Citation Nr: 0001828 Decision Date: 01/21/00 Archive Date: 01/28/00 DOCKET NO. 94-25 539 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for a testicular disorder. 2. Entitlement to service connection for a prostate disorder. 3. Entitlement to service connection for torn ligaments of the right wrist. 4. Entitlement to service connection for scaphoid fracture of the left wrist. 5. Entitlement to service connection for skeletal disorders of the head and neck. 6. Entitlement to service connection for post-traumatic stress disorder (PTSD). 7. Entitlement to an increased rating for cervical strain, currently evaluated as 10 percent disabling. 8. Entitlement to a total disability rating for compensation purposes based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Daniel R. McGarry INTRODUCTION The veteran had active service from February 1983 to January 1986. He also had active duty in the Mississippi Army National Guard during March to July 1991 and in September and October 1992. In a September 1996 decision, the Board denied entitlement to service connection for testicular and prostate disorders. By an Order dated in August 1997, the United States Court of Veterans Appeals (now the United States Court of Appeals for Veteran's claims, hereinafter referred to as the Court) vacated the Board's September 1996 decision and remanded the issues numbered one through five above to the Board, for the Board to conduct a hearing and to ensure the development and adjudication of claims of service connection for neck and head injuries in association with the skeletal functions, torn ligaments on right wrist, and a scarfoid (sic) fracture on left wrist, and for the RO to issue a statement of the case addressing all issues raised by the appellant. By a letter to the Board received in October 1998, the veteran withdrew his request for a hearing before a member of the Board. In a September 1999 statement, he also indicated that he did not want a hearing at the RO or before the Board. The Board remanded the case in November 1998 for the RO to address the issues raised by the Court's Order. The veteran has also since November 1998 perfected an appeal of the RO's denials of an increased rating for neck strain, service connection for PTSD, and entitlement to TDIU. The case has been returned to the Board for appellate action. The Board notes that the veteran's neuropsychiatric disorder has been recently attributed to in-service head trauma which the veteran has asserted he sustained during his active military service. The Court's Order referred only to service connection for "skeletal functions." The issue of entitlement to service connection for a neuropsychiatric disorder secondary to head trauma has not been adjudicated by the RO. Consequently, this issue is referred to the RO for appropriate action. 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) 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. Consequently, the Board will consider whether this case warrants the assignment of an extraschedular rating. FINDINGS OF FACT 1. The record contains no competent medical evidence of a nexus between the veteran's current complaints of testicular pain and swelling and any disease or injury he incurred during his active military service. 2. The record contains no medical evidence that the veteran had a prostate disorder during his active military service, nor any competent medical evidence or opinion indicating a relationship between the post-service diagnoses of prostatitis and any in-service disease or injury. 3. The record contains no competent medical evidence that the veteran has a current right wrist disability, no evidence that he incurred a disease or injury of the right wrist during his active service, and no competent medical evidence of a nexus between any current disability and any in-service disease or injury. 4. The record contains no competent medical evidence of a link between a current left wrist disability and any in- service disease or injury, nor any medical evidence that the veteran incurred any disease or injury affecting his left wrist during his active military service. 5. The record does not contain competent evidence of a nexus between any current skeletal disability of the head or neck and injury or disease during the veteran's active service. 6. The record contains a diagnosis of PTSD based upon the veteran's report of in-service, noncombat stressors. 7. The service-connected neck strain, which is the sole service-connected disability, is manifested by not more than slight limitation of motion of the cervical segment of the spine. 8. The veteran's service-connected disability from neck strain alone does not render him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for a testicular disorder is not well grounded. 38 U.S.C.A. §§ 101(16), 1110, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). 2. The claim of entitlement to service connection for a prostate disorder is not well grounded. 38 U.S.C.A. §§ 101(16), 1110, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). 3. The claim of entitlement to service connection for torn ligaments of the right wrist is not well grounded. 38 U.S.C.A. §§ 101(16), 1110, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). 4. The claim of entitlement to service connection for residuals of fracture of the scaphoid of the left wrist is not well grounded. 38 U.S.C.A. §§ 101(16), 1110, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). 5. The claim of entitlement to service connection for skeletal disorders of the head and neck is not well grounded. 38 U.S.C.A. §§ 101(16), 1110, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). 6. The claim of entitlement to service connection for PTSD is well grounded. 38 U.S.C.A. §§ 101(16), 1110, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). 7. The criteria for a rating in excess of 10 percent for neck strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.10, 4.40, 4.41, 4.45, 4.71a, Diagnostic Code 5290 (1999). 8. The criteria for a total disability evaluation based on individual unemployability due to service-connected disability are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.340, 3.341, 4.16 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 101(16), 1110 (West 1991); 38 C.F.R. § 3.303 (1999). With chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The law provides that "a person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded." 38 U.S.C.A. § 5107(a) (West 1991). A well- grounded claim is a plausible claim which is meritorious on its own or is capable of substantiation. See Murphy v. Derwinski, Vet. App. 78, 81 (1990). The three elements of a well-grounded claim 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 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 (1995); see also 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1999). Generally, competent medical evidence is required to meet each of the three elements. However, for the second element, the kind of evidence to make a claim well grounded depends upon the types of issues presented by the claim. Grottveit v. Derwinski, 5 Vet. App. 91, 92-93 (1993). For some factual issues, such as the occurrence of an injury, competent lay evidence may be sufficient. However, where the claim involves issues of medical fact, such as medical causation or medical diagnosis, competent medical evidence is required. Id. at 93. For the reasons discussed below, the Board finds that the veteran's claims of entitlement to service connection for disorders of the testicles, prostate, and left and right wrist, and skeletal disorders of the head and neck are not well grounded. Although the RO did not specifically state that it denied the veteran's claim of entitlement to service connection for disorders of the testicles and prostate on the basis that they were not well grounded, the Board concludes that this error was not prejudicial to the claimant. See Edenfield v. Brown, 8 Vet. App. 384 (1995) (deciding that the remedy for the Board's deciding on the merits a claim that is not well grounded should be affirmance, on the basis of nonprejudicial error). While the RO denied service connection on the merits, the Board concludes that denying the claims because they are not well grounded is not prejudicial to the appellant, as the appellant's arguments concerning the merits of the claims included, at least by inference, the argument that sufficient evidence to establish well-grounded claims is of record. Therefore, the Board finds that it is not necessary to remand such matters for the issuance of a supplemental statement of the case concerning whether or not the claims are well grounded. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993); VAOPGCPREC 16-92 (O.G.C. Prec. 16-92) at 7-10. Where a claim is not well grounded it is incomplete, and the Department of Veterans Affairs (VA) is obliged under 38 U.S.C.A. § 5103(a) to advise the claimant of the evidence needed to complete his application. Robinette v. Brown, 8 Vet. App. 69, 77-80 (1995). In this case, the RO informed the appellant of the necessary evidence in the claims form he completed, in its notices of rating decisions, and in the statements of the case and supplemental statement of the case. The discussion below informs the veteran of the types of evidence lacking, and which he should submit for well- grounded claims. Unlike the situation in Robinette, in this case the veteran has not advised VA of the existence of any particular evidence which, if obtained, would render his claim well grounded. A. Testicular Disorder In a July 1993 statement, the veteran asserted that he had a disorder of the testicles which was manifested by swelling testicles and blood in his urine. VA outpatient treatment records show that the veteran underwent a genitourinary examination in March 1993. His penis, epididymes, and testes were normal. During treatment in June 1993, the veteran gave a history of intermittent hematuria associated with testitulcar swelling, last occuring in January and February of 1993. On examination, his testes were descended and had no lesions. The reported diagnosis was history of hematuria. During a VA examination in August 1993, the veteran told the examiner that he developed testicular swelling and pain while in service in 1984. He indicated that he also had an episode of hematuria in service. He stated that he still had episodes of swelling in his testes lasting from 30 minutes to two hours with associated gross hematuria. He reported that he would have hematuria for one voiding and that the next time he voided his urine would be clear. He denied having associated dysuria. He reported voiding with a good stream. On examination, both testes were normal in size and consistency. Both epididymides were normal. There was no enlargement of the tail or the head of the epididymis on either side. There was slight subjective tenderness bilaterally of the head and the tail. A urinalysis was negative for blood. The examiner reported an impression of testicular discomfort with associated hematuria probably secondary to mild recurrent prostatitis. The veteran was seen again for a genitourinary consultation in early October 1993. He complained that his testicles swelled and "drew back in." He had discomfort when his bladder was full and discomfort with urination. The examiner noted a positive history of nocturia and polydipsia. Physical examination of the testes was normal. There was some tenderness at the internal rings. The right testes was mildly firm to palpation. The reported impression was bilateral orchalgia and urinary frequency. A bilateral testicular ultrasound conducted later in October 1993 was normal. In February 1996, the veteran's complaints of testicular pain were diagnosed as chronic orchalgia. During VA treatment in July 1997, the veteran complained of pain in his rectum and both testicles. An examination revealed an external hemorrhoid and palpable knots of the spermatic cord on the right. There were no other testicular masses. No diagnosis pertinent to a testicular disorder was reported. The veteran's service medical records show that he was treated on one occasion for complaints of dizziness after a long distance run. The examiner noted that the veteran was a runner who ran about 12 miles per day. On the preceding day, he had run 37 miles. The veteran gave a history of episodes of bright red blood in his urine. The examiner reported an impression of probable mild rhabdomyolysis, anemia, and history of hematuria. When seen several days later, the veteran was completely asymptomatic. He was urinating normally. A physical examination was normal. The examiner noted an impression of iron deficient anemia presumed secondary to hemolysis from trauma of long-distance running, ferouria, and status post mild rhabdomyolysis, resolved. During follow-up treatment in May 1985, the veteran reported that he had been running 15 miles per day. The examiner noted an impression of resolved anemia from iron deficiency secondary to iron loss in urine secondary to traumatic hemolysis. The report of the veteran's medical examination for separation from service does not indicate that he had complaints of a genitourinary nature. An examiner reported that the veteran's genitourinary system was clinically normal. The veteran has asserted, at least by implication, that his current symptoms are related to the symptoms documented in service. However, the record contains no competent medical evidence or opinion that there is any relationship between the veteran's in-service complaints of hematuria and the veteran's current genitourinary complaints. In the absence of evidence that the veteran has the expertise to render opinions about such a relationship, his assertions are afforded no probative weight. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The Board finds that the record contains no competent medical evidence of a nexus between the veteran's current complaints of testicular pain and swelling and any disease or injury he incurred during his active military service. Therefore, the Board concludes that the claim for service connection for a disorder of the testicles is not well grounded. B. Prostate Disorder In mid March 1993, the veteran underwent an intravenous pyelogram with nephrotomograms. His kidneys were normal in size and shape. No renal masses were demonstrated. In June 1993, the veteran's prostate was described as benign. The reported diagnosis was history of hematuria. The veteran underwent cystoscopy in August 1993. His prostate gland was A-shaped and mildly obstructing. The prostate was erythematous. His bladder had mucosal edema. There were no obvious tumors, foreign bodies, or stones. The post- operative diagnosis was lower tract obstructive symptoms and hematuria. The veteran's symptoms of rectal and testicular pain were diagnosed as prostatitis and hemorrhoid in July 1997. The Board has reviewed the entire record and finds no indication that the veteran had a prostate disorder during his active military service. Further, the record is devoid of any medical evidence or opinion indicating a relationship between the recent diagnoses of prostatitis and any in- service disease or injury. As the second and third elements of the Caluza analysis are not satisfied, the Board concludes that the claim of entitlement to service connection for prostatitis is not well grounded. C. Torn Ligaments of the Right Wrist and Fracture of the Left Scaphoid Service medical records contain no indication that the veteran had complaints, diagnoses, or treatment of a left or right wrist disorder. At his medical examination for separation from service, the veteran's upper extremities were clinically normal. VA medical records dated in April 1994 show that the veteran injured both wrists in a fall while playing basketball. An X-ray of the right wrist showed a lunotriquetral separation. An X-ray of the left wrist showed a fracture of the scaphoid. The left scaphoid fracture was reduced by screw fixation. During a VA orthopedic examination in January 1999, the veteran reported that he had fallen and injured both hands. He also stated that he had injured his right wrist in a motor vehicle accident in 1984. He complained that the right wrist hurt with certain movements. He demonstrated a combination of flexion and radial deviation. He complained that his left wrist was intermittently painful. On examination, the right wrist had no swelling, deformity, or atrophy. The wrist had 80 degrees of flexion, 80 degrees of extension, 20 degrees of right radial deviation, and 45 degrees of ulnar deviation. X-rays with multiple views of the right wrist revealed no evidence of fracture, dislocation, narrowing of the articular cartilage, osteophyte formation, or other evidence of disease. There was a 4 x 4 millimeter area of sclerotic bone (a bone island) in the lunate which was described as having no clinical significance. The reported diagnosis was status post sprain of the right wrist without objective evidence (physical examination and X-ray) of residual pathology. Examination of the left wrist revealed several small scars from reduction and percutaneous fixation. There was a small, well-healed scar in the palm of the left hand. The left wrist had 45 degrees of flexion, 60 degrees of extension, 10 degrees of radial deviation, and 45 degrees of ulnar deviation. There was no swelling or deformity. There was no atrophy to indicate limitation in use of the left wrist and hand. An X-ray of the left wrist showed an orthopedic screw transfixing the fracture of the left navicular bone. The fracture had completely healed. The reported diagnosis was healed fracture of the left carpal navicular without residual disability by objective X-ray examination. With respect to the veteran's claim for service connection for a right wrist disorder, he has presented no evidence which satisfies any of the elements of the Caluza analysis. There is no medical evidence that he has a current right wrist disability. There is no evidence that he incurred a disease or injury of the right wrist during his active service, and there is no competent medical evidence of a nexus between any current disability and any in-service disease or injury. The Board concludes that the claim for service connection for a right wrist disorder is not well grounded. Concerning the claim for service connection for a left wrist disorder, the record contains no competent medical evidence of a link between a current left wrist disability and any in- service disease or injury. Further the record contains no medical evidence that the veteran incurred any disease or injury affecting his left wrist during his active military service. The second and third elements of the Caluza analysis are not satisfied. The claim for service connection for a left wrist disorder is not well grounded. D. Skeletal Disorders of the Head and Neck The Board first notes that service connection is in effect for "neck strains". Moreover, this issue related to the Court's Order granting the joint motion for remand, in part for consideration of the issue of "service connection for skeletal functions". Thus, the Board will address only whether there is a disability involving the skeletal head and neck. Concerning the first element of a well-grounded claim -- evidence of current disability as provided by a medical diagnosis - the Board notes reports dated in January 1992 and February 1999 from a chiropractor, Robert J. Armstrong, D.C. Both reports refer to clinical and x-ray examination. The earlier report contains diagnoses that include degenerative joint disease and cervical spondylosis (acquired). The later report refers to diagnosis of subluxation and the cervical and thoracic spine with severe rotational malposition of C-6 through T-6 and significant anterior slippage of C-3 through C-5. These reports satisfy the first element for the neck. The record does not refer to current skeletal disability of the head. Concerning the second element -- evidence of incurrence or aggravation of a disease or injury in service - the Board notes that the service medical records show that the veteran was involved in a motor vehicle accident in August 1984. He complained of a sore neck immediately after the accident. When examined in an emergency room, he denied sustaining trauma to his head. He had tenderness in the lateral posterior neck muscles. X-rays of the cervical spine were negative. The diagnosis was cervical strain. A cervical collar was prescribed. The veteran's symptoms of neck stiffness and pain gradually resolved with physical therapy during the next several months. However, he had a recurrence of neck pain in May 1985 and again in September and October 1985. Lateral and oblique X-rays of the cervical spine taken in September 1985 were negative. In October 1985, his symptoms were diagnosed as chronic cervical strain. The veteran was involved in another automobile accident in January 1986. When examined on the day of the accident, his complaints were of back pain causing difficulty breathing. He reported a momentary loss of consciousness due to hitting his head. On examination, his neck was supple, without masses. The veteran's back was tender between the scapulae. An examiner reported a diagnosis of multiple contusions. When examined a week after the January 1986 accident, the veteran did not have complaints associated with his head or neck. His chief complaint was of back pain. On examination, his spine was tender at the level of the inferior scapulae. The reported diagnosis was contusion of the back. When examined two weeks after the accident, the veteran reported that he had sustained head and back injuries. He complained of headache, low back pain, and pain in his upper thoracic spine. He showed discomfort with palpation of his skull. Physical and neurological examinations were normal aside from a finding of papular lesions on the top of the veteran's head. A treatment note contains an impression of musculoskeletal pain due to trauma. During his medical examination for separation from service in late January 1986, the veteran reported a history of head and neck injury. An examiner reported that the veteran's head, spine, and musculoskeletal systems were clinically normal. Concerning the third element -- evidence of a nexus between current disability and injury or disease during service - the record does not contain competent medical evidence linking any current skeletal disorder of the head or neck to any injury or disease during the veteran's active military service. Although Dr. Armstrong, the veteran's chiropractor, seems to indicate such a relationship, he also indicates that the link was self-reported by the veteran. The bare transcription of a lay history is not transformed into "competent medical evidence" merely because it is transcribed into the report of a medical professional. LeShore v. Brown, 8 Vet. App. 406 (1995). None of the other medical records or reports of record, as detailed below, attribute any current skeletal disorder of the head or neck to an inservice injury. Consequently, this claim is not well grounded. During a VA examination in July 1986, the veteran reported that he injured his neck in an automobile accident in 1984. He also reported that in January 1986, the car he was driving overturned and he hit his head and had loss of consciousness for five minutes. His current complaints were of head and neck pain and neck stiffness. X-rays of the cervical and thoracic spine showed normal vertebral alignment. Intervertebral disc spaces were within normal limits. No significant degenerative changes were seen. The paraspinal soft tissues in the thoracic area were unremarkable. The examiner did not report a diagnosis of any abnormality of the skeletal aspects of the head or neck. X-rays of the cervical spine were also normal during VA examinations in October 1991, February 1992, and August 1993. VA outpatient treatment records document the veteran complaints of chronic neck pain. The veteran also complained of headache in September 1991. Generally, the veteran's symptoms have been attributed to muscular and soft tissue strain rather than a disorder of the skeletal system. During the January 1999 VA orthopedic examination, the veteran told the examiner that he sustained a cerebral concussion and neck injury from a motor vehicle accident in 1984. He reported that he sustained a second concussion and neck injury when he was thrown through a windshield during a motor vehicle accident in 1985. Range of motion findings were described as unreliable due to the veteran's lack of cooperation. A neurological examination was normal. X-rays of the cervical spine from four views showed no evidence of fracture, dislocation, narrowing of disc spaces, osteophyte formation, or other evidence of orthopedic pathology. The pertinent impression was status post sprain, cervical spine, without objective evidence of residual pathology by X-ray examination. During a VA neurological examination in January 1999, the examiner noted that no cerebral injuries were reported after the veteran's in-service automobile accidents. The injury to his head was described as a "nick" injury. A complete neurological examination could not be accomplished because of the veteran's restlessness. However, cranial nerves III through XII were unremarkable. There were no head abnormalities. Head movements caused neck discomfort. There was a rapid, moderately severe tremor of the extended hands which was thought to be due to tension, anxiety, or hyperactivity. Motor examination was normal. Sensory examination was normal except for a small area on the palmer service of the left wrist in the vicinity of an old scar which had lack of sensation to pain and temperature. Reflexes in the upper extremities were brisk at 3+ and symmetrical. The examiner reported that the veteran had no significant neurologic deficits related to his head or neck injury. In a May 1999 letter, a chiropractor reported the veteran's complaints of headache, neck pain, and pain into both hands. A foramina compression test was positive. A central distraction test was also positive for foramina compression. X-rays were interpreted as showing anterior slippage of the of the third, fourth, and fifth cervical vertebrae (C3, C4, and C5), and rotational malposition of the C6 through sixth thoracic vertebrae (T6). The reported diagnosis included cervical spondylosis, subluxation of the cervical and thoracic spine, with severe rotational malposition of C6 through T6 and significant slippage of C-3 through C-5 associated with headaches, neck pain, and intermittent paresthesia of the brachial plexus. The chiropractor referred to a letter dated in January 1992 in which he identified as the "mechanism of onset" of the veteran's neck disorder "an accident while in military service'' as self-reported by the veteran. During a VA examination in June 1999, the veteran complained of pain in his neck, head, and all over his body. Passive range of motion in his shoulders was normal. Active range of motion was limited due to lack of effort. Examination of the cervical spine revealed no paraspinal tenderness. Passive ranges of motion included 30 degrees of extension, 50 degrees of flexion, 20 degrees of left lateral flexion, 30 degrees of right lateral flexion, and 50 degrees of left and right rotation. Active range of motion was inconsistent. Deep tendon reflexes were 2+ and symmetrical. Sensory function was intact. However, the veteran had subjective complaints of "dullness" at times in certain areas. No muscle atrophy, weakness, or fasciculations were noted. There was no paraspinal tenderness or tenderness over the trapezius muscles. The impression was chronic pain with history of injury to neck. Magnetic resonance imagings (MRI) of the veteran's cervical spine and brain were conducted in August 1999. Axial views of the spinal canal and neural foramina were unremarkable. The study was described as within normal limits. The MRI of the brain showed the ventricle system in midline. There was no evidence of intracerebral bleed or midline shift. There were small areas of increased signal in the projection of the right parietal lobe and also posterolateral to the posterior horn of the right lateral ventricle which were thought to represent old focal infarcts. E. PTSD The Court has held that a PTSD claim is well grounded where the veteran has "submitted medical evidence of a current disability; lay evidence (presumed to be credible for these purposes) of an in-service stressor, which in a PTSD case is the equivalent of in-service incurrence or aggravation; and medical evidence of a nexus between service and the current PTSD disability". Patton v. West, 12 Vet. App. 272, 276 (1999), citing Cohen v. Brown, 10 Vet. App. 128, 136-37 (1997). In this case, the January 1999 VA psychiatric examination report contains a diagnosis of PTSD, among other diagnoses. This diagnosis was based on the veteran's report of stressors in service, including three automobile accidents; an incident at Fort Irving, California, in November 1985, when the veteran was participating in a truck convoy and the lead truck went off a cliff and the men inside were killed when they encountered a sand storm; and an incident during his basic training in 1983, when a soldier with whom the veteran was acquainted attempted suicide by jumping from a building. This diagnosis, based upon in-service stressors related by the veteran and presumed credible for the purpose of a well- grounded claim, satisfies the elements of a well-grounded claim for service connection for PTSD. As discussed below, further development of the evidence is necessary. II. Increased Rating for Neck Strain The veteran has presented a well-grounded claim for increased disability evaluation for his service-connected disabilities within the meaning of 38 U.S.C.A. § 5107(a) (West 1991); 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 satisfied that all appropriate development has been accomplished and that VA has no further duty to assist the veteran in developing facts pertinent to his claim. The veteran has not advised VA of the existence of additional evidence which may be obtained. Disability evaluations are based upon the average impairment of earning capacity as contemplated by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). Although VA must consider the entire record, the most pertinent evidence, because of effective date law and regulations, is created in proximity to the recent claim. 38 U.S.C.A. § 5110 (West 1991). VA utilizes a rating schedule which is used primarily as a guide in the evaluation of disabilities resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1999). It is essential, both in the examination and in the evaluation of disability, that each disability be viewed in relation to its history. 38 C.F.R. § 4.1 (1999). The veteran's in-service neck injury sustained in the August 1984 automobile accident was diagnosed as cervical strain. The associated symptoms persisted and were diagnosed more than a year later as chronic cervical strain. Chronic neck pain was noted on the report of the veteran's medical examination for separation from service. The veteran was granted service connection for history of neck strains by the RO's May 1987 rating decision. Initially, the associated disability was rated zero percent disabling utilizing Diagnostic Code 5290. Under that diagnostic code, limitation of motion of the cervical spine is rated 10, 20, or 30 percent disabling for slight, moderate, or severe limitation, respectively. The veteran requested a re-evaluation of his service- connected disability from neck strain in August 1991. In support of his claim, he submitted a report from a chiropractor dated in January 1992. The chiropractor reported that the mechanism of onset of the veteran's cervical and thoracic spine disorders was an accident while the veteran was in military service. His findings included spondylosis, osteoarthritis, limitation of cervical motion, and slight vertebral rotation. The veteran underwent a VA orthopedic examination in February 1992. He told the examiner that he sustained a "whiplash" injury in a 1984 motor vehicle accident. He was given a neck brace and underwent physical therapy. He reported that his neck pain continued and was not relieved by medication. On examination, the veteran had the following ranges of motion in his neck; 30 degrees of flexion; 30 degrees of extension; 40 degrees of right rotation; 45 degrees of left rotation; 30 degrees of right deviation; 40 degrees of left deviation. With each of such movements he complained of pain in the strap muscles of the neck on the opposite side. He had full range of motion in his shoulders, forearms, and hands. The examiner could not objectively identify any sensory or motor deficit. X-rays of the cervical spine showed satisfactory alignment, normal intervertebral disc spaces and normal-sized neural foramen. No significant degenerative changes were demonstrated. The reported diagnosis was history of cervical strain with persisting subjective features and moderate impairment of the cervical motion which was at least partly a matter of tension and/or voluntary resistance. In a May 1992 rating decision, the RO increased the rating for neck strain to 10 percent, effective from the date of the veteran's August 1991 claim. The 10 percent rating has remained in effect since that time. The veteran had similar complaints concerning his neck during a VA examination in August 1993. He described neck pain and radiating pain into the trapezial region bilaterally as well as into the inner scapular region. Range of motion examination showed right and left lateral turning of 80 degrees. Flexion was 50 degrees and extension was 30 degrees. The veteran had increased pain on extremes of motion. There was bilateral paracervical tenderness. On neurological examination, reflexes and sensation were intact. Strength was within normal limits. VA outpatient treatment records document that the veteran continued to have complaints of and receive treatment for neck pain. During the January 1999 VA orthopedic examination, he complained of intermittent pain on both sides of his neck. He reported that occasionally, the pain radiated down to both hands. On examination, the veteran held his head in a normal way. The following ranges of motion in the neck were reported: flexion, 50 degrees; extension, 40 degrees; left rotation, 30 degrees; right rotation, 30 degrees; left lateral bending, 10 degrees; right lateral bending, 20 degrees. However, the examiner reported that the range of motion findings were not reliable, as the veteran was not fully cooperative in the examination. X-rays of the cervical spine showed the vertebral bodies intact and in good alignment. Paracervical soft tissue appeared unremarkable. The examining physician reported an impression of status post sprain of the cervical spine without objective evidence of residual pathology by X-ray examination. During the June 1999 VA orthopedic examination, the veteran's complaints were described as inconsistent. The examiner reported that the veteran was uncooperative during the examination. On examination, he did not appear to be in any acute distress. He walked with a normal gait pattern. He sat in a chair without apparent discomfort. He was able to get on and off of the examination table without discomfort. Active range of motion in his shoulders was limited mainly due to lack of effort. However, passive range of motion was normal. During passive range of motion of his shoulders, the veteran was complaining of pain in his feet. No paraspinal tenderness was noted. Passive range of motion of the neck was 50 degrees of flexion, 20 degrees of left lateral flexion, 30 degrees of right lateral flexion, and 50 degrees of left and right rotation. Active range of motion was totally inconsistent. However, during routine movements and activities in the examination room, there did not seem to be any limitation of range of motion in the neck. The veteran's performance of range of motion and other examination exercises was inconsistent throughout the examination. A neurological examination did not conclusively demonstrate an abnormality. Reflexes and sensory function were intact. There were no motor deficits. There was no paraspinal or trapezius muscle tenderness. According to the examiner, X- rays and physical examination were not suggestive of any obvious pathology. The reported impression was chronic pain with a history of injury to the neck. The examiner recommended an MRI study. In August 1999, an MRI of the neck was within normal limits. The Board has reviewed the entire record. The medical evidence contained therein indicates that the veteran's symptoms associated with his service-connected neck strain have been thoroughly evaluated from a clinical standpoint. Other than the findings reported by the veteran's chiropractor in 1992 and 1999, the record contains no objective findings of pathology to account for the veteran's subjective complaints of neck pain. Reliable clinical findings do not show more than slight limitation of motion of the cervical spine. Therefore, the Board concludes that the criteria for a schedular rating in excess of 10 percent under Diagnostic Code 5290 have not been met. The Board has considered the findings reported by a chiropractor in January 1992 and May 1999. The chiropractor's interpretation of X-rays is inconsistent with the clinical findings, X-rays, and recent MRI study of the veteran's neck. The overwhelming preponderance of the evidence indicates that there is no identifiable neck pathology to explain the veteran's subjective complaints of neck pain. In reaching its decision, the Board has considered the complete history of the disability in question as well as the current clinical manifestation and the effect the disability may have on the earning capacity of the veteran. 38 C. F. R. §§ 4.1, 4.2, 4.41 (1999). The original injuries has been reviewed and the functional impairment that can be attributed to pain or weakness has been taken into account. See DeLuca v. Brown, 8 Vet. App 202 (1999). In this regard, the Board notes that findings during VA examinations have consistently showed no motor deficits. Further, the veteran's complaints of neck pain have not been objectively verified on a clinical basis. No muscle atrophy, weakness, tenderness, or soft tissue pathology has been identified. There are no clinical findings which would verify any complaints of excess fatigability, incoordination, painful motion, or more than slight limitation of motion due to pain. The Board has also considered the provisions of 38 C.F.R. § 4.7, which provide for assignment of the next higher evaluation where the disability picture more closely approximates the criteria for the next higher evaluations. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. Absent clinical findings of more than slight limitation of motion in the veteran's cervical spine, his service-connected disability from neck strain, as discussed above, does not approximate the criteria for the next higher schedular rating of 20 percent. 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) (1999). 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. The Board first notes that the schedular evaluations in this case are not inadequate. A 10 percent evaluation contemplates slight limitation of motion of the cervical spine. Higher rating are provided for moderate and severe limitation of motion, but the medical evidence reflects that the veteran does not have more than slight limitation of motion. Second, the Board finds no evidence of an exceptional disability picture in this case. The veteran has not required hospitalization or frequent treatment for his neck strain, nor is it otherwise shown that the service-connected neck disorder otherwise so markedly interferes with employment as to render impractical the application of regular schedular standards. There is no evidence that the impairment resulting solely from the neck strain warrants extra-schedular consideration. Rather, for the reasons noted above, the Board concludes that the impairment resulting from neck strain, including the effect of pain on function and movement, is adequately compensated by the 10 percent schedular evaluation. Therefore, extraschedular consideration under 38 C.F.R. § 3.321(b) is not warranted in this case. III. TDIU VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the appellant is precluded, by reason of his service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16 (1999). Under the applicable regulations, benefits based on individual unemployability are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. Under 38 C.F.R. § 4.16, if there is only one such disability, it must be rated at least 60 percent disabling to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. In Hatlestad, v. Derwinski, 1 Vet. App. 164 (1991), the Court referred to apparent conflicts in the regulations pertaining to individual unemployability benefits. Specifically, the Court indicated there was a need to discuss whether the standard delineated in the controlling regulations was an "objective" one based on the average industrial impairment or a "subjective" one based upon the veteran's actual industrial impairment. The Board is bound in its decisions by the regulations, the Secretary's instructions, and the precedent opinion of the chief legal officer of VA. 38 U.S.C.A. § 7104(c) (West 1991). In a pertinent precedent decision, the VA General Counsel concluded that the controlling VA regulations generally provide that veterans who, in light of their individual circumstances, but without regard to age, are unable to secure and follow a substantially gainful occupation as the result of service- connected disability shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by the circumstances. Thus, the criteria include a subjective standard. It was also determined that "unemployability" is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91 (O.G.C. Prec. 75-91); 57 Fed. Reg. 2317 (1992). The Court has held that a veteran's advancing age and non- service connected disabilities may not be considered in the determination of whether a veteran is entitled to a total disability rating based upon individual unemployability. For a veteran to prevail on a claim based on unemployability, it is necessary that the record reflect some factor which places the claimant in a different position than other veterans with the same disability rating. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In discussing the unemployability criteria, the Court, in Moore v. Derwinski, 1 Vet. App. 83 (1991), indicated in essence, that the unemployability question, that is, the ability or inability to engage in substantial gainful activity, had to be looked at in a practical manner, and that the thrust was whether a particular job was realistically within the capabilities, both physical and mental, of the appellant. Clearly, the veteran does no meet the percentage threshold for consideration for TDIU. He has one service-connected disability, which is rated 10 percent disabling. However, he may nonetheless be entitled to TDIU based on an extraschedular considerations. The question to be addressed is whether there are unusual circumstances, peculiar to this veteran, which prevent him from having the usual amount of success to be expected in overcoming the handicap of his service-connected disability. In this case, the Board finds no such unusual circumstances. The record does not indicate that the veteran has had frequent hospitalizations or frequent treatment for his service-connected disability, or that such disability otherwise markedly interferes with employment. Recent VA examinations have identified no pathology to account for the veteran's subjective complaints about his neck. The veteran is a high school graduate and has taken some college level courses. He has post-service work experience as a letter carrier for the U.S. Postal service. Only minimal functional impairment has been attributed to his service-connected neck strain. Although the veteran has been described by a VA psychiatrist as unemployable, his unemployability has been attributed to his nonservice-connected neuropsychiatric disorder. The Board also notes that the veteran has been unemployed since his hospitalization in April 1996 for treatment of a neuropsychiatric disorder. However, lack of employment is not conclusive evidence of unemployability. The veteran's assertions that his service-connected disability renders him unemployable are not supported by the medical evidence. Based on the description of the impairment due to the service-connected neck disorder, as contained in the medical reports, the Board finds that the veteran's service-connected disability does not render him unemployable. The record does not reflect any unusual circumstances that place the veteran in a different position than other veterans with the same disability rating. Accordingly, the Board concludes that he is not entitled to a total rating for compensation based on unemployability. ORDER Service connection is denied for disorders of the testicles and prostate, torn ligaments of the right wrist, fracture scaphoid of the left wrist, and skeletal disorders of the head and neck. The claim for entitlement to service connection for PTSD is well grounded. To this extent, the appeal is granted. An increased rating for neck strain is denied. A total disability rating based on individual unemployability is denied. REMAND As discussed above, the veteran has presented a well-grounded claim for service connection for PTSD. The elements required to establish service connection for PTSD are 1) a current, clear medical diagnosis of PTSD, which is presumed to include both the adequacy of the PTSD symptomatology and the sufficiency of a claimed in-service stressor; 2) credible supporting evidence that the claimed in-service stressor actually occurred; and 3) medical evidence of a causal nexus, or link, between the current symptomatology and the specific claimed in-service stressor. 38 C.F.R. § 3.304(f) (1999); Cohen v. Brown, 10 Vet. App. 128, 138 (1997). In this case, although the January 1999 VA examination report contains a diagnosis of PTSD based on the veteran's report of in-service stressors, a medical summary, dated in July 1999, by a psychiatrist who had treated the veteran for several years indicates that the veteran did not fit the criteria for PTSD. Moreover, as the stressors described by the veteran are not combat related, there must be independent verification that the claimed stressors actually occurred. The description of the automobile accidents that the veteran gave the VA examiner does not correlate with the information in the medical records contemporaneous to the accidents. In addition, the record contains no independent verification of the alleged truck accident in a California desert sandstorm or the attempted suicide of a fellow soldier during the veteran's basic training. Accordingly, the case is REMANDED for the following actions: 1. The RO should verify the alleged truck accident in a California desert sandstorm and/or the attempted suicide of a fellow soldier during the veteran's basic training. If necessary, additional information should be obtained from the veteran. If there is insufficient evidence to attempt to verify these incidents through the U.S. Armed Services Center for Research of Unit Records (USASCRUR), formerly the U.S. Army & Joint Services Environmental Support Group, or by other means, the record should so indicate. 2. The RO should schedule the veteran for another examination by a board of at least two psychiatrists to determine whether the veteran has a current, clear medical diagnosis of PTSD. The claims folder must be made available to the examiners for a complete study of the case, including the reports of in-service motor vehicle accidents, the veteran's previous psychiatric treatment, and the verification or lack thereof of the other stressors related by the veteran. 3. After the above development has been completed to the extent possible, the RO should again consider the claim of service connection for PTSD. If the decision remains adverse to the veteran, he and his representative should be given a supplemental statement of the case and an opportunity to respond thereto. Thereafter, the case should be returned to the Board, if in order. The veteran need take no action unless otherwise notified. The purposes of this remand are to ensure compliance with due process considerations. The Board intimates no opinion as to the ultimate outcome of this case. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. MARY GALLAGHER Member, Board of Veterans' Appeals