Citation Nr: 1111802 Decision Date: 03/24/11 Archive Date: 04/06/11 DOCKET NO. 09-40 257 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa THE ISSUES 1. Entitlement to service connection for a bilateral hip disability, to include as secondary to a service-connected disability. 2. Entitlement to an initial compensable rating prior to December 21, 2009, and in excess of 20 percent on and after that date for supraspinatus and trapezius muscle sprain of the left shoulder. 3. Entitlement to an initial rating in excess of 10 percent for chondromalacia of the femoral condyle and patellofemoral pain syndrome of the right knee. 4. Entitlement to an initial compensable rating prior to December 21, 2009, and in excess of 10 percent on and after that date for chondromalacia of the patella and patellofemoral pain syndrome of the left knee. 5. Entitlement to an initial rating in excess of 20 percent for mild osteoarthritis of the right acromioclavicular joint with labral tear and rotator cuff tendonitis, status post slap repair. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J.B. Freeman, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1993 to January 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2008 rating decision of the RO in Des Moines, Iowa, which denied service connection for a bilateral hip condition and granted service connection for the bilateral shoulders and bilateral knees, assigning a 20 percent rating to the right shoulder and a 10 percent rating to the right knee, and noncompensable ratings for the left shoulder and left knee. During the pendency of the appeal, increased evaluations from noncompensable percent to 20 percent was granted for the left shoulder and from noncompensable to 10 percent for the left knee by rating decision dated in February 2010. The Veteran was also granted a temporary total rating for his right shoulder disability from May 30 to August 1, 2008, following surgery. The Board notes, with respect to increased ratings, the United States Court of Appeals for Veterans Claims (Court) has held that on a claim for an original or increased rating, the appellant will generally be presumed to be seeking the maximum benefit allowed by law or regulations, and it follows that such a claim remains in controversy where less than the maximum benefit is allowed. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Court further held that, where a claimant has filed a notice of disagreement as to a RO decision assigning a particular rating, a subsequent RO decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the appeal. Id. The Veteran testified before the undersigned at a January 2011 videoconference hearing. A transcript has been associated with the file. The issue of an initial rating in excess of 20 percent is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. At no time during the current appeal has the Veteran been diagnosed with a bilateral hip disability. 2. The Veteran's left arm is his minor arm. 3. Prior to December 21, 2009, the Veteran's left shoulder supraspinatus and trapezius muscle sprain has been manifested by flexion to 180 degrees, abduction to 180 degrees, internal rotation to 85 degrees, external rotation to 90 degrees, with pain free motion and no additional functional loss due to lack of endurance, weakness, incoordination. 4. On and after December 21, 2009, the Veteran's left shoulder supraspinatus and trapezius muscle sprain has been manifested by flexion and abduction beyond the shoulder level, with popping, crepitus, and evidence of painful motion. 5. The Veteran's service-connected chondromalacia of the femoral condyle and patellofemoral pain syndrome of the right knee has been manifested by extension to zero degrees, flexion to 135 degrees, without objective evidence of cartilage disorders, ligament instability, ankylosis, tibia or fibula impairment, or genu recurvatum. 6. Prior to December 21, 2009, the Veteran's chondromalacia of the patella and patellofemoral pain syndrome of the left knee was manifested by extension to zero degrees, flexion to 140 degrees, without objective evidence of additional functional loss due to pain, incoordination, fatiguability or loss of endurance, cartilage disorders, ligament instability, ankylosis, tibia or fibula impairment, or genu recurvatum. 7. On and after December 21, 2009, the Veteran's chondromalacia of the patella and patellofemoral pain syndrome of the left knee was manifested by extension to zero degrees, flexion to 140 degrees, without objective evidence of cartilage disorders, ligament instability, ankylosis, tibia or fibula impairment, or genu recurvatum. CONCLUSIONS OF LAW 1. A bilateral hip disability was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1154(b), 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2010). 2. Prior to December 21, 2009, the criteria for an initial compensable rating for left shoulder supraspinatus and trapezius muscle sprain are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2010). 3. On and after December 21, 2009, the criteria for an initial rating in excess of 20 percent for left shoulder supraspinatus and trapezius muscle sprain are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71, Diagnostic Code 5201 (2010). 4. The criteria for an initial evaluation greater than 10 percent for chondromalacia of the femoral condyle and patellofemoral pain syndrome of the right knee are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2010). 5. Prior to December 21, 2009, the criteria for an initial compensable rating for chondromalacia of the patella and patellofemoral pain syndrome of the left knee are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2010). 6. On and after December 21, 2009, the criteria for an initial rating in excess of 10 percent for chondromalacia of the patella and patellofemoral pain syndrome of the left knee are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims folders. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. 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 Veteran 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 appellant). 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 claimant. 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 Veteran 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. Veterans Claims Assistance Act (VCAA) VA has met all statutory and regulatory notice and duty to assist provisions as to the Veteran's claims for service connection and increased initial ratings. 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) (2010). 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; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Court observed that a claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. See 38 U.S.C. § 5103(a); see also Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). Compliance with the first Quartuccio element requires notice of these five elements. See id. Prior to initial adjudication of the Veteran's appeal, a letter dated in February 2008 fully satisfied the duty to notify provisions with respect to the service connection claim on appeal. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, at 187. [This correspondence also addressed the underlying issues of entitlement to service connection for left shoulder and bilateral knee disabilities. As these issues were granted by the rating action on appeal, no further VCAA notice pertaining to the downstream increased rating claims for the left shoulder and bilateral knee disabilities is necessary. Dingess, supra. 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. The Veteran testified that he receives all his treatment through VA. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). If VA provides a claimant with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran was afforded a 2008 medical examination to obtain an opinion as to whether the Veteran had a bilateral hip disability as the result of service or a service-connected disability. The examiner concluded that the Veteran lacked objective evidence that would allow for a diagnosis of a current disability. This opinion was rendered by a medical professional following a thorough examination and interview of the Veteran and review of the claims file. The examiner obtained an accurate history and listened to the Veteran's assertions. The examiner laid a factual foundation and reasoned basis for the conclusions that were reached. Therefore, the Board finds that the examination is adequate. See Nieves-Rodriguez, supra. For increased ratings claims, 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 on the left shoulder and bilateral knee claims in March 2008 and December 2009. The Veteran has not reported receiving any recent treatment specifically for this condition (other than at VA and the private treatment mentioned above, records of which are in the file), and there are no records suggesting an increase in disability has occurred as compared to the prior VA examination findings. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disorders since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. The 2008 and 2009 VA examination reports are thorough and supported by VA outpatient treatment records. The examinations in this case are adequate upon which to base a decision. 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 Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). II. Service Connection The Veteran contends that he has bilateral hip condition that has been present since service or, in the alternative, is due to his service-connected knee disabilities. For the reasons that follow, the Board concludes that service connection is not warranted. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. 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. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder, there must be (1) competent and credible evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) competent and credible evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Service connection may also be established on a secondary basis for disability which is proximately due to, or the result of, a service connected disease or injury. 38 C.F.R. § 3.310(a) (2010). Secondary service connection may also be established for a disorder which is aggravated by a service- connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(c). Establishing service connection on a secondary basis essentially requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service connected disability. Id. Regardless of the method of service connection, a current disability is necessary for a grant of entitlement. When a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C.A. § 1110 (West 2002). See also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (in the absence of proof of a present disability, there can be no valid claim) & McClain v. Nicholson, 21 Vet. App. 319 (2007) (which stipulates that a service connection claim may be granted if a diagnosis of a chronic disability was made during the pendency of the appeal, even if the most recent medical evidence suggests that the disability resolved). The Veteran has numerous service treatment records showing joint complaints. Although the Veteran indicated in his claim and in testimony that his service treatment records should show hip complaints, none appear. The Veteran was placed on several physical profiles in 1999 and 2001. The profiles indicate that the Veteran was not restricted from performing hip exercises. The Veteran underwent a VA examination in March 2008 after separating from service and filing the instant claim. He reported bilateral hip pain at the time, inside the hip joint with grinding in the left. The Veteran described pain in the right hip that went to the lateral and anterior proximal thigh region. The Veteran reported that the pain was not aggravated by anything and occurred when he walks, gets up in the morning and walking up and down stairs. The examiner felt some grinding and popping during range of motion testing, and may have some decreased range of motion, but that was difficult to assess. The right hip was found to have probably no range of motion deficit. The Veteran's gait was normal. The hips were not tender to palpation, but had positive FABER (Flexion, ABduction, and External Rotation of the hip). The examiner conducted a thorough review of the Veteran's service treatment records and did not find specific hip complaints, though many other joint complaints were seen. The examiner noted that x-rays of the hips in February 2008 were negative. The examiner indicated that the Veteran had bilateral hip pain with some limit in range of motion likely due to deconditioning. The examiner filed a May 2008 addendum indicating that the Veteran had pain and some tightness through the hip joint but no diagnosable condition of the hips. 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. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). The Board does not question the Veteran's earnest reports of pain, grinding and tightness in the hips. The law permits subjective reports of discomfort without requiring a finding of disability. In light of the contemporaneous medical findings, based on a complete and accurate review of the Veteran's medical records and a thorough examination of the Veteran, the Board places more weight on the examiner's findings of no diagnosable condition. Thus, the Board finds that, at no time during the current appeal, has the Veteran been found to have a bilateral hip disability. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (in which the Court held that, in the absence of proof of a present disability, there can be no valid claim) & McClain v. Nicholson, 21 Vet. App. 319 (2007) (which stipulates that a service connection claim may be granted if a diagnosis of a chronic disability was made during the pendency of the appeal, even if the most recent medical evidence suggests that the disability resolved). Without a diagnosis of a disability of the hips at any time during the current appeal, service connection is not warranted regardless of the theory of entitlement. As such, the Board finds that the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). III. Initial Ratings The Veteran contends that he is entitled to initial ratings in excess of 10 percent for his right knee patellofemoral pain syndrome and compensable ratings prior to December 21, 2009, for his left shoulder supraspinatus and trapezius muscle sprain and left knee patellofemoral pain syndrome and in excess of 20 percent for the left shoulder and left knee each on and after December 21, 2009. For the reasons that follow, the Board concludes that increased ratings are not 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 (West 2002 & Supp. 2010); 38 C.F.R. § 4.1 (2010). 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 (2010). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2010). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2010). In the present case, it should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. a. Left Shoulder Supraspinatus and Trapezius Muscle Sprain The Veteran's left shoulder muscle sprain has been rated under Diagnostic Code (DC) 5201, for limitation of motion of the shoulder. See 38 C.F.R. § 4.71a (2010). Ratings under DC 5201 are based on impairment of either the major or minor arm. Id. The Veteran testified and the record agrees that the Veteran is right handed and that his right arm is his major arm. Thus, the Board will consider the ratings only for the minor side in rating his left shoulder disability. A 20 percent rating is assigned for limitation of motion at shoulder level on the major or minor side. A 20 percent rating is assigned for limitation of motion to midway between side and shoulder level on the minor side. A 30 percent rating is assigned for limitation of motion of the arm to 25 degrees from side on the minor side. Normal range of motion in the shoulder is from 0 to 180 degrees of forward elevation (flexion) and 0 to 180 degrees of shoulder abduction. See 38 C.F.R. § 4.71a, Plate I (2010). Service treatment records do not provide range of motion testing for the left shoulder. The Veteran underwent a March 2008 VA examination. At that time, the Veteran had pain free motion in the left shoulder with abduction and forward flexion from zero to 180 degrees, internal rotation zero to 85 degrees, and external rotation of zero to 90 degrees. The Veteran was tender along the supraspinatus/trapezius muscle above the scapula without impingement signs, apprehension and drop arm, or crepitus. The Veteran was negative for DeLuca criteria for all joints, all planes of motion. The Veteran's VA treatment records do not reveal further range of motion testing between March 2008 and the Veteran's next VA examination on December 21, 2009. The Veteran complained of worsening symptoms in submissions to the RO. As a result, the RO scheduled him for the December 2009 VA examination. At that time, the Veteran was found to have forward flexion to 155 degrees, abduction to 180 degrees, internal rotation to 75 degrees and external rotation to 90 degrees. The Veteran reported give way, popping, intense pain and an inability to keep his arm up for extended periods. The examiner noted there was additional limitation of motion due to pain, with flexion reduced to 150 degrees, abduction to 165 degrees, internal rotation to 65 degrees and external rotation to 60 degrees. The range of motion results at both VA examinations exceeds the minimum requirements for a compensable rating under DC 5201. The RO assigned the 20 percent rating, effective December 21, 2009, for the additional loss of function shown by the Veteran's reports of give way, popping, intense pain and an inability to keep his arm up for extended periods. The 20 percent was the minimum assignable rating under DC 5201. The evidence does not show this additional loss prior to December 21, 2009. The criteria for a rating in excess of 20 percent are clearly not met when the Veteran's forward flexion and abduction have exceeded shoulder level throughout the period on appeal. The Board finds that the assignment of a noncompensable rating prior to December 21, 2009, and a 20 percent rating on and after that date is consistent with the evidence of record. The evidence does not satisfy the criteria for a compensable rating prior to December 21, 2009, or for a rating in excess of 20 percent on and after that date. The Board has considered other, potentially applicable Diagnostic Codes. The Veteran does not have ankylosis (DC 5200), humeral impairment (DC 5202), dislocation, nonunion or malunion of either the clavicle or scapula (DC 5203). The rating based on limitation of motion appears to be the most applicable Diagnostic Code. The Board has also considered the rule of DeLuca. The Veteran did not have additional functional loss shown by the evidence prior to December 21, 2009, either by his own report or found in the medical evidence. The Veteran did have additional functional loss, found on December 21, 2009, which has already been compensated by the assignment of the 20 percent rating. As such, the Board finds that the preponderance of the evidence is against the Veteran's left shoulder claim on a schedular basis. Consequently, the benefit-of-the-doubt rule does not apply, and the left shoulder claim must be denied on a schedular basis. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). b. Bilateral Knee Ratings The Veteran's right and left knee disabilities have been rated under DC 5260, for limitation of flexion. See 38 C.F.R. § 4.71a. The criteria for ratings on limitation of motion of the knee are in two groups, limitation of flexion and limitation of extension. Limitation of flexion of a leg warrants a noncompensable evaluation if flexion is limited to 60 degrees, a 10 percent evaluation if flexion is limited to 45 degrees, a 20 percent evaluation if flexion is limited to 30 degrees or a 30 percent evaluation if flexion is limited to 15 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2010). Limitation of extension of a leg warrants a noncompensable evaluation if extension is limited to 5 degrees, a 10 percent evaluation if extension is limited to 10 degrees, a 20 percent evaluation if extension is limited to 15 degrees, a 30 percent evaluation if extension is limited to 20 degrees, a 40 percent evaluation if extension is limited to 30 degrees or a 50 percent evaluation if extension is limited to 45 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2010). Separate ratings may be awarded for limitation of flexion and limitation of extension of the same knee joint. VAOPGCPREC 09-04 (Sept. 17, 2004). Service treatment records do not provide range of motion testing for either knee, despite many instances of treatment. The Veteran underwent a March 2008 VA examination which included evaluations of both knees. The Veteran had ranges of motion of extension to zero degrees and flexion to 140 degrees. The Veteran had pain at the end of the right knee range of motion. The Veteran also underwent a December 21, 2009, VA examination. The report indicates that the Veteran had range of motion of zero to 140 degrees in the left knee and zero to 135 degrees in the right. The Veteran's VA treatment records do not provide range of motion testing for either knee. The Board finds that the range of motion testing of record greatly exceeds even the criteria for a compensable rating for either extension or flexion of either knee throughout the period on appeal. An increased (compensable) rating for either the left or right knee on the basis of limitation of extension or flexion is not warranted for any portion of the appeal period. Knee instability is rated under DC 5257. 38 C.F.R. § 4.71a, DC 5257 (2010). A 10 percent rating requires slight recurrent subluxation or lateral instability of a knee. A 20 percent rating requires moderate subluxation or lateral instability of a knee. A 30 percent evaluation is warranted for severe knee impairment with recurrent subluxation or lateral instability. Id. Subluxation of the patella is "incomplete or partial dislocation of the knee cap." Rykhus v. Brown, 6 Vet. App. 354, 358 (1993) (citing Dorland's Illustrated Medical Dictionary at 1241, 1599 (27th edition 1988)). In rating instability, the Board observes that the words "slight," "moderate," and "severe," as used in the various diagnostic codes, are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The March 2008 VA examination report indicates that the Veteran's knees were stable on testing. The Veteran complained of giveway at his December 2009 VA examination. On examination, the Veteran had a normal gait and no instability was found in either knee. The remaining evidence does not reveal instability or reports of ligament problems since separation from service. The Board finds that the Veteran does not have ligament instability or patella subluxation to a "slight" degree. The Veteran has complaints of giveway, but no objective evidence of instability has been found. The Board finds that, in the absence of objective evidence, that the Veteran's complaints of giveway do not rise to the level of "slight" instability. A separate compensable rating under DC 5257 is not warranted for either knee at any time during the appeal period. Diagnostic Code 5258 (dislocated semilunar cartilage) and Diagnostic Code 5259 (removal of semilunar cartilage, symptomatic) both address issues of cartilage damage. A 10 percent rating is available for symptomatic removal of cartilage. 38 C.F.R. § 4.71a, DC 5259. This is the only rating available under this DC. See id. A 20 percent rating is available for dislocated, symptomatic cartilage with frequent episodes of "locking," pain and effusion into the joint. 38 C.F.R. § 4.71a, DC 5258. While the Veteran reports episodes of locking, his service treatment records and VA examination reports indicate negative McMurray's tests, which would show the presence of cartilage disorders, if positive. Similarly, the Veteran underwent a January 2010 MRI of both knees, which was not interpreted to show any cartilage disorders. The Board finds that the Veteran does not have current semilunar cartilage disorders. The Board finds that ratings under these provisions are not warranted for either knee. Additional Diagnostic Codes provide for additional ratings for disabilities of the knees depending on the symptoms shown. Since the record does not show that the Veteran's knee disorders involves ankylosis, tibia or fibula impairment, or genu recurvatum, additional ratings for the Veteran's knee disorders are not warranted under 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263 (2010). The Board has also considered the rule of DeLuca. The Veteran has been rated at a 10 percent level for the right knee throughout the period on appeal, despite his right knee objective findings exceeding the minimum criteria for a compensable rating under the range of motion Diagnostic Criteria, as discussed above. The Board finds that the Veteran has already been awarded a rating under the rule of DeLuca for the right knee. A further grant would constitute pyramiding. For the left knee, the RO granted a 10 percent, effective December 21, 2009, for objective evidence of additional functional loss first shown at the December 2009 VA examination. The Veteran complained of pain in his knees during the first VA examination in March 2008, but had no pain during testing, including repetitive testing, in the left knee. The Veteran was not tender in that knee at that time. He did not have crepitus in that knee at that time. The Veteran's VA treatment records do not show objective evidence of additional functional loss prior to December 21, 2009. The Board finds that the Veteran did not have additional functional loss due to pain, incoordination, fatiguability or lack of endurance prior to December 21, 2009. The Board concludes that a rating under the DeLuca criteria is not warranted prior to December 21, 2009. The Board further concludes that a rating under DeLuca is already in effect as of December 21, 2009, and that a further grant would constitute pyramiding. As such, the Board finds that the preponderance of the evidence is against the Veteran's bilateral knee claims on a schedular basis. Consequently, the benefit-of-the-doubt rule does not apply, and the claims must be denied on a schedular basis. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). c. Additional Considerations 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 evaluations for the Veteran's left shoulder and bilateral knee disabilities are not inadequate. The Veteran has not identified symptoms that are different from those anticipated by the ratings schedule. The Veteran's disabilities are rated incorporating all his complained of symptoms. It does not appear that the Veteran has an "exceptional or unusual" disability; he merely disagrees with the assigned evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected disorders that are unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations for those service-connected disabilities are adequate. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is moot. See Thun, supra. 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 has considered the possibility of staged ratings. The RO has already assigned staged ratings for the left shoulder and left knee disabilities. The Board, however, concludes that the criteria for further staged ratings for the left shoulder and left knee and staged ratings for the right knee have at no time been met, because the criteria for increased ratings beyond those assigned have not been met at any time. Accordingly, further staged ratings are inapplicable. See id. As such, the Board finds that the preponderance of the evidence is against the Veteran's increased rating claims. Consequently, the benefit-of-the-doubt rule does not apply, and the claims must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to service connection for a bilateral hip disability, to include as secondary to a service-connected disability, is denied. Entitlement to an initial compensable rating prior to December 21, 2009, and in excess of 20 percent on and after that date, for supraspinatus and trapezius muscle sprain of the left shoulder is denied. Entitlement to an initial rating in excess of 10 percent for chondromalacia of the femoral condyle and patellofemoral pain syndrome of the right knee is denied. Entitlement to an initial compensable rating prior to December 21, 2009, and in excess of 20 percent on and after that date, for chondromalacia of the patella and patellofemoral pain syndrome of the left knee is denied. REMAND The Veteran indicated in his right shoulder pain had been increasing during his hearing before the undersigned. He testified further that the shoulder felt like it did just before his 2008 surgery. The Board notes that the Veteran's last VA examination in connection with his claim was in December 2009. As the Veteran's statements suggest an increase in symptomatology since his last VA examination, the Board finds that an additional evaluation would be helpful in resolving the issues raised by the instant appeal. The Veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination. Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). Additionally, the Veteran reports that he receives ongoing treatment through the VA Medical Center (VAMC) in Iowa City and the satellite clinic in Bettendorf for his right shoulder. The records on file reflect treatment only through January 2010. To correctly assess the Veteran's current disability, all records of treatment from January 2010 to the present must be considered. Therefore, those records must be obtained for the file. Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's medical records from the Iowa City VAMC for treatment concerning the right shoulder disability from January 2010 to the present. All efforts to obtain VA records should be fully documented, and the VA facility must provide a negative response if records are not available. 2. Schedule the Veteran for a VA examination to determine the current nature and severity of his right shoulder mild osteoarthritis of the acromioclavicular joint and labral tear, status post SLAP repair. Sufficient evaluations should be scheduled to evaluate the Veteran's symptomatology. All indicated tests and studies should be accomplished and the findings then reported in detail. The examiner should identify the limitation of motion imposed by the Veteran's service-connected right shoulder disability with a full description of the effect of the disabilities upon his ordinary activities. The examiner should fully describe any weakened movement, excess fatigability, and incoordination present. Any other pertinent pathology shown on evaluation should be acknowledged in the examination report. 3. Then, the RO should readjudicate this increased rating claim remaining on appeal. If the benefit sought is not granted, the Veteran and his representative should be furnished a SSOC and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claim. His cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ THERESA M. CATINO Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs