Citation Nr: 1338147 Decision Date: 11/20/13 Archive Date: 12/06/13 DOCKET NO. 03-26 083 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for a cervical spine disability. 2. Entitlement to an initial rating in excess of 10 for a right shoulder disability. 3. Entitlement to an initial compensable rating for Wolff-Parkinson-White disease. 4. Entitlement to an initial compensable rating for hemorrhoids. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. L. Douglas, Counsel INTRODUCTION The appellant is a veteran who served on active duty from July 1976 to July 2002. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2002 rating decision by the Columbia, South Carolina, Regional Office (RO) of the Department of Veterans Affairs (VA). In March 2005, the Veteran testified at a video conference hearing before the undersigned Acting Veterans Law Judge. A copy of the transcript of that hearing is of record. The issues on appeal were adequately explained to him and the submission of evidence which he may have overlooked and which would be advantageous to his position was suggested. See 38 C.F.R. § 3.103(c) (2013); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Board, in pertinent part, remanded the issues on appeal for additional development in July 2006 and June 2013. A July 2013 rating decision granted an increased 10 percent rating for the Veteran's service-connected right shoulder disability. An effective date was established for this increased rating from August 1, 2002, the date following the Veteran's separation from active service. The Veteran continues to seek the maximum benefit allowed by law for this disability. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). The issue provided on the title page as to this matter has been revised. In addition to the paper claims file, there is a Virtual VA (VVA) electronic claims file associated with the Veteran's claim. Both the Board and originating agency (see June 2012 and September 2013 Supplemental Statements of the Case (SSOCs)) have reviewed VA treatment records and examination reports dated from 2002 to 2013 contained in the VVA file. The VVA file also contains a September 2013 Informal Hearing Presentation submitted by the Veteran's representative. The other documents in the VVA file are either duplicative of the evidence in the paper claims file or irrelevant to this appeal. FINDINGS OF FACT 1. For the period of the appeal, the Veteran's service-connected cervical spine disability has been manifested by no more than slight limitation of cervical spine motion, including as a result of pain and dysfunction. Forward flexion has been limited to no less than 40 degrees; ankylosis has not been present; and there have been no incapacitating episodes. 2. For the period of the appeal, the Veteran's service-connected right shoulder disability has been manifested by no more than painful motion of a major joint with arthritis. Ankylosis, limitation of motion of the arm at the shoulder level, nonunion, or dislocation is not shown. 3. For the period of the appeal, the Veteran's service-connected Wolff-Parkinson-White disease has been manifested by no more than a heart disorder than requires medication, with no documented episode of paroxysmal atrial fibrillation or other supraventricular tachycardia. 4. For the period of the appeal, the Veteran's service-connected hemorrhoids have been manifested by no more than mild or moderate symptoms. CONCLUSIONS OF LAW 1. The criteria for initial rating in excess of 10 percent for a cervical spine disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5290, 5295 (effective prior to September 23, 2003); 38 C.F.R. §§ 4.1, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5237 (2013). 2. The criteria for initial rating in excess of 10 percent for a right shoulder disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5201 (2013). 3. The criteria for an initial compensable rating for Wolff-Parkinson-White disease have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.31, 4.104, Diagnostic Code 7010 (2013). 4. The criteria for an initial compensable rating for hemorrhoids have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.114, Diagnostic Code 7336 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Assist and Notify 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; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). As part of the notice, VA is specifically to inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The United States Court of Appeals for Veterans Claims (Court) has also held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The Court further held that VA failed to demonstrate that "lack of such a pre-AOJ-decision notice was not prejudicial to the appellant, see 38 U.S.C. § 7261(b)(2) (as amended by the Veterans Benefits Act of 2002, Pub. L. No. 107-330, § 401, 116 Stat. 2820, 2832) (providing that '[i]n making the determinations under [section 7261(a)], the Court shall...take due account of the rule of prejudicial error')." The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In any event, however, the statutory scheme contemplates that, once a decision awarding service connection, a disability rating, and an effective date have been made, statutory notice has served its purpose, and its application is no longer required because the claim has already been substantiated. Dingess/Hartman, 19 Vet. App. 473, 490-91 (2006). Here, the Veteran is exercising his right to appeal the initial ratings assigned. A January 2003 statement of the case (SOC) properly provided the Veteran with notice of the criteria for rating cervical spine, shoulder, heart and hemorrhoid disabilities, and further notice on the downstream issue of an initial increased rating, including of what the evidence showed, and why the current ratings were assigned. The Veteran has had opportunity to respond. He is not prejudiced by this process. Notably, he does not allege that notice in this case was less than adequate or that he has been prejudiced by any notice deficiency. Regarding VA's duty to assist, all appropriate development to obtain the Veteran's service treatment records (STRs) and pertinent medical records (including VA and private) has been completed. The Veteran has not identified any pertinent, outstanding records that could be obtained to substantiate his claim. The Board is also unaware of any such records. The Veteran has provided testimony in support of his claim. The development requested on remand in July 2006 and June 2013 has been substantially completed. The Board finds that there has been substantial compliance with its remand instructions and additional remand is not required. D'Aries v. Peake, 22 Vet. App. 97 (2008) (noting that substantial rather than strict compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). There is no evidence of any additional existing pertinent records. In July 2013, the Veteran's service representative reported that they had no additional evidence to provide in support of the claims. The Board finds that further attempts to obtain additional evidence would be futile. The Veteran was afforded the appropriate VA examinations, most recently in 2013. When VA undertakes to provide a VA examination or obtain a VA opinion it must ensure that the examination or opinion is adequate. VA medical opinions obtained in this case are adequate as they are predicated on a substantial review of the record and medical findings and consider the Veteran's complaints and symptoms. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion as to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4) (2013). The available medical evidence is sufficient for adequate determinations. Increased Rating Claims Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. This 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 percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. For the application of this schedule, accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. Over a period of many years, a veteran's disability claim may require reratings in accordance with changes in laws, medical knowledge and his or her physical or mental condition. It is thus essential, both in the examination and in the evaluation of disability, that each disability be viewed in relation to its history. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The Court has held that a claim for a higher rating when placed in appellate status by disagreement with the original or initial rating award (service connection having been allowed, but not yet ultimately resolved), remains an "original claim" and is not a new claim for an increased rating. See Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Id. at 126. It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses is prohibited. 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. 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. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Cervical Spine Disability The Veteran contends that a rating in excess of 10 percent is warranted for his cervical spine disability. In statements in support of his claim he asserted, in essence, that his neck pain was the result of his duties on airborne jump status for 26 years. He testified in March 2005 that he experienced stiffness three to four times per week. His treatment at that time included medication and physical therapy exercises. He stated he had missed two days of school that semester due to morning neck pain. STRs show that upon retirement examination in November 2001 the Veteran complained of upper spine pain. On VA examination in January 2002 there was full extension and extension of the cervical spine. Left and right lateral bending and rotation of the neck were without limitation. Spurling's, emit, and Hoffman's signs were negative. Motor strength was 5/5 to the upper extremities and deep tendon reflexes were 2+ and symmetric. X-ray studies revealed some straightening of the cervical spine and mild loss of disc height at C5-6. Service connection was established for a cervical spine disorder in March 2002. A noncompensable rating was assigned effective from August 1, 2002. On VA examination in December 2006 the Veteran complained of bilateral upper trapezius pain, more on the right than left. He denied any acute incapacitating episodes in the past 12 months in which a physician had prescribed bed rest. He used a TENS unit and medication with some relief. It was noted he reported he was a cafeteria manager and that his neck disorder did not affect his usual occupation. He reported, however, that he sometimes experienced sharp pain in the neck and that driving was difficult because of decreased range of neck motion. He stated that approximately twice per month he experienced flare-ups lasting three to four days. The examiner noted neck flexion to 40 degrees and extension to 35 degrees. Right rotation was to 45 degrees and left rotation was to 50 degrees. Lateral flexion to the right was to 35 degrees and to the left was to 30 degrees. The motions were without pain and did not change with repetitive use. There was no spasm or tenderness. Motor strength, tone, and light touch sensation were normal in the upper extremities. Deep tendon reflexes were 2+ in the upper extremities. The diagnoses included cervical degenerative joint disease. A June 2007 rating decision, in pertinent part, granted an increased 10 percent rating, effective from August 1, 2002. VA examination in June 2013 revealed multi-level degenerative disc disease from C4-5 through C6-7. It was noted the Veteran did not report flare-ups that impacted the function of his cervical spine. Range of motion studies revealed forward flexion to 40 degrees, extension to 35 degrees, right lateral flexion to 35 degrees, left lateral flexion to 35 degrees, right lateral rotation to 35 degrees, and left lateral rotation to 35 degrees. Objective evidence of painful motion began at the end points of these motions. Range of motion was unchanged on repetitive motion testing. There was no evidence of additional limitation in range of motion following repetitive-use testing and no functional loss or functional impairment of the cervical spine. There was no localized tenderness or pain to palpation to the cervical spine, there was no guarding or muscle spasm, and no muscle atrophy. Upper extremity strength, deep tendon reflexes, and sensory examinations were normal. There was no radicular pain, no other signs or symptoms due to radiculopathy, and no evidence of other neurologic abnormalities. The examiner noted that X-ray studies revealed arthritis and multi-level degenerative disc disease. The disorder was found not to render the Veteran unable to secure and maintain a substantially gainful light physical and sedentary type of employment comparable to his present job. The disorder was described as currently mild and was noted to only be problem in a very heavy physical type of job. The evidence of record also includes VA treatment records dated from 2002 to 2013, which show no findings of forward flexion of the neck limited to 30 degrees or less, ankylosis, or incapacitating episodes. The Rating Schedule criteria for disabilities of the spine were amended and the diagnostic codes renumbered effective September 26, 2003. See 68 Fed. Reg. 51,454 (Aug. 27, 2003). Where the law or regulations governing a claim are changed while the claim is pending the version most favorable to the claimant applies (from the effective date of the change), absent congressional intent to the contrary. VA's General Counsel, in a precedent opinion, has held that when a new regulation is issued while a claim is pending before VA, unless clearly specified otherwise, VA must apply the new provision to the claim from the effective date of the change as long as the application would not produce retroactive effects. VAOPGCPREC 7-2003 (Nov. 19, 2003); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The Rating Schedule provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a 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. In the absence of limitation of motion, a 20 percent rating is assigned with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating is assigned with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Ratings based on X-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2013). Prior to September 26, 2003, the rating criteria for limitation of cervical spine motion provided ratings for limitation that was severe (30 percent), moderate (20 percent), and slight (10 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5290 (effective prior to September 26, 2003). Prior to September 26, 2003, the rating criteria for lumbosacral strain provided ratings for disorders that were severe, with listing of whole spine to opposite side, positive Goldthwaite's sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion (40 percent); with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position (20 percent); with characteristic pain on motion (10 percent); and with slight subjective symptoms only (0 percent). 38 C.F.R. § 4.71a , Diagnostic Code 5295 (effective prior to September 26, 2003). Effective September 26, 2003, the rating criteria for the spine were revised and the diagnostic codes were renumbered (including cervical strain, Diagnostic Code 5237, and degenerative arthritis of the spine, Diagnostic Code 5242) and are to be evaluated under the general rating formula for rating diseases and injuries of the spine (outlined below). 38 C.F.R. § 4.71a (2013). Under the general rating formula for rating diseases and injuries of the spine, effective September 26, 2003, with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. A rating of 10 percent is warranted if forward flexion of the cervical spine is greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted if forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees, or the combined range of motion of the cervical spine is not greater than 170 degrees, or muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted if forward flexion of the cervical spine in 15 degrees or less or favorable ankylosis of the entire cervical spine. A 40 percent evaluation is warranted if there is unfavorable ankylosis of the entire cervical spine. Unfavorable ankylosis of the entire spine warrants a 100 percent rating. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2013). Intervertebral disc syndrome will be evaluated under the general formula for rating diseases and injuries of the spine (outlined above) or under the formula for rating intervertebral disc syndrome based on incapacitating episodes (outlined below), whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2013). Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent rating is warranted for incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. For purposes of evaluation under Diagnostic Code 5243, an "incapacitating episode" is a period of acute signs and symptoms due to Intervertebral Disc Syndrome that require bed rest as prescribed by a physician and treatment by a physician. 38 C.F.R. § 4,71a, Diagnostic Code 5243 (2013). There are several notes set out after the diagnostic criteria, which provide the following: First, associated objective neurologic abnormalities are to be rated separately under an appropriate diagnostic code. Second, for purposes of VA compensation, normal forward flexion of the cervical spine is 0 to 45 degrees, normal extension is 0 to 45 degrees, normal left and right lateral flexion is 0 to 45 degrees, and normal left and right lateral rotation is 0 to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is to 340 degrees. Third, in exceptional cases, an examiner may state that, because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in the regulation. Fourth, each range of motion should be rounded to the nearest 5 degrees. Fifth, unfavorable ankylosis is a condition in which the entire cervical spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Sixth, disabilities of the thoracolumbar and cervical spine segments shall be separately evaluated, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2013). The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See note at "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124(a). "[F]unctional loss due to pain is to be rated at the same level as the functional loss when flexion is impeded." Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1993). The Court has held that pain itself does not rise to the level of functional loss as contemplated by VA regulations, but that pain may result in functional loss if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination[, or] endurance." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Based upon the evidence of record, the Board finds the Veteran's service-connected cervical spine disability is manifested by no more than slight limitation of motion. VA examination in January 2002 revealed full extension and extension of the cervical spine with left and right lateral bending and rotation of the neck motion without limitation. Combined range of motion in December 2006 was 235 degrees without pain and the range did not change with repetitive use. The examiner noted there was no spasm or tenderness. Combined range of motion in June 2013 was 215 degrees with objective evidence of painful motion at those end points. There was no evidence at that time of additional limitation in range of motion following repetitive-use testing and no functional loss or functional impairment of the cervical spine. There was no localized tenderness or pain to palpation to the cervical spine, no guarding or muscle spasm, and no muscle atrophy. There was no evidence of radiculopathy, ankylosis, or incapacitating episodes. Without more significant limitation of motion or incapacitating episodes, an increased rating is not warranted under 38 C.F.R. § 4.71a , Diagnostic Codes 5235-5243. See Fenderson, supra. The Board has also considered whether a separate compensable rating for neurological impairment is warranted during the period of the appeal. However, the medical evidence of record does not show any evidence of neurological impairment due to the cervical spine disability. See June 2013 VA examination report which notes findings of no neurological impairment. Therefore, the Board finds that an additional award for neurological impairment is not warranted for any portion of the initial rating period. The Board acknowledges that the Veteran, as a lay person, is competent to provide evidence of his experienced symptoms. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (finding lay testimony competent when it concerns features or symptoms of injury or illness). Although he reported having morning neck stiffness and flare-ups of neck pain, his statements as to a more severe disability are not shown by objective evidence and are inconsistent with the June 2013 VA examiner's finding that his disability is mild. The Board finds his statements as to more severe symptoms and limitation of motion, including during flare-ups, are not credible as to this fact. There is no objective evidence of more movement than normal, weakened movement, excess fatigability, incoordination or impaired ability to execute skilled movements smoothly, swelling, deformity, or atrophy of disuse. The January 2002, December 2006 and June 2013 VA examination findings are found to be persuasive as to the severity of the Veteran's service-connected cervical spine disability. The examiners are shown to have reviewed the evidence of record and to have conducted thorough examinations with adequate consideration of the Veteran's reported symptoms. Therefore, the claim for a higher schedular rating under the old or new rating criteria is not warranted. The Board further finds there is no evidence of any unusual or exceptional circumstances that would take this case outside the norm so as to warrant an extra-schedular rating. The Veteran's service-connected cervical spine disability is found to be adequately rated under the available schedular criteria and the objective findings of impairment are well documented. Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology (pain and limitation of motion) of his cervical spine disability. An evaluation in excess of that assigned is provided for certain manifestations of the service-connected disability at issue, but the medical evidence reflects that those manifestations are not present in this case. The Court in Thun v. Peake, 22 Vet. App. 111 (2008), has established a three-step inquiry for determining whether a veteran is entitled to extra-schedular rating consideration. 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 level of disability and symptomatology and is found to be inadequate, then 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 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. The overall evidence of record in this case is not indicative of a marked interference with employment as a result of the service-connected disability. In fact, the June 2013 VA examiner found the Veteran's cervical spine disability was mild and that it should not to render him unable to secure and maintain a substantially gainful light physical and sedentary type of employment comparable to his present job. There is also no evidence of other related factors such as frequent periods of hospitalization due to this disability. Therefore, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). When all the evidence is assembled, VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert, supra; Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The Board finds that the preponderance of the evidence is against the Veteran's claim. Right Shoulder Disability The Veteran contends that a rating in excess of 10 percent is warranted for his right shoulder disability. In statements and testimony in support of his claim he asserted, in essence, that he has experienced constant pain, exacerbated by lifting. He testified that he had very little motion and flexibility in the arm and that his doctors had indicated it was due to arthritis and bursitis. He stated his symptoms were worse during rainy and cold weather. STRs show that the Veteran complained of right shoulder pain upon retirement examination in November 2001. On VA examination in January 2002 he reported he did not recall any specific right shoulder injury, but that it may have occurred during a parachute jump. He complained of pain on the outside of the shoulder and limited range of motion secondary to popping and grinding with significant activity. It was noted he was right hand dominant. Range of motion studies revealed abduction to 160 degrees, forward flexion to 160 degrees, external rotation to 45 degrees, and internal rotation to the back pocket. Motor strength was 5/5 in all motor groups with negative Hawkin's sign, negative Neer sign, negative slap apprehension, negative apprehension, negative cross-arm reduction sign, and a 2+ radial pulse. X-ray study of the right shoulder was negative. VA treatment records dated in December 2003 noted occupational therapy treatment revealed flexion to 120 degrees, abduction to 120 degrees, external rotation to 85 degrees, and internal rotation to 35 degrees with difficulty reaching behind the back. Provisional diagnoses included right shoulder pain and bursitis. At his VA examination in December 2006 the Veteran complained of right shoulder pain, particularly at night. There was no stability and no flare-ups. He reported that the disorder limited his lifting at work and interfered with his sleep and carrying and holding his granddaughter. The examiner noted abduction to 180 degrees, flexion to 145 degrees, external rotation to 90 degrees, and internal rotation to 45 degrees. These motions were without pain except for right internal rotation with end-of-range pain. Range of motion was not additionally limited following repetitive use. Supraspinatus strength was normal. There was some right posterior shoulder pain on extreme passive flexion as an impingement sign. The diagnoses included right shoulder impingement. The evidence of record also includes VA treatment records dated from 2007 to 2013, which show no findings of limitation of arm motion to 25 from the side, to midway between side and shoulder level, or at shoulder level. VA examination in June 2013 revealed degenerative joint disease of the right shoulder based upon X-ray examination. The Veteran did not report flare-ups that impacted function of the shoulder and/or arm. Right shoulder flexion was to 170 degrees and abduction was to 100 degrees. Post-repetitive motion testing revealed flexion to 170 degrees and abduction to 100 degrees. There was no evidence of additional limitation in range of motion following repetitive-use testing and no functional loss or functional impairment of the shoulder. There was no localized tenderness or pain to palpation of the joint, soft tissue, or biceps tendon, and no evidence of guarding. Muscle strength to the abduction and forward flexion were normal. Hawkin's impingement, empty-can, external rotation/infraspinatus strength, and lift-off subcapsularis testing were negative. There was no history of mechanical symptoms and no history of recurrent dislocations. Crank apprehension and relocation testing was negative. It was noted that arthritis was shown by X-ray study. The examiner stated that the shoulder disorder would limit a heavy physical type of work, but that it should not to render the Veteran unable to secure and maintain a substantially gainful light physical and sedentary type of employment comparable to his present job. The Rating Schedule provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a 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. In the absence of limitation of motion, a 20 percent rating is assigned with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating is assigned with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Ratings based on X-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Rating are provided for limitation of arm motion for the major arm when motion is limited to 25 from the side (40 percent), limited to midway between side and shoulder level (30 percent), and at shoulder level (20 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5201. Other diagnostic codes for rating shoulder disability (5200, 5202, and 5203) are not for consideration because, as will be discussed below, the pathology required by such codes-ankylosis of the scapulohumeral articulation; flail shoulder; false flail joint; fibrous union of the humerus; recurrent dislocation of the humerus at the scapulohumeral joint; malunion of the humerus; or impairment of the clavicle or scapula ankylosis-is not shown.) Normal ranges of shoulder motion are defined by VA regulation as follows: forward elevation (flexion) from zero to 180 degrees; abduction from zero to 180 degrees; and internal and external rotation to 90 degrees. Lifting the arm to shoulder level is lifting it to 90 degrees. 38 C.F.R. § 4.71, Plate I. Based upon the evidence of record, the Board finds the Veteran's service-connected right shoulder disability is manifested by no more than arthritis and noncompensable limitation of motion. VA examination in January 2002 revealed abduction to 160 degrees and forward flexion to 160 degrees. An X-ray study of the right shoulder at that time was negative. On VA examination in December 2006 abduction was to 180 degrees and flexion was to 145 degrees without pain. Range of motion was not additionally limited following repetitive use. VA examination in June 2013 revealed flexion to 170 degrees and abduction to 100 degrees. The Veteran did not report flare-ups that impacted function of the shoulder and/or arm. There was no evidence of additional limitation in range of motion following repetitive-use testing and no functional loss or functional impairment. Although the Veteran has reported having constant right shoulder pain, his statements as to a more severe disability are not shown by objective evidence and are inconsistent with the examination findings as to the severity of his disability. There is no objective evidence of more movement than normal, weakened movement, excess fatigability, incoordination or impaired ability to execute skilled movements smoothly, swelling, deformity, or atrophy of disuse. The January 2002, December 2006, and June 2013 VA examination findings are found to be persuasive as to the severity of the Veteran's service-connected right shoulder disability. The examiners are shown to have reviewed the evidence of record and to have conducted thorough examinations with adequate consideration of the Veteran's reported symptoms. The Board notes that examinations have revealed decreased internal and external rotation, but that the Rating Schedule does not provide ratings based upon limitation of these motions absent ankylosis of scapulohumeral articulation or dislocation, nonunion, or malunion of the clavicle or scapula which are not shown in this case. See 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5203. Therefore, the claim for a higher schedular rating is not warranted. The Board further finds there is no evidence of any unusual or exceptional circumstances that would take this case outside the norm so as to warrant an extra-schedular rating. The Veteran's service-connected right shoulder disability is found to be adequately rated under the available schedular criteria and the objective findings of impairment are well documented. The overall evidence of record in this case is not indicative of a marked interference with employment as a result of the service-connected disability. In fact, the June 2013 VA examiner found the Veteran's right shoulder disability should not to render him unable to secure and maintain a substantially gainful light physical and sedentary type of employment comparable to his present job. There is also no evidence of other related factors such as frequent periods of hospitalization due to this disability. Therefore, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. The Board finds that the preponderance of the evidence is against the Veteran's claim. When all the evidence is assembled, VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert, supra; Ortiz, supra. The Board finds that the preponderance of the evidence is against the Veteran's claim. Wolff-Parkinson-White Disease The Veteran contends that a compensable rating is warranted for his service-connected heart disability (Wolff-Parkinson-White disease). In March 2005, he testified that he was treated in service for supraventricular tachycardia arrhythmia and that he was presently taking medication for high blood pressure and irregular heart beat. Service connection has been separately established for hypertension and has not been developed for appellate review. On VA examination in January 2002 the Veteran reported that he had experienced palpitation while doing exercises during active service and underwent cardiac catheterization and ablation of Wolff-Parkinson-White syndrome. It was noted he still had palpitations now and then, but that he was not on any medications and did not have a pacemaker or defibrillator. The examiner noted that on heart examination S-1 and S-2 were audible with no murmurs. It was noted that an echo study revealed an ejection fraction of 62 percent, a normal left ventricle, a dilated left atrial chamber, a normal right atrial chamber, and a normal right ventricular chamber. Exercise tolerance testing was 14.2. The exercise stress test by Bruce protocol was adequate by heart rate and double product. VA treatment records dated in July 2011 noted a stress test Regadenoson with myocardial perfusion imaging revealed normal left ventricular size and function. The left atrium was mildly dilated. VA examination in June 2013 included a diagnosis of Wolff-Parkinson-White syndrome. The examiner noted that at present the Veteran's heart rate was normal with no evidence of tachycardia. It was noted that continuous medication was required for the condition. There had been no episodes of cardiac arrhythmia in the past 12 months. The examiner stated that the heart disorder would prevent heavy physical type of employment, but that it should not to render the Veteran unable to secure and maintain a substantially gainful light physical and sedentary type of employment comparable to his present job. The disorder was noted to have been quite stable since the ablation procedure and that medication maintenance was regulating his heart rhythm quite well. Evidence of record includes VA treatment records dated from 2002 to 2013, which do not show one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor. The Rating Schedule for supraventricular arrhythmias provides that with paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year documented by ECG or Holter monitor (30 percent) and with permanent atrial fibrillation (lone atrial fibrillation), or, one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor (10 percent). 38 C.F.R. § 4.104, Diagnostic Code 7010. Wolff-Parkinson-White syndrome is defined as the association of paroxysmal tachycardia (or atrial fibrillation) and preexcitation, in which the electrocardiogram displays a short P-R interval and a wide QRS complex which characteristically shows an early QRS vector (delta wave). See Dorland's Illustrated Medical Dictionary1837 (30th ed. 2003). Based upon the evidence of record, the Board finds the Veteran's service-connected Wolff-Parkinson-White disease is manifested by no more than required medication with no documented episode of paroxysmal atrial fibrillation or other supraventricular tachycardia. Although the Veteran contends that he continued to experience heart palpitations, episodes of paroxysmal atrial fibrillation or other supraventricular tachycardia are complex medical findings for which medical expertise is required. The Veteran is not shown to have acquired such medical expertise and the June 2013 VA examiner's opinion is found to be persuasive. The examiner is shown to have reviewed the evidence of record and to have conducted a thorough examination with adequate consideration of the Veteran's reported symptoms. Therefore, the claim for a higher schedular rating is not warranted. The Board further finds there is no evidence of any unusual or exceptional circumstances that would take this case outside the norm so as to warrant an extraschedular rating. The Veteran's service-connected heart disability is found to be adequately rated under the available schedular criteria and the objective findings of impairment are well documented. The overall evidence of record in this case is not indicative of a marked interference with employment as a result of the service-connected disability. In fact, the June 2013 VA examiner found the Veteran's heart disability should not to render him unable to secure and maintain a substantially gainful light physical and sedentary type of employment comparable to his present job. There is also no evidence of other related factors such as frequent periods of hospitalization due to this disability. Therefore, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. The Board finds that the preponderance of the evidence is against the Veteran's claim. When all the evidence is assembled, VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert, supra; Ortiz, supra. The Board finds that the preponderance of the evidence is against the Veteran's claim. Hemorrhoids The Veteran contends that a compensable rating is warranted for his service-connected hemorrhoids. At his March 2005 hearing he testified that he continued to have problems with hemorrhoids that occasionally dropped and that he had to use medication every day. On VA examination in January 2002 the Veteran complained of hemorrhoids with bleeding every three to six months. He stated he used Preparation H for treatment. Rectal examination revealed hemorrhoids at the 3:00 and 4:00 positions with no fissure or ulceration. Hemoccult stool was negative. The diagnoses included internal hemorrhoids. VA examination in June 2013 revealed mild or moderate internal or external hemorrhoids. The examiner noted his treatment plan did not include continuous medication. It was noted the disorder did not render the Veteran unable to secure and maintain substantially gainful physical and sedentary type of employment. The disorder was found to be mild and non-acute and it was noted it should be of no hindrance to any type of occupation. Evidence of record includes VA treatment records dated from 2002 to 2013, which do not show external or internal hemorrhoids with persistent bleeding and with secondary anemia, or with fissures, or large or thrombotic, irreducible hemorrhoids, with excessive redundant tissue, evidencing frequent recurrences. The Rating Schedule for external or internal hemorrhoids provides ratings with persistent bleeding and with secondary anemia, or with fissures (20 percent), with large or thrombotic, irreducible hemorrhoids, with excessive redundant tissue, evidencing frequent recurrences (10 percent), and with mild or moderate symptoms (0 percent). 38 C.F.R. § 4.114 , Diagnostic Code 7336. Based upon the evidence of record, the Board finds the Veteran's service-connected hemorrhoids are manifested by no more than mild or moderate symptoms. Although the Veteran is competent to provide evidence as to his observable symptoms such as protruding hemorrhoids, pain, and bleeding, his statements as to a more severe hemorrhoid disability are inconsistent with the opinion of the June 2013 examiner that the disorder did not require continuous medication with only mild to moderate symptoms. To the extent his statements are inconsistent with the objective medical findings they are not credible due to inconsistency and his pecuniary interest in the outcome of his claim. The June 2013 VA examiner's opinion as to the severity of the disability is found to be persuasive. The examiner is shown to have reviewed the evidence of record and to have conducted a thorough examination with adequate consideration of the Veteran's reported symptoms. Therefore, the claim for a higher schedular rating is not warranted. The Board further finds there is no evidence of any unusual or exceptional circumstances that would take this case outside the norm so as to warrant an extraschedular rating. The Veteran's service-connected hemorrhoids are found to be adequately rated under the available schedular criteria and the objective findings of impairment are well documented. The overall evidence of record in this case is not indicative of a marked interference with employment as a result of the service-connected disability. In fact, the June 2013 VA examiner found the disability should not to render him unable to secure and maintain a substantially gainful physical and sedentary type of employment. There is also no evidence of other related factors such as frequent periods of hospitalization due to this disability. Therefore, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. The Board finds that the preponderance of the evidence is against the Veteran's claim. When all the evidence is assembled, VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert, supra; Ortiz, supra. The Board finds that the preponderance of the evidence is against the Veteran's claim. ORDER Entitlement to an initial rating in excess of 10 percent for a cervical spine disability is denied. Entitlement to an initial rating in excess of 10 percent for a right shoulder disability is denied. Entitlement to an initial compensable rating for Wolff-Parkinson-White disease is denied. Entitlement to an initial compensable rating for hemorrhoids is denied. ____________________________________________ K. R. FLETCHER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs