BVA9501665 DOCKET NO. 90-19 460 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES Entitlement to service connection for a right shoulder disorder diagnosed as post-brachial plexus injury, residuals of a fracture of the right clavicle, and right acromioclavicular separation. Entitlement to an increased evaluation for cervical strain with C-5 radiculopathy, status post-cervical foraminotomy, and status post-cervical diskectomy and fusion, currently evaluated as 40 percent disabling. Entitlement to extension of a temporary total convalescence evaluation beyond December 31, 1990, for post-operative residuals of anterior diskectomy of C4-5, C5-6, and C6-7 with fusion using left iliac crest bone graft. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESSES AT HEARINGS ON APPEAL Appellant and James Slaymaker ATTORNEY FOR THE BOARD Ronald R. Bosch, Counsel INTRODUCTION The veteran served on active duty from September 1974 to June 1977. This appeal arose from a June 1989 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The RO denied entitlement to an increased evaluation for service- connected disability of the cervical spine then diagnosed as cervical strain. In an August 1989 rating decision, the RO granted an increased evaluation of 20 percent for cervical spine disability then diagnosed as cervical strain with C5 radiculopathy and status post cervical foraminotomy effective September 27, 1988; and granted a temporary total convalescence evaluation for cervical spine disability effective from June 6 to July 31, 1989, and reinstated the 20 percent evaluation effective August 1, 1989. The above determinations were affirmed in rating decisions issued in November 1989 and March 1990. The RO affirmed previous determinations in an August 1990 rating decision. In September 1990, the RO granted entitlement to service connection for a left iliac crest bone graft site which was assigned a noncompensable evaluation; denied entitlement to an increased evaluation for disability of the cervical spine; and granted entitlement to a temporary total convalescence evaluation for cervical spine disability effective from August 21 to October 31, 1990, and reinstated the prior 20 percent evaluation effective November 1, 1990. The above determinations were affirmed by the RO in September 1991. In November 1990, the RO affirmed 20 percent evaluation for disability of the cervical spine and granted extension of the temporary total convalescence evaluation from November 1 to December 1, 1990. In a December 1990 rating decision, the RO granted extension of the temporary total convalescence evaluation from December 1, 1990, to January 1, 1991; and affirmed the 20 percent evaluation for disability of the cervical spine. Additional extension of the temporary total convalescence evaluation was denied in rating decisions issued in February and April 1991. When this case was initially before the Board of Veterans' Appeals (Board) for appellate review, it was REMANDED to the RO for further development in June 1991. The RO denied entitlement to service connection for a disability of the right shoulder in a January 1992 rating decision. The denial was affirmed as was the evaluation for the disability of the cervical spine in another rating decision issued in January 1992. When this case was last before the Board for appellate review, it was REMANDED to the RO for further development in November 1992. In a June 1993 rating decision, the RO affirmed the determinations previously entered and granted an increased evaluation of 40 percent for disability of the cervical spine. The case has been returned for final appellate review. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he has a chronic disability of the right shoulder which either is directly related to accidental trauma sustained in service or developed as the result of his service-connected disability of the cervical spine. He argues that his chronic disabling manifestations of his cervical spine disability would more appropriately be evaluated as 60 percent disabling under diagnostic code 5293. The appellant argues that correspondence on file from his private attending physicians clearly show that he was unable to return to work until May 1, 1991, thereby warranting entitlement to extension of the temporary total convalescence evaluation to this date. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims files. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against a grant of service connection for a right shoulder disability, and that the record supports grants of an increased evaluation of 60 percent for disability of the cervical spine and extension of a temporary total evaluation for cervical spine surgery through May 1, 1991. FINDINGS OF FACT 1. A chronic disability of the right shoulder was not shown in active service; nor is one shown to be causally related to a service-connected disability. 2. Cervical strain with C-5 radiculopathy with status post- cervical foraminotomy and status post-cervical diskectomy and fusion is productive of pronounced impairment. 3. The veteran continued to convalesce from cervical surgery performed on August 21, 1990, through April 30, 1991. CONCLUSIONS OF LAW 1. A disability of the right shoulder was not incurred in or aggravated by active service, nor is one proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.310(a) (1993). 2. The schedular criteria for an increased evaluation of 60 percent for cervical strain with C5 radiculopathy, status post- cervical foraminotomy and status post-cervical diskectomy have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.40, 4.71(a), Diagnostic Code 5293. 3. The requirements for extension of a temporary total convalescence evaluation for post-operative residuals of anterior diskectomy of C4-5, C5-6, and C6-7 with fusion using left iliac crest bone graft through April 30, 1991, have been met. 38 U.S.C.A. § 5107; 38 C.F.R. § 4.30. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, the Board finds that the appellant's claims are well grounded within the meaning of 38 U.S.C.A. § 5107(a), in that he has presented claims which are plausible. The Board is satisfied that as a result of the June 1991 and November 1992 remands of the claimant's case to the RO for further development, all relevant facts have been properly developed, and that no further assistance to the veteran is required in order to comply with 38 U.S.C.A. § 5107(a). The veteran contends that he has a chronic disability of his right shoulder either directly due to trauma sustained in service or as the result of his service-connected disability of the cervical spine, that his cervical spine disability has increased in severity, and that he continued to convalesce from his August 21, 1990 surgery until May 1, 1991, when he was cleared to return to work by his private attending physician. In the paragraphs below the Board will explain why the appellant does not have a disability of the right shoulder either due to service or secondary to his service-connected cervical spine disability, why his cervical spine disability is productive of pronounced impairment warranting the assignment of a 60 percent evaluation, and why extension of his temporary total convalescence evaluation for cervical spine surgery is warranted through May 1, 1991. As these issues deal with closely interrelated subject matter, the Board will historically develop the evidentiary record in the initial discussion below and then explain the specific reasons for the determinations in light of the exposition of the record. A review of the service medical records discloses that the veteran related that he had been troubled by neck symptomatology he categorized as whiplash sine 1973. He reinjured his neck in a trampoline accident in 1975. Additional injury was sustained in 1976 in a snowmobile turnover and two weeks later when he fell off a truck. He was treated on a symptomatic basis for cervical strain. Such treatment included use of a cervical collar subsequent to each injury. The service medical records are negative for any evidence or findings of a chronic disorder of the right shoulder. VA conducted a general medical examination of the veteran in October 1977. He complained of neck symptomatology. On musculoskeletal examination he demonstrated what was described as moderately decreased range of motion of the cervical spine in all directions with complaints of pain. Pain was chiefly on the right side where the muscles were tender in the mid cervical area. An x-ray of the cervical spine was interpreted as showing a mild asymmetry at the C1-2 level on the odontoid view with distance between C1 and the odontoid 3.5 centimeters on the right and 5.0 millimeters on the left. Rotary subluxation could not be ruled out. The examination diagnosis was consistent with the clinical findings reported on examination. On file are VA outpatient treatment reports dated during the 1980's. They include numerous references to treatment of the appellant for chronic right shoulder and cervical symptomatology. In October 1985, he was seen with complaints of right shoulder pain. He related that two months previously he had been thrown off a motorcycle. His subsequent right shoulder pain had improved, but worsened after he sneezed. A physical examination disclosed point tenderness over the lateral aspect of the acromioclavicular joint. A radiographic study was interpreted as showing a subacute avulsion fracture at the distal right clavicle. The outpatient treatment reports dated prior to October 1985 are silent as to any right shoulder symptomatology. In September 1987 the appellant was hospitalized by VA with right long thoracic nerve palsy since an injury in 1984. His complaints included increasing right shoulder pain. The hospital diagnosis was status post right acromioclavicular joint resection for altered mechanics due to long thoracic nerve paralysis. A follow-up outpatient treatment report dated in October 1987 shows the veteran related having been in a bike accident two and one- half years previously, having fallen off a truck in service ten years previously, and having injured his right shoulder both times. He was again hospitalized in June 1989 at which time he underwent a cervical foraminotomy. The hospital discharge diagnosis was C5 radiculopathy. VA outpatient treatment reports dated during the late 1980's show continued and frequent treatment for chronic right shoulder and cervical symptomatology. VA conducted orthopedic and neurologic examinations of the veteran in October 1989. He complained that his disability had worsened markedly. It was determined that he used a transcutaneous electrical nerve stimulating unit sporadically. By history, he wore it full time two days a week and approximately one to two hours per day the rest of the week. The veteran related that he originally injured his neck prior to service in 1973 when he suffered a muscle pull in his neck. This resolved completely prior to service and he had no problems with his neck in basic training or advanced individual training. His first episode of neck problems in service occurred in 1975 when he was injured on a trampoline. He landed improperly on the side of his head and neck and hyperextended the right side of his neck. The claimant injured his neck again in 1976 when he was riding a snowmobile and it turned over and he traumatized the right side of his neck. Two weeks after the snowmobile accident he was involved in an accident where he fell out of the back of a two and one-half ton truck in service. He related that he had had continuing progressive problems with his neck since 1977. The examiner noted that in approximately 1979 he was one of the California State arm wrestling champions. In 1984 he was in a motorcycle accident where he traumatized the right side of his neck and also injured the long thoracic nerve on the right side. He had had chronic progressive symptoms since that time and had developed a winging of the right scapula with pain, stiffness of the neck, and loss of motion of the neck. He was receiving physical therapy three times weekly. He had had some increase in motion of the neck. He had pain daily. He was being considered for muscle transposition surgery in order to help with the winging of the right scapula. The examiner commented that an August 1989 electromyographic study done at a private medical center showed no involvement of the C5 dermatome, but did demonstrate long thoracic nerve impingement with denervation of the serratus anterior muscles. On examination the veteran's carriage and posture showed marked winging of the right scapula. The examiner also noted that his gait was normal with no antalgic or steppage gait. A musculoskeletal examination of the cervical spine showed marked limitation of motion with mild cervical spasm. Forward flexion was to 30 degrees, backward extension was to 20 degrees, right lateral flexion was to 25 degrees, left lateral flexion was to 15 degrees, right rotation was to 40 degrees, left rotation was to 25 degrees. No crepitus was present. An examination of the left shoulder and arm was noted to be normal. An examination of the right shoulder disclosed pronounced winging of the right scapula. There was atrophy of the deltoid muscle and the serratus anterior muscles on the right. Right shoulder range of motion disclosed abduction of 160 degrees, forward elevation to 145 degrees, external rotation to 40 degrees, and internal rotation to 60 degrees. The examiner noted that a clinical inspection of the arms disclosed remarkable muscle development and tone. The veteran had well-developed biceps bilaterally with his right arm biceps measuring 33.5 centimeters and the left arm biceps measuring 31.5 centimeters. The right forearm circumference was 32 centimeters and the left forearm circumference was 30.5 centimeters. The examiner noted that the measurements had been taken with the arms relaxed and extended. A neurologic examination showed minimal reduction of right hand grip strength. Reflexes were noted to be normal in both upper extremities and symmetrical. There was a subjective sensory deficit to vibration and fine touch along the ulnar aspect of both forearms. An electromyogram was noted to show that the appellant had no strict dermatomal sensory neuropathy. The diagnoses were chronic cervical strain with history of C5 radiculopathy, and status post-cervical foraminotomy. The veteran provided testimony before a hearing officer at the RO in December 1989. He testified as to the reasons he felt that his cervical spine disability was more disabling than evaluated at that time. On file is a letter dated in January 1990 from E.B. Zussman, D.O., a physiatrist. He advised that a review of his treatment notes pertaining to the veteran allowed him to conclude that the problems the veteran was currently having were related to a 1975 fall from a truck resulting in an injury of the cervical spine. The claims file contains a report of a medical examination dated in May 1990 from Howard S. An, M.D. He noted that the veteran had severe neck and bilateral arm pain in the distribution of C5 nerve roots. He had instability which was borderline, which may be due to disc disease in addition to a previous foraminotomy. Dr. An advised the veteran that the most important thing to do was to get his range of motion improved and to strengthen his neck muscles by doing isometric exercises. He was also encouraged to stop smoking as nutrition to the discs would decrease by smoking. If he improved with non-steroidal anti- inflammatory medication and physical therapy, then surgery would not be necessary. He noted that the veteran was still employed making eyeglasses. On file is a VA abbreviated medical record of treatment pertaining to an admission of the veteran in June 1990 for treatment of cervical radiculopathy. The appellant was privately hospitalized on August 21, 1990, with a 15 year history of neck pain after getting thrown from a truck. He had radicular symptoms, pain, and stiffness extending to his upper extremities. He underwent an anterior diskectomy and fusion of C4-5, C5-6, and C6-7 with left iliac crest bone graft. Because he was ambulating without difficulty and was stable, he was discharged to his home on August 24, 1990, with follow-up appointment three weeks after discharge. An August 24, 1990 medical note from Howard S. An, M.D., shows the veteran had undergone an anterior cervical fusion and should be off from work for three months. In his September 1990 letter, Dr. An noted that the veteran was three and one-half weeks status post cervical surgery. He was doing quite well with minimal pain in his arms. He still had some discomfort in the back of the scapular region. He was intact neurologically and the skin incision had healed nicely. An x-ray of the cervical spine was said to reveal good position of the bone graft and it was starting to incorporate. Dr. An noted that the veteran would continue to wear a Philadelphia collar for another three weeks and then would switch to a soft collar. He was to start on a vigorous range of motion and strengthening exercise program in about six weeks. In his November 1990 letter, Dr. An noted that he evaluated the veteran two and one-half months after his August 1990 cervical surgery. He had been doing range of motion exercises and isometric strengthening exercises for the last few weeks. Even though his symptoms had improved after surgery, he still had residual neck pain and stiffness. On examination the neck incision was seen to have healed. The appellant was intact neurologcally. He was doing fairly well. Dr. An noted that he had told the veteran it was important to continue doing range of motion exercises and his strengthening exercise program to get as much function as possible. He was a little slow on rehabilitation and further exercise was necessary before he went back to work. Dr. An anticipated that the veteran would be able to return to work the first part of January 1991. In a January 1991 medical statement, Dr. An advised that the veteran would be able to return to work on February 1, 1991. In his February 1991 correspondence, Dr. An noted that the veteran was coming along after his cervical surgery, but his range of motion was not improving and he had residual neck pain. He was sending him to formal physical therapy. Dr. An noted that the veteran related he could not return to light duty work since such work was not permitted at the time. In a February 1991 statement, Dr. An advised that the veteran would be able to return to work on March 18, 1991. He included a medical statement pertaining to the veteran's physical therapy. In his March 1991 correspondence, Dr. An advised that the veteran had sustained a fall the previous January. He was undergoing physical therapy three times per week. Dr. An stated that the appellant would be able to return to work on May 1, 1991. VA conducted orthopedic and neurologic examinations of the appellant in May 1991. He reported that since his August 1990 cervical spine surgery he had undergone considerable rehabilitation training. He stated that he still had pains in his arms and neck, but the pains were less than before. On examination cervical spine flexion was to 20 degrees, extension backward was to 10 degrees, rotation to the right was to 20 degrees, and rotation to the left was to 40 degrees. Deep tendon reflexes of the upper extremities were 1+ on the right and absent on the left side. Grip strength was stronger in the non dominant left hand and arm. The diagnosis was post-operative status, removal of multiple cervical intervertebral discs and fusion with residuals. In a May 1991 letter, Dr. An advised that the veteran was doing somewhat better after his cervical spine surgery. He had fewer symptoms in his arm, but he still got intermittent neck pain, particularly with lifting and bending episodes. His neck pain was constantly tender and it radiated down to both shoulders. He also had some intermittent pain in the rib cage and persistent tenderness to the bone graft site. An examination disclosed that winging of the scapula on the right side was improved since the preoperative status. An x-ray showed solid healing with flexion/extension from C4 to C7. There was persistent mild angulation which was present preoperatively due to a foraminotomy procedure in the past. Dr. An felt that the veteran would be in a better position if he could find a job that was less strenuous to his neck and back. He was able to perform some activities such as lifting up to 30 pounds and perform work that did not involve significant vibration and prolonged sitting for more than two hours at a time. In his December 1991 letter, Dr. An noted that the veteran's shoulder problem included weakness of the shoulder girdle muscles secondary to a pinched nerve in the neck. The pinched nerve in the neck required two operations to relieve the neck and shoulder pain. As far as Dr. An knew, the veteran's shoulder was being treated by the Sports Medicine Division for conditioning and rehabilitation. Therefore, his shoulder problem was secondary to his cervical spine disability involving a pinched nerve and thereby affecting the muscles around the shoulder. The claims file contains a substantial quantity of medical reports from non-VA health care professionals pertaining to rehabilitative therapy undergone by the veteran for residuals of his August 1990 cervical spine surgery during 1992. On file is a letter dated in January 1992 from Kevin P. Black, M.D. Dr. Black noted that the veteran was evaluated in April 1990 for complaints of neck and shoulder pain. After evaluations on several occasions, Dr. Black felt that the veteran's shoulder complaints were due to problems with his cervical spine and he was subsequently referred to Dr. An for evaluation and treatment. A January 1992 VA functional capacity evaluation report shows that the veteran's cervical spine range of motion was very limited in all directions. His posture was significant for a right shoulder which was much lower than the left shoulder, pronounced winging of the right scapula and a left shift of the head and thoracic spine. It was noted that such a pattern might be consistent with protection of a long standing painful and/or weak right upper extremity. The appellant was noted to demonstrate pain behaviors during test activities which correlated with his subjective scores as given during the examination. The fact that he passed 10 of the 11 validity criteria indicated that the examination was a valid assessment of his capabilities. It was noted that further physical therapy had little to offer him at the time. In his April 1992 letter, Dr. Black advised that the veteran had been referred to him by VA for evaluation of neck and shoulder pain. He noted that after completing a magnetic resonance imaging of the right shoulder, he could find no abnormalities other than those incurred in the resection of the right distal clavicle. After evaluation on several occasions, and review of VA records, Dr. Black felt that the veteran's right shoulder complaints were due to problems in his cervical spine. There was little that could be done until the cervical spine problems had been corrected. The veteran provided testimony before a travel member of the Board at the RO in June 1992. He testified as to his ongoing right shoulder and cervical spine symptomatology both on present and historical bases. The claims file contains a substantial quantity of treatment reports from VA dated from the early 1980's to the early 1990's documenting the veteran's repeated visits for treatment of chronic cervical spine symptomatology and later right shoulder symptomatology for the most part manifested by unrelenting pain. The records show that for many years he was tried on a number of modalities to attempt to alleviate ever increasing pain and other symptomatology. The veteran was examined by a Board of two VA neurologists in March 1993. It was noted that he sustained early cervical spine injuries involving a snowmobile accident and falling off a truck while on active duty in December 1975. From December 1975 to June 1977, there were recorded incidents of chronic pain involving headaches and cervical strain. From 1982 to 1984 he had made several visits to the VA medical facility with complaints of cervical strain, muscle spasms, and headaches. In August 1984 the veteran fell on his right upper back and noted chronic recurring cervical pain. In 1985 he was thrown from a motorcycle, again sustaining right shoulder and cervical injuries. In that year he was noted to have a vesicular rash suggestive of shingles. In 1988 reflex sympathetic dystrophy was implied in his physical status. In June 1989 he underwent a foraminotomy at C5. In 1990 he underwent an anterior cervical fusion. The veteran complained of recurring pain in the neck with headaches and muscle spasms. He was using a transcutaneous electrical nerve stimulating unit and several medications to decrease pain and relieve muscle tension. On examination he was observed to have obvious winging of the scapula with specific strength in the right serratus anterior noted to be 2 out of 5. He also had weakness in the lower trapezius region at a grade of 3 out of 5 and weakness in the left trapezius with grade 4 out of 5. He had been through extensive rehabilitation with no improvement in his strength of the serratus anterior muscle. An electromyographic study of muscles and nerves in the upper extremities in June 1990 revealed a chronic C5, C6 radiculopathy, more involved on the right with evidence of reinnervation bilaterally. The involvement of the long thoracic nerve with some denervation of the anterior serratus muscle with signs of paraspinal muscle irritability (denervation signs) dated back to 1985 and showed prolonged latency in the long thoracic nerve. These signs were not apparent at the present time because of masking from other electrophysiologic processes. The VA neurologists noted that the early cervical injuries involving a snowmobile accident and falling from a truck while on active duty had established a chronic pain pattern which had recurred throughout the veteran's subsequent clinical life. Although he alleged injury to the right shoulder persisting since the injuries on active duty, there was absolutely no mention in any clinic visits or medically directed work-up while on active duty despite the several doctor progress notes that had been made available. After the appellant's fall in 1984, he had noted that he did injure his right upper back and complained of chronic recurring cervical pain not localized to either side. After his motor vehicle accident in 1985, however, he was specific in noting right shoulder pain but had not seen a physician until three months after the fact. At that time an evaluation was performed and indicated chronic persisting injury to the right upper extremity primarily limited by pain and an electromyographic study showed some evidence of mild denervation in the low cervical paraspinal muscles. There were notes in the record implicating a spontaneous occurrence of acute onset of a stiff neck and grinding sensations in the neck with numbness in the hand in January 1985 prior to the motor vehicle accident. An examination at that time reported some spasm in the right trapezius. This implied the presence of a neurogenic process prior to the motor vehicle accident but was unclear with regard to proximal etiology. It was apparent, however, that recurring neck injury did place the veteran at risk for osteoarthritic changes which in this case could be presumed to have led to the radiculopathy later requiring surgery. Since the winging of the scapula was not noted ot be apparent directly after his motor vehicle accident, the process appeared to have been a slowly progressive one relating primarily to radiculopathy. However, in 1985 there was also noted a vesicular rash suggestive of shingles. Shingles was noted by the neurologists to be a herpetic viral infection of C-fiber nerves which would not cause a motor deficit but would compound a pain process. An examination performed in 1988 revealed a cold right hand and electrical shooting pains into the back of the hand, all suggesting a possible reflex sympathetic dystrophy. Reflex sympathetic dystrophy was noted by the neurologists to be an unfortunate problem typically involving peripheral nerves in which a motor sweating or other autonomic nerve would produce pain in the process of autonomic motor activity. This played a role of making the veteran's pain worse. Because of the persistence in physical complaints, the veteran eventually had a C5 foraminotomy performed in June 1989 and later an anterior cervical fusion in August 1990 with an anterior diskectomy. The anterior fusion was from C4 through C7. Of significance was the fact that the appellant also had surgery on his clavicle following the motor vehicle accident to help alleviate pain and restricted movement in his shoulder. The VA neurologists noted that because the veteran did not seek medical help directly after the fall from his motorcycle in 1985, the injuries associated with that accident had not been clarified. Indirectly, however, it was clear that there was a progressive neurogenic process showing much more involvement over time and subsequent electromyograms indicated that the process involved nerve roots on both sides of the body with some predilection for severity on the right. Although indirect trauma to the long thoracic nerve was possible, this was in fact not severed and electromyographic studies had only shown partial injury with maintenance of function at the present time. The VA neurologists noted that although the right shoulder injury could not be claimed to involve incidents of cervical spine trauma while on active duty, the predilection to osteoarthritic changes which had later produced radiculopathy on both sides and had been major contributors to the appellant's pain process and had led to surgery, did relate specifically to injuries as they were noted on active duty. Certainly the presence of the chronic pain syndrome which had been present continuously from December 1975 was due to injury while on active duty. There were no clear abnormalities stemming from either the foraminotomy or the cervical fusion. In fact, these procedures were done to relieve disability and did not imply any particular complications. There was some contribution to local damage to the right shoulder implied in the motor vehicle accident when he was thrown from the motorcycle, but this did not detract from the chronic progressive form of the motor disability from osteoarthritic related radiculopathy and certainly had no bearing on the presence of a chronic pain syndrome stemming from the veteran's initial injury on active duty. VA conducted a special orthopedic examination of the claimant in April 1993. The examiner noted that he presented for evaluation of right shoulder and posterior trapezial pain. The examiner recounted the medical history of the veteran. On physical examination there was revealed obvious winging of the scapula. There was some atrophy of the inferior and supraspinatus muscle but not of the deltoid muscle. The veteran had full passive range of motion of the right shoulder, but with no impingement sign or supraspinatus sign. His strength at the extremes of motion was somewhat limited due to the winging of his scapula, and not due to pain. He was tender along the border of the trapezius and had no point tenderness in the right shoulder. There was minimal tenderness at the distal clavicle where a gap was felt at the prior clavicle resection area. Strength testing was 5/5 throughout other than the serratus anterior muscle. Reflexes were 2+ and symmetric. There was normal sensation throughout. The VA examiner noted that he did not feel that the veteran had any organic right shoulder pathology. His right shoulder biomechanics were obviously altered by his scapular winging due to either a long thoracic nerve injury or a C5-6-7 radiculopathy depending on which electromyographic study was accurate. The examiner noted that the veteran's posterior right shoulder pain was very consistent with cervical radiculopathy, and in fact seemed to be related to his injury sustained while on active duty. It did not appear that he had any new right shoulder pathology. The conclusion from the above medical information is that the veteran does not currently have a right shoulder condition as a disease entity. At least one is not identified. This is the medical opinion of the VA neurologists and orthopedist who most recently examined the veteran. Their examination and analysis were thorough and highly credible. Also, Dr. An and Dr. Black say essentially the same thing: the veteran does not have a right shoulder disability apart from his neck impairment; his problem is the neck; the symptoms he feels in his shoulder actually came from the pathology in his neck. We might add that while the veteran did experience some shoulder ailment due to the motorcycle accident in 1984, those symptoms seem to have cleared and what the veteran experiences in his shoulder stem from pathology identified as cervical radiculopathy for which service connection is already in effect. The Board can conclude that the veteran does not have a right shoulder disorder which was incurred in or aggravated by service or which is secondary to a service connected disability. 38 U.S.C.A. § § 1110, 1131, 5107; 38 C.F.R. § 3.310(a) The next issue for appellate consideration is whether the veteran is adequately rated for his cervical spine disability at 40 perecnt. We think not. The current 40 percent evaluation under diagnostic code 5293 of the VA Schedule for Rating Disabilities contemplates severe intervertebral disc syndrome productive of recurrent attacks with intermittent relief. The next higher evaluation of 60 percent requires a demonstration of pronounced intervertebral disc syndrome. This is to be manifested by persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurologic findings appropriate to the site of the diseased disc with little intermittent relief. The appellant has required treatment on inpatient and outpatient bases for persistent, unrelenting pain by both VA and non-VA health care professionals. Despite the various modalities, including surgery to obtain relief, his actual improvement has been short-lived at best and he has relapsed into pain. The veteran is dependent upon regular medical attention, medications, transcutaneous electrical nerve stimulating units, surgery, etc., to manage his pain syndrome. As the Board noted above, his symptoms encompass his cervical region and radiate to his upper extremities. In hearings the appellant and a witness have described in detail his attempts to deal with his disability on a daily basis. Efforts to control pain have not always been successful. Considering the medical findings a related by the various physicians the Board finds that a 60 percent evaluation would more properly reflect the current level of impairment of the cervical disability of the spine. The veteran's cervical spine disability has not rendered his disability picture unusual or exceptional in nature. It has not markedly interfered with employment as the record indicates that the appellant must seek other than his previous kind of employment as a maker of eyeglasses which required that he maintain an uncomfortable posture. The cervical spine disability has not required frequent periods of inpatient care as to render impractical the application of regular schedular standards, thereby precluding the assignment of a higher evaluation on an extraschedular basis. 38 C.F.R. § 3.321(b)(1). A 100 percent evaluation is not warranted for the cervical spine disability under diagnostic code 5286 as ankylosis of the spine at an unfavorable angle is not shown. An increased evaluation under the criteria of 38 C.F.R. § 4.40 for pain is not warranted as such pain is contemplated in the proposed 60 percent evaluation under diagnostic code 5293. The Board finds that the record supports a grant of an increased evaluation of 60 percent for cervical strain with C-5 radiculopathy, status post-cervical foraminotomy, and status post-cervical diskectomy and fusion. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.40, 4.71(a), Diagnostic Code 5293. The remaining issue for appellate review concerns whether the appellant continued to convalesce from his August 1990 surgery subsequent to December 30, 1990, when his temporary total convalescence evaluation terminated. It has been argued that the veteran in fact continued to convalesce and could not return to work until May 1, 1991, as reported by his private attending physician. A review of the evidence of record discloses that the appellant was privately hospitalized on August 21, 1990, at which time he underwent an anterior diskectomy of C4-5, C5-6, and C6-7 with fusion using the left iliac crest bone graft. Subsequently dated medical treatment reports show that he apparently experienced some improvement in his symptoms; however, this improvement was fluctual in nature. He continued to relapse into disabling pain and required continued rehabilitative therapy. A series of letters from his private attending physician noted that his treatment regimen repeatedly had to be extended or prolonged during early 1991 based on his disabling symptomatology. His physician's last correspondence definitively noted that the veteran was expected to return to less physically demanding employment on May 1, 1991. There is no evidence on file to contradict the veteran's non-VA health care professional. His private attending physician is the individual who is deemed to best know his potential for a return to work. The medical documentation proximate to the correspondence from the veteran's private physician dated in 1990 and 1991, supports the finding that while the veteran may have experienced an improvement in his physical status. His return to employment was finally determined to be May 1, 1991. Accordingly, the Board finds that extension of the temporary total evaluation for post-operative residuals of anterior diskectomy of C4-5, C5-6, and C6-7 with fusion using the left iliac crest bone graft is warranted through April 30 ,1991. 38 U.S.C.A. § 5107; 38 C.F.R. § 4.30. ORDER Entitlement to service connection for a right shoulder disability is denied. Entitlement to an increased evaluation of 60 percent for cervical strain with C5 radiculopathy, status post-cervical foraminotomy and status post-cervical diskectomy and fusion is granted, subject to pertinent criteria governing the payment of monetary benefits. Entitlement to extension of a temporary total convalescence evaluation through April 30, 1991, for post-operative residuals of anterior diskectomy of C4-5, C5-6, and C6-7 with fusion, is granted subject to pertinent criteria governing the payment of monetary benefits. BRUCE KANNEE Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.