Citation Nr: 1339352 Decision Date: 12/02/13 Archive Date: 12/13/13 DOCKET NO. 10-47 028 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUES 1. Entitlement to service connection for left ear hearing loss disability. 2. Entitlement to an increased rating for right shoulder degenerative changes, currently evaluated as 20 percent disabling. 3. Entitlement to an increased rating for right upper extremity weakness, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Barone, Counsel INTRODUCTION Please note that this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Veteran had active service from August 1958 to August 1961. This matter comes before the Board of Veterans' Appeals (Board) from an April 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Albuquerque, New Mexico. It is noted that the Veteran submitted copies of VA medical records in November 2013. As these documents are duplicative of the evidence already of record, remand for a supplemental statement of the case is not required pursuant to 38 C.F.R. § 19.31 (2013). It is also noted that in a statement dated in October 2013, the Veteran raised the issue of entitlement to service connection for residuals of a concussion. This matter, which has not yet been adjudicated, is referred to the RO for the appropriate consideration. The issue of entitlement to an increased rating for right upper extremity weakness is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Left ear hearing loss disability was not manifest in service or within one year of service, and is unrelated to service. 2. Right shoulder degenerative changes are manifested by pain and abduction limited to 90 degrees; there is no ankylosis and no impairment of the clavicle or scapula. CONCLUSIONS OF LAW 1. Left ear hearing loss disability was not incurred in service and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1110, 1112, 1113, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2013). 2. The criteria for the assignment of an initial disability rating in excess of 20 percent for right shoulder degenerative changes have not been met. 38 U.S.C.A. §§ 1155 , 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5010, 5201, 5203 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). On March 3, 2006, the U. S. Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. A letter dated in December 2007 discussed the evidence necessary to support claims for service connection and increased ratings. The evidence of record was listed and the Veteran was informed of the allocation of responsibilities between himself and VA. The Veteran was also advised of the manner in which VA determines disability ratings and effective dates. The Board finds that the content of the notice fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The appellant has been provided with every opportunity to submit evidence and argument in support of his claim and to respond to VA notices. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of his claim. With respect VA's duty to assist, the Board notes that VA, Indian Health Service, and private medical records have been associated with the claims file. Additional private records were sought but a negative response was received. The Veteran was informed of this in the statement of the case. The Veteran has not identified and authorized the release of any additional non-VA records. The Veteran was afforded VA examinations. The Board finds that the examination reports are adequate in that the examinations were performed by a provider who reviewed the Veteran's pertinent history, interviewed the Veteran, and conducted complete physical examinations prior to rendering his conclusions. The Board finds that the reports are a sufficient basis upon which to base a decision in this appeal. Neither the appellant nor his representative has identified any additional evidence or information which could be obtained to substantiate the claims. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that the RO has complied with the duty to assist requirements of the VCAA and the implementing regulations. For the foregoing reasons, it is not prejudicial to the appellant for the Board to proceed to a final decision in this appeal. Analysis Service Connection Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110 (wartime service), 1131 (peacetime service); 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service incurrence or aggravation of diseases of the central nervous system (e.g., sensorineural hearing loss) may be presumed to have been incurred or aggravated if it is manifested to a compensable degree within a year of the Veteran's discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. The Board notes that the U.S. Court of Appeals for the Federal Circuit recently clarified that the continuity of symptomatology language in § 3.303(b) is limited to the chronic diseases listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002). The Court has observed that the threshold for normal hearing is from 0 to 20 decibels, and that higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). However, for the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2013). Service treatment records indicate that on enlistment examination in July 1958, the Veteran endorsed running ears. He denied ear trouble. The examiner noted that there was a shiny area of exudate over the inferior segment of the left ear drum. On otolaryngology consultation, the impression was history of recent otitis media on the left. The provider noted that there was some residual purulent material remaining in the external canal. The hearing test at the time of the enlistment examination indicated 15/15 on whispered voice testing. The summary of defects and diagnoses included recent otitis media, left. The note of a physician dated in August 1958 indicated that physical inspection revealed no new findings. At that time, the Veteran denied further ear symptoms, and examination revealed scarred tympanic membranes but no exudate or perforation. On airborne training examination in November 1958, the Veteran endorsed ear trouble but denied running ears. The examiner made no comment. The Veteran's ears were normal, and whispered voice testing was 15/15 bilaterally. On airborne training examination in