Citation Nr: 20007285 Decision Date: 01/28/20 Archive Date: 01/28/20 DOCKET NO. 19-07 178 DATE: January 28, 2020 ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD) is denied. Entitlement to service connection for a back disorder is denied. Entitlement to a disability rating higher than 10 percent for left ankle, tendonitis, retrocalcaneal bursitis and calcaneal spur (left ankle disability) is denied. For the entire appeal period, a 20 percent disability rating, but not higher, for left clavicle fracture residuals (left clavicle disability) is granted, subject to the rules governing the payment of monetary benefits. FINDINGS OF FACT 1. The Veteran’s hypertension did not have its onset in service, or manifest to a compensable degree within one year of service discharge and is not otherwise related to service or service-connected disability. 2. The Veteran does not have PTSD under the appropriate Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria, and his unspecified depressive disorder is not related to service. 3. The Veteran is not shown to have a back disorder. 4. The Veteran’s left ankle disability has been manifested by no more than moderate limitation of motion; marked limitation of motion is not shown and there is no clinical evidence of ankylosis, malunion, or astragalectomy. The rating criteria reasonably describe his disability level and symptomatology. 5. Giving the Veteran the benefit of the doubt, his service-connected left clavicle disability has been manifested by functional impairment due to painful motion. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5103, 5103A 5107(b); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for an acquired psychiatric disorder including PTSD, are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304. 3. The criteria for service connection for a back disorder are not met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. § 3.303. 4. The criteria for a disability rating higher than 10 percent for the left ankle disability are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.321(b)(1), 4.71a Diagnostic Code (DC) DC 5271. 5. The criteria for a 20 percent disability rating, but no higher, for the left clavicle disability are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.71a, DC 5201. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1983 to June 2006. In an August 2016 rating decision, the Agency of Original Jurisdiction (AOJ) denied service connection for hypertension. Prior to the expiration of the appeal period for the August 2016 rating decision, the Veteran submitted an August 2016 private medical opinion, indicating that the current hypertension was diagnosed within a year of service discharge. The Board finds that the medical opinion is new and that it directly pertains to the basis for the prior final denial, by addressing whether hypertension is linked to service. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Where new and material evidence is received within one year after the initial denial, the denial is not final, and the claim remains pending. 38 C.F.R. § 3.156(b). In August 2016, the Veteran submitted a petition to reopen the claim of service connection for hypertension. The December 2016 rating decision declined to reopen the claim, finding that new and material evidence had not been submitted. Because, however, new and material evidence was received within the appeal period of the August 2016 rating decision, that decision is not final, and new and material evidence is not required; accordingly, the Board will consider the claim of service connection for hypertension de novo. Service Connection The Veteran is seeking service connection for hypertension, a psychiatric disorder, and a back disorder. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Certain chronic diseases are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). Continuity of symptomatology may also provide a basis for a grant of service connection for those diseases defined as “chronic” by VA. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 446 (1995) (en banc). In order to establish service connection for a claimed secondary disorder, there must be medical evidence of a current disability; evidence of a service-connected disability; and medical evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, any reasonable doubt is resolved in favor of the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. hypertension The Veteran asserts that his hypertension was diagnosed and treated within a year of service discharge. More recently he has claimed that his hypertension is caused, or made worse, by his psychiatric disorder. For VA compensation purposes, the term “hypertension” means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. Multiple blood pressure readings are required to confirm the diagnosis of hypertension with 2 or more readings on at least 3 different days. 38 C.F.R. § 4.104, DC 7101, Note 1. Service treatment records fail to reveal any evidence of elevated blood pressure readings sufficiently high to require treatment, or to result in a diagnosis of hypertension. As such, there is no evidence of hypertension during active military service. There is also no objective evidence that the Veteran was diagnosed as having hypertension within one year of his service discharge. Post-service private treatment records begin in 2007 but do not report hypertension until 2010. See clinical records from Piedmont Physicians Group. Because hypertension was not demonstrated until several years following his separation from active duty, the Veteran may not be allowed service connection on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309. In August 2016, a private physician stated that the Veteran was diagnosed with hypertension and treated with medication within one year of service discharge based on physician and pharmacy records. See medical opinion from P.J. Yocum, dated August 1, 2016. Unfortunately, this opinion, while supportive of the claim, is limited in terms of its ultimate probative value as the physician did not explain what evidence supported his conclusion and did not reference specific clinical data or evidence to support his opinion. Also, because the opinion is not corroborated by contemporaneous medical records it diminishes the probative value of its findings. Since the doctor has essentially relied on a history that is not supported in the record, the opinion does not provide a sufficient basis upon which to support the claim. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). After weighing all the evidence, the Board is unable to attribute the hypertension to service. In this case, any assertion by the Veteran that his hypertension is related to service treads into the realm of medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). Because the evidence of record fails to establish that the claimed hypertension was present in service, and there is no competent medical evidence relating it to military service, the claim cannot be granted. Accordingly, the preponderance of the evidence is against the claim and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b). To the extent that the Veteran now contends that his hypertension is related to his psychiatric problems, as discussed in detail below, service connection for a psychiatric disorder has been denied; therefore, it cannot serve as the basis of a grant of service connection for hypertension. Therefore, the claim, on a secondary basis, must be denied as a matter of law. See 38 C.F.R. § 3.310(a); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). 2. psychiatric disorder The Veteran is seeking service connection for psychiatric symptoms, claimed as PTSD, which he asserts are related to his military service. Through his representative, he argues that his PTSD stems from an in-service motor vehicle accident. There are particular requirements for establishing service connection for PTSD in 38 C.F.R. § 3.304(f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). In order to grant service connection for PTSD to a non-combat veteran, there must be credible evidence to support the veteran’s assertion that the stressful event occurred. A stressor need not be corroborated in every detail. Suozzi v. Brown, 10 Vet. App. 307, 311 (1997). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. Cohen, supra; Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996). However, if a stressor claimed by a veteran is related to fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). A diagnosis of PTSD must conform to the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM). 38 C.F.R. § 4.125(a). The Board recognizes that the Veterans Benefits Administration is now required to apply concepts and principles set forth in the upon the to the recently-updated Fifth Edition, (DSM-5). The Veteran’s DD Form 214 shows that he did not receive any commendations or awards, such as the Combat Infantryman Badge, Purple Heart, or similar citation, typically awarded primarily or exclusively for circumstances relating to combat. Moreover, his reported in-service stressor does not fall within the scope fear of hostile military or terrorist activity under 38 C.F.R. § 3.304 (f)(3). The other critical element is that the Veteran lacks a diagnosis of PTSD consistent with DSM criteria. Service treatment records confirm the Veteran was involved in an automobile accident in April 1992, with injuries confined to left clavicle fracture. However, they fail to reveal any psychiatric signs or symptoms prior to his separation from service. There is also no post-service evidence that the Veteran was diagnosed with a chronic psychiatric disorder. In fact, these records include negative PTSD and depression screenings and show multiple instances where he denied psychiatric symptoms altogether. In addition, his medication lists did not include any of the commonly prescribed medications used to treat psychiatric disorders. VA outpatient treatment records dated from 2012 to 2018. The only medical documentation of pertinent complaints or psychiatric treatment is in an opinion submitted by a private physician. At that time the Veteran gave a history of declining social functioning following his retirement from the Air Force. He reported anhedonia in the form of social distancing relative to his military service stating that he had difficulties with “being at risk” since his retirement from the Air Force. The physician found the symptoms did not meet the diagnostic criteria for PTSD and that the appropriate diagnosis was persistent depressive disorder. A review PTSD Disability Benefits Questionnaire (DBQ) dated August 5, 2016. The examiner did not suggest that any pertinent symptomatology originated during military service and there is no other evidence of record to suggest the presence of depressive disorder prior to the indicated date of diagnosis. Based on the evidence in this case, the Board finds that service connection for PTSD is not warranted as the overall disability picture fails to establish a valid diagnosis during the appeal period. The Board is also unable to attribute the post-service development of depressive disorder to military service. The Veteran did not experience chronic psychiatric symptoms in service and there is no evidence linking the diagnosed depressive disorder to service and the Board finds that the criteria to obtain an etiology opinion have not been met because the record does not document psychiatric complaints or treatment during service or for several years after. Duenas v. Principi, 18 Vet. App. 512, 519 (2004). The Veteran’s representative has challenged the adequacy of this medical opinion on the basis that the private examiner failed to give an opinion regarding whether the depressive disorder was related to service. Generally, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). However, because this is a private medical opinion, Barr does not apply, so the representative’s complaint does not provide a basis upon which to remand this claim for additional examination. 3. back disorder The Veteran asserts that he has a back disorder that had its onset during service. Unfortunately, the primary impediment to a grant of service connection is the absence of medical evidence of a current disability. Service treatment records are entirely negative for back complaints. At his retirement physical in June 2006, the Veteran did not report any back problems and clinical evaluation of all major body systems, to include the spine, was within normal limits. Although the Veteran now claims to have a back disorder, post service clinical records show no objective physical or clinical findings or confirmed diagnosis. Post-service records show he is not currently undergoing treatment for back problems and no such complaints are documented in any report of past medical history. Rather these records include instances where he denied back problems altogether. See clinical records dated 2007 to 2015 from Piedmont Physicians Group; Atlanta Heart Associates, Piedmont Healthcare; Eagles Landing Family Practice. In addition, VA treatment records dated from 2016 to 2018 have been associated with the claims file and at no point reflect any specific back complaints and no such complaints are documented in “active problem lists” or in any report of past medical history. See clinical records from Atlanta VA Medical Center and Atlanta VA CBOC. Since service and post-service treatment records provide no basis to grant this claim, and in fact provide evidence against it, the Board finds no basis for VA to provide an examination. Duenas v. Principi, 18 Vet. App. 512, 519 (2004) (holding that VA is not obligated to provide an examination for a medical nexus opinion where, as here, the supporting evidence of record consists only of a lay statement). At this point the Veteran has not provided any meaningful description of current back problems to trigger a VA examination through evidence of symptoms of a potential disability. Having reviewed the evidence of record, the Board finds that the weight of the evidence reflects that the Veteran does not currently have a back disorder. To the extent that such complaints were made or otherwise documented, there is no competent evidence which suggests the complaints constitute an actual chronic disability. The Veteran has also not described or presented evidence of any specific functional loss or impairment due to back pain. See Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018) (holding that pain alone may constitute a disability, even without an identifiable underlying pathology, provided that such pain is productive of functional impairment). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F.3d 1328 (1997) (holding that the VA’s and the Court’s interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As the Veteran does not have a current back disorder or related functional impairment, service connection cannot be awarded. Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Increased Rating The Veteran is seeking increased disability ratings for his service-connected left clavicle and left ankle disabilities. Disability ratings are determined by comparing a veteran’s present symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A review of the recorded history of a disability is necessary to make an accurate rating. 38 C.F.R. §§ 4.2, 4.41. The regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 4. left ankle disability The Veteran’s left ankle disability is evaluated as 10 percent disabling under DC 5271 for moderate limitation of motion of the ankle. A 20 percent evaluation is assigned for marked limitation of motion of the ankle. 38 C.F.R. § 4.71a. Normal ankle dorsiflexion is to 20 degrees and normal plantar flexion is to 45 degrees. 38 C.F.R. § 4.71, Plate II. The Board observes that the terms “moderate” and “marked” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for an “equitable and just” decision. 38 C.F.R. §§ 4.2, 4.6. The current 10 percent disability rating is based, primarily on findings from a July 2015 VA examination. The Veteran reported symptoms began after a severe sprained ankle when playing basketball. Since then he has had moderate discomfort after periods of standing, lengthy walking, or running. He described flare ups of ankle stiffness after extended usage, which results in functional loss/impairment. Range of motion of the left ankle was normal with 20 degrees plantar dorsiflexion and 45 degrees of plantar flexion. Pain caused functional loss on dorsiflexion and there was evidence of localized tenderness on of the medial side of the ankle. There was also evidence of pain with weight bearing but no crepitus. There was no additional loss of motion with repetitive-use testing, but additional factors contributing to disability included less movement than normal, swelling, disturbance of locomotion, and interference with standing. Muscle strength was normal at 5/5 with no evidence of atrophy, ankylosis, instability, or dislocation. There was no history of shin splints, stress fractures, malunion of calcaneus (os calcis) or talus (astragalus), or talectomy. Imaging studies of the left ankle showed minimal calcification at the level of Achilles tendon insertion on the posterior os calcis and calcaneal spur formation, but were negative for arthritis. The Veteran reported that he did not use any assistive devices, but the left ankle disability impacted his ability to work due to limited walking and weight bearing from pain. When examined in September 2016, the Veteran continued to report left ankle discomfort which he described as stiffness and aching. He denied any surgeries or physical therapy, but occasionally used over the counter medications with some relief. He did not report flare-ups but described functional loss/impairment in that his left ankle impairs his ability to run, walk/stand for prolonged periods, or engage in physical activities outdoors. Range of motion of the left ankle was 40 degrees of plantar flexion and 20 degrees of dorsiflexion. Pain caused decreased range of motion resulting in functional loss, but there was no evidence of pain with weight bearing tenderness or crepitus. There was no additional loss of motion with repetitive-use testing. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. However, the examiner noted that the degree of limitation of motion due to pain, fatigue, weakness or in-coordination with flare-ups, could not accurately estimated since this must be determined objectively and the measurements cannot be determined without direct contact with the Veteran during the flares. There were no additional factors contributing to disability. Muscle strength was normal at 5/5 with no evidence of atrophy, ankylosis, joint instability. There was no history of shin splints, stress fractures, achilles tendonitis/tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or talectomy. Imaging studies were negative for arthritis and the Veteran did not use any assistive devices as a normal mode of locomotion. The examiner noted that since the Veteran’s symptoms were heightened by everyday physical activities, his left ankle condition may limit his ability to perform tasks associated with physical work that requires prolonged standing, walking, repetitive use and/or weight bearing activities. His left ankle condition likely had no impact on his ability to perform sedentary work. The most recent examination in January 2019 shows left ankle range of motion was normal at 45 degrees of plantar flexion and 20 degrees of dorsiflexion. Pain was noted on exam, but did not result in/cause functional loss. There was no evidence of pain with weight bearing, tenderness/pain on palpation, or crepitus. There was no additional loss of motion with repetitive-use testing. The examiner was unable to say without mere speculation whether pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time as there was no additional evaluation beyond initial exam. There were no additional factors contributing to disability. Muscle strength was normal at 5/5 with no evidence of atrophy, ankylosis, or joint instability. There was no history of shin splints, stress fractures, achilles tendonitis/tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or talectomy. There were no other pertinent physical findings, complications, conditions signs or symptoms related to the left ankle disability. The Veteran did not use any assistive devices and imaging studies were negative for arthritis. The examiner noted the Veteran displayed a great amount of strength to prevent passive range of motion and stability testing of his ankle and was observed to have a non-antalgic gait. He had full passive range of motion and there was no swelling or instability. There was no evidence of pain on passive range of motion testing or with non-weight bearing. The Board finds that while the preceding evidence supports the grant of a 10 percent disability rating, a higher evaluation is not warranted. In this case, the Veteran’s left ankle disability falls short of being characterized as marked. Rather the record largely reflects findings of essentially normal or near-normal range of motion with no reduction in strength and no objective evidence of instability. Although, VA examiners have found functional loss due to pain on movement, examination findings do not suggest that his essentially full range of motion would change to the degree required for a higher rating after repetitive use, due to pain, or with weight bearing. Given that the Veteran’s complaints do not prevent him from achieving substantial measured range of motion of the left ankle they do not support a finding of additional functional loss for a higher rating. The Veteran’s complaints have been taken into consideration, but there is no evidence that his left ankle disability suffers significant or additional functional loss beyond that contemplated by the assigned 10 percent evaluation. See 38 C.F.R. § 4.71, DC 5271; 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Correia v. McDonald, 28 Vet. App. 158 (2016), and Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board also finds that no other diagnostic code pertaining to the left ankle would provide any higher evaluation. There is no evidence of ankylosis, malunion of the os calcis or astragalus, or astragalectomy as contemplated by DCs 5270, 5272, 5273, and 5274. 38 C.F.R. § 4.71a. Accordingly, there is no basis for a higher rating. The preponderance of the evidence is against the claim, and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b). The Veteran now contends, through his representative, that he is entitled to an increased rating for this disability on an extraschedular basis. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical). The Court has set out a sequential three-step analysis, based on the language of 38 C.F.R. § 3.321 (b)(1), to determine whether to refer a case for extraschedular consideration. Thun v. Peake, 22 Vet. App. 111 (2008). Step one is to determine whether the schedular rating adequately contemplates a claimant’s disability picture. If the criteria reasonably describe the disability level and symptomatology, then the claimant’s disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral to the Under Secretary for Benefits or the Director, Compensation Service for consideration of an extraschedular rating is required. If, however, the schedular criteria do not contemplate the claimant’s level of disability and symptomatology and are therefore found to be inadequate, step two is to determine whether the claimant’s disability picture is exceptional, with such related factors as marked interference with employment or frequent periods of hospitalization, as to render impractical the application of the regular schedular criteria. If the claimant’s disability picture meets this second step, then the third and last step is to refer the case to the Under Secretary for Benefits or the Director, Compensation Service to determine whether an extraschedular rating is warranted. In this case, the manifestations of the Veteran’s left ankle disability are fully contemplated by the schedular rating criteria. The Veteran has reported chronic pain and other functional loss, which are expressly contemplated by the rating criteria which assess pain, range of motion and limitation of function. He did not report any additional specific symptoms related to his left ankle. The Board finds that all symptoms identified by the Veteran have been specifically contemplated by the criteria for the 10 percent rating that he is already receiving. There are no symptoms attributable to his service-connected left ankle that are left uncompensated or unaccounted for by the assignment of schedular rating. There is no need to consider the second step of the inquiry, namely whether there are “related factors” such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board’s “threshold” finding that the rating criteria were adequate to evaluate the claimant’s disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). As such, referral for extraschedular consideration is not warranted. The preponderance of the evidence is against the claim, and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b). 5. left clavicle fracture The Veteran’s left clavicle is currently rated as noncompensable. Disabilities of the shoulder and arm are rated under DCs 5200 through 5203. 38 C.F.R. § 4.71a. Under DC 5203 malunion of the clavicle or scapula or nonunion without loose movement is rated as 10 percent disabling. Nonunion of the clavicle or scapula with loose movement or dislocation of the clavicle or scapula warrants a 20 percent rating. 38 C.F.R. § 4.71a. Under DC 5201 limitation of motion of the major or minor arm at shoulder level is rated as 20 percent disabling. Limitation of motion of the minor arm midway between the side and shoulder level also warrants a 20 percent rating. When motion is limited to 25 degrees from the side, a 30 percent rating is warranted for the minor arm. Id. The normal range of motion of the shoulder is forward elevation (flexion) from zero to 180 degrees; abduction from zero to 180 degrees; and internal and external rotation to 90 degrees. Lifting the arm to shoulder level is lifting it to 90 degrees. Id., Plate I. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. 38 C.F.R. § 4.69. The evidence establishes the Veteran is right-handed, so his left clavicle disability is rated for impairment of the minor upper extremity. The current noncompensable evaluation is based, in part on findings from a July 2015 VA examination report. The Veteran reported he fractured his left clavicle in an automobile accident. His range of motion has always been affected and is more evident when lifting items with his arms fully extended overhead, carrying items, or swimming. Over the years range of motion has been further reduced and the Veteran is in limited in daily activities. He described flare ups of the left shoulder as problems lifting, pushing, and pulling. Range of motion showed flexion to 170 degrees and abduction to 140 degrees, with objective evidence of pain that causes an inability to lift over the head. External and internal rotation were to 70 degrees. There was evidence of pain with weight bearing and tenderness/pain around the lateral side of the shoulder. There was no evidence of crepitus or additional limitation of motion after repetitive use testing, but there was functional loss/impairment due to less movement than normal and weakened movement. The examiner was unable to say without mere speculation whether pain, weakness, fatigability or incoordination significantly limit functional ability with flare ups as the examination was not conducted during a flare up. Muscle strength was slightly weakened at 4/5 for both abduction and flexion with no evidence of atrophy or ankylosis. There was evidence of rotator cuff conditions and instability but no recurrent dislocation. The Veteran was unable to perform crank apprehension and relocation test. The examiner noted that the Veteran’s clavicle condition affected range of motion of the shoulder and there was localized tenderness of the AC joint and cross-body adduction test was positive. Imaging studies showed an old healed left clavicle fracture but were negative for arthritis. The Veteran did not use any assistive devices and the left shoulder impacted his ability to work in that overhead activities, lifting, pulling, pushing and some skilled movements were affected. The diagnoses included status post clavicle fracture, shoulder strain and rotator cuff tendonitis. During VA examination in November 2016, range of motion showed flexion to 110 degrees and abduction to 110 degrees, which contributes to functional loss as he does not have full range of motion. External and internal rotation were to 45 degrees. Pain was noted on exam, but did not result in/cause functional loss. There was evidence of pain with weight bearing but no tenderness or evidence of crepitus. There was no additional limitation of motion after repetitive use testing. The examiner could not determine or accurately estimate the degree of limitation of motion due to pain, fatigue, weakness or in-coordination with flare-ups, without resorting to mere speculation since the measurements could not be determined without direct contact with the Veteran during the flares. Muscle strength was slightly weakened at 4/5 for both abduction and flexion with no evidence of atrophy or ankylosis. There were no additional factors contributing to disability including recurrent dislocation or shoulder instability. A rotator cuff condition was suspected but the examiner was unable to test for it. Imaging studies showed an old healed left clavicle fracture but were negative for arthritis and the Veteran did not use any assistive devices. The examiner noted that since the Veteran’s symptoms were heightened by physical activities, his left shoulder condition may limit his ability to perform tasks associated with physical work that requires periods of raising his left arm above his head or lifting objects greater than 25 pounds, but likely had no impact on his ability to perform sedentary work. The examiner also noted that the Veteran’s left shoulder pain and impairment were more consistent with a rotator cuff pathology and are NOT a residual or progression of his service-related old left midclavicular fracture which occurred 24 years ago. Subsequently dated VA outpatient records show that while the Veteran continued to report chronic pain, he maintained a conservative treatment plan for his left shoulder disability, including pain medication and physical therapy. Moreover, the clinical findings from these records are not materially different from those reported on the prior VA examinations and show no indication of a worsening in range of motion or functional impairment. Based on the preceding evidence, the criteria for a compensable evaluation for the Veteran’s left shoulder disability are not met under DC 5203. The evidence of record, including VA examinations does not show malunion or nonunion of the clavicle or scapula. The Veteran has not required surgery and the left clavicle disability is not so severe as to necessitate the use of braces or other special devices. However, the Board does find that a 20 percent evaluation, but no higher is warranted under DC 5201 for limitation of motion of the arm as it affords a better approximation of the disability picture presented. VA examinations show the Veteran can achieve at least 110 degrees of both abduction, i.e., he was capable of reaching the arm above shoulder level, and forward elevation of the arm. However, he has consistently reported that his left clavicle disability is manifested by chronic pain which increases with activity. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). He is competent to report observable symptoms, such as pain and functional impairment. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). As such, the minimum compensable rating of 20 percent under DC 5201 is warranted for the left shoulder joint. See 38 C.F.R. § 4.59. See Burton v. Shinseki, 25 Vet. App. 1 (2011). A rating higher than 20 percent is not warranted. At no point during the appeal period does the evidence indicate that the Veteran experienced limitation of motion to 25 degrees from the side. Therefore, a 30 percent rating is not warranted. (Continued on the next page)   The Board also finds that no other diagnostic code pertaining to the shoulder would provide any higher disability evaluation. There is no evidence of ankylosis, or impairment of the humerus, as contemplated by DCs 5200 and 5202. 38 C.F.R. § 4.71a. Therefore, ratings under these diagnostic codes are not warranted. Accordingly, the Board finds that the evidence supports the assignment of a 20 percent rating for the Veteran’s left clavicle disability during the appeal period. 38 C.F.R. § 3.102. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.R. Bryant The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.