Citation Nr: 1039932 Decision Date: 10/25/10 Archive Date: 11/01/10 DOCKET NO. 04-28 621A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio THE ISSUE Entitlement to a rating in excess of 10 percent for residuals of a left shoulder injury prior to April 6, 2006. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD O. Lee, Associate Counsel INTRODUCTION The Veteran had unverified active service from December 1978 to June 1982. This matter comes before the Board of Veterans' Appeals (Board) on remand from the United States Court of Appeals for Veterans Claims (Court). In an August 2010 Order, the Court endorsed an August 2010 joint motion for remand, vacated the part of the November 2009 Board decision that denied entitlement to a rating in excess of 10 percent for residuals of a left shoulder injury for the period prior to April 6, 2006, and remanded the matter for compliance with the instructions in the joint motion. This case was previously before the Board on appeal from a March 2004 rating decision by the RO in Cleveland, Ohio. The Board remanded the case for additional development in June 2008. Thereafter, in a November 2009 decision, the Board denied entitlement to a rating in excess of 10 percent for residuals of a left shoulder injury prior to April 6, 2006, granted an increased rating of 30 percent for residuals of a left shoulder injury from April 6, 2006 to December 12, 2008, and granted an increased rating of 30 percent for residuals of a left shoulder injury from December 12, 2008 onward. The Veteran testified before the undersigned at a May 2008 videoconference hearing. He also testified at an October 2004 hearing before a Decision Review Officer (DRO). Transcripts of these proceedings have been associated with the claims file. FINDINGS OF FACT 1. The Veteran is left hand dominant. 2. Prior to April 6, 2006, the Veteran's left shoulder disability was manifested by arthritis, scapular thoracic crepitation, tenderness, impingement, limitation of motion, and additional functional limitation due to painful motion. CONCLUSION OF LAW The criteria for an increased rating of 20 percent, but no higher, for residuals of a left shoulder injury prior to April 6, 2006 are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5201, 5203 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the appellant's claims file, and has an obligation to provide reasons and bases supporting the decision. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. The Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2010). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his possession that pertains to the claim. The requirement of requesting that the claimant provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Any error related to this element is harmless. For an increased compensation claim, the veteran must be notified that he must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded by, Vazquez- Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Recently, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that the notice described in 38 U.S.C. § 5103(a) need not be veteran specific, i.e., it need not notify the veteran of alternative diagnostic codes, and that that the statutory scheme does not require "daily life" evidence for proper claim adjudication. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Thus, any error related to the aforementioned is harmless. Prior to and following the initial adjudication of the Veteran's claim, letters dated in December 2003, August 2004 and July 2008 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. at 187; Pelegrini II, 18 Vet. App. at 120-21. The letters advised the Veteran of the information necessary to substantiate the claim, and of his and VA's respective obligations for obtaining specified different types of evidence. The Veteran was informed of the specific types of evidence he could submit, which would be pertinent to his claim, and advised to send any medical reports that he had. He was also told that it was ultimately his responsibility to support the claim with appropriate evidence. The July 2008 letter specifically advised the Veteran of all the information required under Vazquez-Flores. In addition, March 2006 and July 2008 letters provided the Veteran with notice concerning the assignment of disability ratings and effective dates. See Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). Subsequent to the issuance of the August 2004, March 2006 and July 2008 letters, the Veteran's claim was readjudicated in an August 2009 rating decision and supplemental statement of the case (SSOC). Thus, there was no deficiency in notice and a harmless error analysis is not necessary. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran's Social Security Administration records have been associated with the file. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2010). The RO provided the Veteran appropriate VA examinations in January 2004 and December 2008. As noted above, the Veteran is only appealing the issue of entitlement to an increased rating for his left shoulder disability for the period prior to April 6, 2006. Consequently, there is no additional examination that can be performed, which would substantiate the Veteran's claim. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Increased Rating The Veteran is seeking a disability rating in excess of 10 percent for the period prior to April 6, 2006 for his service- connected residuals of a left shoulder injury. For the reasons that follow, the Board finds that an increased rating of 20 percent, but no higher, is warranted. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board acknowledges that the Veteran is competent to give evidence about what he experienced; for example, he is competent to report that he experiences certain symptoms. See, e.g., Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Competency, however, must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997). He is not, however, competent to diagnose any medical disorder or render an opinion as to the severity of any current disorder because he does not have the requisite medical knowledge or training. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). As a preliminary matter, the Board notes that the Veteran previously filed separate claims of service connection for cervical strain and left hand paresthesias as secondary to his service-connected left shoulder disability. In conjunction with those claims, the Veteran underwent VA examinations in September 2006. He was diagnosed with, among other things, a cervical strain that was unrelated to his left shoulder. It was noted, however, that the Veteran did have generalized pain in the left shoulder that also radiated into the trapezius on the left side of his neck. Thereafter, the RO issued an October 2006 RO rating decision denying secondary service connection for the cervical strain and granting secondary service connection for left hand paresthesias. With respect to the Veteran's nonservice-connected cervical strain, the Board notes that when it is not possible to separate the effects of a service-connected disability from a non-service- connected disability, 38 C.F.R. § 3.102 requires that reasonable doubt be resolved in the claimant's favor, thus attributing such signs and symptoms to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). For the period prior to April 6, 2006, the Veteran's service- connected left shoulder disability is assigned a rating of 10 percent under Diagnostic Code 5203 for scapula impairment. The Veteran testified at the May 2008 videoconference hearing that he is left-handed. See also VA physical therapy treatment record, April 2006. As his left shoulder and arm are among his major extremities, they will be rated as such. Diagnostic Code 5203 provides ratings for impairment of the clavicle or scapula. Malunion of the clavicle or scapula is rated as 10 percent for the major or minor shoulder. Nonunion of the clavicle or scapula without loose movement is rated as 10 percent for the major or minor shoulder; nonunion of the clavicle or scapula with loose movement is rated as 20 percent for the major or minor shoulder. Dislocation of the clavicle or scapula with loose movement is rated as 20 percent for the major or minor shoulder. Diagnostic Code 5203 provides an alternative rating based on impairment of function of the contiguous joint. 38 C.F.R. § 4.71a. Diagnostic Code 5201 provides that limitation of motion of the arm at the shoulder level is rated as 20 percent for the major shoulder and 20 percent for the minor shoulder; limitation of motion of the arm midway between the side and shoulder level is rated as 30 percent for the major shoulder and 20 percent for the minor shoulder; limitation of motion of the arm to 25 degrees from the side is rated as 40 percent for the major shoulder and 30 percent for the minor shoulder. 38 C.F.R. § 4.71a. Full range of motion of the shoulder is 0 to 180 degrees of abduction and forward elevation (flexion) and 0 to 90 degrees of internal and external rotation. 38 C.F.R. § 4.71, Plate I. Diagnostic Code 5010 provides that arthritis due to trauma that is substantiated by X-ray findings is to be rated as degenerative arthritis. Under Diagnostic Code 5003, degenerative arthritis, established by X-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. However, when limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each major joint or groups of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. For the purpose of rating disability from arthritis, the shoulder is considered a major joint. 38 C.F.R. § 4.45(f). A compensable evaluation under Diagnostic Codes 5003 and 38 C.F.R. § 4.59 (for painful motion) is in order where arthritis is established by X- ray findings and no actual limitation of motion of the affected joint is demonstrated. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). In the case of DeLuca v. Brown, 8 Vet. App. 202 (1996), the United States Court of Appeals for Veterans Claims (Court) held that ratings based on limitation of motion do not subsume 38 C.F.R. § 4.40 or 38 C.F.R. § 4.45. It was also held that the provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare- ups. In order to establish a rating higher than 10 percent prior to April 6, 2006 under Diagnostic Code 5203, the medical evidence would need to show either nonunion of the clavicle or scapula with loose movement, or dislocation of the clavicle or scapula. 38 C.F.R. § 4.71a. On VA examination in January 2004, range of motion testing revealed abduction and flexion to 105 degrees and internal and external rotation to 75 degrees, both limited by pain. The Veteran seemed to have decent strength, but pain with push-and- pull. He also held his left shoulder in an elevated position that caused some pain over the trapezius muscles. No other swelling or deformity was noted in the left shoulder and no obvious signs of instability were detected. Physical examination showed marked scapular thoracic crepitation. X-rays demonstrated minimal degenerative arthritic changes of the left acromioclavicular and shoulder joints, but no fracture, dislocation or destructive bone changes. The final diagnosis was residuals of a left shoulder injury. VA orthopedic treatment notes dated in August 2004 show that the Veteran was found to have considerable amount of UU scapular/thoracic crepitus medial to the border of the scapula. It was tender throughout this region. There was no erythema or swelling. Examination of the left shoulder revealed signs of impingement. There was pain on the lateral aspect of the deltoid when the arm was brought to 90 degrees abduction and internal rotation. Isolated strength testing revealed supraspinatus, external rotator, internal rotators to be 5/5 strength. It was noted that there was no pain over the acromioclavicular joint, but that the Veteran held his shoulder girdle in a flexed position up towards his neck. The AC joint on the left, which was not particularly tender, was comparable to the AC joint on the right. The impression was scapular/thoracic and left shoulder bursitis. VA physical therapy notes dated in October 2004 indicate that a diagnosis of left scapulothoracic and some deltoid bursitis. Active range of motion measurements revealed limitation of flexion at 90 degrees. A protraction and winging of the scapula during flexion was noted. Abduction was 100 degrees with increase in elevation of the scapula. External rotation was 70 degrees, and internal rotation was 45 degrees. Postural assessment revealed a winging of the left scapula. Manual muscle tests revealed limitations for shoulder flexion, abduction and a 3+/5 muscle grade with increase in winging of the left scapula. All other manual muscle tests revealed a 4/5 muscle grade for the shoulder. Manual muscle tests for the left scapula revealed limitations for the serratus anterior at a 3/5, and for the rhomboid, mid trapezius and low trapezius at a 4/5 muscle grade. Palpation elicited pain at the subacromial space, and throughout the scapular musculature. Neer test was positive. VA orthopedic treatment notes dated in January 2005 indicate that the Veteran had significant guarding of his shoulder with active muscle spasm with movements; it was noted that some of this was acted by the Veteran. Range of motion testing revealed flexion to 100 degrees, abduction to 140 degrees, and internal rotation to L4. On passive range of motion, snapping was felt with scapular thoracic movement, causing discomfort. There was also pain with abduction past 90 degrees at the lateral aspect of the acromion. Strength was 5/5 for internal rotation, external rotation, abduction, supraspinatus, adduction, and deltoid strength. There was tenderness to palpation over the acromioclavicular joint over the lateral aspect of the acromion in addition to the anterior aspects of the shoulder. The Veteran was also tender to palpation on the inferior medial aspect of the scapula. With pressing a wall there was no evidence of winging of the scapula. It was noted that it was very difficult to perform laxity and stability tests of the shoulders because of the Veteran's spasticity and guarding. The Veteran has a negative Jahnke test and did not appear to have a positive apprehension test on examination. He did not have sulcus sign and had no anterior or posterior translation on shift test. Hawkin's and Neer's testing was positive for his anterior lateral shoulder pain. Light touch and pinprick were intact distally in the left and right upper extremities. X-rays revealed minimal degenerative changes about the AC joint. No fracture or dislocation was identified. There was no significant joint space narrowing, abnormal intra-articular calcification, or acute bony abnormality. The assessments were left shoulder scapular thoracic pain secondary to snapping scapula, acromioclavicular joint arthritis and impingements syndrome. An April 2005 CT scan showed mild to moderate degenerative changes of the AC joint. There was no acute fracture-dislocation of the left shoulder joint. It was also noted that there was no gross evidence of tear of the supraspinatus tendon, no significant impingement on the supraspinatus, and no acute fracture identified in the glenoid cavity. The humeral head was intact, the glenohumeral relation was normal, and the coracoid was intact. In light of the foregoing, the Board finds that the criteria to support a rating in excess of 10 percent under Diagnostic Code 5203 for the Veteran's left shoulder disability have not been met at any time prior to April 6, 2006. The evidence does not show nonunion of the clavicle or scapula with loose movement, or dislocation of the clavicle or scapula, as is required for a higher evaluation of 20 percent under Diagnostic Code 5203. 38 C.F.R. § 4.71a. Indeed, X-rays and CT scan were all negative for fracture and dislocation. The Board will now consider whether a higher rating may be assigned for the Veteran's AC arthritis under Diagnostic Code 5003, which rates degenerative arthritis on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint involved. 38 C.F.R. § 4.71a. Under Diagnostic Code 5201, limitation of motion of the major arm at shoulder level is rated as 20 percent disabling, while limitation of motion of the major arm midway between side and shoulder level is rated as 30 percent disabling. In Lineberger v. Brown, 5 Vet. App. 367, 370 (1993), the Court noted that as the minimum 20 percent rating for limited shoulder motion, it should be clarified whether that rating is a result of limitation of motion of abduction only, or whether both limitation of motion of flexion and abduction are required. Subsequently, the Court clarified in Mariano v. Principi, 17 Vet. App. 305, 317-18 (2003), that for a 20 percent rating under Diagnostic Code 5201 the applicable plane of motion was not to be measured by limitation of motion of abduction alone to the shoulder level because 38 C.F.R. § 4.71, Plate I listed both abduction and forward elevation (flexion) as shoulder-arm movements. Diagnostic Code 5201 did not specifically identify the plane of motion (although Diagnostic Code 5200 did refer to abduction), and the title of Diagnostic Code 5201 was "Arm, limitation of motion of" and appeared to be generic without specifying limitation based solely on abduction. The Court left open the question of whether the ratings in Diagnostic Code 5201 required limitation in all planes or limitation in any one plane, but noted that it would be very difficult to satisfy Diagnostic Code 5201 if limitation were required in all planes. Accordingly, the Board concludes that for a rating under Diagnostic Code 5201 the limitation of motion may be in any one plane of motion, e.g., abduction or forward elevation (flexion). The August 2010 joint motion for remand raised the issue of whether separate ratings are available for limitation of motion of flexion and abduction of the arm, given that the Veteran in this case experienced limitation of both flexion and abduction. In VAOPGCPREC 9-04, VA General Counsel held that separate ratings may be assigned for limitation of flexion and limitation of extension of the same knee. The Board notes, however, that by its terms, VAOPGCPREC 9-04 applies to the knee, not the shoulder. Neither VA General Counsel nor the Court has expanded this concept to include any other joint. It would be beyond the Board's authority to expand General Counsel's holding to include joints other than the knee. See 38 U.S.C.A. § 7104(c) (explaining that the Board is bound in its decisions by the regulations and the precedent opinions of the chief legal officer of VA). Furthermore, the Board notes that unlike the rating criteria for knee disabilities, which evaluate limitation of flexion and extension under separate diagnostic codes, namely Diagnostic Codes 5260 and 5261, the rating criteria for shoulder disabilities evaluate limitation of motion under a single diagnostic code, Diagnostic Code 5201. The Board finds that the assignment of separate ratings for limitation of flexion and abduction under the same diagnostic code would constitute improper pyramiding. See 38 C.F.R. § 4.14. The medical evidence, as summarized above, shows that at the January 2004 examination the Veteran's range of motion was 105 degrees abduction and flexion. In October 2004, flexion was 90 degrees and abduction was 100 degrees. In January 2005, flexion was 100 degrees and abduction was 140 degrees. Based on the foregoing, the Board finds that the Veteran is not shown by the preponderance of the evidence to have had limitation of motion at shoulder level prior to April 6, 2006. Although flexion was limited to 90 degrees in October 2004, flexion and abduction of the left arm at the January 2004 examination were higher than shoulder level, abduction in October 2004 was again higher than shoulder level, and flexion and abduction in January 2005 were both higher than shoulder level. The Board will also considered the DeLuca criteria previously discussed. See DeLuca, supra. In August 2004, the Veteran was found to have pain on the lateral aspect of the deltoid when his arm was brought to 90 degrees abduction. Similarly, in January 2005, the Veteran was noted as having pain with abduction past 90 degrees at the lateral aspect of the acromion. Affording the Veteran the benefit of the doubt, the evidence is at least in equipoise in showing that the Veteran's abduction was limited to shoulder level as a result of painful motion. In this regard, a higher rating of 20 percent is warranted under Diagnostic Code 5201 based on greater limitation of motion due to pain on use. See 38 C.F.R. § 4.40. The Board has considered other possible avenues for a higher rating. Impairment of the major humerus involving fibrous union is rated at 50 percent under Diagnostic Code 5202, and intermediate ankylosis of the major scapulohumeral articulation is rated at 40 percent under Diagnostic Code 5200. 38 C.F.R. § 4.71a. There is, however, no evidence of these conditions in the record. Additionally, the medical evidence does not indicate intermediate degrees of residual weakness, pain or limitation of motion so as to warrant a higher rating by analogy to Diagnostic Codes 5200 and 5202. It is also noted that a separate rating for clavicle or scapula impairment under Diagnostic Code 5203 is not warranted, as a 20 percent rating for painful motion has already been established. A second rating Diagnostic Code would compensate the Veteran twice for the same symptoms, violating the anti-pyramiding rule. See 38 C.F.R. § 4.14; VAOPGCPREC 9-98 (August 14, 1998) (explaining that removal of semilunar cartilage may result in complications producing loss of motion). Therefore, a higher rating is not available under the other diagnostic codes for shoulder disabilities. Finally, the Board has also considered whether a referral for extraschedular rating is warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (a threshold finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate is required for extraschedular consideration referral). The schedular evaluation for the Veteran's service-connected residuals of a left shoulder injury prior to April 6, 2006 is not inadequate. His complained-of symptoms are those contemplated by the rating criteria. There are no symptoms left uncompensated or unaccounted for by the assignment of a schedular rating. It does not appear that the Veteran had an "exceptional or unusual" disability; he merely disagrees with the assigned evaluation for his level of impairment. In other words, he did not have any symptoms from his service-connected disability that were unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations for that service- connected disability are adequate. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is moot. See Thun, supra. As such, the Board concludes that an increased rating of 20 percent, but no higher, is warranted for the Veteran's residuals of a left shoulder injury prior to April 6, 2006. The benefit- of-the-doubt rule has been applied in arriving at this decision. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to an increased rating of 20 percent, but no higher, for residuals of a left shoulder injury prior to April 6, 2006 is granted. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs