Citation Nr: 20021023 Decision Date: 03/24/20 Archive Date: 03/24/20 DOCKET NO. 14-09 887 DATE: March 24, 2020 ORDER Entitlement to an initial rating in excess of 100 percent for Post-traumatic stress disorder (PTSD) due to military sexual trauma (MST) is granted from January 4, 2012, to May 2, 2019. Entitlement to an initial 30 percent rating for residuals of left shoulder trauma and surgery (left shoulder disability) is granted. Entitlement to a separate 10 percent rating, but no higher, for a left shoulder scar is granted. REMANDED Entitlement to a TDIU due to service-connected disabilities from October 5, 2009, is remanded. FINDINGS OF FACT 1. The Veteran’s PTSD due to military sexual trauma, has been productive of total occupational and social impairment. 2. Resolving all reasonable doubt in the Veteran’s favor, his left shoulder disability has been manifested by pain, weakness, and limited range of motion that with consideration of functional loss most nearly approximates limitation of motion to 25 degrees from the side, but unfavorable ankylosis and fibrous union, nonunion, malunion, or loss of the head of the humerus were not shown. 3. The evidence is at least evenly balanced as to whether Veteran’s left shoulder scar is painful; it is not shown to be of the face, head or neck, measure greater than 39 square cm or be unstable. CONCLUSIONS OF LAW 1. The criteria for an initial 100 percent rating for PTSD due to MST from January 4, 2012, to May 2, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411. 2. The criteria for an initial rating of 30 percent, but no higher, for a left shoulder disability have been met. 38 U.S.C. §§ 1155, 5, 5107; 38 C.F.R. §§ 3.321 (b)(1), 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5200-5204, 4.124a, Diagnostic Code 8519. 3. The criteria establishing a separate 10 percent evaluation, and no higher, for a left shoulder scar have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1-4.10, 4.118, Diagnostic Codes 7800-7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1976 to August 1978. The Board of Veterans’ Appeals (Board) notes that the Veteran was granted a 100 percent rating for his PTSD effective May 3, 2019 in the November 2019 Rating Decision. That decision constituted a full grant of the benefits sought from that date forward. However, as the instant appeal dates back to January 2012 (the date the Veteran filed his original claim for service connection), the issue of entitlement to an initial rating in excess of 70 percent for PTSD prior to May 3, 2019 remains before the Board. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board also notes that the Veteran’s left shoulder claim was remanded in January 2018 because it was inextricably intertwined with weather a clear and unmistakable error (CUE) occurred in the March 1984 rating decision. However, that issue was addressed in the February 2019 Board decision, which denied the CUE claim. Thus, the Veteran’s claim for a higher rating is currently before the Board and will be adjudicated herein. Legal Criteria or Increased Ratings Disability ratings are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The Veteran’s entire history is to be considered when making disability evaluations. See generally Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1995); 38 C.F.R. § 4.1. 1. An initial rating of 100 percent for PTSD due to MST is granted from January 4, 2012, to May 2, 2019. The Veteran contends his “mental condition warrants a 100% evaluation rather than a 70% evaluation.” See January 2012 NOD. The Veteran stated that he has symptoms consistent with a 100 percent rating including gross impairment in thought process, disorientation, persistent danger to self and others, and inability to perform activities of daily living. Id. The Veteran’s PTSD is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § § 4.130. Under the General Rating Formula, a 100-percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Nevertheless, all ratings in the general rating formula are associated with objectively observable symptomatology, and in Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013), the Federal Circuit stated that “a veteran may only qualify for a given disability rating under Section 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” The Federal Circuit further noted that Section 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas.” Vazquez-Claudio v. Shinseki, 713 F.3d 117. Thus, “[a]lthough the veteran’s symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran’s level of impairment in ‘most areas.’” Id. at 118. As such, the Board will consider both the Veteran’s specific symptomatology as well as the occupational and social impairment associated with the DC to determine whether an increased evaluation is warranted. Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). The amendments replace those references with references to the recently published Fifth Edition (DSM-5). See 80 Fed. Reg. 53, 14308 (March 19, 2015). This claim is governed by the DSM-5. Factual Background As an initial matter, the Board notes that the Veteran’s appeal for an initial increased rating for his service-connected PTSD dates back to his initial claim for service connection, received on January 4, 2012. Thus, the appellate period is from January 4, 2012, to May 2, 2019. The Veteran’s VA treatment records reflect treatment for his psychiatric disability, to include through the use of psychotherapy and psychotropic medications. During a January 2012 psychotherapy session, the Veteran reported passive suicide ideation with no plan. See January 2012 VA Psychotherapy in Office Session in CAPRI received November 2012. He also endorsed symptoms of anhedonia, diminished energy, depressive ruminations dominated by feelings of hopelessness, helplessness, and worthlessness. He also described periods of overwhelming sadness and depression due to MST. The psychotherapist indicated that treatment would focus on emotional stabilization. His treatment records also confirm he was prescribed Sertraline. See January 2012 Mental Health Consult in CAPRI received November 2012. The VA social worker noted in April 2012, that the Veteran experienced moderate depression “punctuated by [] periods of severe mood lowering. At these times he experiences anhedonia, diminished energy, reduced motivation, social withdrawal, and depressive ruminations.” See April 2012 VA Psychotherapy Note in CAPRI received November 2012. At a June 2012 VA Mental Health Consult, the Veteran reported that he was living in a camper without electricity or running water for the past two years. See June 2012 VA Mental Health Consult in CAPRI received November 2012. He also endorsed symptoms of depression, sleep disturbance, poor self-esteem, and social isolation. The VA clinician noted that the Veteran last worked as a helper in 1995. He also reported that he does not see his mother due to conflict with his two brothers. As for social support, the Veteran reported he had a dog but no real friends. The clinician also noted the Veteran’s experienced problems with financial, unemployment, social isolation, physical illness, and pain. The Veteran was first provided a VA examination for his PTSD claim in November 2012. See November 2012 VA Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire (DBQ). The Veteran reported he was divorced twice and is currently separated from his third wife. He also reported that he has three biological children from a second marriage but had not had contact with them for past 10 years. Since leaving active service the Veteran was charged with a driving under the influence (DUI) and has been unable to work due to physical impairments and alcohol abuse. However, he reported he has been sober for the past 14 years, and has lived in a camper in the mountains for past 12 years. He also reported that he was treated for suicidal intent with a plan in 2008. The examiner found that the Veteran experienced symptoms of depressed mood, chronic sleep impairment, disturbances of motivation or mood, difficulty in adapting to stressful circumstances, including work and social impairment, and an inability to establish and maintain effective relationships. The Veteran called the VA in February 2013 regarding the November 2012 VA examination. See February 2013 VA Form 21-0820, Report of General Information. The Veteran requested a re-evaluation by a male physician because he was unable to fully discuss his MST and resulting symptoms to the female VA examiner in November 2012. The Veteran was provided another VA examination in July 2015. See July 2015 VA Initial PTSD DBQ. The examiner assessed the Veteran with PSTD with depression and found it resulted in occupational and social impairment with occasional decrease in work efficiency. The Veteran reported that he has no close friends, and denied participating in any social activities. The Veteran reported he was married and divorced three times. His most recent marriage ended in 2005 due to inability to go out in public places. He also denying having any children. The Veteran’s PTSD symptoms included: recurrent, involuntary, and intrusive distressing memories of the traumatic event; marked psychological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event; peristent negative emotional state; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; irritable behavior and angry outburst (with little or no provocation); reckless or self-destructive behavior; hypervigilance; exaggerated startle response; and sleep disturbance. The examiner noted that the Veteran’s Beck Depression Inventory, 2nd Edition (BDI-II) fell within the severe range for depression. An addendum VA opinion regarding the Veteran’s employability was obtained in April 2016. See April 2016 VA Compensation and Pension Examination Report. The examiner noted that the Veteran last worked in a labor position and had also worked in fast-food, yard work, and mechanic positions. The examiner found that the Veteran would not be precluded from working in these fields due to PTSD. However, the examiner opined “PTSD could interfere with engagement with other employees, given anger/irritability, hypervigilance, and anxiety in crowded areas.” The examiner also noted that poor sleep could impact energy level and performance of job duties. In June 2016, the Veteran reported that was not doing well psychologically. See June 2016 VA Mental Health Note in CAPRI received November 2016. The VA psychologist noted that the Veteran “regressed in functioning such that he’s barricading inside his house and leaving his home only when no one is within the vicinity.” During another psychiatric treatment in June 2016, the Veteran stated he would not get a service dog due to anxiety about interacting with others during training. See June 2016 VA Psychiatry Note in CAPRI received February 2017. He also reported that he is unable to stand in long lines at grocery store due to anxiety. He further noted that he went to grocery store five times to obtain 40 items. In October 2016, the VA psychologist noted that the Veteran had severe social isolation as a result of PTSD. See October 2016 VA Mental Health Treatment Note in in CAPRI received November 2016. The Veteran’s representative argued in the January 2017 Appellate Brief that the Veteran was entitled to a 100 percent rating for his PTSD. See January 2017 Appellate Brief. Specifically, she stated: Perceptual disturbances and paranoia were also noted in the resulting psychiatric hospitalization [in 2009]. Although subsequent treatment reports indicate [the Veteran] denied ongoing problems of this nature, the matter was not further explored to ensure he was not merely hiding his difficulties as he had in the past. He and his wife are [separated] and he lives a very isolated lifestyle in a very isolated area, so there is no third party to observe and report his aberrant thoughts, perceptual disturbances, or inappropriate or potential dangerous behaviors. See January 2017 Appellate Brief. During an October 2018 VA psychiatric appointment, the Veteran recently reported he got into a fight at a gas station. See October 2018 VA Mental Health Note in CAPRI received April 2019. He stated that he had a flashback when a man tapped him on his shoulder. The Veteran turned around and hit the man. He further noted that the police were called, but the man declined to press charges when he learned the Veteran was a disabled veteran. The Veteran also stated, “I can’t go out again. Pray for me.” The VA psychologist noted that the Veteran “remains distraught about his behavior however he rationalizes that no one should tap another person on the shoulder.” She also stated that the Veteran will likely become more cloistered inside his home. In November 2018, the Veteran’s medication prescribed to treat his depression was increased. See November 2018 VA Pharmacy Note in CAPRI received April 2019. The Veteran reported that he filed for a restraining order against his estranged wife due to problems with her in January 2019. See January 2019 VA Social Worker Telephone Contact Note in CAPRI received April 2019. In February 2019, the Veteran reported that he was living with his stepson who cleans, shops, and cooks for himself and the Veteran. See February 2019 VA Mental Health Note in CAPRI received April 2019. However, in April 2019, the Veteran reported that his stepson was moving out to go live with his estranged wife. See April 2019 VA Mental Health Note in CAPRI received April 2019. The psychologist noted that the “Veteran’s life will return to a solitary, avoidant-based existence as his step-son elects to return to his mother’s home.” In May 2019, the Veteran was provided another VA examination for his PTSD. See May 2019 VA Review PTSD DBQ. The examiner found that the Veteran had total occupational and social impairment. The examiner noted that the Veteran is going through a divorce and rarely leaves the house. The examiner found that the Veteran PTSD symptoms included: recurrent, involuntary, and intrusive distressing memories of the traumatic event(s); intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s); marked physiological reactions to internal or external cues that symbolize ore resemble an aspect of the traumatic event(s); persistent and exaggerated negative beliefs or expectations about oneself, others, or the world; persistent negative emotional state; markedly diminished interest or participation in significant activities; hypervigilance; exaggerated startle response; problems with concentration; and sleep disturbance. The examiner further stated that his PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Analysis The Board finds, after reviewing the entire record, that the Veteran’s PTSD has been shown to be productive of total occupational and social impairment throughout the appeal period. In so finding, the Board observes that the Veteran experienced symptoms consistent with the criteria for the 100 percent rating. For example, he exhibited memory loss for names of close relatives during the July 2015 VA examination because he reported he was divorced three times and denied having any children. However, the Veteran reported he had three children in the November 2012 VA examination, and in February 2019 reported that he was seeking a restraining order against his estranged wife which shows he was still married. The Board also agrees with the Veteran’s representative argument in January 2017, that the Veteran displayed gross impairment in thought process or communication. Specifically, the Veteran’s altercation at the gas station in 2018 because someone tapped him on the shoulder and vowing not to go out again is evidence that Veteran experienced gross impairment in thought process. Further evidence includes the Veteran reported in June 2016 that he went to the store five times in order to obtain 40 items due to anxiety of standing in long line. The Board also finds that the Veteran exhibited symptoms of persistent delusions because he experienced flashbacks and nightmares on a continuous basis and was unable to go outside of his home as a result. The Veteran’s VA treatment records reflect that he was severely isolated and consistently noted he barricaded or cloistered himself in his home. The Board also agrees that the Veteran’s VA treatment records do not reflect the full extent of the Veteran’s symptoms because they did not fully explore the Veteran’s symptoms. However, the VA examinations from July 2015 and May 2019 consistently found the Veteran had severe PTSD symptoms which included: recurrent, involuntary, and intrusive distressing memories of the traumatic event; marked psychological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event; peristent negative emotional state; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; irritable behavior and angry outburst (with little or no provocation); reckless or self-destructive behavior; hypervigilance; exaggerated startle response; and sleep disturbance. Finally, the record demonstrates that the Veteran experienced intermittent inability to perform ADLs as indicated by notations that the Veteran endorsed symptoms of anhedonia, diminished energy, reduced motivation, social withdrawal, and depressive ruminations. The Board also finds that the frequency, severity, and duration of the Veteran’s symptoms are consistent with the 100 percent criteria because the Veteran received continual psychiatric treatment at the VA and his symptoms did not improve as noted by the Veteran’s near total isolation, thus demonstrating total occupational and social impairment. Finally, the Board has considered the Veteran’s lay statements concerning the symptoms of the service-connected disability and his medical history and finds that the Veteran provided is competent and credible evidence of his symptoms as noted in his VA treatment or during his VA examinations. In short, the evidence establishes that the Veteran’s PTSD has resulted in near-total social isolation; constant depression and feelings of hopelessness, which appears to often prevent the Veteran from performing the activities of daily living; inappropriate behavior; and, most importantly, gross impairment in thought process or communication. Moreover, the evidence reflects that the Veteran’s hypervigilance and anxiety issues severely impact his ability to function in a job-like setting. Given the extensive social and occupational impairment described above, the Board finds that his symptoms more nearly approximate the criteria for a 100 percent disability rating. See 38 C.F.R. §§ 4.7, 4.130. Accordingly, his claim for a 100 percent rating prior to May 3, 2019 is granted. 2. Residuals of left shoulder trauma. The Veteran seeks a compensable rating for his left shoulder disability. The Veteran’s left shoulder disability is currently rated under Diagnostic Codes (DCs) 8519-5201, for paralysis of the long thoracic nerve (DC 8519) with a residual condition of limitation of motion of the arm (DC 5201). See 38 C.F.R. § 4.27. The record shows that the Veteran is right-hand dominant; thus, his left shoulder is his minor shoulder for rating purposes. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). DCs 5200 through 5203 address disability ratings for the shoulder and arm. DC 5200 provides for the evaluation of a shoulder or arm disability if there is ankylosis of the scapulohumeral articulation. 38 C.F.R. § 4.71a. DC 5201 provides that limitation of motion of the minor arm at shoulder level is rated as 20 percent; limitation of motion of the minor arm to midway between the side and shoulder level is rated as 20 percent; and limitation of motion of the minor arm to 25 degrees from the side is rated as 30 percent. 38 C.F.R. § 4.71a, DC 5201. The United States Court of Appeal for the Federal Circuit has held that DC 5201 does not provide separate ratings for limitations on flexion, extension, abduction and rotation, but rather permits only a single rating for limitation of motion of an arm. Yonek v. Shinseki, 722 F.3d 1355, 1359 (Fed. Cir. 2013). Impairment of the clavicle or scapula is rated under DC 5203. That provision provides that malunion of the clavicle or scapula, or nonunion without loose movement, warrants a 10 percent rating on either side. Nonunion with loose movement or dislocation of the clavicle or scapula warrants a 20 percent rating on either side. Alternatively, these disabilities may be rated based on impairment of function of the contiguous joint. 38 C.F.R. § 4.71a, DC 5203. The Board notes that DC 5202 provides for ratings from 20 to 70 percent for the minor shoulder and arm where there is impairment of the humerus, including malunion, recurrent dislocation at the scapulohumeral joint, fibrous union, nonunion, or loss of the head of the humerus. 38 C.F.R. § 4.71a, DC 5202. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 degrees to 180 degrees, abduction from 0 degrees to 180 degrees, external rotation from 0 degrees to 90 degrees, and internal rotation from 0 degrees to 90 degrees. 38 C.F.R. § 4.71, Plate I. In determining whether the Veteran has limitation of motion to shoulder level, it is necessary to consider forward flexion and abduction. See Mariano v. Principi, 17 Vet. App. 305, 314-16 (2003). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 38 C.F.R. § 4.40. VA must consider “functional loss” of a musculoskeletal disability separately from consideration under the diagnostic codes; “functional loss” may occur as a result of weakness, fatigability, incoordination or pain on motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain 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.” Mitchell v. Shinseki, 25 Vet. App. 32 (2011). When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the DCs predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Under DC 8519, a 20 percent rating will be assigned for complete paralysis of the long thoracic nerve on the minor side, including the inability to raise the arm above shoulder level, or a winged scapula deformity; or for severe incomplete paralysis of the long thoracic nerve on the minor side. Moderate incomplete paralysis on the minor side warrants a 10 percent rating; and mild incomplete paralysis on the minor side warrants a noncompensable rating. A Note provides that such ratings are not to be combined with loss of motion above the shoulder level. 38 C.F.R. § 4.124(a), DC 8519. Factual Background The Veteran filed a petition to reopen his claim for service connection for a left shoulder disability on October 5, 2009. Service connection was granted effective October 5, 2009. Thus, the relevant period on appeal began on October 5, 2009. The Veteran’s VA treatment records confirm the Veteran treated his left shoulder pain with a lidocaine topical patch since October 2009. See VA Pharmacy Note in CAPRI received November 2012. The Veteran complained of chronic left shoulder pain during a January 2012 VA anesthesia consult. See January 2012 VA Anesthesia Consult in CAPRI received November 2012. The VA pain specialist noted that the Veteran had a painful scar and pain with motion on flexion, extension, abduction, and adduction of his left shoulder. The Veteran was provided a VA examination for his left shoulder disability in March 2016. See March 2016 VA Shoulder and Arm Conditions DBQ. The examiner noted that the Veteran was right hand dominant. The Veteran reported flare-ups which occurred two to three times a week that lasted an hour and severely limited activity. The Veteran described functional loss or impairment as impaired ability to lift, reach, dress, put on trousers, do yard work, do housework, and wash dishes. On range of motion (ROM) testing, the Veteran demonstrated flexion to 50 degrees, abduction to 35 degrees, external rotation to zero (0) degrees, and internal rotation to 56 degrees. The examiner indicated pain was noted on examination and caused functional loss in all four ROM tests. He further noted that there was evidence of pain on weight bearing and objective evidence of localized tenderness or pain on palpation. However, there was no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with three repetitions and no additional functional loss or ROM loss was found afterwards. The examiner stated he was unable to opine whether pain, weakness, fatigability, or incoordination significantly limited functional ability with flare-ups without resorting to speculation. He explained that he could not compare because Veteran was not being tested during flare-up and non-flare up conditions. The examiner noted that the Veteran’s remote treatment records mentioned muscle atrophy, but no atrophy was found on examination. There was no evidence of ankylosis. The Veteran was unable to perform the Hawkins Impingement, empty-can, external rotation, and lift-off subscapularis tests. There was no evidence of left shoulder instability, or clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular joint conditions. Nor did the Veteran have an impairment of the humerus. The Veteran was noted to have a left shoulder scar that was painful, but was not unstable, or greater than 39 square centimeters (cm) (6 square inches). An x-ray of the Veteran’s left shoulder taken at the examination found no evidence of fracture, dislocation, or arthritis. As for assistive devices, the Veteran was noted to use a sling for his left shoulder on a regular basis. Finally, the examiner opined that the Veteran’s left shoulder disability severely impaired sedentary and physical work due to his impairments. A VA examination pertaining to the Veteran’s left shoulder scar was also obtained in March 2016. See VA March 2016 VA Scars/Disfigurement DBQ. The Veteran was assessed with surgical scar left shoulder. The examiner noted that the Veteran had a linear surgical scar measuring 26.5 x 0.5 cm which causes sharp pain but was not unstable. He was noted to have only one linear scar. He did not have any scars due to burns, or scars or other disfigurement of the head, face, or neck. The Veteran was also provided a neurological examination pertaining to his left shoulder. See March 2016 VA Peripheral Nerves Conditions DBQ. He was assessed with complex regional pain syndrome left upper extremity. The examiner found that the Veteran had severe constant pain and mild numbness in his left upper extremity. The examiner noted an electromyogram (EMG) for his left upper extremity in April 2011 was normal. The examiner also found that the Veteran’s long thoracic nerve showed moderate incomplete paralysis. The Veteran reported multiple locations of pain including pain in his left shoulder in February 2017. See February 2017 VA Primary Care Note in CAPRI received February 2017. On physical examination, the Veteran had poor ROM with discomfort with motion. He was subsequently provided a corticosteroid injection for his pain. The Veteran’s VA treatment records also confirm he was prescribed opioid medications for his left shoulder pain. Analysis Resolving reasonable doubt in the Veteran’s favor, the Board finds that the Veteran’s left (minor) shoulder disability has been manifested by pain and limited range of motion that most nearly approximates limitation in motion of the minor arm to 25 degrees from the side, considering flare-ups and additional functional impairment due to pain, weakness, fatigue, and lack of endurance. See 38 C.F.R. § 4.71a, DC 5201. Notably, the March 2016 VA examination demonstrated flexion to 50 degrees, abduction to 35 degrees, external rotation to zero (0) degrees, and internal rotation to 56 degrees. Pain was present in all planes of motion and on weight-bearing and caused additional functional loss. The Veteran reported flare-ups that occurred two to three times a week and severely limited his ability to lift, reach, dress, put on trousers, do yard work, do housework, and wash dishes. The Board acknowledges that the Veteran had pain, tenderness and less movement than normal of his left shoulder as the Veteran had pain on flexion, abduction, external rotation and internal rotation and tenderness on palpation of the AC joint of the left shoulder. As such, when accounting for frequent flare-ups, the Veteran’s left shoulder disability has been manifested by abduction limited to less than 25 degrees. The Board has considered whether a higher rating is appropriate at any point under an analogous DC. There are no higher ratings available under DC 5203. Moreover, the record does not reflect dislocation, nonunion, or malunion of the left clavicle or scapula. A rating under DC 5202 is not warranted because the Veteran does not have fibrous union of the humerus, nonunion of the humerus, or loss of head of the humerus. As the Veteran does not have ankylosis of the left shoulder a rating under DC 5200 is not available. Finally, to the extent the March 2016 examination failed to comply with the holding in Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) (which requires examiners to estimate the additional functional loss from flare-ups) such non-compliance is harmless error. In this respect, the Court in Johnston v. Brown, 10 Vet. App. 80 (1997), indicated that where the Veteran is in receipt of the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis, the cited regulations are not for application. Thus, as the Veteran is in receipt of the maximum schedular rating based on limitation of motion for the left shoulder and a higher rating requires ankylosis or other symptoms unrelated to limitation of motion, 38 C.F.R. § 4.40 and 4.45 are not for application. Left shoulder scar As part of the left shoulder claim for increase, the Board finds that the issue of a separate compensable rating for postoperative scar is raised. In relevant part, DC 7804 provides a 10 percent rating for one painful scar. 38 C.F.R. § 4.118, DC 7804. As the March 2016 VA examination reflects that he had a painful postoperative left shoulder scar, a separate 10 percent rating is warranted pursuant to DC 7804. See VA March 2016 VA Scars/Disfigurement DBQ; see also Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991) (the Board has a duty to acknowledge and consider all regulations that are potentially applicable). There is no evidence or argument that a higher separate rating for the scar is warranted. Neurological Impairment The Board notes that the Veteran’s left shoulder disability was rated under the hyphenated DCs 5201-8519. In this regard, DCs 8519, 8619, and 8719, provide for ratings for the minor side from 0 to 20 percent for paralysis, neuritis, or neuralgia of the long thoracic nerve, respectively. Such ratings are based on limitation of motion of the arm below the shoulder level and a winged scapula deformity. See 38 C.F.R. § 4.124a, DCs 8519, 8619, 8719. However, the Veteran’s limitation of motion is already fully contemplated by the currently assigned rating of 30 percent for this period. See 38 C.F.R. § 4.14 (evaluation of the same disability under various diagnosis is to be avoided, noting that disabilities from injuries to the nerves and joints of an extremity may overlap to a great extent). In sum, the Board concludes that the objective medical evidence and the Veteran’s statements regarding his left shoulder symptomatology show disability that most nearly approximates that which warrants the assignment of an initial 30 percent disability rating under DC 5201 throughout the entire period on appeal and that a separate 10 percent rating is warranted for left shoulder scar. See 38 C.F.R. § 4.7. As shown above, and as required by Schafrath, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the Veteran. The Board finds no provision upon which to assign a greater or separate rating. Accordingly, the Board grants an initial 30 percent rating for his left shoulder disability and a separate 10 percent rating of his left shoulder scar. REASONS FOR REMAND 1. TDIU from October 5, 2009. As noted above, the claim for service connection for a left shoulder was originally filed on October 5, 2009, and that is the date of claim for purposes of the issue of entitlement to a TDIU. See Harper v. Wilkie, 30 Vet. App. 356, 361-62 (2018) (the Veteran’s notice of disagreement with the initial rating assigned in connection with the grant of service connection, combined with evidence of unemployability, resulted in the issue of entitlement to a TDIU from the effective date of the grant of service connection being on appeal). The Veteran contends that he is permanently unemployable due to his service-connected left shoulder and PTSD disabilities, and that a TDIU is warranted. See October 2009 VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. The Court has recognized that a 100 percent rating under the Schedule for Rating Disabilities means that a veteran is totally disabled. Holland v. Brown, 6 Vet. App. 443, 446 (1994), citing Swan v. Derwinski, 1 Vet. App. 20, 22 (1990). Thus, if VA has found a veteran to be totally disabled as a result of a particular service-connected disability or combination of disabilities pursuant to the rating schedule, there is no need, and no authority, to otherwise rate that veteran totally disabled on any other basis. See Herlehy v. Principi, 15 Vet. App. 33, 35 (2001) (finding a request for TDIU moot where 100 percent schedular rating was awarded for the same period). However, a grant of a 100 percent disability does not always render the issue of TDIU moot. VA’s duty to maximize a claimant’s benefits includes consideration of whether his disabilities establishes entitlement to special monthly compensation (SMC) under 38 U.S.C.A. § 1114. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). Specifically, SMC may be warranted if the Veteran has a 100 percent disability rating for a single disability, and VA finds that TDIU is warranted based solely on the disabilities other than the disability that is rated at 100 percent. See Bradley, 22 Vet. App. 280 (analyzing 38 U.S.C.A. § 1114 (s)); see also 75 Fed. Reg. 11,229-04 (March 10, 2010) (withdrawing VAOPGCPREC 6-1999). The Board notes that the Veteran was granted a 100 percent rating for PTSD beginning January 4, 2012 as discussed above. However, the Board must consider whether the Veteran’s service-connected left shoulder disability and scar warrant consideration of a TDIU, which would possibly implicate consideration of SMC benefits. The Board finds that a remand is warranted to address whether extraschedular TDIU is warranted for the left shoulder disability from October 5, 2009 (the date of the original claim for service connection for the disability and the Veteran’s assertions of unemployability). For the period on consideration, the Veteran was service-connected for residuals of a left shoulder trauma which has been assigned a rating of 30 percent herein along with a 10 percent rating for left shoulder scar. Thus, the Veteran’s combined disability rating is 40 percent. Accordingly, the schedular requirements for TDIU are not met because the Veteran does not one disability rated as 60 percent or a total disability rating of 70 percent for multiple disabilities. 38 C.F.R. § 4.16(a). When the Veteran is too disabled to work because of service-connected disabilities but does not meet the schedular criteria for TDIU, whether to grant TDIU must first be assessed by the Director of the Compensation Service. 38 C.F.R. § 4.16(b). As the Veteran did not meet the schedular requirements for TDIU from October 5, 2009, and there is evidence that he was unemployable due to his service-connected disabilities as reflected by his receipt of Social Security Administration disability benefits for his left shoulder. Additionally, the Veteran’s former employer J.M. submitted a buddy statement in April 2010 stating that he had to terminate the Veteran’s employment due to left shoulder pain and depression. See April 2010 Buddy/Lay statement. Thus, a remand is required for the Director of Compensation Service to determine if an extraschedular rating is warranted for a TDIU under 38 C.F.R. § 4.16(b), as the result of the service-connected disabilities. The matters are REMANDED for the following action: 1. Refer to the Director, Compensation and Pension Service, the matter of whether a TDIU is warranted on an extraschedular basis pursuant to 38 C.F.R. § 4.16(b) from October 5, 2009. Should the Director indicate that further evidentiary development is required, such development should be undertaken. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Gunella Lilly, Associate Counsel 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.