Citation Nr: 21000482 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 13-22 415 DATE: January 5, 2021 ORDER Service connection for a thyroid disorder is denied. A schedular rating in excess of 40 percent for a lumbar spine disability is denied. A schedular rating in excess of 10 percent prior to August 31, 2011, and in excess of 30 percent afterwards, for residuals of a shell fragment wound to the neck (neck disability) is denied. A compensable schedular rating for residuals of a shell fragment wound to the forehead (forehead SFW) is denied. A compensable schedular rating in excess of 10 percent for a painful scar due to residuals of a shell fragment wound to the left hand (left hand scar) is denied. A schedular rating in excess of 10 percent for a painful scar due to residuals of a shell fragment wound to the neck (neck scar) is denied. A schedular rating in excess of 10 percent for a painful scar due to residuals of a shell fragment wound to the forehead (forehead scar) is denied. An initial schedular rating of 100 percent for posttraumatic stress disorder (PTSD) is granted. FINDINGS OF FACT 1. A thyroid disorder is not due to or the result of the Veteran’s active service, to include presumed exposure to herbicide agents and to presumed exposure to contaminated water during service at Camp Lejeune, North Carolina, or due to the Veteran’s neck disability. 2. Ankylosis of the thoracolumbar spine is not shown, and the Veteran is not prescribed bed rest to treat his lumbar spine disability. 3. Prior to August 31, 2011, the Veteran’s neck disability was not shown to result in a moderately severe disability. 4. From August 31, 2011, ankylosis of the cervical spine has not been shown; the Veteran is not prescribed bed rest to treat his neck disability; and a severe neck disability was not shown. 5. The Veteran’s forehead SFW does not result in a moderate disability. 6. The Veteran’s left hand scar is painful, but does not result in any disabling effects. 7. The Veteran’s neck scar is painful, but does not result in any disabling effects. 8. The Veteran’s forehead scar is painful, but does not result in any disabling effects. 9. The Veteran’s PTSD results in persistent delusions or hallucinations and intermittent inability to perform activities of daily living. CONCLUSIONS OF LAW 1. The criteria for service connection for a thyroid disorder have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303, 3.307, 3.309, 3.310. 2. The criteria for a schedular rating in excess of 40 percent for a lumbar spine disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5242-43. 3. The criteria for a schedular rating in excess of 10 percent prior to August 31, 2011, for a neck disability have not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.56, 4.73, Diagnostic Code 5320. 4. The criteria for a schedular rating in excess of 30 percent from August 31, 2011, for a neck disability have not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.56, 4.71a, Diagnostic Code 5242, 4.73, Diagnostic Code 5320. 5. The criteria for a schedular compensable rating for a forehead SFW have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.56, 4.73, Diagnostic Code 5399-5308. 6. The criteria for a schedular compensable rating in excess of 10 percent for a left hand scar have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7801-02, 7804-05. 7. The criteria for a schedular rating in excess of 10 percent for a neck scar have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7801-02, 7804-05. 8. The criteria for a schedular rating in excess of 10 percent for a forehead scar have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7801-02, 7804-05. 9. The criteria for an initial schedular rating of 100 percent for PTSD have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from September 1966 to July 1969, to include service in the Republic of Vietnam. The Veteran was awarded the Purple Heart Medal for his service. In connection with this appeal, the Veteran and his son testified at a hearing before the undersigned in July 2017. A January 2020 rating decision granted service connection for left lower extremity radiculopathy and assigned an initial rating of 20 percent effective September 17, 2019. The Veteran was provided appellate rights but did not appeal either the effective date or the rating assigned. As such, entitlement to an increased rating for left lower extremity radiculopathy is not before the Board. Additional evidence has been received following the September 2020 supplemental statement of the case, that it is not accompanied by a waiver of RO review. However, the Board has determined that this evidence, which pertains to the Veteran’s thyroid disorder, lumbar spine disorder, residuals of shell fragments wounds, scars, or PTSD, is not “pertinent” as defined at 38 C.F.R. § 20.1304(c). In addition, the new evidence does not show any complaints or treatment of the Veteran’s thyroid disorder, lumbar spine disorder, residuals of shell fragments wounds, scars, or PTSD as it only contains requests for medication refills and telephone conversations regarding his PTSD. Accordingly, a remand for RO consideration is not required. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disability which is aggravated by a service-connected disability. In order to prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509 (1998). Service connection may be granted on a presumptive basis for certain diseases associated with exposure to certain herbicide agents even though there is no record of such disease during service, if they manifest to a compensable degree any time after service, in a veteran who had active military, naval, or air service for at least 90 days, during the period beginning on January 9, 1962 and ending on May 7, 1975, in the Republic of Vietnam, including the waters offshore, and other locations if the conditions of service involved duty or visitation in Vietnam. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e), 3.313. This presumption may be rebutted by affirmative evidence to the contrary. 38 U.S.C. § 1113; 38 C.F.R. §§ 3.307, 3.309. The Republic of Vietnam includes the 12 nautical mile territorial sea. See Procopio v. Wilkie, No. 17-1821 (Fed Cir. 2019). The Veteran’s service records show that he had service in the Republic of Vietnam. Thus, he is presumed to have been exposed to herbicide agents, such as Agent Orange. However, a thyroid disorder is not a disease subject to presumptive service connection. 38 C.F.R. § 3.309. As such, presumptive service connection based on herbicide agent exposure is not warranted. Persons residing or working at Camp LeJeune from August 1, 1953 to December 31, 1987, were potentially exposed to drinking water contaminated with volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE), benzene, and vinyl chloride that were in on the on-base water-supply systems. VA has determined that a veteran who served at Camp Lejeune for a period of no less than 30 days between August 1953 and December 1987 is presumed to have been exposed during such service to contaminants in the water supply. 38 C.F.R. §§ 3.307, 3.309. The Veteran’s service records show that he was stationed at Camp Lejeune from July 1967 to November 1967. Thus, he is presumed to have been exposed to contaminants in the water supply. However, a thyroid disorder is not a disease subject to presumptive service connection. 38 C.F.R. § 3.309. As such, presumptive service connection based on exposure to contaminants in the water supply is not warranted. The Veteran filed a service connection claim for a thyroid disorder, which was denied by an October 2009 rating decision. At the July 2017 Board hearing, he testified that the shrapnel in his neck affected his thyroid. While he testified that his physician linked his neck disability to his thyroid removal, the claims file does not contain any medical opinion from his physician regarding his thyroid disorder. In November 2017 and July 2020 Board decisions, the claim was remanded for further development. The Veteran’s STRs do not show any complaints, treatment, or diagnosis of a thyroid disorder during his active service. The Veteran’s medical records show he underwent thyroid surgery in 1982 and was diagnosed with hypothyroidism, over a decade after his separation from active service. As such, the record contains no diagnosis of a thyroid disorder either in service or within one year after service, which would preclude service connection on the basis of continuity of symptomology or on any presumptive basis. There is no medical evidence linking the Veteran’s thyroid disorder to his active service, and he has not submitted any medical opinion that even suggests that his thyroid disorder either began during or was otherwise caused by his active service. See Shedden, 381 F.3d 1163, 1167. Instead, the Veteran asserts that his thyroid disorder is secondary to his service-connected neck disability. Accordingly, direct service connection for a thyroid disorder is not warranted. In March 2013, the Veteran was afforded a VA examination. Unfortunately, the examiner reported that an opinion regarding secondary service connection could not be expressed without resorting to mere speculation. In November 2019, the Veteran was afforded a VA examination. However, the VA examiner did not provide an opinion regarding the etiology of the Veteran’s thyroid disorder. In January 2020, a VA examiner reviewed the Veteran’s claims file. The examiner opined that the Veteran’s thyroid disorder was less likely than not due to the Veteran’s active service, to include any exposure to contaminants in the water supply at Camp Lejeune. The examiner reported that there were not events during the Veteran’s active service to account for his thyroid disorder. The examiner reported that there were no particular solvents or chemicals linked to the development of thyroid cancer. The examiner also opined that the Veteran’s thyroid disorder was less likely than not due to or aggravated beyond its natural progression by his service-connected neck disability. The examiner reported that the two conditions were not medically related. The examiner reported that the Veteran’s thyroid disorder was a separate entity entirely from the Veteran’s service-connected neck disability and unrelated to it. The examiner reported that the medical literature did not support a medical relationship between the two conditions. The examiner reported that it was accepted as a medical fact that trauma, including grenade fragments, did not cause thyroid cancer or any residuals. The Veteran has not submitted any competent medical evidence supporting his assertion that his thyroid disorder was due to or aggravated by his service-connected neck disability. Furthermore, VA obtained a medical opinion in an effort to support the Veteran in establishing his claim. The January 2020 VA examiner opined that the Veteran’s thyroid disorder was less likely than not due to his active service, due to his service-connected neck disability, or aggravated by his service-connected neck disability. After weighing all the evidence, the Board finds great probative value in the January 2020 VA examiner’s opinion. This negative opinion is sufficient to satisfy the statutory requirements of producing an adequate statement of reasons and bases where the expert has fairly considered material evidence which appears to support the Veteran’s position. Wray v. Brown, 7 Vet. App. 488, at 492-93 (1995). Consideration has been given to the Veteran’s assertions that his thyroid disorder is due to his service-connected neck disability. He is clearly competent to report symptoms of a thyroid disorder. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, he has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he has received any special training or acquired any medical expertise in evaluating thyroid disorders or residuals of shell fragment wounds. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, the Veteran’s assertions do not constitute competent medical evidence. Accordingly, as the criteria for service connection for a thyroid disorder have not been met, the claim is denied. Increased Rating 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. § 1155; 38 C.F.R., Part 4. 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.   Lumbar Spine Disability The Veteran filed an increased rating claim for a lumbar spine disability in March 2009. An October 2009 rating decision continued the assigned 40 percent rating. He asserts that he is entitled to a higher rating. At the July 2017 Board hearing, he testified that he had ankylosis and incapacitating episodes daily. In November 2017 and July 2020 Board decisions, the claim was remanded for further development. Back disabilities are rated under either the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome (IVDS) based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a. Under the current Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least one week but less than two weeks during a 12-month period on appeal. A 20 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least two weeks but less than four weeks during a 12-month period on appeal. A 40 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least four weeks but less than six weeks during a 12-month period on appeal. A 60 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least six weeks during a 12-month period on appeal. 38 C.F.R. § 4.71a, Diagnostic Code 5243. An incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). The evidence of record does not appear to show that the Veteran has experienced any IVDS in his lumbar spine. The June 2009 VA examiner indicated that the Veteran had IVDS but was not placed on bedrest by a physician during the previous 12 months. The March 2018 and November 2019 VA examiners indicated that the Veteran did not have IVDS. In addition, despite the Veteran’s testimony that he had daily incapacitating episodes of lumbar spine pain, there is no evidence showing that the Veteran has been prescribed any bed rest to treat his lumbar spine disability. Because the prescription of bed rest is a foundational requirement of a rating under this section of the rating schedule, the absence of any prescribed bed rest precludes a rating from being assigned under it. As such, a rating based on IVDS is not appropriate, and it is therefore more beneficial to evaluate the Veteran’s lumbar spine disability under the General Rating Formula for Diseases and Injuries of the Spine. Under the General Rating Formula for Diseases and Injuries of the Spine, a 40 percent evaluation is warranted if forward flexion of the thoracolumbar spine is 30 degrees or less or there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Normal ranges of motion of the thoracolumbar spine are flexion from 0 to 90 degrees, extension from 0 to 30 degrees, lateral flexion from 0 to 30 degrees, and lateral rotation from 0 to 30 degrees. 38 C.F.R. § 4.71, Plate V. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). The Veteran’s medical records show that he treated for back pain but do not contain findings consistent with ankylosis of the thoracolumbar spine. While the Veteran testified at the July 2017 Board hearing that he was told he had ankylosis, the June 2009, March 2018, and November 2019 VA examiners indicated that the Veteran did not have any ankylosis of the spine. The Veteran’s medical records also show that he denied having any incontinence in July 2012, May 2017, October 2018, February 2019, May 2019, August 2019, November 2019, January 2020, February 2020, and August 2020. Furthermore, the June 2009 VA examiner indicated that the Veteran did not have a history of urinary or fecal incontinence. The March 2018 and November 2019 VA examiners indicated that the Veteran did not have any bowel or bladder problems. After a complete review of the entire claims file, the medical evidence does not show ankylosis of the spine or any bladder or bowel dysfunction. As such, a rating in excess of 40 percent is not warranted. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). However, the Veteran is in receipt of the maximum rating allowed based on range of motion. The only higher ratings available contemplate ankylosis of the spine. Where a musculoskeletal disability is evaluated at the highest rating available based upon limitation of motion, further DeLuca analysis is foreclosed. Johnston v. Brown, 10 Vet. App. 80 (1997). Accordingly, the criteria for a schedular rating in excess of 40 percent for a lumbar spine disability have not been met, and the claim is denied. Neck Disability The Veteran filed an increased rating claim for a neck disability in March 2009. An October 2009 rating decision continued the assigned 10 percent rating under Diagnostic Code 5320. A January 2020 rating decision granted a 30 percent rating under Diagnostic Code 5242 effective August 31, 2011. He asserts that he is entitled to higher ratings. At the July 2017 Board hearing, he testified that it was hard to move his neck. In November 2017 and July 2020 Board decisions, the claim was remanded for further development. Prior to August 31, 2011, the Veteran’s neck disability was evaluated under Diagnostic Code 5320. Muscle Group damage is evaluated according to whether the disability occurred in the dominant or non-dominant arm, and is categorized as slight, moderate, moderately severe, or severe. See 38 C.F.R. §§ 4.55, 4.56, and 4.73. 38 C.F.R. § 4.56(c) describes the cardinal signs and symptoms of muscle disability as loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. A “slight disability” of the muscles involves a simple would of the muscle without debridement or infection. 38 C.F.R. § 4.56(d)(1). A “moderate disability” of the muscles involves a through-and-through or deep penetrating wound of a relatively short track by a single bullet or small shell or a shrapnel fragment, and the absence of explosive effect of high-velocity missile and of residuals of debridement or of prolonged infection. There must be evidence of in-service treatment of the wound. There must be a record in the file of consistent complaint of one or more of the cardinal symptoms of muscle disability, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. The objective findings include entrance and, if present, exit scars which are linear or relatively small, and so situated as to indicate a relatively short track of the missile through the muscle tissue, and signs of some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). A “moderately severe” disability of the muscles involves a through-and-through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. There must be evidence in the file showing hospitalization for a prolonged period for treatment of the wound. There must be a record of consistent complaint of cardinal signs and symptoms of muscle disability, and if present, evidence of inability to keep up with work requirements. The objective findings include entrance and, if present, exit scars indicating the track of missile through one or more Muscle Groups, indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side, and tests of strength and endurance compared with sound side must demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). Finally, a “severe disability” of the muscles involves a through-and-through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. There must be evidence showing hospitalization for a prolonged period for treatment of the wound. There must also be a record of consistent complaint of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries, and if present, evidence of inability to keep up with work requirements. The objective findings include ragged, depressed and adherent scars indicating wide damage to Muscle Groups in missile track, palpation showing loss of deep fascia or muscle substance, or soft flabby muscles in wound area, muscles swelling and hardening abnormally in contraction, and tests of strength, endurance, or coordinated movements compared with the corresponding muscles of uninjured side indicating severe impairment of function. 38 C.F.R. § 4.56(d)(4). A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56(b). Under Diagnostic Code 5320, for muscle group XX for the cervical spine region, a moderate impairment is assigned a 10 percent rating, a moderately severe impairment is assigned a 20 percent rating, and a severe impairment is assigned a 40 percent rating. From August 31, 2011, the Veteran’s neck disability is evaluated under Diagnostic Code 5242 as cervical spine arthritis was a progression of the Veteran’s neck shell fragment wound. Neck disabilities are rated under either the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome (IVDS) based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least one week but less than two weeks during a 12-month period on appeal. A 20 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least two weeks but less than four weeks during a 12-month period on appeal. A 40 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least four weeks but less than six weeks during a 12-month period on appeal. A 60 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least six weeks during a 12-month period on appeal. 