Citation Nr: 21071406 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 17-14 729 DATE: November 30, 2021 ORDER Entitlement to an initial 20 percent disability rating, but no higher, for lumbosacral strain prior to June 24, 2021, is granted. Entitlement to a disability rating in excess of 20 percent for lumbosacral strain since June 24, 2021, is denied. Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for a left shoulder disability is remanded. FINDINGS OF FACT 1. Prior to June 24, 2021, the Veteran's service-connected lumbosacral strain was manifested by forward flexion of the thoracolumbar spine to no less than 80 degrees and a combined range of motion to no less than 230 degrees, as well as muscle spasm of the back, but not by favorable ankylosis (or the functional equivalent) of the entire thoracolumbar spine. 2. Since June 24, 2021, the Veteran's service-connected lumbosacral strain has been manifested by forward flexion of the thoracolumbar spine to no less than 75 degrees as well as muscle spasms or guarding severe enough to result in abnormal gait or abnormal spinal contour, but not by favorable ankylosis (or the functional equivalent) of the entire thoracolumbar spine. 3. The Veteran's PTSD symptoms have been manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. CONCLUSIONS OF LAW 1. Prior to June 24, 2021, the criteria for a 20 percent initial disability rating, but no higher, for lumbosacral strain have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 2. Since June 24, 2021, the criteria for a disability rating in excess of 20 percent for lumbosacral strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 3. The criteria for entitlement to an initial rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1131, 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304(f), Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 2010 to April 2015. These matters come before the Board of Veterans' Appeals (Board) on appeal from November 2015 and April 2016 Rating Decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Board virtual hearing before the undersigned Veterans Law Judge (VLJ) in October 2020. A transcript of that hearing has been associated with the claims file. The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. § §§ 3.102, 3.156(a), 3.159, 3.326(a). Here, the Veteran has not raised any issues with regard to the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381(Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. Here, the records reflects that the Veteran is gainfully employed as a utility technician, and he has not asserted that he is unable to maintain employment due to service-connected disabilities. As such, TDIU entitlement has not been raised by the record, and a claim of entitlement to a TDIU is not within the Board's jurisdiction. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule). Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, as is the case here, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119 (1999). Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. 1. Entitlement to higher initial disability ratings for lumbosacral strain The Veteran seeks entitlement to higher disability ratings for his service-connected lumbosacral strain. The disability was initially evaluated as 10 percent disabling under Diagnostic Code 5237. However, in an August 2021 Rating Decision, the RO increased his disability rating to 20 percent under Diagnostic Code 5237 effective June 24, 2021, the date of a VA examination revealing worsened symptomatology. As such, the Board will assess the propriety of the 10 percent rating assigned prior to June 24, 2021, as well as the 20 percent rating assigned since June 24, 2021. During the pendency of this appeal, VA promulgated new regulations governing ratings for the musculoskeletal system and muscle disabilities, effective February 7, 2021. See 85 Fed. Reg. 76,453 (Nov. 30, 2020). When a law or regulation changes during the pendency of a Veteran's appeal, the version most favorable to the Veteran applies, absent congressional intent to the contrary. The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; VAOPGCPREC 3-2000, 65 Fed. Reg. 33, 422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, the Veteran is entitled to application of the criteria that are most favorable to his claim, except that an award based on the amended regulations may not be made effective before the effective date of the change. In pertinent part, 38 C.F.R. § 4.71a, Diagnostic Code 5242 for degenerative arthritis of the spine was revised to apply to degenerative arthritis, degenerative disc disease other than Intervertebral Disc Syndrome (IVDS). In addition, 38 C.F.R. § 4.71a, Diagnostic Code 5243 for IVDS was revised to include an instruction to assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve root. Diagnostic Code 5242 should be assigned for all other disc diagnoses. Significantly, the actual rating criteria (the General Rating Formula for Diseases and Injuries of the Spine and the Formula for Rating IVDS Based on Incapacitating Episodes) were not changed. Under the rating criteria, back disabilities are rated under either the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating 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 General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted when: forward flexion of the thoracolumbar spine is limited to greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine is limited to greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine is limited to greater than 120 degrees but not greater than 235 degrees; or, the combined range of motion of the cervical spine is limited to greater than 170 degrees but not greater than 335 degrees; or, there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted when: forward flexion of the thoracolumbar spine is limited to greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine is limited to greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine is limited to not greater than 120 degrees; or, the combined range of motion of the cervical spine is limited to not greater than 170 degrees; or, there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted when: forward flexion of the cervical spine is limited to 15 degrees or less; or there is favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted when there is: unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted when there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Code 5243. Normal ranges of motion of the thoracolumbar spine are flexion from zero to 90 degrees, extension from zero to 30 degrees, lateral flexion from zero to 30 degrees, and lateral rotation from zero to 30 degrees. 38 C.F.R. § 4.71, Plate V. The Board notes that ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Dorland's Illustrated Medical Dictionary 93 (30th ed. 2003). See also 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, NOTE (5) (defining ankylosis as fixation of a joint in a particular position). Unfavorable ankylosis is defined as a condition in which the entire spine is fixed in flexion or extension and results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. Recently, the U.S. Court of Appeals for Veterans Claims (Court) held that the requirement of ankylosis in the General Rating Formula for Injuries and Diseases of the Spine can be met with evidence of the functional equivalent of ankylosis (i.e., functional immobility of the joint) during a flare-up. Chavis v. McDonough, 34 Vet. App. 1 (2021). Under the current Formula for Rating IVDS 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 2 weeks during the past 12 months. A 20 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 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). In evaluating disabilities of the musculoskeletal system, it is also necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability. 38 C.F.R. § 4.45. Even if range of motion was slightly limited by pain, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. The Board also notes that under Diagnostic Code 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. In the absence of limitation of motion, a 20 percent evaluation is warranted for x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Both sacroiliac joints, along with the lumbosacral articulation, are considered to be a single group of minor joints. 38 C.F.R. § 4.45 (f). Multiple involvement of the lumbar vertebrae is also considered to be a group of minor joints. Id. Furthermore, with any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Here, a review of the Veteran's VA treatment records document "mild diffuse muscle spasm, fair to good range of motion, tenderness" in September 2015. In an October 2015 treatment note, the Veteran reported that he had a follow-up with the East Orange VA Medical Center and that a doctor said he had muscle spasm of the back. A February 2016 mental health note indicated that the Veteran was prescribed paroxetine to treat psychiatric symptoms but stopped taking it due to adverse side effects such as teeth grinding and muscle spasms. The Veteran was provided with a VA Back (Thoracolumbar Spine) Conditions examination in September 2015, at which time he was diagnosed as having lumbosacral strain. Subjectively, the Veteran denied any flare-ups, but indicated that although his spine symptoms did not stop him from doing anything, they did limit what he could lift. Upon objective examination, range of motion testing revealed forward flexion limited to 80 degrees; extension limited to 30 degrees; lateral flexion limited to 30 degrees, bilaterally; and lateral rotation limited to 30 degrees, bilaterally. However, there was no pain noted upon examination, and the limited range of motion itself did not contribute to a functional loss. There was no evidence of pain with weight bearing, and no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive use testing with at least three repetitions, with no additional loss of function or range of motion after three repetitions. Although the Veteran was not being examined immediately after repetitive use over time, the examination was neither medically consistent nor inconsistent with his statements describing functional loss with repetitive use over time. There was no guarding or muscle spasm of the thoracolumbar spine. Muscle strength testing revealed normal strength in the bilateral hips, ankles, and toes, with no evidence of muscle atrophy. Reflex examination revealed normal deep tendon reflexes in the bilateral knee and ankles. Sensory examination revealed normal sensation to light touch (dermatome) in the bilateral upper anterior thighs, thighs/knees, lower legs/ankles, and foot/toes. Straight leg raising test was negative, and there no evidence of radicular pain or any other signs or symptoms due to radiculopathy. Additionally, there was no evidence of ankylosis or intervertebral disc syndrome (IVDS) of the thoracolumbar spine. Imaging studies did not document arthritis. At his October 2020 Board virtual hearing, the Veteran testified that he experienced muscle spasms of the back approximately once per week that caused him to walk slower. He also indicated that his back pain was not constant, but rather associated with periodic flare-ups. The Veteran further testified that he had stayed home from work approximately two times per month due to back symptomatology and rested, which his attorney claimed constituted an "incapacitating episode." The Veteran was most recently provided with a VA Back (Thoracolumbar Spine) Conditions examination in June 2021, at which time he was diagnosed as having lumbosacral strain. Subjectively, the Veteran described instability when quickly performing side-to-side lateral movement, balance issues when going up and down steps, inability to run, pain upon walking in excess of 15 minutes, pain upon lifting more than 20 pounds, pain upon kneeling, and weakness in his back upon standing up. However, the Veteran denied any flare-ups of the thoracolumbar spine or any additional functional loss or functional impairment of the joints. Upon objective examination, range of motion testing revealed forward flexion limited to 80 degrees; extension limited to 25 degrees; lateral flexion limited to 25 degrees, bilaterally; and lateral rotation limited to 30 degrees, bilaterally (with pain during forward flexion and extension, although this did not affect range of motion). The limited range of motion itself contributed to functional loss, as described by the Veteran in his subjective complaints above. Passive range of motion was the same as active range of motion. There was evidence of pain with weight bearing and upon active motion. However, there was no evidence of crepitus or localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran was able to perform repetitive use testing with at least three repetitions, with no additional loss of function or range of motion after three repetitions. The Veteran was examined immediately after repetitive use over time, with the evidence suggesting pain and weakness with repeated use over time. Estimated ranges of motion immediately after repeated use over included forward flexion limited to 75 degrees; extension limited to 25 degrees; lateral flexion limited to 25 degrees, bilaterally; and lateral rotation limited to 30 degrees, bilaterally. Guarding and muscle spasm of the thoracolumbar spine resulted in abnormal gait or abnormal spine contour. Muscle strength testing revealed normal strength in the bilateral ankles and toes, as well as active movement against some resistance in the bilateral hips, with no evidence of muscle atrophy. Reflex examination revealed normal deep tendon reflexes in the bilateral knee and ankles. Sensory examination revealed normal sensation to light touch (dermatome) in the bilateral upper anterior thighs, thighs/knees, lower legs/ankles, and foot/toes. Straight leg raising test was negative, and there no evidence of radicular pain or any other signs or symptoms due to radiculopathy. Additionally, there was no evidence of ankylosis or IVDS of the thoracolumbar spine. Based on the above evidence, the Board finds that a disability rating of 20 percent, but no greater, is warranted prior to June 24, 2021. Although the September 2015 examination report explicitly found that there was no guarding or muscle spasm of the thoracolumbar spine, VA treatment records dating back to 2015 documented muscle spasm. Additionally, the Veteran reported muscle spasm of the back at his October 2020 Board virtual hearing. Although the record does not indicate that the muscle spasm documented in 2015 resulted in abnormal gait or abnormal spinal contour, the Board will resolve reasonable doubt in the Veteran's favor and find that it did, especially in light of the June 2021 VA examination report which later documented guarding and muscle spasm of the thoracolumbar spine resulting in abnormal gait or abnormal spine contour. As such, the Veteran is entitled to a 20 percent disability rating for lumbosacral strain prior to June 24, 2021, as recommended by his attorney at the October 2020 Board hearing, based on his testimony regarding back spasms and flare-ups. However, the Veteran is not entitled to a disability rating in excess of 20 percent prior to June 24, 2021. Specifically, the medical evidence of record reflected forward flexion to no less than 80 degrees and combined range of motion of the thoracolumbar spine to no less than 230 degrees, without pain noted on active range of motion. The examiner found there to be no additional range of motion loss with repeated use, and the Veteran denied flare-ups. Further, the examiner found no evidence of IVDS or the functional equivalent of ankylosis. Although the Veteran's attorney attempted to characterize staying home from work and resting due to back symptoms as an "incapacitating episode," the Board emphasizes that incapacitating episodes are defined as periods of acute signs and symptoms due to IVDS that require bed rest prescribed by a physician and treatment by a physician. Under this definition, there is no evidence of incapacitating episodes in the record. For the next-higher 40 percent rating to be warranted, the evidence must demonstrate either forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. As the medical evidence does not reflect the criteria necessary for a 40 percent disability rating prior to July 24, 2021, only a 20 percent initial disability rating is warranted for this period. Regarding neurological impairment, the lay and medical evidence of record prior to July 24, 2021, is against a finding that the Veteran has any neurological abnormality associated with his lumbar spine disability. As such, the Board finds that a disability rating of 40 percent is not warranted for the Veteran's lumbosacral strain prior to June 24, 2021. Similarly, the Board finds that, since June 24, 2021, a disability rating in excess of 20 percent for the Veteran's lumbar spine disability is again not warranted. During the June 2021 VA examination, forward flexion was, at worst, limited to 75 degrees, with combined range of motion of the lumbar spine, at worst, to 210 degrees, with pain noted during flexion and extension. The Veteran again denied any flare-ups. The Board acknowledges that pain and weakness were evident with repeated use over time; however, the additional functional loss is already contemplated in the range of motion findings considered above. See DeLuca, supra. Although guarding and muscle spasm of the thoracolumbar spine resulted in abnormal gait or abnormal spine contour, there was no evidence of ankylosis or the functional equivalent of ankylosis. Similarly, the Veteran was not diagnosed as having IVDS. As the Veteran is already in receipt of a 20 percent disability rating under Diagnostic Code 5237 for guarding and muscle spasm severe enough to result in an abnormal gait, for the next-higher 40 percent rating to be warranted, the evidence must demonstrate either forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Here, the medical evidence from June 24, 2021, to the present only reflects forward flexion of the lumbar spine to, at worst, 75 degrees, and it does not demonstrate favorable ankylosis of the entire thoracolumbar spine or the functional equivalent thereof. Regarding neurological impairment, the lay and medical evidence of record from June 24, 2021, to the present is against a finding that the Veteran has other neurological abnormality associated with his lumbar spine disability. Therefore, the currently assigned 20 percent disability rating for the Veteran's chronic lumbosacral strain since June 24, 2021, is appropriate and a higher rating is not warranted. 2. Entitlement to an initial disability rating in excess of 50 percent for PTSD The Veteran seeks entitlement to a higher initial disability rating for his service-connected PTSD, which has been rated as 50 percent disabling pursuant to Diagnostic Code 9411. Under Diagnostic Code 9411, a 70 percent rating is prescribed when there is evidence of 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); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. Symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). A veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Additionally, while symptomatology should be the primary focus when deciding entitlement to a given disability rating, § 4.130 requires that those symptoms have caused the requisite occupational and social impairment. Id. Here, the Veteran was provided with a VA PTSD examination in September 2015, at which time he was diagnosed as having PTSD. At that time, the Veteran reported "good" relationships with his wife and 2-year-old daughter. Additionally, the Veteran indicated that he continued to engage in social activities but preferred to be around people he already knew, reporting that he became irritated easily with others. He was employed as a carpenter at the time. Upon examination, the examiner indicated that the Veteran's symptoms included depressed mood, anxiety, flattened affect, and difficulty in establishing and maintaining effective work and social relationships. His mood was "OK," while his affect was constricted. The Veteran made minimal eye contact. He denied suicidal ideation. The Veteran was dressed casually and neatly and was cooperative throughout the examination. His speech was of normal rate and tone, and his thought processes appeared logical and coherent. His judgment, impulse control, and concentration appeared intact. The Veteran denied the presence of manic or psychotic symptoms, and no delusional material was elicited. Significantly, the examiner concluded that the Veteran's PTSD symptomatology resulted in merely occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran was most recently provided with a VA PTSD examination in June 2021, at which time he was diagnosed as having PTSD. Subjectively, the Veteran described social withdrawal, both at home and at work, as well as difficulty dealing with people, although he was "OK" with people with whom he was comfortable. The Veteran further reported panic attacks once per week, causing him to take a break from his job in order to collect himself before proceeding to the next task. The Veteran described positive relationships with his family, although he experienced some current issues with his wife of eight years due to her not listening well when he attempted to express his feelings to her. The Veteran was employed as a utility technician, which allowed him to work by himself. Upon examination, the examiner indicated that the Veteran's symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, flattened affect, difficulty in establishing and maintaining effective work and social relationships, as well as difficulty adapting to stressful circumstances, including work or a work like setting. The Veteran's speech was normal and his thought processes were logical. However, he appeared sad, depressed, and exhibited very flat affect. The Veteran was fully oriented, and his attitude was cooperative. Eye contact and motor activity were both minimal. The Veteran did not report major memory or concentration difficulties. He was deemed to be a credible informant, and denied any thoughts of suicide or homicide. There was no evidence of psychosis. Insight was adequate, while his judgment was intact. Significantly, the examiner concluded that the Veteran's psychiatric symptomatology resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran's VA treatment records reveal symptoms and impairments similar to those reflected in the VA examinations. For example, a September 2015 VA Mental Health Consult noted the Veteran denied a history of suicide attempts or self injury and no current suicidal or homicidal ideation or hallucinations or paranoid ideation. The Veteran reported for the visit appropriately groomed/dress and was open and cooperative during the visit with clear, coherent and goal-directed speech. The physician noted the Veteran reported panic attacks several times a day, as well as nightmares and increased irritability. During other mental health visits and telephone encounters throughout the appeal period, the Veteran denied suicidal ideation. In an October 2020 Mental Health Telephone Encounter, the Veteran reported no significant change in his PTSD-related symptoms, although he acknowledged difficulty sleeping and occasional nightmares along with increased alcohol consumption. Based on the evidence, the Board concludes that a rating in excess of 50 percent is not warranted. Throughout the period on appeal, the Veteran's PTSD has been manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. As indicated previously, a 70 percent rating is warranted where there is 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); inability to establish and maintain effective relationships. In examining the frequency, duration, and severity of his PTSD symptoms, the Board finds that the evidence shows that the Veteran experienced depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, flattened affect, difficulty in establishing and maintaining effective work and social relationships, as well as difficulty adapting to stressful circumstances. However, there is no indication that such symptoms affected his ability to function independently, as he reported working successfully as a utility technician, maintaining employment with no medical reports of consistent time off due to PTSD symptoms, and performing his activities of daily living. There is no indication that judgment, impulse control, or thought processes were impaired. The Veteran denied, and the record otherwise does not demonstrate, suicidal ideation, obsessional rituals which interfere with routine activities, intermittently illogical speech, impaired impulse control, spatial disorientation, or neglect of personal appearance. There have been no findings of, and the Veteran has not reported, psychosis, delusions, visual hallucinations, or inappropriate behavior. The Veteran maintained relationships with his spouse, children, and close friends. This demonstrates that he was able to establish and maintain effective relationships. As such, the Board finds that the severity of the Veteran's symptoms is fully contemplated in the assigned 50 percent rating. The disability picture presented is not one consistent with the criteria for a 70 percent rating, which contemplates, for example, suicidal ideation; obsessional rituals which interfere with routine activities; speech which was 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; and inability to establish and maintain effective relationships. Therefore, a rating in excess of 50 percent is not warranted. The preponderance of the evidence of record also weighs against a finding that PTSD symptoms resulted in total social impairment, as contemplated by the rating criteria for a 100 percent rating, and in so finding, the Board determines that the severity of PTSD symptomatology does not more nearly approximate the level of disability contemplated by a 100 percent rating. A 100 percent rating requires a factual conclusion that the PTSD symptomatology results in both total occupational and total social impairment. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board finds that total occupational and social impairment is not shown by the evidence of record as the Veteran worked full time and maintained relationships his spouse, children, and close friends. REASONS FOR REMAND The Veteran also seeks entitlement to service connection for a left shoulder disability. Unfortunately, the Board finds that additional development must be undertaken before this claim can be adjudicated on the merits. The Veteran testified at his October 2020 Board virtual hearing that he gradually incurred a disability of the left shoulder over time as a result of carrying an M240 machine gun plus ammunition (weighing approximately 130 pounds) as well as AT4 anti-tank weapons on a daily basis while deployed as an infantryman with the 502nd Infantry Regiment of the 101st Airborne Division in Afghanistan. He further testified that he sought treatment for left shoulder symptoms upon his return from deployment in approximately August 2011, and that he was prescribed Ibuprofen at that time. A review of the Veteran's records confirms that he served as an infantryman in Afghanistan from October 2010 to May 2011, and again from February 2014 to October 2014, and that he received the Combat Infantryman Badge. His service treatment records also show that he was prescribed Ibuprofen for pain relief on several occasions, to include April 2010, May 2010, September 2012, and October 2013. He was prescribed Ibuprofen in October 2013 for "body aches." The Veteran also testified that he continued to experience left shoulder pain and clicking continuously into the present, although he had not sought medical treatment for the condition and instead opted to self-medicate with Tylenol and Ibuprofen when needed. As such, the Board's previous Remand in April 2021 directed that the Veteran be provided with an appropriate VA examination to determine the nature and etiology of any diagnosed left shoulder disability. Specifically, the examiner was requested to opine as to whether it was at least as likely as not that any diagnosed left shoulder disability was incurred during the Veteran's active service or within one year thereafter, or was otherwise causally related to his active service or to an incident therein. Crucially, the examiner was instructed to consider and address the Veteran's testimony that he began experiencing left shoulder symptomatology in service as a result of carrying an M240 machine gun plus ammunition (weighing approximately 130 pounds) as well as AT4 anti-tank weapons on a daily basis in his capacity as an infantryman while serving in Afghanistan. The examiner was advised that the Veteran was competent to report that he experienced symptoms such as left shoulder pain and clicking since active service; if the examiner had reason (based on other evidence of record or medical knowledge) to question the Veteran's self-reported history, then the examiner was directed to state and provide a complete explanation why that was so. Pursuant to the Board's April 2021 Remand directives, the Veteran was provided with a VA Shoulder and Arm Conditions examination in June 2021, at which time he was diagnosed as having left shoulder strain by a nurse practitioner. No imaging studies were performed in conjunction with the examination. Nonetheless, the examining nurse practitioner opined that the Veteran's diagnosed left shoulder strain was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. In support of this conclusion, the examiner explained that: No ongoing care or diagnostic workups. Insufficient medical evidence supporting claim of Left Shoulder issues. Consideration given to the Veterans testimony that veteran began experiencing left shoulder symptomatology in service as a result of carrying an M240 machine gun plus ammunition (weighing approximately 130 pounds) as well as AT4 anti-tank weapons on a daily basis in his capacity as an infantryman while serving in Afghanistan. Questions remain regarding complaints of pain with no medical follow up for veteran reported issues with left shoulder. In August 2020, the RO obtained an addendum opinion from the same examining nurse practitioner, as the original June 2021 report failed to opine as to whether it was at least as likely as not (50 percent or greater probability) that any diagnosed left shoulder disability was diagnosed within one year of the Veteran's active service. The examiner responded that: No ongoing care or diagnostic workups. Insufficient medical evidence supporting claim of Left Shoulder issues. Consideration given to the Veterans testimony that veteran began experiencing left shoulder symptomatology in service as a result of carrying an M240 machine gun plus ammunition (weighing approximately 130 pounds) as well as AT4 anti-tank weapons on a daily basis in his capacity as an infantryman while serving in Afghanistan. Questions remain regarding complaints of pain with no medical follow up for veteran reported issues with left shoulder. Therefore, it is my medical opinion that that the Veteran has a diagnosis of (a) left shoulder strain that WAS LESS LIKELY THAN NOT (less than 50 percent probability) incurred in or caused by (the) left shoulder during service. The Board finds that the above medical opinions are inadequate. The Board emphasizes that its Remand advised the examiner that the Veteran was competent to report that he experienced symptoms such as left shoulder pain and clicking since active service; and, if the examiner had reason (based on other evidence of record or medical knowledge) to question the Veteran's self-reported history, then the examiner was directed to state and provide a complete explanation why that was so. Here, although the examiner claimed that consideration was given to the Veteran's reported history of symptomatology, the negative nexus opinions appeared to be based solely on a lack of "ongoing care or diagnostic workups." However, the Board emphasizes that an opinion that relies solely on the absence of symptoms or treatment in service is not adequate. A lack of medical evidence in the service medical records does not preclude service connection. Buchanan v Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an absolute bar to a service connection claim). Moreover, an opinion that relies on an absence of in-service findings and does not reflect full consideration of the Veteran's theory of causation is inadequate. See McKinney v. McDonald, 28 Vet. App. 15, 30-31 (2016) (VA examiner's failure to consider a veteran's testimony when formulating an opinion renders that opinion inadequate). Additionally, the June 2021 examiner's opinion did not address the service treatment records showing that the Veteran was prescribed Ibuprofen for pain relief on several occasions, to include April 2010, May 2010, September 2012, and October 2013, and did not discuss the likelihood as to whether these treatments were related to the Veteran's left shoulder symptomatology, as credibly reported by the Veteran. Remand is required for a new VA examination and opinion, preferably by an orthopedic specialist. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). As the June 2021 VA Shoulder and Arm Conditions examination is inadequate, remand is required to obtain an adequate opinion. The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate examination, preferably by an orthopedic specialist, to determine the probable nature and etiology of any diagnosed left shoulder disability, to include left shoulder strain. The examiner should review the claims file and indicate such on the examination report. Any testing deemed necessary, to include imaging studies to determine the presence of arthritis, should be conducted, and the results thereof should be noted in the examination report. All relevant shoulder pathology shown on examination should be annotated in the examination report. Following a review of the claims file, as well as an interview with, and examination of, the Veteran, the examiner is asked to answer the following: a. List any left shoulder disability by either (1) diagnosis or (2) functional impairment that presently exists or that has existed during the appeal period. b. For each left shoulder disability identified, opine as to whether it is at least as likely as not (50 percent or greater probability) that any such diagnosed left shoulder disability was incurred during the Veteran's active service or within one year thereafter, or is otherwise causally related to his active service or to an incident therein. In answering this question, the examiner should consider and address the Veteran's testimony that he began experiencing left shoulder symptomatology in service as a result of carrying an M240 machine gun plus ammunition (weighing approximately 130 pounds) as well as AT4 anti-tank weapons on a daily basis in his capacity as an infantryman while serving in Afghanistan. The examiner is also asked to acknowledge and address the service treatment records showing that the Veteran was prescribed Ibuprofen for pain relief on several occasions (to include April 2010, May 2010, September 2012, and October 2013) and discuss the Veteran's allegation that he was prescribed these medications at the time to alleviate shoulder pain. The examiner is advised that the Veteran is competent to report that he has had symptoms such as left shoulder pain and clicking since active service. If the examiner has reason (based on other evidence of record or medical knowledge) to question the Veteran's self-reported history, then the examiner should so state and provide a complete explanation why this is so. A complete rationale for all opinions expressed must be provided. The examiner is advised that an opinion that relies solely only on the absence of symptoms or treatment in service is not adequate, and that a lack of medical evidence in the service medical records does not preclude service connection. Buchanan v Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). An examiner's report that he or she cannot provide an opinion without resort to speculation is inadequate unless the examiner provides a rationale for that statement. As such, if the examiner is unable to offer an opinion, then it is essential that the examiner provide a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide the opinion is based on the limits of medical knowledge. 2. Then, after undertaking any other development deemed appropriate, readjudicate the issue remaining on appeal considering all evidence added to the record since the August 2021 Supplemental Statement of the Case. If the benefit sought is not granted, then furnish the Veteran and his attorney with another Supplemental Statement of the Case and afford them an opportunity to respond before the record is returned to the Board for further review. Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Anthony M. Flamini 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.