Citation Nr: 0006303 Decision Date: 03/09/00 Archive Date: 03/17/00 DOCKET NO. 96-49 211 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a bilateral shoulder disorder. 2. Entitlement to a disability rating greater than 30 percent for tension headaches. 3. Entitlement to a disability rating greater than 30 percent for cervical spine strain. 4. Entitlement to a disability rating greater than 20 percent for lumbosacral strain. REPRESENTATION Appellant represented by: Oklahoma Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Michelle L. Nelsen, Associate Counsel INTRODUCTION The veteran had active duty from March 1988 to August 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decisions dated in December 1995, May 1996, and June 1997 by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The case returns to the Board following a remand to the RO in March 1998. In a June 1999 communication, the veteran withdrew her claim for service connection for a disorder of the ulnar nerve. During the October 1997 hearing, the veteran and her representative agreed that she had not timely filed a substantive appeal for the issue of service connection for carpal tunnel syndrome. In a June 1998 statement, the veteran expressed a desire for reconsideration of that claim. The matter is referred to the RO for the appropriate action. FINDINGS OF FACT 1. There is no competent medical evidence of a nexus between the veteran's alleged bilateral shoulder disorder and her period of active duty service or a service-connected disability. 2. The veteran's tension headaches occurred two to five times a week and were generally relieved by medication, sleep, or a combination thereof. When the headaches were not relieved, she dealt with the headache, though she was limited in her ability to function. 3. The veteran's cervical spine strain is manifested by subjective complaints of constant pain, particularly with any motion, as well as arm pain, and muscle tightness. Objectively, there is substantial limitation of motion and evidence of muscle spasm and tenderness. X-rays and magnetic resonance imaging have generally shown no abnormalities. 4. The veteran's lumbosacral strain is manifested by constant pain aggravated by prolonged sitting, standing, or walking, pain with any motion of the lumbar spine, and muscle tenderness. Objectively, there is substantial limitation of motion. The evidence is generally negative for muscle spasm or muscle changes. Neurological examination is generally normal. X-rays and magnetic resonance imaging have generally shown no abnormalities. CONCLUSIONS OF LAW 1. The veteran's claim of entitlement to service connection for a bilateral shoulder disorder is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.102 (1999). 2. The criteria for a disability rating greater than 30 percent for tension headaches have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.1-4.7, 4.21, 4.124a, Diagnostic Code 8100 (1999). 3. The criteria for a disability rating greater than 30 percent for cervical spine strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.1-4.7, 4.20, 4.21, 4.40, 4.45, 4.71a, Diagnostic Code 5290 (1999). 4. The criteria for a disability rating greater than 20 percent for lumbosacral strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.1-4.7, 4.20, 4.21, 4.40, 4.45, 4.71a, Diagnostic Code 5295 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection for a Bilateral Shoulder Disorder Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303(a) (1999). Direct service connection requires a finding that there is a current disability that has a definite relationship with an injury or disease or some other manifestation of the disability during service. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992). A disorder may be service connected if the evidence of record, regardless of its date, shows that the veteran had a chronic disorder in service or during an applicable presumptive period, and that the veteran still has such a disorder. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-95 (1997). Such evidence must be medical unless it relates to a disorder that may be competently demonstrated by lay observation. Savage, 10 Vet. App. at 495. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). If the disorder is not chronic, it may still be service connected if the disorder is observed in service or an applicable presumptive period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present disorder to that symptomatology. Id. at 496-97. Again, whether medical evidence or lay evidence is sufficient to relate the current disorder to the in-service symptomatology depends on the nature of the disorder in question. Id. Disorders diagnosed after discharge may still be service connected if all the evidence, including pertinent service records, establish that the disorder was incurred in-service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). A disability is service connected if it is proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a). In addition, secondary service connection may also be established when there is aggravation of a veteran's non-service connected condition that is proximately due to or the result of a service-connected condition. Allen v. Brown, 7 Vet. App. 439, 448 (1995); Tobin v. Derwinski, 2 Vet. App. 34, 39 (1991). In those circumstances, compensation is allowable for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. However, a person claiming VA benefits must meet the initial burden of submitting evidence "sufficient to justify a belief in a fair and impartial individual that the claim is well grounded." 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78, 91 (1990); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). A claim that is well grounded is plausible, meritorious on its own, or capable of substantiation. Murphy, 1 Vet. App. at 81; Moreau v. Brown, 9 Vet. App. 389, 393 (1996). For purposes of determining whether a claim is well grounded, the Board presumes the truthfulness of the supporting evidence. Arms v. West, 12 Vet. App. 188, 193 (1999); Robinette v. Brown, 8 Vet. App. 69, 75 (1995); King v. Brown, 5 Vet. App. 19, 21 (1993). In order for a claim to be well grounded, there must be competent evidence of a current disability (a medical diagnosis); of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and of a nexus between the in-service injury or disease and the current disability (medical evidence). Epps v. Gober, 126 F.3d 1464, 1468 (1997); Caluza, 7 Vet. App. 498, 504 (1995). Where the determinative issue involves a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status do not constitute competent medical evidence. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Secondary service connection claims must also be well grounded. 38 U.S.C.A. § 5107(a); Wallin v. West, 11 Vet. App. 509, 512 (1998); Locher v. Brown, 9 Vet. App. 535, 538 (1996); Jones v. Brown, 7 Vet. App. 134, 136-38 (1994). A secondary service connection claim is well grounded only if there is medical evidence to connect the asserted secondary disorder to the service-connected disability. Velez v. West, 11 Vet. App. 148, 158 (1998). VA cannot undertake to assist a veteran in developing facts pertinent to his claim until and unless the veteran submits a well grounded claim. Morton v. West, 12 Vet. App. 477, 486 (1999). In this case, the veteran asserts that there is a basis either for direct service connection for a bilateral shoulder disorder or a secondary basis as due to the service-connected cervical spine or lumbosacral spine disorder. To the extent the veteran's assertion tends to show in-service incurrence of the alleged disorder, the Board accepts the assertion as true in determining whether the claim is well grounded. Arms, 12 Vet. App. at 193; Robinette, 8 Vet. App. at 75; King, 5 Vet. App. at 21. However, the Board finds that the claim is not well grounded initially because there is no diagnosis of a chronic bilateral shoulder disorder. A claim is not well grounded if there is no present disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). On this point, the Board makes two observations. First, although the evidence shows complaints of shoulder pain, there is no diagnosis of a chronic shoulder disorder. The Board emphasizes that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, No. 97-1948 (U.S. Vet. App. December 2, 1999). Second, the complaints of shoulder pain of record are shown to be related to the muscles, particularly the muscles affecting the cervical area. The veteran is currently service-connected for cervical spine strain. See 38 C.F.R. § 4.14 (rating the same disability under various diagnoses is to be avoided). Absent a diagnosis of a chronic shoulder disorder, the veteran's present claim is not well grounded. Moreover, when there is no diagnosis of a present disability, there necessarily can be no medical evidence that links the disability to service or to a service-connected disability. Such evidence is also required to establish a well grounded claim. Epps, 126 F.3d at 1468; Velez, 11 Vet. App. at 158. The veteran has not submitted any evidence to show that she is a trained medical professional. Therefore, although she is competent to relate and describe symptoms, she is not competent to offer an opinion on matters that require medical knowledge, such as a diagnosis or a determination of etiology. Grottveit, 5 Vet. App. at 93; Espiritu, 2 Vet. App. at 494. Under these circumstances, the Board finds that the veteran has not submitted a well grounded claim for service connection for a bilateral shoulder disorder. 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.102; Epps, 126 F.3d at 1468. Therefore, the duty to assist is not triggered and VA has no obligation to further develop the veteran's claim. Epps, 126 F.3d at 1469; Morton, 12 Vet. App. at 486; Grivois v. Brown, 5 Vet. App. 136, 140 (1994). If the veteran wishes to complete her application for service connection for a bilateral shoulder disorder, she should submit competent medical evidence that shows that she suffers from a currently diagnosed bilateral shoulder disorder that is either related to service or to a service-connected disability. 38 U.S.C.A. § 5103(a); Robinette, 8 Vet. App. at 77-80. Claims for Increased Disability Ratings When a claimant is awarded service connection for a disability and subsequently appeals the RO's initial assignment of a rating for that disability, the claim continues to be well grounded as long as the rating schedule provides for a higher rating and the claim remains open. Shipwash v. Brown, 8 Vet. App. 218, 224 (1995). Accordingly, the Board finds that both of these claims are well grounded. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.102 (1999). In addition, the Board is also satisfied that all relevant facts have been properly and sufficiently developed to address the issue at hand. On this point, the Board notes that, in its March 1998 remand, it ordered that the RO should secure the veteran's Vocational Rehabilitation folder and associate it with the claims folder. This instruction was not accomplished. The United States Court of Appeals for Veterans Claims (hereinafter "the Court") has held that a remand by the Court or the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). Failure of the Board to insure compliance with remand instructions constitutes error and warrants the vacating of a subsequent Board decision. Id. However, where a veteran has not been harmed by an error in a Board determination, the error is not prejudicial. Id. (citing 38 U.S.C.A. § 7261(b)) ("Court shall take due account of the rule of prejudicial error"). The Board finds that the RO's failure to secure the Vocational Rehabilitation folder is not prejudicial error. The requested information has evidence as to the veteran's employability. The Board emphasizes that the RO determined by rating decision dated July 1999 that the veteran was entitled to a total disability rating by reason of individual unemployability effective from the date of receipt of the August 1994. Therefore, it is affirmatively shown that the veteran is not currently employable. There is no need for the Board to review the Vocational Rehabilitation folder. Factual Background The veteran's service records showed that she was discharged from active duty service on August 3, 1994. In correspondence dated in November 1994, James W. Toy, D.C., indicated that the veteran presented two days after a fall on August 1, 1994. Since the injury, she complained of low back pain, neck problems, pain between the shoulders, arm problems, leg pain, sore and weak muscles, numbness, loss of feeling, dizziness, and headaches. Examination revealed diminished cervical motion with pain on all maneuvers. There was foramina compression bilaterally as well as in the neutral position. The diagnosis was wry neck, cervical kyphosis, and contusion of the neck. Dr. Toy related that the veteran responded well to care, which was terminated when she was asymptomatic. The veteran was afforded a VA orthopedic examination in December 1994. Her subjective complaints about the neck included recurrent feeling of tenseness and tightness. She had recurrent headaches affecting the frontal and posterior areas of the head and neck. They occurred two to three times a week and lasted three to four hours. The headaches were usually relieved by resting. Motrin and Tylenol had not provided relief. Examination revealed normal gait and posture. Spinal curvature was normal. There was pain in the paravertebral muscles in the mid to low cervical area and some tenderness to punch over the low cervical spine and the paravertebral muscles. No spasm was palpable. Motion testing of the cervical spine revealed forward flexion to 50 degrees, backward extension to 40 degrees, and full lateral flexion and rotation. Neurological examination was normal. The diagnosis was history of neck injury, intermittently symptomatic, rule out X-ray changes, and history of tension- type headaches. X-rays of the cervical spine were negative for abnormalities. In December 1994, the veteran was also afforded a VA ears, nose, and throat examination. She reported a history of, and was diagnosed as having, migraine headaches. VA outpatient records dated in March and September 1995 showed continued neck complaints of pain and limitation of motion. The veteran underwent another VA orthopedic examination in September 1995. She continued to have neck pain and tightness, as well as a pulling sensation in the neck and upper back with forward and backward neck motion. The pain occurred daily and was sometimes sharp. She also had pain with any type of lifting, but it did not radiate into the upper extremities in a sharp, shooting fashion. There was no numbness, tingling, or weakness in the upper extremities on a chronic basis. Examination revealed some straightening of the normal cervical lordosis with diffuse spasm of the paraspinous muscles and the trapezius muscle on the left. Motion testing of the cervical spine showed forward flexion to 20 degrees, backward extension to 20 degrees, lateral flexion to 20 degrees bilaterally, right rotation to 30 degrees, and left rotation to 35 degrees. Neurological examination was normal. The diagnosis was chronic cervical strain with limitation of motion and pain, mild to moderate in severity. The examiner commented that there was no evidence of cervical radiculopathy or myelopathy on examination. The veteran presented for an additional VA orthopedic examination in November 1995. Her complaints were unchanged with respect to the cervical spine. She added that she occasionally dropped objects when the neck pain was particularly severe or when she was trying to grip something strongly. She felt numbness in the fingertips, but otherwise denied numbness, tingling, or weakness in the upper extremities. She suffered low back stiffness and pain without into the legs. There was no numbness, tingling, or weakness in the legs. On examination, gait was normal. Neurological examination was normal throughout. Cervical examination was unchanged. Examination of the low back revealed normal posture and lumbar lordosis. There was no paraspinous muscle spasm detected. Straight leg raising was negative bilaterally. There was full range of motion of the lumbosacral spine. X-rays of the lumbosacral spine were unremarkable. The diagnosis was mild chronic lumbosacral strain without radiculopathy and chronic cervical strain with limitation of motion and pain, as well as symptomatology in the upper back and shoulders. The examiner commented that neurological examination was normal without evidence of a nerve problem VA outpatient records dated from March to May 1996 showed continued complaints of neck and back pain and limitation of motion. March 1996 progress notes indicated that previous X- rays of the cervical spine were within normal limits. The May 1996 report of electromyography (EMG) indicated that study findings were compatible with a median neuropathy at the right wrist (carpal tunnel syndrome). The results did not meet the criteria for cervical polyradiculopathy. The veteran submitted a report dated in January 1997 from Neal D. Perry, D.C. Her subjective complaints included headaches and symptoms in the neck, shoulder, arms, hands, mid and low back. On examination, she was ambulatory but appeared to have slight difficulty with gait but ambulatory. A general neurological examination was normal. Sternomastoid and upper trapezius strength was normal bilaterally. Examination of the cervical spine showed tenderness and spasm throughout the cervical area bilaterally. Forward flexion was to 10 degrees, backward extension was to 5 degrees, lateral flexion was to 5 degrees bilaterally, and rotation was to 10 degrees bilaterally. All maneuvers were associated with pain, spasm, and sedentary inflexibility. There was increased sensation to pinwheel and light tough in the dermatomes corresponding to the nerve root levels at C1-8 bilaterally. Deep tendon reflexes were 2+ throughout the upper extremities bilaterally. All muscles tested were graded at 4. Examination of the lumbar spine revealed tenderness and spasm in the lower lumbar and sacral areas bilaterally. On motion testing, there was forward flexion to 20 degrees, backward extension to 10 degrees, lateral flexion to 10 degrees bilaterally, right rotation to 15 degrees, and left rotation to 20 degrees, all associated with pain, spasm, and sedentary inflexibility. There was increased sensation to pain and light tough in the dermatomes corresponding to the nerve root levels of L1-5 on the left and S1-2 on the left. Deep tendon reflexes were 2+ bilaterally. Lasegue's sign was positive, bilateral leg raise was positive bilaterally, and Goldthwaite's sign was positive on the left. All dorsolumbar muscles tested were rated at 4. X-rays of the cervical spine showed subluxation of C5-6 and C6-7 along with foraminal encroachment at C7-T1 facetal areas and ankylosis with arthritic infiltration in the lower cervical spine. X-rays of the lumbosacral spine showed subluxation of L3-4 and L4-5 with increased joint spaces between L4-5 and L5-S1 along with subluxation of the left sacroiliac joint accompanied by posterior eccentric rotation of the left ilium. Facetal areas of the lumbar spine revealed arthritis infiltration with ankylosis. The diagnosis was multiple vertebral motor unit derangement, diffuse cervicobrachial syndrome, lumbosacral instability, diffuse chronic myofascial pain syndrome, and arthritic infiltration accompanied by ankylosis in the lower cervical and lumbar spinal areas. The veteran was afforded a VA orthopedic examination in March 1997. She complained of chronic neck and low back pain. At times, the neck pain seemed to cause sharp pains throughout the entire right upper extremity with intermittent sharp pains and paresthesias in the right hand. She could sit, stand, or walk for about one hour. She avoided bending and lifting. Various therapies had not provided relief. Medications included Robaxin, Motrin, and Tylenol. Headaches now occurred about four times a week and were now common in the top front of the head and in the temporal area as well as in the posterior head and neck and were associated with photophobia. Although occasionally the headaches were partially relieved by Motrin, they were generally relieved by sleep. Examination revealed normal gait, posture, and spine curvature. The veteran related having tenderness even to light touch in the cervical and lumbar spine and paravertebral muscles, although no spasm was palpable. Cervical motion testing showed forward flexion to 15 degrees, backward extension to the neutral position only, and lateral flexion and rotation to 20 degrees. The veteran related having pain with any motion of the cervical spine. Lumbar motion testing showed forward flexion to 40 degrees, backward extension to 10 degrees, and lateral flexion and rotation to 20 degrees. Again, the veteran related having pain with any motion of the lumbar spine. Neurological examination was normal. The diagnosis was symptomatic neck with limitation of motion, rule out X-ray changes, symptomatic low back with limitation of motion, rule out X-ray changes, and history of tension-type headaches. The examiner commented that previous X-rays of the cervical and lumbar spines had been normal and that, clinically, the veteran had no objective changes in the spine, such that her symptoms were out of proportion to findings of examination. X-rays taken for the examination revealed normal lumbosacral spine and cervical spine. The veteran testified before a member of the Board in October 1997. She related that she had headaches four to fives times a week. She either took medication or went to a dark room to sleep, or tried both at the same time. Sometimes the headaches resolved. The headaches lasted from four hours to all day. She dealt with the headaches when medication and sleep did not work, though they limited her ability to do anything. With respect to her low back disability, the veteran indicated that VA issued her a back brace. She continued to have pain with any low back motion and very limited forward motion. Concerning the cervical spine disability, the veteran continued to have very limited motion. She had to turn her whole body to look at things rather only turn the neck. She explained that both the lumbar and cervical disorders prevented her from working. The veteran had applied for Social Security benefits but had been denied. She appealed that decision. On additional questioning, she indicated that her medications included Tylenol, Motrin, and methocarbamol. In June 1998, pursuant to the Board's March 1998 remand, the RO initiated additional development of the veteran's claim. June 1998 correspondence from the National Personnel Records Center indicated that it had no additional service medical records for the veteran. In August 1998, the veteran related that she had no additional medical evidence that should be secured for her claim. In October 1998, the Social Security Administration indicated that the veteran's disability claim had been denied. An October 1998 report of contact with the veteran reflected the veteran's statement that the evidence used for her Social Security disability claim was identical to evidence used in her VA claim. There had been no special Social Security examination. The RO received a statement from D.R. Bartel, M.D., of North Texas Neurology Associates, dated in June 1998. Dr. Bartel related that magnetic resonance imaging (MRI) showed no abnormalities of the cervical or lumbar regions. Pursuant to the Board's remand, the veteran was afforded another VA orthopedic examination in June 1999. The examiner specifically indicated that he reviewed the claims folder for the examination. At this time, the veteran related that she had chronic neck pain, particularly in the low neck area, which could radiate across the posterior shoulder area and intermittently down the right arm to the hand and occasionally to the left arm. The pain was constant but increased with weather changes. There was associated limitation of neck motion. The veteran also had chronic low back pain that increased with weather changes. She explained that she had low back pain after walking one block, neck and low back pain