38 C.F.R. § 4.71a, Diagnostic Code 5243. An incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). The evidence of record does not show that the Veteran has experienced IVDS for his cervical spine disability. The September 2019 VA examiner indicated that the Veteran did not have IVDS. In addition, the record does not show that the Veteran has been prescribed any bed rest to treat his neck disability during the course of his appeal, and there is no contention to the contrary. Because the prescription of bed rest is a foundational requirement of a rating under this section of the rating schedule, the absence of any prescribed bed rest precludes a rating from being assigned under it. As such, a rating based on IVDS is not appropriate and the Veteran’s neck disability will thus be evaluated under the General Rating Formula for Diseases and Injuries of the Spine. Under the General Rating Formula for Diseases or Injuries of the Spine, a 20 percent evaluation is warranted if forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees, combined range of motion of the cervical spine is not greater than 170 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis is present. A 30 percent evaluation is warranted if forward flexion of the cervical spine is 15 degrees or less or there is favorable ankylosis of the entire cervical spine. A 40 percent evaluation is warranted if there is unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted if there is unfavorable ankylosis of the entire spine. Normal ranges of motion of the cervical spine are flexion from 0 to 45 degrees, extension from 0 to 45 degrees, lateral flexion from 0 to 45 degrees, and lateral rotation from 0 to 80 degrees. 38 C.F.R. § 4.71, Plate V. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). The Veteran’s medical records do not contain findings consistent with a higher rating. In June 2009, the Veteran was afforded a VA examination. He reported having increased muscle pain with movement of his head. The examiner indicated that muscle function was normal and there were no residuals of nerve damage, tendon damage, or bone damage. The examiner indicated there were no more than mild effects on the Veteran’s daily activities. On August 31, 2011, the Veteran was afforded a VA examination. He reported worsening of his neck disability since the June 2009 VA examination. On examination, he demonstrated cervical spine flexion to 10 degrees with pain. Repetitive use testing resulted in no additional limitation of flexion. In September 2019, the Veteran was afforded a VA examination. He denied having any flare-ups. He reported functional loss that included neck tenderness. On examination, he demonstrated cervical spine flexion to 5 degrees with pain. The examiner indicated that there was no evidence of pain with weight bearing. The examiner indicated there was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the cervical spine. The examiner indicated that the Veteran was not able to perform repetitive use testing. The examiner indicated that pain, fatigue, and lack of endurance caused functional loss, but the examiner was not able to describe in terms of range of motion. The examiner indicated that the Veteran did not have radiculopathy or any other neurological abnormality related to a cervical spine condition such as bowel or bladder incontinence. The examiner indicated that the Veteran did not have ankylosis. The examiner reported that the Veteran’s cervical spine arthritis was a progression of the Veteran’s neck disability. Applying the regulations to the facts in the case, the Veteran’s neck disability prior to August 31, 2011, did not show findings consistent with moderately severe findings. Therefore, the criteria for a schedular rating in excess of 10 percent for the Veteran’s neck disability have not been met prior to August 31, 2011. Beginning August 31, 2011, the Veteran was assigned a 30 percent rating for his limited cervical spine range of motion. Under the current regulations, the only available ratings in excess of 30 percent requires unfavorable ankylosis of the entire cervical spine, which would be rated at 40 percent, or unfavorable ankylosis of the entire spine, which would be rated at 100 percent. No objective medical evidence has shown any ankylosis, and no argument has been advanced to the contrary. As such, an orthopedic rating in excess of 30 percent is not warranted. In addition, the Veteran’s neck disability has not resulted in findings consistent with severe findings under Diagnostic Code 5320. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca, 8 Vet. App. 202. However, the Veteran is in receipt of the maximum rating allowed based range of motion. The only ratings available are a 40 percent for ankylosis of the entire cervical spine and 100 percent rating for ankylosis of the entire spine. Where a musculoskeletal disability is evaluated at the highest rating available based upon limitation of motion, further DeLuca analysis is foreclosed. Johnston, 10 Vet. App. 80. Accordingly, the criteria for a schedular rating in excess of 10 percent prior to August 31, 2011, and in excess of 30 percent afterwards, for a neck disability have not been met, and the claim is denied. Forehead SFW The Veteran filed an increased rating claim for a forehead SFW in March 2009. An October 2009 rating decision continued the assigned noncompensable rating. He asserts that he is entitled to a compensable rating. In November 2017 and July 2020 Board decisions, the claim was remanded for further development. The Veteran’s forehead SFW is evaluated under Diagnostic Code 5399-5308. Hyphenated diagnostic codes are used when a rating under one Diagnostic Code requires use of an additional Diagnostic Code to identify the specific basis for the evaluation assigned. Here, the Veteran's forehead is rated under Diagnostic Code 5308 for muscle group VIII. Under Diagnostic Code 5308, for muscle group VIII, a moderate impairment is assigned a 10 percent rating, a moderately severe impairment is assigned a 30 percent rating, and a severe impairment is assigned a 40 percent rating. The Veteran’s treatment records do not contain findings consistent with a higher rating. In June 2009, the Veteran was afforded a VA examination. The examiner reported that the forehead SFW had no disabling effects. In August 2011, the Veteran was afforded a VA examination. The examiner reported that the forehead SFW had no disabling effects. In November 2019, the Veteran was afforded a VA examination. The examiner reported that there was no change in the Veteran’s forehead SFW. Applying the regulations to the facts in the case, the Veteran’s forehead SFW has not shown to result in any disabling effects. Therefore, the criteria for a schedular compensable rating gave not been met. The Board has considered all other potentially applicable Diagnostic Codes, but has found that no other Diagnostic Codes would result in more favorable findings. Accordingly, the criteria for a schedular compensable rating for a forehead SFW have not been met, and the claim is denied.   Left Hand, Neck, and Forehead Scars The Veteran filed an increased rating claim for his left hand scar in March 2009. An October 2009 rating decision granted an increased rating of 10 percent effective March 18, 2009, the date his increased rating claim was received by VA. A January 2020 rating decision granted service connection for a neck scar rated at 10 percent disabling effective September 17, 2019, and service connection for a forehead scar rated at 10 percent disabling effective September 17, 2019. He asserts that he is entitled to higher ratings. At the July 2017 Board hearing, he testified that his scars were painful and resulted in headaches. In November 2017 and July 2020 Board decisions, the claim was remanded for further development. The Veteran’s left hand, neck, and forehead scars are rated under Diagnostic Code 7804. Under Diagnostic Code 7800, a scar(s) of the head, face, or neck is assigned a 10 percent disabling for a scar with one characteristic of disfigurement. A 30 percent rating is assigned for a scar with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. A 50 percent rating is assigned for a scar with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. An 80 percent rating is assigned for a scar with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. Under Diagnostic Code 7801, a 10 percent rating is assigned for scars other than the head, face, or neck that are deep or that cause limited motion with an area exceeding 6 square inches (39 square centimeters). A 20 percent rating is assigned with an area exceeding 12 square inches (77 square centimeters). A 30 percent rating is assigned for scars with an area exceeding 72 square inches (465 square centimeters). A 40 percent rating is assigned for scars exceeding 144 square inches (929 square centimeters). Under Diagnostic Code 7802, a 10 percent rating is assigned for scars other than the head, face, or neck that are superficial with an area exceeding 144 square inches (929 square centimeters). Under Diagnostic Code 7804, a 10 percent rating is assigned for one or two scars that are unstable or painful, a 20 percent rating is assigned for three or four scars that are unstable or painful, and a 30 percent rating is assigned for five or more scars that are unstable or painful. Under Diagnostic Code 7805, any disabling effects not considered in a rating provided under Diagnostic Codes 7800-04 are evaluated under an appropriate Diagnostic Code. The Veteran’s treatment records do not show any symptoms or complaints related to the Veteran’s left hand, neck, and forehead scars. In June 2009, the Veteran was afforded a VA examination. The examiner reported that the Veteran’s forehead scar had no breakdown and measured 1.0 centimeters by 0.2 centimeters. The examiner reported that the Veteran’s left hand scar had no breakdown and measured 2.0 centimeters by 2.5 centimeters. The Veteran reported the scar was painful. In August 2011, the Veteran was afforded a VA examination. The examiner reported that the Veteran’s scars measured 1.0 centimeters by 0.5 centimeters, 7.0 centimeters by 0.5 centimeters, and 1.0 centimeters by 0.5 centimeters. The examiner indicated that was no skin breakdown, no abnormal texture, no inflammation, no edema, no keloid formation, no hypo or hyper pigmentation, no underlying soft tissue loss, no adherent to underlying tissue, and had no disabling effects. The Veteran reported the scars were painful. In March 2018, the Veteran was afforded a VA examination. The examiner reported that the Veteran had no visible scars. The examiner reported that the Veteran’s scars had faded to the point they were no longer visible. In September 2019, the Veteran was afforded a VA examination. The examiner indicated that the Veteran had a left hand scar that was painful, but was not unstable with frequent loss of covering of skin over the scar. The examiner reported that the Veteran’s left hand scar measured 6.0 centimeters by 0.1 centimeters. The examiner reported that the Veteran had two scars of the head, face, or neck that were painful, but were not unstable with frequent loss of covering of skin over the scars. The examiner reported that the Veteran’s neck scar measured 4.0 centimeters by 0.1 centimeters and the Veteran’s forehead scar measured 5.0 centimeters by 0.1 centimeters. The examiner reported that the total area of head, face, and neck scars were 10.0 centimeters by 0.2 square centimeters. The examiner indicated that was no skin breakdown, no abnormal texture, no inflammation, no edema, no keloid formation, no hypo or hyper pigmentation, no underlying soft tissue loss, no adherent to underlying tissue, no gross distortion or asymmetry of facial features, and had no disabling effects. The medical evidence of record shows that the Veteran’s left hand scar was painful. The Veteran was assigned a 10 percent rating for a painful left hand scar. At the September 2019 VA examination, the Veteran reported that his neck and forehead scars were also painful. The January 2020 rating decision granted separate 10 percent ratings under Diagnostic Code 7804 for his neck and forehead scars effective September 17, 2019. Under Diagnostic Code 7804, three painful scars result in a 20 percent evaluation. Currently, the Veteran’s three scars are separately rated at 10 percent, which combines to a 30 percent rating. However, the Board will not disturb the separately assigned ratings and ratings in excess of 10 percent for the Veteran’s left hand, neck, and forehead scars is not warranted. As such, the criteria for a schedular rating in excess of 10 percent for a left hand scar have not been met, and the claim is denied. The criteria for a schedular rating in excess of 10 percent for a neck scar have not been met, and the claim is denied. The criteria for a schedular rating in excess of 10 percent for a forehead scar have not been met, and the claim is denied. PTSD The Veteran filed a service connection claim for PTSD in March 2009. An October 2009 rating decision granted service connection and assigned a 30 percent rating effective March 18, 2019, the date his service connection claim was received by VA. A May 2013 rating decision granted an increased rating of 50 percent effective September 1, 2011. He asserts that he is entitled to higher ratings. In November 2017 and July 2020 Board decisions, the claim was remanded for further development. Under the General Rating Formula for Mental Disorders, a 30 percent evaluation is assigned when a veteran’s mental disability causes occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is assigned when a veteran’s mental disability causes 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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is assigned when a veteran’s mental disability causes 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 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 work like setting); or an inability to establish and maintain effective relationships. A 100 percent rating is assigned when a veteran’s mental disability causes total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; danger of hurting self or others; intermittent inability to perform activities of living (including maintenance of minimal hygiene); disorientation to time or place; or, memory loss for names of close relatives, occupation, or own name. When rating a mental disorder, VA must consider the frequency, severity, and duration of the Veteran’s psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. The rating agency must assign a rating based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. When rating the level of disability from a mental disorder, the rating agency must consider the extent of social impairment but cannot assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. Furthermore, the specified factors for each incremental rating are examples, rather than requirements, for a particular rating. The Board will not limit its analysis solely to whether the Veteran exhibited the symptoms listed in the rating criteria. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Indeed, the symptoms listed under § 4.130 are not intended to serve as an exhaustive list of the symptoms that VA may consider but as examples of the type of degree of symptoms, or the effects, that would warrant a particular rating. Mauerhan, 16 Vet. App. at 442 (2002). The Veteran’s actual symptomatology, and resulting social and occupational impairment, will be the primary focus when assigning a disability rating for a mental disorder, and the Veteran may qualify for a particular rating by demonstrating the particular symptoms associated with that percentage, or other symptoms of similar severity, frequency, and duration. Vazquez Claudio v. Shinseki, 713 F.3d 112, 116 17 (Fed. Cir. 2013). In March 2016, the Veteran’s physician completed a Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire (DBQ). His physician indicated that the Veteran’s PTSD resulted in persistent delusions or hallucinations. In July 2017, the Veteran’s physician completed another DBQ. His physician reported that the Veteran’s PTSD resulted in persistent delusions or hallucinations and an intermittent inability to perform activities of daily living. His physician indicated that the Veteran’s PTSD resulted in total occupational and social impairment. Accordingly, the Veteran’s physician indicated that the Veteran had PTSD symptoms consistent with a 100 percent rating. Accordingly, the criteria for an initial schedular rating of 100 percent for PTSD have been met, and the claim is granted. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Berryman, 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.