Citation Nr: 1602013 Decision Date: 01/19/16 Archive Date: 01/27/16 DOCKET NO. 12-03 539 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) from April 21, 2009 to November 13, 2009. 2. Entitlement to a rating in excess of 30 percent for PTSD from November 13, 2009 to January 2, 2012. 3. Entitlement to a rating in excess of 30 percent for PTSD from January 3, 2012. 4. Entitlement to an initial rating in excess of 10 percent for a low back strain prior to January 3, 2012. 5. Entitlement to a rating in excess of 10 percent for a low back strain from January 3, 2012. 6. Entitlement to an initial rating in excess of 10 percent for a right shoulder impingement syndrome with chronic tendonitis of the suprapspinatus and biceps tendon prior to January 3, 2012. 7. Entitlement to a rating in excess of 10 percent for a right shoulder impingement syndrome with chronic tendonitis of the supraspinatus and biceps tendon, from January 3, 2012. 8. Entitlement to a compensable rating for bilateral shin stress fractures prior to January 3, 2012. 9. Entitlement to a compensable rating for bilateral shin stress fractures from January 3, 2012. 10. Entitlement to an initial compensable rating for bilateral hearing loss. 11. Entitlement to service connection for a headache disorder. ATTORNEY FOR THE BOARD Ryan Frank, Associate Counsel INTRODUCTION The Veteran had verified active duty service from January 2002 to August 2002 and from October 2002 to April 2009. This case comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Pittsburgh, Pennsylvania Department of Veterans Affairs (VA) Regional Office (RO). This appeal was processed using the Veterans Benefits Management System and Virtual VA paperless claims processing systems. In a statement dated January 18, 2012, the Veteran stated his plan to file claims of entitlement to service connection for an acquired psychiatric disorder, a sleep disorder to include snoring and a terror disorder, an antinuclear antibody disorder, an elevated creatine kinase level, residuals of a left ring finger injury, spinal arthritis, osteoarthritis, lumbago, chronic rhinitis, multiple joint arthralgia, tension-type headaches, dyspepsia, hematuria, metatarsalgia, residuals of metatarsal stress fractures, finger joint pain, lower leg periostitis, and essential hypertension. The Veteran, however, is advised that a claim for benefits must be submitted on the application form prescribed by the Secretary. 38 C.F.R. §§ 3.1(p), 3.155, 3.160 (2015). See also 79 Fed. Reg. 57660 (Sep. 25, 2014) (All claims governed by VA's adjudication regulations must be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises.) The issues of entitlement to service connection for a headache disorder, entitlement to higher ratings for posttraumatic stress disorder, a low back strain, a right shoulder impingement syndrome with chronic tendonitis of the supraspinatus and biceps tendon, and for residuals of shin stress fractures from January 3, 2012; and the question what initial rating is warranted for a bilateral hearing loss are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. From April 21, 2009 to November 13, 2009, symptoms of the Veteran's PTSD did not most nearly approximate occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 2. From November 13, 2009 to January 2, 2012, symptoms of the Veteran's PTSD did not most nearly approximate occupational and social impairment with reduced reliability and productivity. 3. The preponderance of the evidence is against a finding that the Veteran's low back strain was manifested by a limitation of forward thoracolumbar flexion to 60 degrees or less, a combined range of thoracolumbar motion to 120 degrees or less, muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour, ankylosis, or incapacitating episodes prior to January 3, 2012. 4. The preponderance of the evidence is against a finding that the Veteran's right shoulder impingement syndrome with chronic tendonitis supraspinatus and biceps tendon was manifested by ankylosis, a limitation of motion to the shoulder level, or malunion, nonunion, or dislocation of the humerus, clavicle or scapula prior to January 3, 2012. 5. The preponderance of the evidence is against a finding that the Veteran's bilateral shin stress fractures were manifested by malunion or nonunion of the tibia and fibula with slight knee or ankle disability prior to January 3, 2012. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 50 percent for PTSD from April 21, 2009 to November 13, 2009 were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.129, 4.130, Diagnostic Code 9411 (2015). 2. The criteria for a rating higher than 30 percent for PTSD were not met from November 13, 2009 to January 2, 2012. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code 9411. 3. The criteria for a rating higher than 10 percent for a low back strain were not met prior to January 3, 2012. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2015). 4. The criteria for a rating higher than 10 percent for a right shoulder impingement syndrome with chronic tendonitis supraspinatus and biceps tendon were not met prior to January 3, 2012. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5201 & 5024 (2015). 5. The criteria for a compensable rating for bilateral shin stress fractures were not met prior to January 3, 2012. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5262 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in correspondence dated July 2009 of the information and evidence needed to substantiate and complete the claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability evaluations and effective dates are assigned. VA has fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate his claims, and as warranted by law, affording VA examinations. There is no evidence that additional records have yet to be requested, or that additional examinations for the issues addressed are in order. The Board has reviewed all the evidence in the Veteran's claims file, which includes his written contentions, service treatment records, post-service treatment records, and VA examination reports. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Relevant Laws and Regulations Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2015). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation will be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2015). Where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). In determining the appropriate rating for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Factors of joint disability include increased or limited motion, weakened movement, excess fatigability, incoordination, and painful movement, including during flare-ups and after repeated use. DeLuca v. Brown, 8 Vet. App. 202, 206-08 (1995); 38 C.F.R. § 4.45. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. Additionally, "pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Pain in a particular joint may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Id.; 38 C.F.R. § 4.40. Under 38 C.F.R. § 4.59, painful joints are entitled to at least the minimum compensable rating for the joint. In adjudicating a claim for VA benefits, VA is 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. 38 U.S.C.A. § 5107(b). VA is to resolve any reasonable doubt in the Veteran's favor. 38 C.F.R. § 3.102. PTSD In an April 2010 rating decision, VA granted entitlement to service connection and assigned a 50 percent rating for PTSD effective April 21, 2009 and a 30 percent rating effective November 13, 2009. The Veteran's PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, which is the general rating formula for mental disorders. Under the general rating formula, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of ability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A score under the global assessment of functioning scale reflects the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996) (quoting the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). A veteran's assigned global assessment of functioning score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard, 9 Vet. App at 267; Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the global assessment of functioning score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the global assessment of functioning score must be considered in the light of the actual symptoms of the veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a) (2015). A score of between 51 and 60 indicates that the Veteran has moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging between 61 and 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. See DSM-IV. In March 2009, a Physical Evaluation Board determined that the Veteran's PTSD and bilateral shin and foot pain due to stress fractures rendered him unfit for retention. The Physical Evaluation Board assigned a 50 percent rating for the Veteran's PTSD under Diagnostic Code 9411 and placed him on the Temporary Disability Retired List. The basis for this rating was a February 2009 psychiatric consultation in which the Veteran reported depression, anxiety, and difficulty with decision making and concentration. The February 2009 examiner noted that the Veteran was "very critical of himself and appears to think of himself as less functional than his command has found him to be." The examiner found that the Veteran's PTSD "causes clinically significant distress or impairment in social, occupational, or other important areas of functioning." "When a mental disorder that develops in service as a result of a highly stressful event is severe enough to bring about the veteran's release from active military service, the rating agency shall assign an evaluation of not less than 50 percent and schedule an examination within the six month period following the veteran's discharge to determine whether a change in evaluation is warranted." 38 C.F.R. § 4.129. The Veteran was afforded a VA examination in November 2009. The Veteran reported distressing memories, nightmares, an exaggerated startle response, anger and irritability on an almost daily basis, frequent difficulty concentrating, hypervigilance, mistrust, a racing heart, fatigue, short term memory problems, intimacy problems, and difficulty staying asleep. The appellant stated that he was not currently taking medication or participating in therapy for any mental health disorder. The examiner found that the Veteran's test results "potentially involve considerable distortion and are unlikely to be an accurate reflection of [the appellant's] objective clinical status." The examiner diagnosed the Veteran with PTSD but characterized it as mild to moderate "due to the fact that he has a tendency to overstate his problem," which he found to be supported "by all three test results and my professional opinion." The examiner assigned a global assessment of functioning score of 61. The record does not reveal any outpatient treatment for any mental health disorder since the end of the Veteran's active duty service. The most recent outpatient treatment record in the Veteran's claims file is dated January 2012. The Veteran is competent to report his own observations with regard to the severity of his symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board notes that the February 2009 and November 2009 examiners both found a tendency for the Veteran to exaggerate his symptoms. For this reason, the claimant's self-reported symptoms are of limited probative value. In a March 2011 statement, the appellant alleged that the November 2009 examination report was "highly false and could not be farther from the truth." Absent any objective evidence that the Veteran's symptoms are worse than the examiners found, the Board finds, given the examiners' agreement about the appellant's tendency to exaggerate, that the examiners' observations of the claimant's symptoms are more credible than his assertions. A review of the evidence of record shows that a rating higher than 50 percent prior to November 13, 2009 is not warranted. Because the Veteran's PTSD was a partial cause of his separation from active duty service, a minimum rating of 50 percent was in order from the date of separation to the date of the November 2009 examination. Nothing in the February 2009 examination report or the Veteran's treatment records reveals symptoms similar to suicidal ideation, obsessional rituals, near-continuous panic or depression, impaired impulse control, spatial disorientation, neglect of appearance or hygiene, difficulty in adapting to stressful circumstances, or inability to establish and maintain effective relationships. A review of the evidence of record shows that a rating higher than 30 percent from November 13, 2009 to January 2, 2012 is not warranted. Based on the examiner's finding, which is both competent and credible that the Veteran's report of his symptoms was so distorted as to render testing unreliable, the most probative evidence in the examination report is the examiner's specific medical conclusion that the appellant's PTSD was mild to moderate, along with the global assessment of functioning score of 61. Mild to moderate PTSD with a global assessment of functioning score of 61 is not consistent with a rating higher than 30 percent. It is well to recall that the November 2009 examiner specifically found that the appellant had a tendency to exaggerate his symptoms. Low Back Strain In an April 2010 rating decision, the RO granted entitlement to service connection and assigned a 10 percent rating for a low back strain effective April 21, 2009 under 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2015), for lumbosacral strain. Diagnostic Code 5237 is governed by the general rating formula for diseases or injuries of the spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. The general formula specifies that the criteria and ratings apply with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area affected by residuals or injury or disease. Id. Under the general formula, a rating of 10 percent is warranted for: forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; a combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. Id. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is from zero to 90 degrees, extension is from zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are from zero to 30 degrees. Id. at Note (2). 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 thoracolumbar spine is 240 degrees. Id. The basis for the April 2010 rating decision was a September 2009 VA examination. During that examination, the Veteran reported that back pain "now rarely occurs since he left active military duty." Thoracolumbar motion was reported to 30 degrees in bilateral lateral rotation, and bilateral lateral flexion with no significant pain triggered and no change on repetition. There is nothing in the record to indicate that the examiner tested the forward flexion or extension of the Veteran's thoracolumbar spine. The examiner found no sign of kyphotic or lordotic misalignment of the spine. X-Rays showed no evidence of scoliosis or distortion and showed that the Veteran's vertebrae were "totally normal in terms of height and size and there were was no evidence of degeneration." The examiner diagnosed chronic lumbago due to myostatic insufficiency. Based on evidence of painful motion, the RO assigned a 10 percent rating. A November 2011 treatment record notes the Veteran's complaint of lower back pain. Physical examination revealed a full range of thoracolumbar motion with no spasms. A January 3, 2012 treatment record notes the Veteran's complaint of lower back pain but also noted muscle spasms and limited range of motion. The January 2012 record provides no further details as to the type or severity of any limitation of motion of the Veteran's thoracolumbar spine. The preponderance of the evidence shows that the Veteran's low back strain has not approximated the criteria for a rating higher than 10 percent at any time prior to January 3, 2012. There is no evidence of ankylosis or any abnormal gait or curvature of the spine. To the degree that the November 2009 examination is deficient in failing to measure every aspect of the range of motion of the Veteran's thoracolumbar spine, the November 2011 finding of a full range of motion cures that defect. There is nothing in the record to indicate any limitation of range of motion until the vague statement in the January 3, 2012 treatment record that the Veteran's thoracolumbar spine "did not demonstrate full range of motion." The Board also considered the Veteran's lay statements. The Veteran is competent to report his own observations with regard to the symptoms of his lumbar spine disability. See Jandreau, 492 F.3d at 1376-77. However, nothing in those statements provides any support for a finding that the Veteran's symptoms were more severe than those discussed above. The only symptom the Veteran has reported is pain, which his current 10 percent rating reflects. In addition, the Board considered whether a higher rating is warranted under the regulations relating to additional functional loss due to pain, weakness, fatigability, incoordination, and other factors under DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45. Nothing in the record prior to January 3, 2012 demonstrates additional functional loss due to pain or any other DeLuca factor. The Board considered whether there are any other Diagnostic Codes which could apply to the Veteran's current lumbar spine disability. Specifically, the Board has considered whether a higher rating is warranted under the formula for rating intervertebral disc syndrome based on incapacitating episodes. The record contains no evidence of a diagnosis of intervertebral disc syndrome or of incapacitating episodes. (An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a.) The Board therefore finds that there are no other potentially applicable Diagnostic Codes by which a higher rating can be assigned. Right Shoulder In a January 2012 rating decision, the RO assigned a 10 percent rating for a right shoulder impingement syndrome with chronic tendonitis suprapspinatus and biceps tendon effective April 21, 2009. The RO rated the Veteran's right shoulder disorder under 38 C.F.R. § 4.71a, Diagnostic Code 5024 (2015), for tenosynovitis. Diagnostic Code 5024 requires that tenosynovitis be rated on the basis of limitation of motion as degenerative arthritis under Diagnostic Code 5003. 38 C.F.R. § 4.71a. Diagnostic Code 5003 provides that degenerative arthritis is rated based on limitation of motion under the appropriate codes for the specific joint involved. Id. In the absence of a compensable limitation of motion, Diagnostic Code 5003 allows for a rating of 10 percent for each major joint or group of minor joints affected. Id. For VA rating purposes, a shoulder is a major joint. 38 C.F.R. § 4.45(f). Disabilities of the shoulder may be rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5200-5203 (2015). The Veteran is right handed. Diagnostic Code 5201 allows, in the major extremity, for a 20 percent rating for limitation of arm motion at shoulder level, a 30 percent rating for limitation of motion to midway between side and shoulder level. Diagnostic Code 5202 allows for ratings of 20 to 80 percent for impairment of the humerus in the major extremity. Diagnostic Code 5203 allows for ratings of 10 to 20 percent for impairment of the clavicle or scapula. Normal ranges of motion of the shoulder are forward flexion and abduction from 0 to 180 degrees and internal and external rotation from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. The Veteran was afforded a VA examination in September 2009 at which he reported pain in his right shoulder. The examiner reported that the Veteran's arms swung normally and both shoulder joints appeared normal on inspection. All tests were negative, other than the Neer and Hawkins impingement test of the right shoulder. The Veteran "was able to grasp the back of his shoulders and neck without delay." An X-Ray revealed that the right humerus head was normally formed and positioned. The examiner diagnosed the Veteran with impingement syndrome due to chronic tendonitis in the right supraspinatous and biceps tendon. The RO assigned a 10 percent rating based on painful motion. A January 3, 2012 treatment record notes that each of the appellant's extremities demonstrated a normal range of motion. The preponderance of the evidence shows that the Veteran's right shoulder disorder has not approximated the criteria for a rating higher than 10 percent at any time prior to January 3, 2012. There is nothing in the record to indicate any limitation of right shoulder motion. The Board considered the Veteran's lay statements. The Veteran is competent to report his own observations with regard to the symptoms of his right shoulder disability. See Jandreau, 492 F.3d at 1376-77. However, nothing in those statements provides any support for a finding that the Veteran's symptoms are more severe than those revealed by the VA examination. The only symptom the Veteran has reported is pain, which his current 10 percent rating reflects. In addition, the Board considered whether a higher rating is warranted under the regulations relating to additional functional loss due to pain, weakness, fatigability, incoordination, and other factors under DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45. Nothing in the record prior to January 3, 2012 demonstrates any additional functional loss due to pain or any other DeLuca factor. The Board considered whether there are any other Diagnostic Codes which could apply to the Veteran's current right shoulder disability. The record contains no evidence of ankylosis or impairment of the humerus, clavicle, or scapula. The Board therefore finds that there are no other potentially applicable Diagnostic Codes by which a higher rating can be assigned. Shin Stress Fractures In an April 2010 rating decision, the RO granted entitlement to service connection for bilateral shin stress fractures with foot pain and assigned noncompensable ratings effective April 21, 2009. In a February 2012 rating decision, the RO assigned a separate 10 percent rating for bilateral metatarsalgia effective April 21, 2009 and removed foot pain from the description of the Veteran's bilateral shin disabilities. The rating for metatarsalgia is not on appeal. Shin stress fractures are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2015), for impairment of the tibia and fibula. Diagnostic Code 5262 provides for ratings of 10 percent for malunion of the tibia and fibula with slight knee or ankle disability. At a September 2009 VA examination the Veteran reported foot pain. The examiner found no sign of limited mobility or pain in the Veteran's ankles. It is not clear from the record whether the examiner tested the range of motion of the Veteran's knees. With regard to the shins, the examiner noted tenderness and diagnosed the Veteran with chronic periostitis in the medial tibia side. The examiner did not report any malunion or nonunion of the tibia and fibula. A January 3, 2012 treatment record notes normal range of motion in all of the Veteran's extremities. The preponderance of the evidence shows that the Veteran's bilateral shin disorder has not approximated the criteria for compensable rating at any time prior to January 3, 2012. There is nothing in the record to indicate any malunion or nonunion of the tibia and fibula or any knee or ankle disability due to shin stress fractures. The Board considered the Veteran's lay statements. The Veteran is competent to report his own observations with regard to the symptoms of his right shoulder disability. See Jandreau, 492 F.3d at 1376-77. However, nothing in those statements provides any support for a finding that the Veteran's symptoms are more severe than those revealed by the VA examination. The only symptom the Veteran has reported is foot pain, which his current separate 10 percent rating for metatarsalgia reflects. The Board considered whether a higher rating is warranted under the regulations relating to additional functional loss due to pain, weakness, fatigability, incoordination, and other factors under DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45. Nothing in the record prior to January 3, 2012 demonstrates additional functional loss due to pain or any other DeLuca factor. The Board considered whether there are any other Diagnostic Codes which could apply to the Veteran's current bilateral shin disability. There are no other Diagnostic Codes directly applicable to the shins. To the extent that the Veteran has reported foot pain that is addressed by the separate 10 percent rating for metatarsalgia. Periostitis is ratable under 38 C.F.R. § 4.71a, Diagnostic Code 5022, based on limitation of motion or as degenerative arthritis under Diagnostic Code 5003, but the record contains no evidence that the Veteran's bilateral shin disability has caused any limitation of motion or painful motion of any joint. The Board therefore finds that there are no other potentially applicable Diagnostic Codes by which a higher rating can be assigned. Extrascheduler Consideration The Board considered whether the Veteran's PTSD, low back strain, right shoulder impingement syndrome, and bilateral shin stress fractures represent an exceptional or unusual disability picture as to render impractical the application of the regular scheduler standards such that referral to the appropriate officials for consideration of extra-scheduler ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2015); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extra-scheduler consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available scheduler evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical.") Here, the rating criteria for each disorder reasonably describe the Veteran's disability level and symptomatology. Thus, his disability pictures are contemplated by the rating schedule, and the assigned scheduler evaluations are adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extra-scheduler consideration is not warranted. Finally, under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extra-scheduler 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. In this case, however, even after applying the doctrine of reasonable doubt, 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 extra-scheduler consideration may be required to compensate the Veteran for any additional disability that can be attributed only to the combined effect of multiple conditions. In reaching this conclusion the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the assignment of a higher disability rating, that doctrine is not applicable. ORDER Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder prior to November 13, 2009 is denied. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder from November 13, 2009 to January 2, 2012 is denied. Entitlement to a rating in excess of 10 percent for a low back strain prior to January 3, 2012 is denied. Entitlement to a rating in excess of 10 percent for a right shoulder impingement syndrome with chronic tendonitis of the supraspinatus and biceps tendon prior to January 3, 2012 is denied. Entitlement to a compensable rating for bilateral shin stress fractures prior to January 3, 2012 is denied. REMAND The Veteran was last afforded a VA examination for PTSD in November 2009, and for his lower back disorder, right shoulder disorder, and shin stress fractures in September 2009, six years ago. The record contains no treatment records of any kind after January 2012, nearly four years ago. Also, in a January 2012 statement, the Veteran reported that the shin disorders had worsened. A remand is necessary to obtain updated treatment records and to afford the Veteran new examinations so that the Board can gain a better understanding of the appellant's current condition. The September 2009 VA examination of the Veteran's hearing was inadequate. The Veteran lives in Germany and, due to the language barrier, the examination did not test the Veteran's speech discrimination ability. A remand is necessary to afford the Veteran an adequate VA examination. During the September 2009 VA examination, the Veteran reported that he did not have a headache. The examiner interpreted this to mean that the Veteran was no longer affected by any headache disorder and performed no further examination with regard to that issue. In a March 2011 statement, the Veteran explained that he only meant that he did not have a headache at that exact moment. A remand is necessary to afford the Veteran a VA examination for headache disorders. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he provide written authorization with the names and addresses of all health care providers, including any within the VA, private, military and Tricare systems that have treated him since January 2012. Thereafter, the AOJ must, at a minimum, attempt to secure all pertinent records from the Wiesbaden Army Health Clinic, Landstuhl Regional Medical Center, and any military disability evaluation board reports. If any records require translation into English, the AOJ shall do so before providing those records to the examiners noted below or to the Board. 2. Schedule the Veteran for an appropriate VA psychiatric examination with a psychiatrist or psychologist to address the current severity of his PTSD. The examiner must be provided access to the Veteran's files in Virtual VA and VBMS. The examiner must specify in the report that all Virtual VA and VBMS records have been reviewed. Any indicated evaluations or studies should be conducted, to specifically include a Structured Interview of Reported Symptoms. A complete rationale for any opinions expressed must be provided. The examiner should specifically provide a full multi-axial diagnosis, to include a global assessment of functioning score related to the Veteran's PTSD. All signs and symptoms of psychiatric disability should be reported in detail. If the examiner concludes that the Veteran has additional psychiatric diagnoses unrelated to his service-connected PTSD, he or she must state whether the symptoms of the separate disorders can be differentiated and provide an explanation as to why they can or cannot be separated or differentiated, and discuss what symptoms are related specifically to the Veteran's service-connected PTSD. The examiner must discuss specifically what, if any, impairment is caused by posttraumatic stress disorder on the appellant's occupational functioning, disregarding the effect of any nonservice-connected disorders of the Veteran. The examiner must set forth all examination findings with a complete explanation based on the facts of this case and any relevant medical literature for the comments and opinions expressed. 3. Schedule the Veteran for a VA orthopedic examination to assess the current severity of his lower back, right shoulder, and bilateral shin disorders. The examiner must be provided access to the appellant's Virtual VA and VBMS files and the examination report should reflect consideration of the Veteran's documented medical history. All indicated tests should be accomplished (to include X-rays if necessary), and all clinical findings reported in detail. In accordance with the latest worksheets for rating the disorders of the low back, right shoulder, and shins, the examiner is to provide a detailed review of the Veteran's pertinent medical history, current complaints, and the nature and extent of each disorder. The impact of each of these disorders on the appellant's ability to work must be addressed. A complete rationale for any opinion expressed must be provided. The examiners must discuss the Veteran's lay statements regarding the history, symptoms, and functional impairment caused by these disorders. The examiners must set forth all examination findings with a complete explanation based on the facts of this case and any relevant medical literature for the comments and opinions expressed. If the examiner is unable to provide any of the opinions requested, that fact must be stated and the reasons why an opinion cannot be provided explained. That is, the examiner must specifically explain why the diagnosis or severity of any lower back, right shoulder, or shin disorder is unknowable. 4. The AOJ should schedule the Veteran for a VA audiological examination by an audiologist to determine the current severity of his service-connected hearing loss. Due to the language barrier issues during the September 2009 VA examination that prevented speech discrimination testing, the Board requests that efforts be undertaken to have all examinations performed at a United States military base. The Virtual VA and VBMS claims files must be provided to the examiner and the examination report should reflect consideration of the Veteran's documented medical history and assertions. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The findings of puretone decibel loss at 1000, 2000, 3000, and 4000 Hertz must be numerically reported, and speech recognition percentage results derived using the Maryland CNC word list. The examiner must specifically address the effect of the Veteran's hearing loss on his occupational functioning and daily activities. 5. The Veteran should be scheduled for a VA examination to determine the nature and etiology of any diagnosed headache disorder. The examiner must be provided access to the appellant's VBMS file and Virtual VA file. The examination report should reflect consideration of the Veteran's documented medical history and assertions. All indicated tests should be accomplished, and all clinical findings reported in detail. If a headache disorder is diagnosed, the examiner must state whether it is at least as likely as not, i.e., is there at least a 50/50 chance, that the disorder is etiologically related to the Veteran's active duty service in any way. The examiner must specifically discuss the October 2008 inservice diagnosis of a mixed headache disorder. The examiner must discuss the service treatment records and the Veteran's lay statements regarding the symptoms of and functional impairment caused by any headache disorder. The examiner must set forth all examination findings with a complete rationale for any opinion offered. If the examiner is unable to provide the opinion requested, that fact must be stated and the reasons why an opinion cannot be provided explained. That is, the examiner must specifically explain why the etiology of any diagnosed headache disorder is unknowable. 6. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2015). 7. Ensure that the medical examination reports comply with this remand. The AOJ must ensure that the examiners have documented consideration of the Veteran's paperless claims file. If any report is insufficient, it must be returned to the examiner for necessary corrective action, as appropriate. 8. After undertaking any other development deemed appropriate, readjudicate the issues on appeal. If any benefit sought is not granted, the Veteran should be furnished with a supplemental statement of the case and afforded an opportunity to respond before the record is returned to the Board for further review. 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 2014). ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs