Citation Nr: 0002323 Decision Date: 01/28/00 Archive Date: 02/02/00 DOCKET NO. 94-35 919 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana THE ISSUES 1. Whether new and material evidence has been received to reopen the claim for entitlement to service connection for a right shoulder disability. 2. Entitlement to service connection for sarcoidosis. 3. Entitlement to an increased rating for post-traumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. 4. Entitlement to an increased rating for postoperative residuals for disc removal at L3-4, currently evaluated as 40 percent disabling. REPRESENTATION Appellant represented by: J. Q. Davis, Attorney WITNESSES AT HEARINGS ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD Sabrina M. Tilley, Counsel INTRODUCTION The veteran served on active duty from January 1967 to October 1975. Historically, service connection was previously denied for a right shoulder disability in the initial rating decision, dated in January 1977. The veteran was notified of that determination by letter dated the following month. He did not appeal that decision. The veteran attempted to reopen his claim for service connection in March 1992. Entitlement to service connection for pulmonary sarcoidosis was denied in May 1981. The veteran was notified of that determination by a letter dated later that month. The veteran provided testimony with respect to service connection for a lung condition at a hearing on appeal in June 1981. The notice of disagreement must be filed with the agency of original jurisdiction, that is, the agency which entered the initial review or determination concerning a claim, and must be filed within one year from the mailing of the notice of the determination. A notice of disagreement is defined as a written communication from a claimant or his or her representative expressing dissatisfaction or disagreement with an adjudicative determination by the originating agency and a desire to contest the result. 38 U.S.C.A. § 7105 (West 1991 & Supp. 1999); 38 C.F.R. § 20.201 (1999). The hearing transcript qualifies as a notice of disagreement in the veteran's case. Tomlin v. Brown, 5 Vet. App. 355 (1993) (statement of appellant's representative at VA hearing, when reduced to writing by hearing transcript, meets requirement that notice of disagreement be in writing as of date of certification of transcript). The originating agency never issued a statement of the case pertaining to that issue. Consequently, the veteran has had an ongoing claim since 1981. The Board notes that the RO has developed the claim with respect to service connection for sarcoidosis in terms of whether new and material evidence was received to reopen a previously denied claim. However, the veteran's claim should be considered de novo for the reasons set forth above. In addition, The Board notes that the veteran at the July 1999 hearing raised a possible claim for secondary service connection for the right shoulder disability. In essence, the veteran testified that the right shoulder disability developed as a result of the wound that he received to the upper chest. However, the veteran is advised that claims for direct service connection and secondary service connection are considered to be separate claims. See Harder v. Brown, 5 Vet. App. 183, 187 (1993). This matter is referred to the RO for appropriate action. FINDINGS OF FACT 1. Service connection was previously denied for a right shoulder disability in a January 1977 rating decision. 2. The veteran was notified of the January 1977 denial of service connection for a right shoulder disability in February 1977, but did not file a timely appeal. 3. Although some of the evidence received since the January 1977 rating decision is new, none of it, either by itself or in connection with evidence previously assembled, is so significant that it must be considered in order to fairly decide the merits of the claim. 4. The record does not contain competent evidence of a nexus between a current sarcoidosis disability and injury or disease during the veteran's active service. 5. The veteran is unemployable by reason of his service- connected PTSD. 6. The veteran's back disability is current productive of pain and limitation of motion, without recent evidence of muscle spasm, absent ankle jerk, radiculopathy or any other neurological finding appropriate to the site of the diseased disc. CONCLUSIONS OF LAW 1. New and material evidence has not been received to reopen the claim for service connection for a right shoulder disability. 38 U.S.C.A. §§ 1110, 1131, 5107, 7105 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.156(a), 3.303 (1999). 2. The veteran's claim for service connection for sarcoidosis is not well grounded. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). 3. The criteria for a 100 percent rating for PTSD have been satisfied. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.10, 4.132, Code 9411 (1996). 4. The criteria for an increased rating for residuals of removal of a disc at L3-4 have not been satisfied. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.10, 4.71a, Code 5293 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. Whether the Claim for Service Connection for a Right Shoulder Disability is Reopened As noted above, service connection was denied for a gunshot wound of the right shoulder in an unappealed rating decision dated in February 1977. The veteran had then reported that he had received a gunshot wound in the right shoulder in August 1967 while serving in the Republic of Vietnam. The evidence then of record consisted of the veteran's service medical records, which show that a scar on the right shoulder was noted on the report of the periodic examination dated in March 1972. An August 1975 consultation report shows that the veteran was noted to have been shot in the right shoulder in 1967. Likewise a scar on the right shoulder was noted on the report of the medical examination for release from active service. The veteran was noted to have had an old metallic fragment wound of the right shoulder. Also of record was the report of the initial VA examination, conducted in November 1976. At that time, the veteran was noted to have a full range of motion in the right shoulder. No fragment wound of the right shoulder was observed. Rather, a fragment wound of the right upper chest with residual scar was noted. Photographs were taken of the upper body including the right shoulder from posterior and anterior views. These have been made a part of the record. In the January 1977 rating decision, the RO granted service connection for shell fragment wound of the right upper chest with residual scar, and denied service connection for residuals of shell fragment wound of the right shoulder, as residuals of a shell fragment wound of the right shoulder were not currently shown. The veteran was notified of that determination in correspondence dated in February 1977. However, the veteran did not initiate an appeal from the denial of service connection for right shoulder disability. Consequently, that determination is final. 38 U.S.C.A. § 7105. The veteran attempted to reopen his claim for service connection in March 1992. The question before the Board is the limited question of whether the veteran has submitted new and material evidence to reopen his previously denied claim. To reopen a finally denied claim, a veteran must submit new and material evidence. 38 U.S.C.A. § 5108, 7104 (West 1991); 38 C.F.R. § 3.104 (1999). As defined by regulation, new and material evidence means evidence not previously submitted to agency decisionmakers which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (1999). Current case law provides for a three-step analysis when a claimant seeks to reopen a final decision based on new and material evidence. First, it must be determined whether new and material evidence has been presented under 38 C.F.R. § 3.156(a); second, if new and material evidence has been presented, it must be determined immediately upon reopening whether, based upon all the evidence and presuming its credibility, the claim as reopened is well grounded pursuant to 38 U.S.C.A. § 5107(a); and third, if the claim is well grounded, the merits of the claim must be evaluated after ensuring the duty to assist under 38 U.S.C.A. § 5107(b) has been fulfilled. See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998) and Winters v. West, 12 Vet. App. 203 (1999) (en banc). In determining whether the evidence presented or secured since the prior final disallowance of the claim is new and material, "the credibility of the [new] evidence" is presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). However, in cases in which a physician relied upon the appellant's account of his medical history and service background, recitations of which had already been rejected in a previous decision, such history articulated by the appellant has no probative value and hence cannot be considered material for the purpose of reopening the veteran's claim. Reonal v. Brown, 5 Vet. App. 458, 460-461 (1993). The new and material evidence must be presented or secured since the time that the claim was finally disallowed on any basis, not only since the time that the claim was last disallowed on the merits. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The Board has reviewed the evidence received into the record since the January 1977 rating decision and finds that no new and material evidence has been received to reopen the claim for service connection for residuals of a gunshot wound of the right shoulder. In the veteran's case, the evidence received into the record since the January 1977 rating decision includes reports of VA and private inpatient and outpatient treatment. This evidence, although new, is cumulative in nature. For example the January 1997 VA report shows that the veteran complained of a painful shoulder that he thinks may be related to the shrapnel wound that he received in 1967. Likewise a March 1998 VA outpatient treatment report shows that the veteran complained of pain in the right shoulder associated with an old shell fragment wound sustained in Vietnam. However, the veteran is advised that evidence which is simply information recorded by a medical examiner, unenhanced by any additional medical comment by the examiner, does not constitute "competent evidence". Such evidence cannot enjoy the presumption of truthfulness accorded by Justus as to the determination of new and material evidence for the purpose of reopening a claim. This is true because a medical professional is not competent to opine as to matters outside the scope of his or her expertise; a bare transcription of a lay history is not transformed into "competent medical evidence" merely because the transcriber happens to be a medical professional. LeShore v. Brown, 8 Vet. App. 406 (1995). With respect to the remainder of the evidence received since the last final decision, because this evidence does not link current disability with injury or disease incurred during the veteran's active service, it cannot be considered material evidence sufficient to reopen his claim. Cornele v. Brown, 6 Vet. App. 59 (1993). This evidence by itself or in connection with evidence previously assembled is not so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (1999). 2. Service Connection for Sarcoidosis. The law requires that a claimant shall have the burden of submitting a claim that is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). The VA benefits system requires more than just an allegation of entitlement. A claimant must submit supporting evidence sufficient to justify a belief by a fair and impartial individual that the claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). Although the claim need not be conclusive, the statute requires the claim to be accompanied by some evidence. Id. The three elements of a "well grounded" claim for service connection are: (1) evidence of a current disability as provided by a medical diagnosis; (2) evidence of incurrence or aggravation of a disease or injury in service as provided by either lay or medical evidence, as the situation dictates; and, (3) a nexus, or link, between the in-service disease or injury and the current disability as provided by competent medical evidence. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd 78 F.3d 604 (Fed. Cir. 1996); see also Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). Without evidence showing that a disease or disability is present, no plausible claim for service connection can be presented, and the claim is not well grounded. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). Although the veteran contends that he has sarcoidosis related to his active service and has provided testimony consistent with these contentions, where the determinative issues involve questions of medical causation or medical diagnosis, competent medical evidence to the effect that the claim is plausible or possible is required. See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). Laypersons are not competent to offer medical opinions. Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). Consequently, lay assertions of medical causation or medical diagnosis cannot constitute evidence to render a claim well grounded under 38 U.S.C.A. § 5107(a). Lathan v. Brown, 7 Vet. App. 359, 365 (1995); Grottveit v. Brown, 5 Vet. App. 91, 95 (1993); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). Hence, the Board finds that the veteran's unsubstantiated allegations alone are an insufficient basis on which to establish a well-grounded claim for service connection for sarcoidosis. The first element of a well-grounded claim -- evidence of current disability as provided by a medical diagnosis -- is satisfied, as post service clinical records confirm that diagnosis. In particular, it has been noted that the diagnosis was establish by biopsy conducted in 1979. The veteran's claim must fail, however, as the record does not contain competent medical evidence of a nexus between the current diagnosis of sarcoidosis and any injury or disease during his active service. None of the medical records or reports contains such an opinion. A veteran may also establish a well-grounded claim for service connection under 38 C.F.R. § 3.303(b) (1999), which is applicable where evidence, regardless of its date, shows that a veteran had chronic condition in service or during an applicable presumptive period, and that the same condition currently exists. Such evidence must be medical unless the condition at issue is a type for which, under case law, lay observation is considered competent to demonstrate its existence. A claim also may be well grounded pursuant to the same regulation if the evidence shows that the condition was observed during service or any applicable presumption period and that continuity of symptomatology was demonstrated thereafter, and includes competent evidence relating the current condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-98 (1997). In the present case, the veteran has stated that he has experienced shortness of breath, which he associates with sarcoidosis, since the 1970s. The veteran's statements to this effect are probative to the extent that they suggest a continuity of symptomatology from his military service. 38 C.F.R. 3.303(b). However, in this case, lay evidence of continuity of symptoms is not sufficient, but a medical nexus is needed. See Savage v. Gober, 10 Vet. App. 488; Falzone v. Brown, 8 Vet. App. 398 (1995). Shortness of breath may be present for a number of reasons. Consequently, competent medical evidence is needed to show that the veteran's complaints of shortness of breath, as continuity of symptomatology, are linked to the veteran's current diagnosis of sarcoidosis. In view of the foregoing, the claim for service connection for sarcoidosis is not well grounded. Accordingly, no duty to assist is triggered by the provisions of 38 U.S.C.A. § 5107. Nonetheless, under 38 U.S.C.A. § 5103(a), VA has a duty to inform the claimant of the evidence necessary to complete his application. See Robinette v. Brown, 8 Vet. App. 69 (1995). This obligation was successfully completed by the RO in its statement of the case. Likewise, the Board's discussion above informs the veteran of the requirements for the completion of his application for the claim for service connection. In reaching this determination the Board recognize that this issue is being disposed of in a manner that differs from that used by the RO. The Board has therefore considered whether the veteran has been given adequate notice to respond, and if not, whether he has been prejudiced thereby. Bernard v. Brown, 4 Vet. App 384, 394 (1993). The Board concludes that he has not been prejudiced by the decision to deny his appeal on the basis that it is not well grounded. See Edenfield v. Brown, 8 Vet. App. 384 (1995). 3. An Increased Rating for PTSD. The Board notes that the veteran has presented a well- grounded claim with respect to an increased rating for the service-connected PTSD. That is, he has presented a claim that is plausible. Cf. Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992) (where veteran asserted that his condition had worsened since the last time his claim for an increased disability evaluation for a service-connected disorder had been considered by VA, he established a well grounded claim for an increased rating). The Board is also satisfied that all appropriate development has been accomplished and that VA has no further duty to assist the veteran. All relevant facts have been properly developed. The recent examinations provide sufficient information to rate the disability in accordance with the applicable rating code. No further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Service-connected disabilities are rated in accordance with a schedule of ratings which are based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. Evaluations are based upon a lack of usefulness in self-support. 38 C.F.R. § 4.10. 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 for the higher rating. 38 C.F.R. § 4.7. In considering the severity of a disability it is essential to trace the medical history of the disability. 38 C.F.R. §§ 4.1, 4.2. In this case, service connection was established for PTSD in a March 1989 rating decision. A temporary total rating under 38 C.F.R. § 4.29 was assigned from September 1988, followed by a schedular rating of 30 percent. Since then, several other temporary total evaluations for hospitalizations have also been assigned. A February 1993 rating decision increased the disability rating for PTSD from 30 percent to 50 percent, which is the veteran's current rating. A rating decision in January 1998 made the 50 percent rating effective from March 28, 1990. In rating the disability, past medical records do not take precedence over current findings in determining whether to increase a disability rating, although a rating specialist is directed to review the recorded history of disability to make a determination a more accurate evaluation. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The criteria in the VA Schedule for Rating Disabilities for evaluating mental disorders were changed during the veteran's appeal. See 38 C.F.R. §§ 4.125-4.132, as revised effective November 7, 1996; 61 Fed. Reg. 52695-52702 (Oct. 8, 1996). Where regulations change during the course of an appeal, the Board must determine, if possible, which set of regulations, the old or the new, is more favorable to the claimant and apply the one more favorable to the case. Karnas v Derwinski, 1 Vet. App. at 312-13. Under the General Rating Formula for Psychoneurotic Disorders, in effect until November 1996, a 100 percent evaluation is assigned when there are totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior; or when the attitudes of all contacts except the most intimate so adversely affected as to result in virtual isolation in the community; or when the veteran is demonstrably unable to obtain or retain employment. See Johnson v. Brown, 7 Vet. App. 95, 97-99 (1994). A 70 percent evaluation is assigned when the veteran's ability to establish and maintain effective or favorable relationships with people is severely impaired and the psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. A 50 percent evaluation is assigned when there is considerable impairment in the ability to establish or maintain effective or favorable relationships with people, and when, by reason of psychoneurotic symptoms, the reliability, efficiency, and flexibility levels are so reduced as to result in considerable industrial impairment. 38 C.F.R. § 4.132, Code 9411 (1996). As revised effective in November 1996, the General Rating Formula for Mental Disorders provides a 100 percent rating for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. A 70 percent rating is assigned for 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 worklike setting); inability to establish and maintain effective relationships. A 50 percent rating is assigned for 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. 38 C.F.R. § 4.130, Code 9411. As noted above, for entitlement to a 100 percent rating under the old criteria, the veteran is required to show only one of three elements -- either virtual isolation in the community, totally incapacitating psychoneurotic symptomatology bordering on gross repudiation of reality, or demonstrable inability to obtain or retain employment due to his service- connected neuropsychiatric disability. Johnson v. Brown, 7 Vet. App. 95, 97-99 (1994). After evaluating the evidence in this case, the Board concludes that the old rating criteria are more favorable to the claimant; hence, these criteria will be applied pursuant to Karnas v Derwinski, 1 Vet. App. at 312-13. The testimony provided at the June 1996 hearing is to the effect that the veteran had two jobs after his discharge from active service. These included off shore work with a drilling company and work with a construction company. Employment ceased in 1978. The veteran reported in addition that he believed himself to be unable to work by reason of his PTSD alone. The preponderance of the clinical evidence on file supports a finding that the veteran's PTSD renders him unable to obtain or retain employment. For instance, the report of the VA examination in May 1997 shows, in pertinent part, that the veteran had PTSD with occupational problems and a Global Assessment of Functioning (GAF) score of 50, indicative of an inability to keep a job, at the time of the examination and over the previous year. Moreover, evidence received on behalf of the veteran's claim from medical experts is consistent with a finding of unemployability. A June 1993 deposition taken from C. Triche, one of the veteran's counselors, indicates that the veteran had been evaluated since 1990 for PTSD. The social worker's opinion - based on the clinical record, discussions with the veteran, and observations of his ability to relate to other people - was that the veteran would not be able to engage in gainful employment on a regular basis due, primarily, to his PTSD. In addition, there was no expectation that the veteran would be able to resume any type of employment in the near future. This opinion was again expressed in a second deposition of C. Triche, M.S.W, in June 1996. It was noted that, although the veteran might have periods when he might seem to experience some improvement in his condition, he would not be able to be gainfully employed. In view of the foregoing, the preponderance of the evidence favors the assignment of a 100 percent rating for PTSD under the old criteria, as the veteran's PTSD is shown to render him unable to obtain or retain employment. 4. Postoperative residuals of a disc removal at L3-4. The Board notes that the veteran has presented a well- grounded claim with respect to an increased rating for the service-connected back disability. That is, he has presented a claim that is plausible. Cf. Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992) (where veteran asserted that his condition had worsened since the last time his claim for an increased disability evaluation for a service-connected disorder had been considered by VA, he established a well grounded claim for an increased rating). The Board is also satisfied that all appropriate development has been accomplished and that VA has no further duty to assist the veteran. All relevant facts have been properly developed. The recent examinations provide sufficient information to rate the disability in accordance with the applicable rating code. No further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Service connection was granted for postoperative residuals of disc removal at L3-4 in a February 1978 Board decision. A May 1978 rating decision assigned the following schedular ratings: 0 percent from October 1975, 40 percent from November 1976, and 20 percent from April 1978. A temporary 100 percent rating was also assigned from June 27, 1976, under 38 C.F.R. § 4.30. An October 1980 rating decision assigned another temporary total rating under 38 C.F.R. § 4.30 from June 1, 1980, followed by resumption of the 20 percent rating on October 1, 1980. By a rating decision dated in September 1981, the schedular rating was increased to a 40 percent rating, effective from October 1, 1980. This increase was based on the May 1981 private medical statement that shows that the veteran demonstrated marked limitation of motion in the lumbar spine, a depressed ankle jerk and lumbar disc disease with nerve root irritation. In addition, the July 1981 VA examination report showed that paravertebral muscles were tight but not in spasm; straight leg raising tests were positive at 60 to 65 degrees, and the veteran demonstrated weakness in the right leg muscles. The evaluation of 40 percent was afforded under the provisions of 38 C.F.R. § 4.71a, Code 5293 that pertains to intervertebral disc syndrome. This is the veteran's current rating. A 40 percent rating is applicable for intervertebral disc syndrome manifested by severe, recurring attacks with intermittent relief. The next higher evaluation of 60 percent requires pronounced intervertebral disc syndrome with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk or other neurological findings appropriate to site of diseased disc, and little intermittent relief. 38 C.F.R. § 4.71a, Code 5293. Diagnostic Code (DC) 5293, intervertebral disc syndrome, involves loss of range of motion because the nerve defects and resulting pain associated with injury to the sciatic nerve may cause limitation of motion of the cervical, thoracic, or lumbar vertebrae. VAOPGCPREC 36-97 (December 12, 1997). A separate evaluation for compensable limitation of motion is therefore not appropriate in this case as the manifestations are not separate and distinct conditions but duplicative or overlapping. As such the assignment of a separate 10 percent rating is contrary to the rules prohibiting pyramiding, embodied in 38 C.F.R. § 4.14. See Esteban v. Derwinski, 6 Vet .App. 259, 262 (1994). The veteran underwent VA examination in September 1995. At that time, the veteran was noted to have a history of a low back injury sustained when he fell out of a truck while in Vietnam. He was hospitalized for several months and subsequently hospitalized repeatedly in 1974 and 1975, prior to his discharge from active service. As reported, the veteran underwent surgery to remove an extruded disc at the level of L3-4 and had two subsequent back surgeries in 1980. On physical examination, the veteran was noted to have tight paravertebral muscles but no muscle spasm. The range of motion was described as 60 degrees of flexion, 15 degrees of backward extension, 30 degrees of rotation, bilaterally, and 25 degrees of lateral flexion, bilaterally. Neurological examination was within normal limits. Likewise, a previous examination, conducted in July 1995, noted that there was no evidence of radiculopathy. Muscle strength in the lower extremities was 5+/5+, and the sensory examination was grossly intact. When examined by VA in May 1997, the veteran reported that he experienced constant pain in the back with exacerbations. The range of motion included 65 degrees of forward flexion, 20 degrees of backward extension, 30 degrees of bilateral lateral flexion and 25 degrees of bilateral rotation. He made references to radiation of pain into the lower extremities as well. However, the examiner noted that no clearly defined radicular pattern was identified. The examination was consistent with status post lumbar diskectomy with chronic low back pain syndrome and intermittent lower extremity pain with neurological findings not sufficient to diagnose radicular syndrome. In the absence of evidence of muscle spasm, absent ankle jerk, radiculopathy or any other neurological finding appropriate to the diseased disc, the preponderance of the evidence is against a higher schedular rating for service- connected residuals of disc removal. It is significant to note that pain is a important feature of the veteran's low back disability picture. At the September 1995 examination, the veteran complained of pain throughout the examination, and, in the examiner's opinion, there was objective evidence of pain. Likewise, the veteran complained of pain at the limits of motion in the lumbar spine. Pain is one of the rating criteria for Diagnostic Code 5293. However, the veteran has not demonstrated the functional loss due to pain that would be equivalent to an evaluation in excess of the current schedular 40 percent rating. 38 C.F.R. §§ 4.40, 4.45, 4.59; De Luca v. Brown, 8 Vet. App. 202 (1995). Factors listed in 38 C.F.R. § 4.45 include less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination, impaired ability to execute skilled movements smoothly; and pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight- bearing are related considerations. Neither the medical records and reports nor the veteran's statements show the presence of such factors as weakened or abnormal movement, excess fatigability, incoordination, pain on movement, swelling, deformity, atrophy of disuse, instability of station, disturbance of locomotion, or interference with sitting, standing, or weight-bearing to a degree that would warrant the assignment of a higher rating. The preponderance of the evidence is against an evaluation in excess of 40 percent for postoperative residuals of disc removal at the level of L3-4 on the basis of functional loss. In Floyd v. Brown, 9 Vet. App. 88 (1996), the Court held that the Board does not have jurisdiction to assign an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (1996) in the first instance. The Board is still obligated to seek out all issues that are reasonably raised from a liberal reading of documents or testimony of record and to identify all potential theories of entitlement to a benefit under the laws and regulations. In Bagwell v. Brown, 9 Vet. App. 337 (1996), the Court clarified that it did not read the regulation as precluding the Board from affirming an RO conclusion that a claim does not meet the criteria for submission pursuant to 38 C.F.R. § 3.321(b)(1) or from reaching such a conclusion on its own. Moreover, the Court did not find the Board's denial of an extraschedular rating in the first instance prejudicial to the veteran, as the question of an extraschedular rating is a component of the appellant's claim and the appellant had full opportunity to present the increased-rating claim before the RO. Bagwell v. Brown, 9 Vet. App. 337 (1996). Consequently, the Board will consider whether this case warrants the assignment of an extraschedular rating. In exceptional cases where schedular evaluations are found to be inadequate, consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities" is made. 38 C.F.R. § 3.321(b)(1). The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. Id. The Board finds that the schedular evaluations in this case are not inadequate. Higher evaluations are available for greater disability, as discussed above, but the required manifestations are not present in this case. Moreover, there is no evidence of an exceptional disability picture in this case. The veteran has not required any recent hospitalizations for his back disability. He also has not demonstrated that the back disability produces marked interference with employment. The evaluation of 40 percent of itself reflects a degree of vocational impairment. 38 C.F.R. § 4.10. In view of the foregoing, there is no basis for consideration of an extraschedular rating. ORDER New and material evidence has not been received to reopen the claim for service connection for a right shoulder disability. The appeal is denied. The veteran's claim for service connection for sarcoidosis is not well grounded. In this regard, the appeal is denied. An 100 percent rating for PTSD is allowed subject to regulations applicable to the payment of monetary awards. An increased rating for a back disability is denied. MARY GALLAGHER MICHAEL D. LYON Member, Board of Veterans' Appeals Member, Board of Veterans' Appeals CONSTANCE B. TOBIAS Member, Board of Veterans' Appeals