after sitting one hour, and low back pain and "stress" in the neck with standing for 20 to 30 minutes. Lifting 5 to 10 pounds or engaging in any overhead activity caused pain in the arms and shoulders and a pulling sensation in the neck. She related no specific complaints of low back pain with lifting. The veteran had a neck brace and special pillow for neck pain, as well as a low back brace. Various therapies and medications provided only temporary relief. Examination revealed normal gait and posture. There was pain to punch of the cervical and lumbosacral spine. There was pain to any palpation of the cervical and lumbar paravertebral muscles, the trapezius muscle in particular, as well as some pain in the deltoid. However, no spasm or other abnormality was palpable. There were no unilateral muscle mass changes and no loss of strength in the upper extremities. Testing the cervical spine revealed forward flexion to 15 degrees, backward extension to neutral position only, and lateral flexion and rotation to 20 degrees. The veteran expressed a great deal of pain with any attempt to move the neck. Testing the lumbar spine revealed forward flexion to 45 degrees, backward extension to 20 degrees, and lateral flexion and rotation to 25 degrees with some pain in the low back with any motion. Low back movement also caused pain in the cervical spine and arms. The diagnosis was symptomatic cervical spine compatible with muscular symptoms with limitation of motion and symptomatic lumbar spine compatible with muscle symptoms with limitation of motion. The examiner commented that, although there were symptoms of moderate to moderately severe functional loss secondary to pain in the neck and low back areas, there were no objective changes to explain the severity of the veteran's symptoms or the limitation of motion present in the cervical and lumbar spine secondary to pain, with examination showing no objective muscular changes and X-rays normal. Analysis Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If a veteran has an unlisted disability, it will be rated under a disease or injury closely related by functions affected, symptomatology, and anatomical location. 38 C.F.R. § 4.20; see 38 C.F.R. § 4.27 (providing specific means of listing diagnostic code for unlisted disease or injury). If two evaluations are potentially applicable, 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. 38 C.F.R. § 4.7. The Board observes that, in a claim of disagreement with the initial rating assigned following a grant of service connection, as is the situation here, separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). See AB v. Brown, 6 Vet. App. 35, 38 (1993) (on a claim for an original or an increased rating, it is presumed that the veteran seeks the maximum benefit allowed by law and regulation, and it follows that such a claim remains in controversy when less than the maximum available benefit is awarded). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). 1. Tension Headaches The veteran's tension headaches are currently evaluated as 30 percent disabling by analogy to Diagnostic Code (Code) 8100, migraine. 38 C.F.R. § 4.124a. A 30 percent rating is assigned when there are characteristic prostrating attacks occurring on an average once a month over the last several months. A maximum schedular rating of 50 percent is in order when there are very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability. In this case, although the evidence shows that the headaches occur with some frequency, ranging from two to five times a week, the evidence of record does not demonstrate that the headaches are prolonged and completely prostrating productive of severe economic impairment. In fact, the veteran concedes that she at times receives partial relief from Motrin. When the headaches were not completely relieved, she was limited in her ability to function, though she was able to deal with the headaches. Accordingly, the Board cannot conclude that the overall disability picture more nearly approximates the criteria for a 50 percent rating for tension headaches. 38 C.F.R. § 4.7. Finally, the Board finds no reason for referral to the Compensation and Pension Service for consideration of an extra-schedular evaluation under 38 C.F.R. § 3.321(b)(1). That is, there is no evidence of exceptional or unusual circumstances to suggest that the veteran is not adequately compensated by the regular rating schedule. Sanchez-Benitez, supra; VAOPGCPREC 36-97. Therefore, the Board finds that the preponderance of the evidence is against a 50 percent disability rating for tension headaches. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.3, 4.7, 4.124a, Code 8100. 2. Cervical Spine Strain The veteran's cervical spine strain is evaluated as 30 percent disabling under Code 5290, limitation of motion of the cervical spine. 38 C.F.R. § 4.71a. A 30 percent rating is the maximum schedular evaluation available under Code 5290. There are other diagnostic codes for spinal disorders that provide an evaluation greater than 30 percent. For example, under Code 5287, unfavorable ankylosis of the cervical spine is rated as 40 percent disabling. Code 5293 provides for a 40 percent rating for intervertebral disc syndrome when the disability was severe, characterized by recurrent attacks with intermittent relief. However, the Board finds that the evidence fails to support the application of either diagnostic code. The evidence does not show unfavorable ankylosis of the cervical spine or cervical disc disease. Therefore, the veteran's cervical spine strain is most appropriately rated under Code 5290. See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of diagnostic code should be upheld so long as it is supported by explanation and evidence). In addition, the Board notes that the veteran previously submitted a service connection claim for ulnar nerve damage with resulting neck and shoulder pain. However, she withdrew that claim in June 1999. As indicated above, Code 5290 provides evaluations for limitation of motion of the cervical spine. When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. However, when a disability is assigned the maximum rating for loss of range of motion, application of 38 C.F.R. §§ 4.40 and 4.45 and DeLuca is not required. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Therefore, as the veteran's neck disability is currently evaluated at the maximum rating for limitation of motion, the Board finds no basis for addition compensation pursuant to DeLuca. In addition, the Board again finds no evidence of exceptional or unusual circumstances to warrant an extra-schedular evaluation under 38 C.F.R. § 3.321(b)(1). Sanchez-Benitez, supra; VAOPGCPREC 36-97. Accordingly, the Board finds that the preponderance of the evidence is against entitlement to a disability rating greater than 30 percent for cervical spine strain. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.3, 4.7, 4.71a, Code 5290. 3. Lumbosacral Strain The veteran's lumbosacral strain is evaluated as 20 percent disabling under Code 5295. 38 C.F.R. § 4.71a. If there is muscle spasm on extreme forward bending and unilateral loss of lateral spine motion in the standing position, a 20 percent rating is warranted. When disability from lumbosacral strain is severe, with listing of whole spine to opposite side, positive Goldthwaite's sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion, a maximum schedular rating of 40 percent is awarded. Again, when a disability is evaluated according to limitation of motion, the Board must also consider additional functional loss due to such factors as more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. DeLuca, 8 Vet. App. at 206; 38 C.F.R. §§ 4.40, 4.45. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston, 10 Vet. App. at 85. In this case, the Board finds that the preponderance of the evidence is against a disability rating greater than 20 percent for lumbosacral strain. The veteran complains of low back pain and limitation of motion due to pain. However, none of the multiple VA examinations show pathology to support her complaints. Johnston, 10 Vet. App. at 85. That is, there is no VA evidence in any of the examinations of muscle spasm, loss of strength, muscle changes, X-rays showing arthritis, or other objective indication of physical pathology. In fact, the letter from Dr. Bartel, a private neurologist, shows that an MRI reveals no abnormalities of the cervical spine or lumbar spine. The Board acknowledges that Dr. Perry's report shows severe findings of pain and limitation of motion, as well as muscle spasm and X-ray evidence of arthritis and ankylosis. However, given the lack of objective evidence of such disability elsewhere in the claims folder, the Board finds that Dr. Perry's do not reflect the predominant disability picture in this case. 38 C.F.R. § 4.7. Finally, the Board again finds no evidence of exceptional or unusual circumstances to warrant an extra-schedular evaluation under 38 C.F.R. § 3.321(b)(1). Sanchez-Benitez, supra; VAOPGCPREC 36-97. Accordingly, the Board finds that the preponderance of the evidence is against entitlement to a disability rating greater than 20 percent for lumbosacral strain. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.3, 4.7, 4.71a, Code 5295. ORDER Entitlement to service connection for a bilateral shoulder disorder is denied. Entitlement to a disability rating greater than 30 percent for tension headaches is denied. Entitlement to a disability rating greater than 30 percent for cervical spine strain is denied. Entitlement to a disability rating greater than 20 percent for lumbosacral spine strain is denied. RENÉE M. PELLETIER Member, Board of Veterans' Appeals Error! Not a valid link.