March 1959, the Veteran's ears were clinically normal. Whispered voice testing was 15/15 bilaterally. The Veteran was deemed qualified for airborne training. On discharge examination in July 1961, the Veteran endorsed ear trouble and running ears in 1958 but no recurrence. His ears were clinically normal on examination, and whispered voice testing was 15/15 bilaterally. Audiometric testing conducted by the Indian Health Service in May 1968 revealed the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 20 15 5 Not tested 15 LEFT 20 15 5 Not tested 20 The form on which these results are reported indicates that the audiogram was plotted to ISO 1964 values. VA audiological testing in April 2006 revealed the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 15 25 30 50 55 LEFT 15 25 30 45 50 Speech recognition scores were 96 percent for the right ear and 92 percent for the left. The Veteran reported that his hearing loss began in service and that he thought it was caused by C-130 aircraft. He stated that he had a hearing test with the U.S. Public Health Service after service. The provider indicated that the Veteran's hearing loss was consistent with the reported history of noise exposure, reported medical conditions, and presbycusis. The Veteran was issued hearing aids in May 2006. On VA examination in August 2010, the Veteran reported noise exposure during service. He specified that he was exposed to noise from C-130 aircraft. Audiometric testing revealed the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 35 60 65 LEFT 20 25 45 60 70 Speech recognition testing resulted in a score of 88 percent for the left ear. The examiner concluded that it was less likely as not that hearing loss was caused by or a result of acoustic trauma from parachute jumps and/or gunfire and landmine blasts during basic training. She reasoned that hearing was 15/15 on whispered voice testing at the time of enlistment and separation. She further noted that at the time of separation, the Veteran reported a history of draining ears but did not report hearing loss. She concluded that his hearing loss was less likely than not caused by or a result of acoustic trauma during service. Private audiometry conducted in January 2011 resulted in the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 25 40 45 Not tested 65 LEFT 30 40 55 Not tested 80 During a VA audiological consultation in March 2011, the following puretone thresholds were elicited: HERTZ 500 1000 2000 3000 4000 RIGHT 15 25 30 50 50 LEFT 15 25 35 50 60 Speech recognition scores were 96 percent bilaterally. The provider noted hearing loss was stable compared to previous results. Upon careful consideration of the foregoing evidence, the Board concludes that service connection is not warranted for left ear hearing loss disability. While the evidence reveals that the Veteran has hearing loss in his left ear, the most competent and probative evidence of record does not etiologically link any such disability to service or any incident therein. Rather, hearing was normal on various examinations during service, and on examination in 1968. The first indication of left ear hearing loss that is considered a disability under VA standards dates to 2006. The August 2010 VA examiner determined that the current hearing loss is not related to service, to include acoustic trauma therein. She stated that hearing was normal on enlistment and separation, and that on separation examination, the Veteran had reported draining ears but not hearing loss. She provided a reasoned opinion based on a complete review of the Veteran's history, interview and examination. In assigning high probative value to the VA examiner's opinion, the Board notes that she had the claims file for review, specifically discussed evidence contained in the claims file, obtained a history from the Veteran, and conducted a complete examination. There is no indication that the VA examiner was not fully aware of the Veteran's past history or that she misstated any relevant fact. The Board thus finds the VA examiner's opinion to be of greater probative value than the Veteran's statements. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.); Neives-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Moreover, while a VA clinician indicated in April 2006 that hearing loss was consistent with the Veteran's reported history of noise exposure in service, medical conditions and presbycusis, such is outweighed by the more probative VA medical examiner's opinion. In this regard, the VA clinician did not provide a rationale for the opinion and did not indicate knowledge of the Veteran's reported history at the time of separation. To the extent that the Veteran asserts that his current left ear hearing loss is related to service, the Board observes that he may attest to factual matters of which he has first-hand knowledge, such as subjective complaints, and his assertions in that regard are entitled to some probative weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). He is competent to report incidents and symptoms in service and symptoms since then. He is not, however, competent to render an opinion as to the cause or etiology of the currently diagnosed left ear hearing loss disability because he does not have the requisite medical knowledge or training, and because such matters are beyond the ability of a lay person to observe. See Rucker v. Brown, 10 Vet. App. 67, 71 (1997); see also See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As discussed, the VA examiner considered the Veteran's documented history, but ultimately concluded that the current hearing loss is not related to service. The Board finds the most probative evidence of record to be this opinion by the competent VA health care provider. Even if the Veteran's statements asserting that his left ear hearing loss is related to service were found to be competent, credible and probative, they are still outweighed by the examiner's opinion. The opinion was provided by a medical professional who reviewed the history, interviewed the Veteran, and provided opinions supported by rationale. The grant of service connection requires competent evidence to establish a diagnosis and, as in this case, relate the diagnosis to the Veteran's service. While the record contains evidence of left ear hearing loss, the preponderance of the evidence is against finding that this diagnosis is related to any injury or disease in service. Accordingly, the doctrine of reasonable doubt is not applicable in the instant appeal. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990); 38 C.F.R. § 3.102 (2013). Evaluation of Right Shoulder Degenerative Changes Disability evaluations are determined by the application of a schedule of ratings, which is based on average industrial impairment. 38 U.S.C.A. § 1155. A proper rating of the Veteran's disability contemplates its history, 38 C.F.R. § 4.1, and must be considered from the point of view of a Veteran working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board notes that where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. 38 C.F.R. §§ 4.1, 4.2 (2013); see also Francisco v. Brown, 7 Vet. App. 55 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), however, the Court held that "staged ratings" are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The Board has concluded that the disability has not significantly changed and that a uniform evaluation is warranted for the period considered. 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). 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. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. §4.7. On VA orthopedic examination in January 2008, the Veteran's history was reviewed. He reported that his symptoms had worsened over the previous five years. He endorsed pain and weakness, but denied a history of deformity, giving way, instability, stiffness, and episodes of dislocation. Range of motion testing revealed external rotation to 75 degrees with pain at 70 degrees, flexion to 170 degrees with pain at 160 degrees, abduction to 165 degrees with pain at 160 degrees, and internal rotation to 90 degrees. The examiner noted that an MRI report indicated supraspinatus tendinopathy and mild acromioclavicular arthropathy. He noted that the impact on the Veteran's occupational functioning resulted from decreased manual dexterity, problems with lifting and carrying, difficulty reaching, and decreased strength. In June 2008 the Veteran was noted to walk into an examination room moving his arms without difficulty. He was able to reach up with his right arm to remove his hat and was also able to remove his shirt using both arms. On examination the Veteran had difficulty abducting his right arm above 90 degrees. He could fold and extend his arms without difficulty but complained of difficulty with rotating backwards. Strength was 5/5. There was no crepitance, deformity, or swelling. On orthopedic consultation in July 2009, the Veteran had abduction to 100 degrees, flexion to 130 degrees, and internal and external rotation to 60 degrees. Strength was fair. Impingement signs were positive. The Veteran's hand and fingers were mobile and sensate with intact capillary refill. In September 2009, range of motion was recorded as abduction to 120 degrees, flexion to 140 degrees, and internal and external rotation to 60 degrees. The Veteran underwent an injection of his right shoulder in December 2009. Subsequently that month, the Veteran reported that his pain was worse than prior to the injection. He indicated that he had decreased range of motion and difficulty driving. He noted that he had not previously had pain that severe. Abduction and flexion were both 100 degrees and internal and external rotation were to 70 degrees. In April 2010, range of motion was noted to be flexion to 150 degrees, abduction to 90 degrees, internal rotation to zero degrees, and external rotation to 60 degrees. The provider noted that there was a definite neurologic component, not from the cervical spine. On VA examination in March 2012, the diagnosis was degenerative joint disease. The examiner noted that the Veteran was right hand dominant. The Veteran did not report flare-ups that impacted the function of the shoulder or arm. Range of motion testing revealed flexion to 150 degrees with pain at 150 degrees, and abduction to 110 degrees with pain at 110 degrees. Following repetitive use testing, flexion and abduction remained unchanged. There was no additional limitation. The examiner identified functional loss or impairment due to less movement that normal and pain on movement. There was localized tenderness or pain on palpation but no guarding. Muscle strength testing was 5/5 on abduction and forward flexion. There was no ankylosis. There was no history of mechanical symptoms or of recurrent dislocation of the scapulohumeral joint. The examiner noted that there was no acromioclavicular joint condition or any other impairment of the clavicle or scapula. The disability affected his work as it was hard to shift gears in the truck when driving. There are several diagnostic codes which pertain to limitation of motion or disabilities of the shoulder. Under Diagnostic Code 5200, which pertains to ankylosis of the scapulohumeral articulation (Note: the scapula and the humerous move as one piece), a 30 percent evaluation is warranted when there is favorable ankylosis of the major upper extremity with abduction to 60 degrees and the ability to reach the mouth and head with the major upper extremity. A 40 percent evaluation is warranted when the ankylosis in the major upper extremity is intermediate between favorable and unfavorable. A 50 percent evaluation is warranted when there is unfavorable ankylosis with abduction limited to 25 degrees from the side. Under Diagnostic Code 5201, which pertains to limitation of motion of the arm, a 20 percent evaluation is warranted when range of motion of the major upper extremity is limited to the shoulder level. A 30 percent evaluation is warranted when range of motion of the major upper extremity is limited to midway between the side and shoulder levels. A 40 percent evaluation is warranted when range of motion of the major upper extremity is limited to 25 degrees from the side. Under Diagnostic Code 5203, which pertains to impairment of the clavicle or scapula, a 10 percent evaluation is warranted where there is malunion of the clavicle or scapula of the major upper extremity; or where there is nonunion of the clavicle or scapula of the major upper extremity without loose movement. A 20 percent evaluation is warranted where there is nonunion of the clavicle or scapula of the major upper extremity with loose movement; or where there is dislocation of the major upper extremity clavicle or scapula. Normal range of motion for the shoulder is 180 degrees of forward elevation and abduction, and 90 degrees of external and internal rotation. See 38 C.F.R. § 4.71a, Plate I. The Veteran's right shoulder disability is currently evaluated as 20 percent disabling pursuant to Diagnostic Code 5201, for limitation motion of the arm. Having reviewed the evidence pertaining to this claim, the Board concludes that an evaluation in excess of 20 percent for the Veteran's right shoulder disability is not warranted. In this regard, the Board observes that the current 20 percent evaluation contemplates motion of the major arm limited to the shoulder level. A higher evaluation requires evidence showing motion limited to midway between the side and shoulder. Such is not shown by the evidence of record. Rather, at worst, the Veteran's range of motion of the right arm was limited to 90 degrees in April 2010, which squarely fits within the criteria for the currently assigned disability rating. Accordingly, an evaluation in excess of 20 percent based on limitation of motion of the arm is not for application at any point during the appeal period. The Board has considered whether a higher evaluation might be applicable based on other various criteria for evaluation of shoulder or arm disability. There is no objective evidence of ankylosis that would warrant a higher evaluation. Moreover, the evidence reflects that there is no impairment of the clavicle or scapula. Thus, the Board finds that the 20 percent evaluation discussed herein is appropriate. The Board accepts that the Veteran has experienced functional impairment, pain, and pain on motion. See DeLuca. The Board also finds the Veteran's own reports of symptomatology to be credible and has considered the functional impact of painful motion to include on use and following repetitive motion. Nevertheless, neither the lay nor medical evidence reflects the functional equivalent of symptoms required for a higher evaluation under diagnostic codes pertinent to the arm and shoulder when considering such factors as pain, weakness, and incoordination. In essence, the more probative evidence consists of that prepared by neutral skilled professionals, who conducted range of motion studies, and such evidence demonstrates that the evaluation assigned herein is appropriate. At no point in time during the period of time contemplated by this claim has the evidence shown that the criteria for a higher rating are met or approximated. Extraschedular Consideration The potential application of various provisions of Title 38 of the Code of Federal Regulations has also been considered but the record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1). 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 level of disability and symptomatology and is found to be inadequate, the Board must 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 extraschedular rating. With respect to the initial inquiry posed by Thun, the Board has been unable to identify an exceptional or unusual disability picture with respect to the Veteran's service-connected right shoulder disability. The evidence demonstrates that the Veteran's symptomatology, including pain and swelling, ultimately results in limitation of motion which is specifically contemplated under the appropriate ratings criteria. Thus, the Board determines that the schedular rating criteria adequately contemplate the Veteran's symptomatology, and that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet.App. 218, 227 (1995). ORDER Entitlement to service connection for left ear hearing loss disability is denied. Entitlement to an evaluation in excess of 20 percent for right shoulder degenerative changes is denied. REMAND The Veteran is currently in receipt of a 20 percent rating for neurological weakness of the right upper extremity, pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8511, for paralysis of the middle radicular group. This rating contemplates mild incomplete paralysis. A higher evaluation requires evidence showing moderate or severe incomplete paralysis. On neurological testing in March2012, the examiner noted that the Veteran had neurologic weakness of the right upper extremity but did not indicate whether there was paralysis of any affected nerve. She noted that EMG testing in October 2007 was normal. On review of the evidence of record, the Board notes that it is unclear whether the Veteran has incomplete paralysis, neuritis, or neuralgia associated with his right shoulder disability, and if so, the severity of any such manifestation. The Board thus concludes that an additional VA examination is necessary to determine the severity of this disability. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the severity of the neurological weakness of his right upper extremity. The claims folder should be forwarded to the examiner for review. Any and all studies, tests and evaluations deemed necessary by the examiner should be performed. The examiner should also elicit a complete history, the pertinent details of which should be included in the examination report. Following examination of the Veteran and review of the claims file, the examiner should identify all currently present neurological manifestations referable to the Veteran's right upper extremity. The examiner should specifically indicate whether there is incomplete paralysis and if so, whether it is mild, moderate, or severe. The examiner should also indicate whether there is neuritis or neuralgia. If any of the above inquiries cannot be addressed, the examiner should provide a complete explanation as to why they cannot be addressed. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 2. Thereafter, ensure that the development above has been completed in accordance with the remand instructions, undertake any other development action that is deemed warranted, and readjudicate the claim. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ____________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs