Citation Nr: 1302118 Decision Date: 01/18/13 Archive Date: 01/23/13 DOCKET NO. 10-37 229 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for a right shoulder disability. 2. Entitlement to an initial rating in excess of 10 percent for a right knee disability. 3. Entitlement to an initial rating in excess of 10 percent for degenerative changes of the thoracic spine. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs ATTORNEY FOR THE BOARD David S. Ames, Counsel INTRODUCTION The Veteran served on active duty from June 2002 to June 2006 and from April 2008 to March 2009. This matter comes properly before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office in Milwaukee, Wisconsin (RO). FINDINGS OF FACT 1. The medical evidence of record shows that the Veteran's right shoulder disability is manifested by pain and limitation of right shoulder motion to, at most, 170 degrees of flexion, 168 degrees of abduction, 90 degrees of external rotation, and 70 degrees of internal rotation. 2. The medical evidence of record shows that the Veteran's right knee disability is manifested by pain, crepitus, patellar grind, and limitation of motion to, at most, 130 degrees of flexion and 0 degrees of extension. 3. The medical evidence of record shows that the Veteran's back disability is manifested by pain, spasm, and limitation of motion to, at most, 65 degrees of flexion, 30 degrees of extension, 30 degrees of right lateral flexion, 30 degrees of left lateral flexion, 30 degrees of right rotation, and 30 degrees of left rotation. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for right shoulder rotator cuff tendonitis have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5201, 5203 (2012). 2. The criteria for an initial rating in excess of 10 percent for right knee patellofemoral stress syndrome have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012). 3. The criteria for an initial rating in excess of 10 percent for degenerative changes of the thoracic spine have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the Veteran is harmless because of the thorough and informative notices provided throughout the adjudication and because the Veteran had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the Veteran, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letter dated in April 2009. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls upon the party attacking the agency determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and his representative suggest actual knowledge of the elements necessary to substantiate the claim. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Thus, VA has satisfied its duty to notify the Veteran and had satisfied that duty prior to the adjudication in the supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the Veteran of any evidence that could not be obtained. The Veteran has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to the claims. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2012). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). The Board may only consider the specific factors enumerated in the applicable rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2012); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). The appeal of the Veteran's claims are based on the assignment of initial ratings following initial awards of service connection for right shoulder rotator cuff tendonitis, degenerative changes of the thoracic spine, and right knee patellofemoral stress syndrome. As such, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial ratings were assigned and should be the evidence used to decide whether an original rating on appeal was erroneous. Fenderson v. West, 12 Vet. App. 119 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson v. West, 12 Vet. App. 119 (1999). Right Shoulder Service connection for right shoulder rotator cuff tendonitis was granted by a May 2009 rating decision and a 10 percent rating was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5203, effective March 26, 2009. In the selection of diagnostic code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With injuries and diseases, preference is to be given to the number assigned to the injury or disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. Unlisted disabilities requiring rating by analogy will be coded by the numbers of the most closely related body part and 99. 38 C.F.R. § 4.27 (2012). The hyphenated diagnostic code in this case indicates that an unlisted musculoskeletal disability, under Diagnostic Code 5299, was the service-connected disability, and impairment of the clavicle or scapula, under Diagnostic Code 5203, was a residual disability. In a May 2009 VA general medical examination report, the Veteran reported that he was right handed and complained of constant pain over the anterior of his right shoulder. He reported that it improved with massages and did not flare-up. The Veteran was reported to have been on a physical profile at the time of his last discharge from active service which restricted pushups and upper body work, and he reported that he presently did not do much lifting and did not play sports. On physical examination, the Veteran's right shoulder had anterior tenderness that was not localized to the biceps tendon, but there was no weakness or deformity. The Veteran had right shoulder range of motion to 180 degrees of flexion, 90 degrees of extension, 180 degrees of abduction, 90 degrees of internal rotation, and 90 degrees of external rotation. Minimal subjective discomfort was noted on both extension and external rotation. On x-ray examination, the Veteran's right shoulder was normal without fracture, dislocation, or degenerative changes. The assessment was right shoulder rotator cuff tendonitis. In a May 2009 VA outpatient medical report, the Veteran complained of right anterior shoulder pain. He reported that he had a full range of motion, but experienced pain with certain motions, sometimes severe. The Veteran also reported that he could not throw balls and experienced constant pain. On physical examination, there was right should pain with palpation of the anterior portion of the shoulder, with some increased tenderness with palpation of the biceps tendon. The Veteran had a full right shoulder range of motion, and experienced the most pain with lifting and externally rotating and then coming forward, as with throwing a baseball. Strength testing was normal. Following repetitive motion, there was no additional functional impairment due to pain, weakness, fatigability, incoordination, or repetition. No opinion could be made without resort to mere speculation regarding additional impairment during a flare-up due to the fact that a flare-up was not occurring during the examination. The assessment was right shoulder pain which limited his activities. A November 2009 VA magnetic resonance imaging (MRI) examination of the Veteran's right shoulder gave an impression of labral tears involving the anterior labrum and the posteroinferior labrum, with no evidence of rotator cuff pathology. In a December 2009 VA orthopedic surgery consultation report, the Veteran complained of right shoulder pain which had grown progressively worse over the previous year. He reported that the pain was worse with overhead activity, at night, and with any type of throwing activities. He denied experiencing numbness, tingling, weakness, instability, or apprehension. On physical examination, the Veteran had right shoulder range of motion to 170 degrees of flexion, with pain at the end of the range; 170 degrees of abduction, with pain at the end of the range; 90 degrees of external rotation; and 45 degrees of internal rotation. Apprehension, load, shift, and impingement tests were negative and no abnormalities of strength were noted. There was significant tenderness to palpation in the bicipital groove, as well as some pain in the posterior aspect of the shoulder joint. There was no tenderness to palpation over the anterolateral or lateral aspects of the shoulder or in the acromioclavicular joint. No neurovascular abnormalities were noted. On x-ray examination of the Veteran's right shoulder, no acute facture, dislocation, or malalignment were identified. The impression was no radiographic abnormality of the right shoulder. Following a review of the Veteran's MRI, the assessment was findings consistent with some bicipital tendonitis and some mild labral pathology. A February 2010 VA outpatient medical report gave an assessment of persistent right shoulder pain. In a December 2010 VA report of contact, the Veteran reported that he had not received treatment for his right shoulder disability since December 2009. He reported that while the shoulder was still sore, he was doing stretching exercises which helped. In a January 2011 VA general medical examination report, the Veteran denied experiencing constant right shoulder pain, though he reported experiencing flare-ups a couple times per week with increased activity. He reported that he was not on any restriction at work due to his shoulder, but stated that he favored his right arm, particularly during flare-ups. The Veteran stated that, overall, his right shoulder disorder did not really restrict him. On physical examination, no impingement, synovitis, or swelling was noted. The Veteran had painless right shoulder range of motion to 180 degrees of flexion, 168 degrees of abduction, 70 degrees of internal rotation, and 90 degrees of external rotation. Following repetitive motion, there was no additional functional impairment due to pain, weakness, fatigability, incoordination, or repetition. No opinion could be made without resort to mere speculation regarding additional impairment during a flare-up due to the fact that a flare-up was not occurring during the examination. The assessment was chronic right shoulder bicipital tendinitis and mild labral tears. The examiner stated that the Veteran's right shoulder disorder was mild and did not restrict work in any significant way. The medical evidence of record shows that the Veteran's right shoulder disability is manifested by pain and limitation of right shoulder motion to, at most, 170 degrees of flexion, 168 degrees of abduction, 90 degrees of external rotation, and 70 degrees of internal rotation. The evidence of record shows that the Veteran is right-handed. Therefore, for rating purposes, his right shoulder is considered his major or dominant extremity. 38 C.F.R. § 4.69 (2012). Under Diagnostic Code 5203, impairment of the major clavicle or scapula warrants a 10 percent rating for malunion or nonunion without loose movement. A 20 percent rating is warranted for nonunion with loose movement or dislocation. 38 C.F.R. § 4.71a, Diagnostic Code 5203 (2012). The medical evidence of record does not show that the Veteran's right shoulder disability has been manifested by nonunion or dislocation of the clavicle or scapula at any point during the period on appeal. Accordingly, a rating in excess of 10 percent is not warranted under Diagnostic Code 5203 at any point during the period on appeal. Under Diagnostic Code 5201, limitation of motion of the major arm at shoulder level warrants a 20 percent rating, limitation of motion of the major arm midway between the side and shoulder level warrants a 30 percent rating, and limitation of motion of the major arm to 25 degrees from the side warrants a 40 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2012). The normal range of motion of a shoulder is from 0 degrees to 180 degrees on forward flexion and abduction, with shoulder level existing at 90 degrees, and from 0 degrees to 90 degrees on external and internal rotation. 38 C.F.R. § 4.71, Plate I (2012). The medical evidence of record does not show that motion of the Veteran's right arm has ever been limited to shoulder level, even with consideration of pain on motion. Accordingly, an initial rating in excess of 10 percent is not warranted for the Veteran's right shoulder disability under Diagnostic Code 5201. 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2012). In addition, there is no medical evidence of record that the Veteran's right shoulder has ever been ankylosed, experienced impairment of the humerus, or had a diagnosis of osteoarthritis as shown through x-ray examination. Therefore, a rating in excess of 10 percent is also not warranted under Diagnostic Codes 5200 and 5202, at any point during the period on appeal. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5200, 5202 (2012). The Veteran has reported right shoulder pain on use, a contention which is substantiated by the medical evidence of record. However, the May 2009 VA general medical examination report stated that the Veteran's pain was minimal, the December 2009 VA orthopedic surgery consultation report stated that the pain occurred at the ends of the ranges of motion, and the January 2011 VA general medical examination report stated that the range of motion that was measured only included painless motion. There is no evidence of record which indicates that the Veteran's right shoulder pain ever limited his right shoulder range of motion to shoulder level or below. Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Accordingly, the preponderance of the medical evidence of record does not demonstrate that the Veteran experienced pain or other symptoms which caused additional limitations sufficient to warrant a rating in excess of 10 percent for the Veteran's right shoulder disorder. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). This claim has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's right shoulder symptoms, the evidence shows no distinct periods of time when his symptoms have varied to such an extent that a rating in excess of the currently assigned rating would be warranted for under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012); Fenderson v. West, 12 Vet. App. 119 (1999). Generally, rating a disability using either the corresponding or analogous diagnostic codes contained in the Schedule is sufficient. 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular ratings for that disability are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); Fisher v. Principi, 4 Vet. App. 57 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria under the Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Schedule, and the assigned schedular rating is adequate, and no referral is required. When service-connected disability affects employment in ways not contemplated by the rating schedule, § 3.321(b)(1) is applicable. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities rating for his right shoulder disorder inadequate. The Veteran's right shoulder disorder was rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5201, 5203 (2012), the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's right shoulder disability is manifested by pain and limitation of right shoulder motion to, at most, 170 degrees of flexion, 168 degrees of abduction, 90 degrees of external rotation, and 70 degrees of internal rotation. When comparing that disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the disability rating currently assigned for his right shoulder disorder. Ratings in excess of the currently assigned rating are provided for certain manifestations of shoulder disabilities, but the medical evidence does not show that those manifestations are present. The Board finds that the criteria for the currently assigned rating for the Veteran's right shoulder disorder reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular rating is adequate and no referral is required. The Board finds that the evidence does not show frequent hospitalization or marked interference with employment. The evidence shows that the Veteran is employed and that his right shoulder does not cause any significant impact on his occupational abilities. He is under no restrictions at work. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.71a, Diagnostic Codes 5201, 5203 (2012). The Board finds that the preponderance of the evidence is against the claim for an increased rating for right shoulder rotator cuff tendonitis. Therefore, the claim is denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Right Knee Service connection for right knee patellofemoral stress syndrome was granted by a May 2009 rating decision and a 0 percent rating was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5260, effective March 26, 2009. The hyphenated diagnostic code in this case indicates that an unlisted musculoskeletal disability, under Diagnostic Code 5299, was the service-connected disability, and limitation of flexion of the leg, under Diagnostic Code 5260, was a residual disability. Subsequently, an August 2010 rating decision assigned a 10 percent rating for right knee patellofemoral stress syndrome under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5260, effective March 26, 2009. In a May 2009 VA general medical examination report, the Veteran complained of right knee popping and giving way, with a spasm sensation on either side of the patella. He also reported pain on the side of the knee cap and behind the knee. The Veteran denied having symptoms when inactive, unless sitting with the knee flexed. However, he reported experiencing pain with crouching, running, or sitting with his knees flexed for an extended period. The Veteran denied locking. He reported that he experienced flare-ups with increased pain resulting in limping approximately two to three times per week. He stated that the flare-ups resolved when he could "pop" his knee. The Veteran also reported that the symptoms increased in the winter. He reported that he did not limit his activities due to his knee, though he could not run as well. On physical examination of the Veteran's right knee, there was no tenderness, swelling, erythema, increased warmth, or deformity. Lachman's, McMurray's, and posterior drawer sign tests were negative. The Veteran's medial and lateral ligaments were intact without patellar grind. The Veteran had painless right knee range of motion to 140 degrees of flexion and 0 degrees of extension. Following repetitive motion, there was no additional functional impairment due to pain, weakness, fatigability, incoordination, or repetition. No opinion could be made without resort to mere speculation regarding additional impairment during a flare-up due to the fact that a flare-up was not occurring during the examination. On x-ray examination, the Veteran's right knee was normal. The assessment was right knee patellofemoral stress syndrome. In a June 2009 VA addendum, the Veteran reported that he had fallen up the stairs a few days before and was experiencing pain and popping in his knee. In a July 2009 VA outpatient medical report, the Veteran complained of right knee pain. He denied locking, but reported that the knee had given out several times and popped when he walked. The Veteran reported that the pain was mainly in the anterior knee, medial and lateral to the patella. He also reported knee swelling and significant pain with running. On physical examination of the Veteran's right knee, there was no effusion. The Veteran had a full range of motion with mild crepitus. There was tenderness medial and lateral to the patella, but the pes anserine area was not tender to palpation. Anterior drawer sign and Lachman's test were negative. The assessment was right knee persistent problem. A November 2009 VA MRI examination of the Veteran's right knee gave an impression of no evidence of ligamentous injury. In a January 2011 VA general medical examination report, the Veteran reported experiencing constant mild pain in his right knee with frequent popping. He denied experiencing flare-ups and locking. He reported that he was not on any restriction at work due to his knee, and stated that his right knee disability did not restrict his work except that it slowed him down. On physical examination, no tenderness, swelling, erythema, increased warmth, or deformity were noted. Lachman's, McMurray's and posterior drawer sign tests were negative. The medial and lateral ligaments were intact, though there was positive patellar grind. There was no instability of the right knee. The Veteran had painless right knee range of motion to 130 degrees of flexion and 0 degrees of extension. Following repetitive motion, there was no additional functional impairment due to pain, weakness, fatigability, incoordination, or repetition. No opinion could be made without resort to mere speculation regarding additional impairment during a flare-up due to the fact that a flare-up was not occurring during the examination. The assessment was right knee patellofemoral stress syndrome. The examiner stated that the Veteran's right knee disorder was mild and did not restrict work in any significant way. Limitation of motion of knee joints is rated under Diagnostic Code 5260 for flexion, and Diagnostic Code 5261 for extension. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012). Under Diagnostic Code 5260, flexion that is limited to 60 degrees is warrants a 0 percent rating; flexion that is limited to 45 degrees warrants a 10 percent rating; and flexion that is limited to 30 degrees warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). Under Diagnostic Code 5261, extension that is limited to 5 degrees warrants a 0 percent rating; extension that is limited to 10 degrees warrants a 10 percent rating; and extension that is limited to 15 degrees warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). Normal motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2012). Recurrent subluxation or lateral instability of the knee warrants a 10 percent rating when it is slight and a 20 percent rating when it is moderate. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). The medical evidence of record shows that the Veteran's right knee disability is manifested by pain, crepitus, patellar grind, and limitation of motion to, at most, 130 degrees of flexion and 0 degrees of extension. Accordingly, the Board finds that a rating in excess of 10 percent is not warranted for the right knee under either Diagnostic Codes 5260 or 5261. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012). In addition, separate ratings for limitation of flexion and extension are not warranted, as the record does not show that the Veteran's right knee ranges of motion have ever been limited to a compensable degree in either flexion or extension. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012); VAOPGCPREC 9-04 (2004), 69 Fed. Reg. 59990 (2004). The Veteran has reported right knee pain on use, a contention which is substantiated by the medical evidence of record. However, the May 2009 VA general medical examination report and the January 2011 VA general medical examination report both stated that the ranges of motion that were measured only included painless motion. There is no evidence of record which indicates that the Veteran's right knee pain ever limited his right knee range of motion to 45 degrees of flexion or 10 degrees of extension. Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Accordingly, the preponderance of the medical evidence of record does not demonstrate that the Veteran experienced pain or other symptoms which caused additional limitations sufficient to warrant a rating in excess of 10 percent for the Veteran's right knee disorder. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). As for other provisions under the Schedule, the Veteran's right knee has never been ankylosed, there was no malunion or nonunion of either the tibia and fibula, there were no symptoms from the removal or dislocation of semilunar cartilage, and the Veteran does not have arthritis of the right knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5256, 5258, 5259, 5262 (2012); VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56704 (1998). Accordingly, an initial rating in excess of 10 percent is not warranted under these diagnostic codes. Furthermore, a separate rating for instability is not warranted for the right knee, as the medical evidence of record does not show recurrent subluxation or lateral instability. While the Veteran reported experiencing instability on multiple occasions, no instability has ever been found on physical examination. The Board finds the objective examination findings of no instability more persuasive. Accordingly, a separate rating for instability is not warranted for the Veteran's right knee disorder. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). This claim has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's right knee symptoms, the evidence shows no distinct periods of time when his symptoms have varied to such an extent that a rating in excess of the currently assigned rating would be warranted for under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012); Fenderson v. West, 12 Vet. App. 119 (1999). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities rating for his right knee disability inadequate. The Veteran's right knee disorder was rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012), the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's right knee disability is manifested by pain, crepitus, patellar grind, and limitation of motion to, at most, 130 degrees of flexion and 0 degrees of extension. When comparing that disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the disability rating currently assigned for his right knee disorder. Ratings in excess of the currently assigned rating are provided for certain manifestations of knee disorders, but the medical evidence does not show that those manifestations are present. The Board finds that the criteria for the currently assigned rating for the Veteran's right knee disorder reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular rating is adequate and no referral is required. The Board finds that the evidence does not show frequent hospitalization or marked interference with employment. The evidence shows that the Veteran is employed and that his right knee does not cause any significant impact on his occupational abilities. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012). The Board finds that the preponderance of the evidence is against the claim for an increased rating for right knee patellofemoral stress syndrome. Therefore, the claim is denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Thoracic Spine Service connection for degenerative changes of the thoracic spine was granted by a May 2009 rating decision and a 10 percent rating was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5242, effective March 26, 2009. In a May 2009 VA general medical examination report, the Veteran complained of pain in the mid back which hurt if he pushed on it, such as with leaning or when his back was hit in that location. He reported that it did not bother him if he was active, and it was a very localized spot which did not involve the lumbar spine. The Veteran denied flare-ups or radicular symptoms, but reported a lot of pain recently due to sitting which pushed on the area. He also denied any associated features, impairment of gait, unsteadiness, or falls. The Veteran denied having any physician prescribed total bed rest in the previous 12 months. He reported that he did not let his back disorder limit his activity. On physical examination, there was very localized tenderness to palpation over T10 to T11, without paraspinal muscle tenderness or spasm. Straight leg raise testing was negative, and no abnormalities of reflex, sense, or muscle were noted. The Veteran's lumbar/thoracic spine range of motion was to 90 degrees of flexion, 30 degrees of extension, 30 degrees of right lateral flexion, 30 degrees of left lateral flexion, 30 degrees of right rotation, and 30 degrees of left rotation. All of the ranges of motion were reported to be painless, except for right and left rotation which had minimal subjective discomfort. Following repetitive motion, there was no additional functional impairment due to pain, weakness, fatigability, incoordination, or repetition. No opinion could be made without resort to mere speculation regarding additional impairment during a flare-up due to the fact that a flare-up was not occurring during the examination. On x-ray examination, the Veteran's lumbar spine was normal, but his thoracic spine had very minimal spurring. The assessment was thoracic spine degenerative changes. In a February 2010 VA outpatient medical report, the Veteran complained of intermittent problems with his low back. He reported that it hurt to lift more than 40 pounds, and he used ice and a massaging shower head. In a March 2010 VA telephone triage report, the Veteran complained of chronic mid to low back pain and stiffness for the previous three weeks. He reported increased urinary frequency, but denied dysuria, hematuria, or constant urinary urgency. In an April 2010 VA outpatient medical report, the Veteran complained of increasing low back pain over the previous several months. He reported that he called VA about the problem the previous month but then thought it would improve. The Veteran reported that the pain increased with doing full sit-ups and some of the physical training requirements for the Army Reserves. He reported that the pain was mainly in the L1-L3 areas and did not radiate to his legs. He denied loss of bowel or bladder control, as well as any gait disturbance. On physical examination of the Veteran's back, there was no pain with palpation of the spinous processes. Spasm and tenderness of the paraspinous muscles was noted in the L1-L3 area. He had a full range of motion at the waist, but there was pain on full flexion. An April 2010 letter from a VA physician stated that the Veteran had a history of low back pain and would be better not doing long runs with backpacks if possible, as it consistently exacerbated his chronic back problem. In a January 2011 VA general medical examination report, the Veteran complained of constant back pain. He reported that it occurred in the center of his back and sometimes radiated down his back, but otherwise stayed in one place. He denied any flare-ups, impairment of gait, unsteadiness, falling, or incapacitating episodes. He reported that he was not on any restriction at work due to his back, and stated that his back disability did not hinder him except that it slowed him down. On physical examination, the Veteran's gait was normal. There was moderate lower thoracic vertebral tenderness, but no paraspinal muscle tenderness or spasm. Straight leg raise testing was negative, and no abnormalities were noted on reflex, sensory, or motor testing. The Veteran had lumbar/thoracic spine range of motion to 65 degrees of flexion, 30 degrees of extension, 30 degrees of right lateral flexion, 30 degrees of left lateral flexion, 30 degrees of right rotation, and 30 degrees of left rotation. All of the ranges of motion were painless, except for extension which had terminal pain. Following repetitive motion, there was no additional functional impairment due to pain, weakness, fatigability, incoordination, or repetition. No opinion could be made without resort to mere speculation regarding additional impairment during a flare-up due to the fact that a flare-up was not occurring during the examination. The assessment was degenerative change of the thoracic spine. The examiner stated that the Veteran's spine disability was mild and did not restrict work in any significant way. The Veteran's service-connected back disability is rated under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5242. Diagnostic Code 5242 provides that degenerative arthritis of the spine is to be rated under the General Rating Formula for Diseases and Injuries of the Spine. The General Rating Formula states that a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, General Rating Formula (2012). Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are rated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula (2012). The medical evidence of record shows that the Veteran's back disability is manifested by pain, spasm, and limitation of motion to, at most, 65 degrees of flexion, 30 degrees of extension, 30 degrees of right lateral flexion, 30 degrees of left lateral flexion, 30 degrees of right rotation, and 30 degrees of left rotation. There is no medical evidence of record that the Veteran's thoracolumbar spine has ever been limited to 60 degrees or less of forward flexion, had a combined range of motion not greater than 120 degrees, or had muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. While muscle spasm was noted on physical examination in April 2010, there is no evidence that the Veteran has ever had an abnormal gait or abnormal spinal contour. The Veteran has reported back pain on use, a contention which is substantiated by the medical evidence of record. However, the May 2009 VA general medical examination report and the January 2011 VA general medical examination report both stated that the ranges of motion that were measured were painless motion, with the exception of minimal pain on bilateral rotation in May 2009 and terminal pain on extension in January 2011. There is no evidence of record which indicates that the Veteran's back pain ever limited his thoracolumbar spine range of motion to 60 degrees of forward flexion or less or a combined range of motion not greater than 120 degrees. Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Accordingly, the preponderance of the medical evidence of record does not demonstrate that the Veteran experienced pain or other symptoms which caused additional limitations sufficient to warrant a rating in excess of 10 percent for the Veteran's back disorder. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). Accordingly, a rating in excess of 10 percent is not warranted under the General Rating Formula for the orthopedic manifestations of the Veteran's service-connected back disability. 38 C.F.R. § 4.71a, General Rating Formula, Diagnostic Code 5242 (2012). With regard to the neurologic manifestations of the Veteran's back disability, the Veteran has never reported experiencing any associated neurological symptoms, including lower extremity radiculopathy, bowel impairment, or bladder impairment. In addition, there is no medical evidence of record that there are any neurologic manifestations of the Veteran's back disability. Therefore, a separate rating for neurologic manifestations of the Veteran's back disorder is not warranted. 38 C.F.R. § 4.71a, General Rating Formula (2012). The Board has also considered evaluating the Veteran's back disability under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Under the Formula for Rating Intervertebral Disc Syndrome, a 10 percent rating is warranted for incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS (2012). For the purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (2012). The evidence of record does not show that the Veteran has ever experienced symptoms requiring bed rest prescribed by a physician at any point during the period on appeal. In May 2009, the Veteran denied having any physician prescribed total bed rest in the previous 12 months, while in January 2011 he denied experiencing any incapacitating episodes. There is no medical evidence of record that any physician has prescribed bed rest, of any duration, for the Veteran's back symptoms at any point during the period on appeal. Accordingly, the medical evidence of record does not show that the Veteran has ever been prescribed bed rest by a physician for a period of at least two weeks in any one year period. Therefore, a rating in excess of 10 percent is not warranted under the Formula for Rating IVDS. 38 C.F.R. § 4.71a, Formula for Rating IVDS (2012). This claim has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's back symptoms, the evidence shows no distinct periods of time when his symptoms have varied to such an extent that a rating in excess of the currently assigned rating would be warranted for under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012); Fenderson v. West, 12 Vet. App. 119 (1999). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities rating for his back disorder inadequate. The Veteran's back disorder was rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2012), the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's back disability is manifested by pain, spasm, and limitation of motion to, at most, 65 degrees of flexion, 30 degrees of extension, 30 degrees of right lateral flexion, 30 degrees of left lateral flexion, 30 degrees of right rotation, and 30 degrees of left rotation. When comparing that disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the disability rating currently assigned for his back disorder. Ratings in excess of the currently assigned rating are provided for certain manifestations of back disorders, but the medical evidence does not show that those manifestations are present. The Board finds that the criteria for the currently assigned rating for the Veteran's back disorder reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular rating is adequate and no referral is required. The Board finds that the evidence does not show frequent hospitalization or marked interference with employment. The evidence shows that the Veteran is employed and that his back does not cause any significant impact on his occupational abilities. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2012). The Board finds that the preponderance of the evidence is against the claim for an increased rating for degenerative changes of the thoracic spine. Therefore, the claim is denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). ORDER A rating in excess of 10 percent for right shoulder rotator cuff tendonitis is denied. A rating in excess of 10 percent for right knee patellofemoral stress syndrome is denied. A rating in excess of 10 percent for degenerative changes of the thoracic spine is denied. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs