 (2008)). The Veteran received notification prior to the initial unfavorable agency decision through a July 2009 letter. The Veteran's claim was subsequently readjudicated, most recently in an April 2013 supplemental statement of the case. The duty to notify the Veteran was satisfied under the circumstances of this case. 38 U.S.C.A. § 5103. VA must also make reasonable efforts to assist the appellant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claims. 38 U.S.C.A. § 5103A (2002); 38 C.F.R. § 3.159 (2012). Service treatment records have been associated with the claims file. All post-service treatment records and reports identified by the Veteran have also been obtained. The Veteran has not identified any additional records that should be obtained prior to a Board decision. Therefore, VA's duty to assist the Veteran in obtaining records has been satisfied. See 38 C.F.R. § 3.159(c)(4). The Veteran was afforded VA examinations in May 2012 and March 2013. See 38 U.S.C.A. § 5103A; see also 38 C.F.R. § 3.159(c)(4); Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). The Board finds the VA examinations adequate for the purposes of the present claim, as it involved a review of the Veteran's pertinent medical history as well as physical and psychological examinations and provides a discussion of the relevant symptomatology. See generally Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the fullest extent possible; no further assistance to the appellant in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103 and 5103A; see 38 C.F.R. § 3.159. ORDER An increase evaluation of 70 percent, but not greater, for PTSD as of April 1, 2009, is granted, subject to the laws and regulations governing the payment of monetary benefits. An increase evaluation of 20 percent for a shell fragment wound, left shoulder is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs