Citation Nr: 1548312 Decision Date: 11/17/15 Archive Date: 11/25/15 DOCKET NO. 09-34 781 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to an initial evaluation in excess of 10 percent for the service-connected herpetic neuralgia of the left sciatic nerve. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Fussell, Counsel INTRODUCTION The Veteran served on active duty from December 1996 to April 2002. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a September 2002 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which awarded service connection for herpes zoster (shingles) and assigned an initial non-compensable evaluation. In October 2004, the RO awarded an increased 10 percent rating for herpes zoster (shingles), and subsequent rating reflect that it was awarded retroactively. In January 2005, the RO recharacterized the disability as herpetic neuralgia of the left sciatic nerve and continued the initial 10 percent rating. A January 2013 Board decision denied reopening of a claim for service connection for headaches as secondary to the service-connected post-herpetic neuralgia of the left sciatic nerve ("herpetic neuralgia") and also denied service connection for chronic pain of the left toe, hip, knee, and shoulder as secondary to the service-connected herpetic neuralgia. The issue of an initial evaluation in excess of 10 percent for the service-connected herpetic neuralgia was remanded for the issuance of a Supplemental Statement of the Case (SSOC) and to afford the Veteran the opportunity to testify at a hearing. The SSOC was issued in February 2013. The hearing was conducted in August 2015 in Washington, D.C. before the undersigned Veterans Law Judge (VLJ) and a transcript is of record. In addition to the paper claim file there are paperless claims electronic files, Veteran's Benefits Management System (VBMS) and Virtual VA. All of these have been reviewed in this case. FINDINGS OF FACT The Veteran's post herpetic neuralgia of the left sciatic nerve is manifested pain and mildly decreased sensation but no impairment of reflexes, weakness, atrophy or organic or trophic changes; and it is not productive of more than moderate neuralgia. CONCLUSION OF LAW The criteria for an initial rating of no greater than 20 percent for herpetic neuralgia of the left sciatic nerve are met. 38 U.S.C.A. § 1151, 5107(b) (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.21, 4.14, 4.21, 4.124a, Diagnostic Code 8720 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION VCAA On November 9, 2000, the Veterans Claims Assistance Act (VCAA) of 2000, Pub.L. No. 106-475, 114 Stat. 2096 was enacted) and replaced Pub. L. 106-398, 114 Stat. 1654, app. § 1661 (Oct. 30, 2000)). Here, the Veteran's initial claim for service connection for residuals of herpes zoster (shingles) incurred inservice was received in March 2002, prior to her discharge from service in April 2002. The VCAA imposes on VA an obligation to notify claimants what information or evidence is needed for claim substantiation and respective evidentiary gathering duties. Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In service connection claims, a claimant is to be informed of five elements: veteran status, existence of a disability, a connection between a veteran's service and the disability (or a service-connected disorder), degree of disability, and effective date of any grant. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice was intended to be provided prior to an initial unfavorable decision but, if not, any such error may be cured by providing notice followed by readjudication, e.g., in an SSOC. Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (Mayfield III), citing Mayfield II, 444 F.3d at 1333-34; see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was not provided VCAA notice prior to adjudication of her service connection claim. Nevertheless, she was provided notice as to how to substantiate a claim for an increased rating by notice letters in March 2008 and December 2009, and this was prior to the readjudication of her claim in the February 2013 SSOC which was issued pursuant to the January 2013 remand portion of a Board decision. See also Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), affm'd in part by Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed.Cir. 2009). Accordingly, the Board finds that VA satisfied its duties to notify the Veteran in this case. As required by 38 U.S.C.A. § 5103A, VA has made reasonable efforts to identify and obtain relevant records for claim substantiation. The Veteran's service treatment records (STRs) have been obtained. The Veteran's VA treatment and private treatment records have been obtained. The Veteran has been given multiple VA rating examinations. The adequacy of the examinations has not been challenged. The Board is entitled to assume the adequacy of a VA examination unless it is challenged. See Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011); Bastien v. Shinseki, 599 F.3d 1301, 1307 (Fed.Cir. 2010); Rizzo v. Shinseki, 580 F.3d 1288, 1290-91 (Fed. Cir. 2009); and Cox v. Nicholson, 20 Vet. App. 563, 569 (2007); and Hilkert v. West, 12 Vet. App. 145, 151 (1999). The case was remanded in January 2013 to issue an SSOC and provide the Veteran an opportunity to testify in support of her claim. The SSOC was issued in February 2013 and the hearing was conducted in August 2015. And all this was in compliance with the January 2013 Board remand. See generally Stegall v. West, 11 Vet. App. 268 (1998). D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999)). As to the August 2015 hearing, 38 C.F.R. § 3.103(c)(2) requires that a presiding VLJ fully explain the issues and suggest the submission of evidence that may have been overlooked but does not require providing such information as to equate with preadjudication of any claim. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). While assistance is required, 38 C.F.R. § 3.103(c)(2) does not require that one presiding at a hearing preadjudicate the claim. Bryant v. Shinseki, 23 Vet. App. 488, 496 (2010) (per curiam). Here, the testimony and questioning at the hearing focused on the elements for claim substantiation, i.e., the severity of the service-connected disability at issue. At the August 2015 hearing it was agreed to hold the case open for 60 days to allow the Veteran the opportunity to submit additional evidence. See pages 32 and 33. This was to include a letter from her employer concerning when she had experienced the painful episodes at work that required her to go home. Page 32. She was also to obtain from her primary care physician a statement or report addressing her flare-ups in terms of frequency and its duration, as well as the anatomical parts that are affected by the pain. That is, the primary care physician should state whether the neurological pain that's affecting the different anatomical parts of her body were definitely associated with or had a direct relationship to the service-connected left sciatic nerve. Page 33. She was also to obtain records or a statement from a chiropractor whom she had seen on five occasions, which should also address the anatomical parts involved and requiring manipulations. Page 35. The Veteran testified that she had been hospitalized in January or February 2015 for a herniated disc in her neck. Pages 35, 36, and 37. For this purpose the Veteran was requested to execute and return the appropriate authorization form. Page 37. However, no additional records or authorization forms were submitted. In this regard, the duty to assist is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence). Also at the hearing the presiding VLJ indicated that additional VA treatment records would be obtained. In this regard, a review of Virtual VA shows that such electronic VA treatment (CAPRI) records are on file. Thus, the Board finds that, consistent with Bryant, Id., the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. Moreover, as there is neither an indication that the Veteran was unaware of what was needed for claim substantiation nor any indication of the existence of additional evidence for claim substantiation, the Board concludes that there has been full VCAA compliance. Background On VA examination in April 2002 the Veteran reported having an outbreak of shingles during service in 2001 with the infection being in the L1 and L2 dermatomes and extending down her leg. Thereafter, neurotrophic medication had been ineffective in relieving pain but she had found the best relief with a combination of Darvocet and Motrin, which she was no longer taking because she was trying to have a child. She now took Lorcet for post-herpetic neuralgia as needed. She was taking a course in psychology but basically occupied herself as a homemaker. On physical examination, as to her gait she had a slight stiffening of forward thrust of the left leg from the hip. He skin was free of herpetic scarring. She walked with a grossly normal gait, and there was no restriction of range of motion. Deep tendon reflexes (DTRs) were 1+, bilaterally, in all extremities, and plantar reflexes were equivocal, bilaterally. The diagnosis was herpes zoster, by history, resolved with complaints of neuropathic pain. A postservice military clinical record in July 2003 shows that the Veteran complained of persistent pain, described as a burning pain, without any sensory deficit or motor dysfunction in her left leg. She characterized the pain as being 9 on a scale of 10, despite treatment with Celebrex and Neurotin. She indicated that the pain radiated down her back to her left great toe. On examination her reflexes were 2/4, bilateral. Muscle strength was 5/5. It was stated that the pain was in the L4 dermatomal pattern. An MRI was negative. A postservice military clinical record in February 2004 shows that the Veteran had not had relief of pain from an epidural injection. The assessment was post herpetic neuralgia. A February 2004 VA outpatient treatment (VAOPT) record shows that the Veteran had a 3 year history of disabling pain from post herpetic neuralgia affecting her left sciatic nerve. In March 2004 the Veteran's husband reported that she had experienced extreme pain for about 2 years, which had many adverse effects on her life. She did not participate in normal physical activities, e.g., working out, bicycling, running, jogging, going for walks or gardening. In March 2004 a friend stated that she had witnessed the Veteran's post herpetic pain and seen her physical condition deteriorate considerably. She was not able to do the many activities she had once enjoyed. She could not take long walks or carry her baby for long periods. An April 2004 statement from a former co-worker and friend reflects that following the Veteran's shingles her life had been in a downward spiral. She had severe daily pain. On official neurology examination in April 2004 the Veteran had no notable skin eruptions. Intrinsic reflexes could be triggered in an identically, lively manner bilateral without deficits. Particularly in the left leg there was no reduced vigor and no areas of reduced sensation to touching, or pain sensations. Sensibility to vibrations was "8/8" bilaterally at the ankle mortises, at the knees, and both hips. There were no zones showing an excessive sensory sensibility or allodynia. It was stated that there were no post herpetic modifications and no lasting radicular deficits. On official psychiatric examination in June 2004 it was noted that the Veteran was employed as a civilian with the Department of Defense. She was not experiencing employment dysfunction. The pertinent diagnosis was a somatization disorder. A July 2004 VAOPT record reflexes that the Veteran's many attempts at the use of medication had not been effective in relieving pain. Pain substantially limited her ability to function at home and at work. It restricted her daily activities, including activities recreationally and with her son and other relationships. Her employer had made multiple accommodations so that she could sustain employment. On VA examination in July 2009 it was reported that the Veteran continued to have post herpetic pain but that there were no flare-ups. She did not utilize any assistive device or brace for her knees or hips. She worked in marketing and was also a full-time student. She had used all of her vacation time due to her symptoms. Her activities of daily living were unaffected. She was able to shower and to dress. She reported that she could not go for walks or workout due to her symptoms. She reported having a burning sensation from her post herpetic neuralgia. On physical examination her gait was normal. She had no current herpetic lesions. Motion of both knees was without obvious pain. She had full range of motion of the hips. There was no additional limitation of motion following repetitive use. There were no flare-ups. There was no effect on coordination, fatigue, weakness or lack of endurance. On VA neurology examination in January 2010 the Veteran reported having flare-ups of herpetic neuralgia with accompanying weakness, fatigue, and functional loss. She had sensations of tingling, prickling, and burning of the skin. On physical examination she had no muscle wasting, atrophy, lesions or loss of fine motor control of either lower extremity. Pulsations and reflexes were 2+ in the lower extremities. Sensations were normal in the lower extremities except for decreased sensation to pinprick in the left lower extremity. The diagnosis was left sciatic post herpetic neuralgia. It was noted that she had limited tolerance for sitting due to pain and that other activities were limited due to pain. VA electronic treatment (CAPRI) records show that in March 2011 it was noted that the Veteran worked full-time as administrative assistant for "FDIC," and had a Bachelor of Science degree in psychology. Her post herpetic neuralgia caused pain that was rated an 8 on a scale of 10. She had had had many treatments for pain that had been ineffective. Her pain from post herpetic neuralgia substantially limited her functioning at work, and at home. It restricted her daily activities, including recreational activities, activities with son and other relationships. The herpetic neuralgia has been very debilitating and partially disabling. At the August 2015 hearing the Veteran testified that she believed that her herpetic neuralgia of the left sciatic nerve, previously classified as herpes zoster (shingle), warranted a rating of at least moderate neuralgia (20%) rather than the current 10 percent for mild neuralgia. Page 11. She rendered testimony as to symptoms affecting her left foot and toe, as well as her left knee, and left shoulder. Pages 4 and 24. She also testified that she had psychiatric symptoms. The presiding VLJ queried whether separate ratings were warranted. Page 24. However, upon a review of the record, it is clear that the January 2013 Board decision denied service connection for chronic pain of the left toe, hip, knee, and shoulder, claimed as secondary to service-connected herpetic neuralgia. Also, the Veteran is separately service-connected for major depression with insomnia and anxiety, currently rated 50 percent. She testified that even her boss had noticed that she limped and put more weight on my right side, and she really did not walk with a limp so much anymore as just shift my normal stride. Page 5. She was in constant pain that she rated as 8 out of 10, reaching even 10 in the evenings, and continued to receive VA treatment. Page 6. There were many days when she had to leave work and go home, and work from home. Page 9. She had extreme pain on ascending and descending stairs, problems walking, stooping and bending, and she did not do any heavy lifting. Page 10. She stated that she had moderate to severe pain in her left thigh, which she believed anyone would describe her as having at least moderate disability. Page 11. She had flare-ups about 3 times monthly. She had gone to the emergency room because of back pain. Page 12. She had had physical therapy and had been given a TENS unit to mask her pain. Page 15. Her doctor in Dallas had felt that she had not received a high enough disability rating and had encouraged the Veteran to apply for such. Page 16. She had weakness of the left side of her body, as well as fatigue based on continuous pain and incoordination on the left side. Page 16. The Veteran testified that she had flare-ups once weekly when she was totally bedridden and incapacitated. Page 21. However, she also described her symptoms as affecting multiple areas, including her back and shoulders. Pages 22 and 23. She worked as an accountant. Page 25. She testified to having pain in her neck, both shoulders, and right arm, as well as her big toe, left knee, and low back. Page 27. The presiding VLJ indicated that the adjudication would include whether the applicable rating criteria permitted a separate rating for the Veteran's low back. Page 29 and 30. The presiding VLJ also stated that the Veteran had not been diagnosed as having intervertebral disc syndrome (IVDS) but the adjudication would include whether a rating based on IVDS was appropriate, and specifically whether a rating could be based on incapacitating episodes (as can be done in rating IVDS). Pages 30 and 31. The Veteran testified that she had been hospitalized in January or February 2015 for a herniated disc in her neck. Pages 35, 36, and 37. Rating Principles Ratings for a service-connected disability are determined by comparing current symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which is based as far as practical on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155. Disabilities are viewed, and examinations are interpreted, historically, in order to accurately reflect the elements of disability present. 38 C.F.R. §§ 4.1, 4.2. A higher rating is assigned if it more nearly approximates such rating. 38 C.F.R. §§ 4.7, 4.21. A higher rating may not be denied on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). Separate ratings may be assigned either initially or during any appeal for an increased rating for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119 (1999) (initial staged ratings). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C.A. § 1155). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a Veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). Under 38 C.F.R. § 4.124a, the schedules for rating diseases of the cranial and peripheral nerves include alternate diagnostic codes for paralysis, neuritis, and neuralgia of each nerve. See 38 C.F.R. § 4.124a, Diagnostic Codes 8205 to 8730. The diagnostic codes for paralysis of a nerve allow for multiple levels of incomplete paralysis, as well as complete paralysis. However, the ratings available for neuritis and neuralgia of the same nerves can be limited to less than the maximum ratings available for paralysis. In rating peripheral neuropathy attention is given to sensory or motor impairment as well as trophic changes (described at 38 C.F.R. § 4.104, Diagnostic Code 7115 as thin skin, absence of hair, dystrophic nails). Peripheral neuropathy which is wholly sensory is mild or, at most, moderate. With dull and intermittent pain in a typical nerve distribution, it is at most moderate. With no organic changes it is moderate or, if of the sciatic nerve, moderately severe. 38 C.F.R. § 4.20. Neuralgia of a peripheral nerve of a lower extremity can receive a maximum rating of moderate incomplete paralysis. 38 C.F.R. § 4.124. Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, can receive a maximum rating of severe, incomplete paralysis. 38 C.F.R. § 4.123. Peripheral nerves ratings are for unilateral involvement; when bilateral, combine with application of the bilateral factor. 38 C.F.R. §§ 4.123, 4.124, 4.124a. Sciatic neurological manifestations are rated under Diagnostic Code 8520, 8620, or 8720 as, respectively, paralysis, neuritis or neuralgia of the sciatic nerve. The criterion for a 10 percent rating is mild incomplete paralysis. The criterion for a 20 percent is moderate incomplete paralysis and 40 percent when moderately severe. When severe with marked muscular atrophy, 60 percent is warranted and 80 percent is warranted for complete paralysis (with foot drop, no active movement possible below the knee, and weakened or, very rarely, lost knee flexion). See also 38 C.F.R. § 4.124a, Diagnostic Codes 8620, 8720 (for sciatic neuritis and neuralgia). Terms such as "slight," "moderate" and "severe" are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "slight" or "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. 'Severe' is a degree descriptor specific to [a] listed disability, and disabilities designated as 'severe' in different DCs are not necessarily equally disabling. See Breniser, 25 Vet.App. at 76-77." Prokarym v. McDonald, No. 13-3478, slip op. at 5 (U.S. Vet. App. Apr. 14, 2015). The ordinary meaning of "severe" is "very great [or] intense," NEW OXFORD AMERICAN DICTIONARY 1599 (3d ed. 2010), or "of a great degree," MERRIAM-WEBSTER DICTIONARY, http://www.merriam-webster.com/dictionary/severe (last visited Mar. 27, 2015). It is used throughout the rating schedule, including in DCs 5276 and 5284, to indicate a very great or intense case of the specific listed disability, in order to differentiate between lesser (or sometimes greater) cases of that same disability within the specific DC." Prokarym v. McDonald, No. 13-3478, slip op. at 5 (U.S. Vet. App. Apr. 14, 2015). The Veteran and other laypersons are competent to testify on factual matters of which they have first-hand knowledge, such as symptoms of pain, and are competent to describe symptoms and their effects on employment or daily activities. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). In evaluating the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Klekar v. West, 12 Vet. App. 503, 507 (1999); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). 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 exists which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. Analysis The Veteran is service-connected for major depression with insomnia and anxiety, rated 50 percent; acne vulgaris, rated 10 percent; herpetic neuralgia of the left sciatic nerve, rated 10 percent; and episodic tonsillitis, which is assigned a noncompensable disability rating. These result in a combined rating of 60 percent. Initially, the Board will address the concerns noted at the Veteran's hearing. First, as to whether the disability may be assigned separate ratings based on her testimony that she has pain in multiple areas, including her left toe, left hip, left knee, both shoulders and her neck, it must be noted that in January 2013 the Board denied service connection for chronic pain of the left toe, hip, knee, and shoulder, which were claimed as due to her inservice shingle infection. Likewise, as to her complaint of pain in her neck and shoulders, she testified that she had a herniated (ruptured) disc in her neck. However, service connection is not in effect for disability of her neck or for any resultant radicular symptoms in her shoulders and arms stemming from a ruptured cervical disc. Similarly, at the hearing it was noted that consideration would be given to the possibility of a rating on the basis of incapacitating episodes, as to which she testified, as analogous to intervertebral disc syndrome. Generally see 38 C.F.R. § 4.71a, Diagnostic Code 5243 (providing, in pertinent part, for evaluation of spinal disability based on duration of incapacitating episodes). However, just as service connection is not in effect for disability of the left toe, hip, knee, and shoulder, service connection is also not in effect for disability of her neck or for any resultant radicular symptoms in her shoulders and arms stemming from a ruptured cervical disc. Consequently, after a thorough review of the record, assigning separate ratings for the various bodily areas as to which the Veteran testified that she has pain and assigning a disability rating based on incapacitating episodes is not warranted. Here, the Veteran's credible testimony is that she had debilitating pain from the post herpetic neuralgia of the left sciatic nerve. However, there have been no outbreaks of herpetic lesions since her military service. On the other hand, her symptoms are wholly sensory in nature. Specifically, she has both decreased sensation as well as debilitating pain, and her testimony as to the latter is corroborated by VA clinical records. Accordingly, with the favorable resolution of doubt in her favor the Board finds that a 20 percent disability evaluation is warranted for the post herpetic neuralgia of her left sciatic nerve which encompasses moderate neuralgia. For neuralgia of most peripheral nerves of a lower extremity the maximum possible rating is for moderate incomplete paralysis. However, as stated above, the exception is the sciatic nerve which may be assigned a rating of 40 percent for moderately severe impairment if there are no organic changes. In this case the Veteran has no accompanying motor deficits. In this regard, there is lay evidence that her activities are restricted in several arenas, and this has been the apparent basis for accompanying clinical notations to the same effect. On the other hand, contrasted against this are the repeated clinical examinations which have found no motor deficit, including no significant impairment of her gait, diminished reflexes, trophic changes or muscular atrophy of any degree. Thus, the Board concludes that the Veteran's disability picture does not more closely approximate moderately severe left sciatica neuropathy. Similarly, a 60 percent rating could be assigned for severe neuralgia of the left sciatic nerve with marked muscular atrophy. Here, not only is there no objective clinical evidence of marked muscular atrophy, there is no clinical evidence of any degree of muscular atrophy, i.e., specifically any degree atrophy which is less than marked. Moreover, while there is sensory disturbance from decreased sensation and pain, which is a rating criteria for rating less than 60 percent, there is no clinical evidence of loss of reflexes or other evidence of motor impairment. Thus, the post herpetic neuralgia does not more closely approximate neuralgia which could otherwise be classified as severe. The Veteran is competent to attest to the subjective symptoms which are experienced, e.g., pain, and objective evidence, e.g., found on clinical examinations, is not required to establish that such symptoms exist. Her testimony as to the impairment caused by her post herpetic neuralgia has been carefully considered, including that with respect to its' impact on her ability to work and her activities of daily living. However, her lay evidence as to the severity of her primary symptom, i.e., pain, is subject to differences in perception of that sensation. In other words, the perception of and tolerance of pain can vary greatly among individuals. On the other hand, objective clinical evidence is obtained by medical professionals who trained in assessing and evaluating disabilities as to actual functional impairment and, as such, has greater probative value. For the reasons stated, and even with consideration given to the doctrine of the favorable resolution of doubt, the Board is not persuaded that the Veteran has ever had more than moderate post herpetic peripheral neuropathy of the left lower extremity at any time during the appeal period. Other Considerations Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2015). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations are inadequate. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Other elements are marked interference with employment or frequent periods of hospitalization. If either (1) the claimant's disability picture is adequately contemplated by the rating schedule or (2) that there are no other "related factors," for example, frequent hospitalizations or marked interference with employment, then referral is not warranted and the other element need not be considered. Addressing the adequacy of the scheduler rating criteria requires a comparison between the level of severity and symptomatology of the Veteran's service-connected disabilities with the criteria in the Rating Schedule. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule and the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Veteran's competent and credible belief that her disability is worse than that which would cause moderate impairment is outweighed by the competent and credible medical examinations that evaluated the full extent of impairment based on objective data. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings than the Veteran's lay statements. Thus, the Board finds that a rating of no more than 20 percent is appropriate. There is no persuasive evidence of occupational or functional impairment due to service-connected disorder or other symptoms which are not already contemplated by the potentially applicable schedular criteria. Specifically, the rating criteria adequately encompass the symptomatology and severity of the Veteran's service-connected disability. Moreover, the rating criteria provide for ratings greater than the 20 percent rating which may be awarded should it increase in severity. The Veteran has not described any unusual or exceptional features associated with his disabilities or described how the disability affects her in an unusual or exceptional manner. Therefore, the Board finds 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); see also Johnson v. McDonald, 762 F3d. 1362; 2014 WL 3844196 (C.A. Fed.); No. 2013-7104, slip op. (Fed. Cir. Aug. 6, 2014) overruling Johnson v. Shinseki, 26 Vet. App. 237, 248 (2013). The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, after applying the benefit of the doubt under Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. In reaching the determination in this case, the Board finds that the preponderance of the evidence is in favor of assigning a 20 percent disability rating but that the preponderance of the evidence is against the assignment of a disability rating in excess thereof. So, there is no doubt to be resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 52 (1990). ORDER An initial rating of no greater than 20 percent for herpetic neuralgia of the left sciatic nerve is granted, subject to applicable law and regulations governing the award of monetary benefits. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs