Citation Nr: 1312830 Decision Date: 04/17/13 Archive Date: 05/02/13 DOCKET NO. 06-20 467 ) DATE ) ) On appeal from the Department of Veterans Affairs(VA) Regional Office (RO) in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for flat feet. 2. Entitlement to service connection for a right knee disability. 3. Entitlement to service connection for a left knee disability. 4. Entitlement to an initial, compensable rating for impingement syndrome of the left shoulder, prior to November 12, 2005. 5. Entitlement to a rating in excess of 20 percent for impingement syndrome of the left shoulder, from November 12, 2005. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A.J. Turnipseed, Counsel INTRODUCTION The Veteran served on active duty from March 2003 to March 2004; he also had prior, verified periods of active duty for training (ACDUTRA) from June 1992 to August 1992, and from June 1993 to August 1993. This appeal to the Board of Veterans' Appeals (Board) arose from a May 2004 rating decision in which the RO granted the Veteran's claim for service connection for impingement syndrome of the left shoulder and awarded a zero percent (noncompensable) rating, effective March 9, 2004, and denied his claims for service connection for flat feet, residuals of left knee surgery, and residuals of right knee surgery. In April 2005, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC) was issued in March 2006, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in May 2006. In August 2007, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge at the RO; a transcript of that hearing is of record. In January 2008, the Board remanded the claims on appeal to the RO, via the Appeals Management Center (AMC) in Washington, DC, for further action, to include additional development of the evidence. After accomplishing further action, the RO granted a higher rating of 20 percent for the Veteran's left shoulder disability, effective April 1, 2010. The RO continued to deny the claims for service connection for a right knee disability, a left knee disability, and for flat feet (as reflected in a May 2010 supplemental SOC (SSOC)) and returned these matters to the Board. In an April 2011 decision, the Board determined that the Veteran met the criteria for a 20 percent rating for impingement syndrome of the left shoulder from November 12, 2005, but denied a compensable rating prior to that date and a rating in excess of 20 percent from that date. At that time, the Board also remanded the claims for service connection for right and left knee disorders and for flat feet to the RO, via the AMC, for additional evidentiary development. The Veteran appealed the Board's April 2011 decision to the United States Court of Appeals for Veterans Claims (Court). In October 2011, the Court granted a the joint motion for remand filed by representatives for both parties, vacating that portion of the decision in which the Board denied a compensable rating for impingement syndrome of the left shoulder prior to November 12, 2005 and a rating for the left shoulder disability in excess of 20 percent from that date, and remanding these matters to the Board for further proceedings consistent with the joint motion. In July 2012, the Board remanded the claims for higher ratings to the RO, via the AMC, for action consistent with the Court Order and joint motion for remand, including scheduling the Veteran for a new VA examination. After accomplishing the requested actions, the AMC continued to deny each claim for higher rating, and returned these matters to the Board for further appellate consideration. The Board's decision addressing the claims for higher ratings for service-connected left shoulder impingement syndrome is set forth below. The claims for service connection for flat feet, a right knee disability, and a left knee disability are addressed in the remand following the order; those matters are being remanded to the RO, via the AMC. VA will notify the Veteran when further action, on his part, is required. As a final preliminary matter, the Board again notes, as noted in the July 2012 Board remand, that, in the joint motion, the parties indicated that the Veteran had raised the issue of entitlement to a convalescence rating under 38 C.F.R. § 4.30 due to surgery performed on his service-connected left shoulder disability in October 2008; however, it does not appear that any action has been taken with respect to this matter has not been addressed by the RO, it is not properly before the Board. Hence, it is again referred to the RO for appropriate action. \ FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each matter herein decided have been accomplished. 2. As the Veteran is right-handed, his service-connected left shoulder disability involves his minor extremity. 3. Prior to November 12, 2005, the Veteran's impingement syndrome of the left shoulder was manifested by pain, tenderness, and limitation of flexion to no less than 180 degrees and abduction to no less than 160 degrees. There is no competent and credible lay or medical evidence of painful motion in the left shoulder prior to November 2005. 4. As of November 12, 2005, the Veteran's impingement syndrome of the left shoulder has been manifested by continued pain and limitation of motion to no less than 68 and 78 degrees in flexion and abduction, respectively, including as a result of pain or other functional impairment. CONCLUSIONS OF LAW 1. The criteria for an initial, compensable rating for impingement syndrome of the left shoulder, prior to November 12, 2005, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (2012). 2. The criteria for a rating in excess of 20 percent for impingement syndrome of the left shoulder, from November 12, 2005, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claims, as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claims; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claims, in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353 -23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO, to include the AMC). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, in a March 2004 letter, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate what was then a claim for service connection, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The May 2004 RO rating decision reflects the initial adjudication of the claim after issuance of the March 2004 letter. After the award of service connection, and the Veteran's disagreement with the initial, noncompensable rating assigned, the SOC set forth the criteria for higher ratings (the timing and form of which suffices, in part, for Dingess/Hartman). Moreover, a February 2008 letter provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. After issuance of the February 2008 letter, and opportunity for the Veteran to respond, the May 2010 supplemental SOC (SSOC) reflects readjudication of the claims. Hence, the Veteran is not shown to be prejudiced by the timing of this notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); 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 in an SOC or SSOC, is sufficient to cure a timing defect). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters herein decided. Pertinent medical evidence associated with the claims file consists of the reports of VA examinations conducted in April 2004, November 2005, April 2010, and October 2012. The evidentiary record also includes VA treatment records dated from 2006 to 2013, to include records dated from 2009 to 2013 that appear in the paperless, electronic (Virtual VA) file associated with the Veteran's paper claims file (which have also been considered by the RO). Also of record and considered in connection with the appeal are the August 2007 hearing transcript and the various written statements provided by the Veteran, and by his representative, on his behalf. The Board also finds that no additional RO action to further develop the record in connection with either claim, prior to appellate consideration, is required. As for the August 2007 Board hearing, the Board points out that the Veteran appeared, along with his authorized representative, and provided testimony on the matters herein decided. The transcript from that hearing reflects that the Veteran was afforded the opportunity to present hearing testimony, argument and evidence. The transcript also reflects appropriate exchanges between the Veteran and the undersigned Veterans Law Judge, in accordance with Stuckey v. West, 13 Vet. App. 163 (1999) and Constantino v. West, 12 Vet. App. 517 (1999). The transcript further reflects that the Veterans Law Judge identified and explained the material issues herein decided, and suggested the submission of evidence that would support the claims. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Board hearing is, thus, legally sufficient. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices, the Veteran has been notified and made aware of the evidence needed to substantiate the claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with either claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matters on appeal, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). ). However, where, as here, the questions for consideration involve entitlement to an initial and subsequently-assigned rating, evaluation of the medical evidence since the award of service connection to consider the appropriateness of "staged ratings" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999) Historically, by rating decision of May 2004, the RO granted service connection for left shoulder impingement syndrome, and assigned an initial, zero percent (noncompensable) rating under the provisions of 38 C.F.R. § 4.118, Diagnostic Code (DC) 5201, effective March 9, 2004. In a May 2010 rating decision, the RO assigned a 20 percent rating, effective April 1, 2010. In a May 2011 rating decision, the Veteran's 20 percent rating was made effective from November 12, 2005. Here, because the RO has already assigned stage ratings for the disability under consideration, the Board will consider the propriety of the rating at each stage, as well as whether any further staged rating is warranted. At the outset, the Board notes that the evidence establishes the Veteran is right-hand dominant; thus, his service-connected left shoulder disability involves his minor extremity. With respect to the minor extremity, DC 9501 provides that limitation of the arm at shoulder level or midway between side and shoulder level warrants a 20 percent rating. A 30 percent rating is warranted for limitation of arm motion at 25 degrees from side. 38 C.F.R. § 4.71a. The Board also notes that, when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Further, in claims for higher ratings for musculoskeletal disabilities, where the Veteran has a noncompensable rating and complains of pain on motion, he may be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton, supra; Id. Review of the record reveals the Veteran's service-connected left shoulder disability is manifested by subjective complaints of left shoulder pain, weakness, and a feeling of instability. The Veteran has consistently reported that he has difficulty lifting his left arm above shoulder level or higher and that he is unable to use his arm. He has also reported that he experiences pain, including at rest, and that his pain results in difficulty sleeping and performing his job. See April 2005 NOD; May 2009 VA Form 9. A. Compensable Rating Prior to November 12, 2005 The pertinent evidence dated prior to November 2005 consists of an April 2004 VA examination report and statements submitted by the Veteran in support of his claim. As noted, pertinent to this period, the Veteran has asserted that he did not have normal range of motion in his left arm and that he was unable to use the left arm at shoulder level or higher or raise it halfway between his side and shoulder level. See April 2005 NOD. On April 2004 VA examination, the Veteran reported experiencing left shoulder pain on a daily basis and that he avoids using his left shoulder if at all possible. On examination, the Veteran was able to demonstrate flexion to 180 degrees, abduction to 160 degrees, and internal and external rotation to 90 degrees. The VA examiner did not note if there was any objective evidence of painful motion. Nevertheless, there was no evidence of tenderness and x-rays were normal. Considering the evidence of record in light of the above, the Board finds that an initial, compensable rating is not warranted for the service-connected left shoulder disability from the March 9, 2004 effective date of the award of service connection through November 11, 2005. At the outset, the Board notes the Veteran has made conflicting assertions regarding the range of motion of his left shoulder. Indeed, the Veteran has maintained that he is unable to lift his arm above shoulder level, but he has also stated that he is unable to raise his arm halfway between his side and shoulder level. See April 2005 NOD. The Veteran, as a layperson, is competent to describe factual matters of which he or she has first-hand knowledge. See, e.g., Washington v. Nicholson, 19 Vet. App. 362 (2005); Layno v. Brown, 6 Vet. App. 465, 470 (1994). As such, the Veteran's report of being unable to use his arm at shoulder level or higher or raise it halfway between shoulder level is considered competent lay evidence, as is his report that he used his right arm to lift his left arm at the April 2004 VA examination. However, competency of evidence differs from weight and credibility, and the Board must analyze the credibility and probative value of all evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). In this context, the Board has considered the Veteran's lay assertions in support of his claim; however, the Board finds that his assertions regarding being unable to raise his arm halfway between his side and shoulder are not considered credible, as they are inconsistent with other evidence of record. The Board finds that the objective clinical findings are the most probative evidence with respect to the functional limitation of the Veteran's service-connected left shoulder disability, as they were generated contemporaneously with treatment provided by medical professionals and includes consideration of the statements made by the Veteran, as well as the objective range of motion findings. These findings do not support the Veteran's assertions, to include the Veteran's report that he used his right arm to raise his left arm during the April 2004 examination (see May 2006 VA Form 9), which clearly would have been noted by the examiner, if such was the case. However, the medical evidence of record is in distinct contrast to any report that the Veteran is unable to use his arm at shoulder level or higher or raise it halfway between shoulder level, as there simply is no objective evidence of limitation of motion of the arm at shoulder. The Board also finds it noteworthy that no complaint of the Veteran being unable to lift his arm between his side and shoulder is documented in 2004 examination report or any other medical evidence pertinent to the period prior to November 12, 2005, but is, instead, reflected in various statements advanced in support of the claim for an initial, compensable rating, which are deemed less persuasive. Cf. White v. Illinois, 502 U.S. 346, 355-56 (1991) (noting that statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment). As such, the Board finds that the Veteran's own assertions advanced in support of his claim for a higher rating are not entitled to more weight than the objective findings rendered by the April 2004 VA examiner. See 38 C.F.R. § 3.159 (a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions); see also Bostain, 11 Vet. App. at 127; Routen v. Brown, 10 Vet. App. at 186. Based on the foregoing, the Board finds the most persuasive evidence weighs against the award of an initial, compensable rating prior to November 2005,and the Veteran has not submitted or identified any outstanding, supporting medical evidence which shows the required level of symptomatology to warrant a compensable rating during the applicable time period. In making this determination, the Board has considered whether a higher rating is warranted prior to November 2005 based upon 38 C.F.R. §§ 4.40, 4.45 and Deluca, supra. The pertinent evidence of record does not relect any complaints of flare-ups in the left shoulder and, while the Veteran reported having pain on a daily basis, there is no lay or medical evidence of record that shows his pain has been so disabling to result in limitation of the arm at shoulder level or below, limitation of arm motion at 25 degrees from side, or any other functional impairment that would warrant the minimum 10 percent rating available under Diagnostic Code 5201. With respect to painful motion, as contemplated by 38 C.F.R. § 4.59 and Burton, supra, the Board also notes there is no competent and credible lay or medical evidence of painful motion in the left shoulder prior to November 2005. Indeed, there were no complaints or findings of painful motion at the April 2004 VA examination and the Veteran has not submitted any lay statements which reflect that he complained of pain while demonstrating movement in his arm at any time prior to November 2005. It follows, then, that the criteria for a compensable rating based upon additional functional impairment due to pain under diagnostic code 5201 is not met. Indeed, even with consideration of the sections 4.40 and 4.45 and DeLuca, as well as section 4.59 and Burton, the record presents no basis assignment of a compensable rating prior to November 2005. The Board has also considered the applicability of other diagnostic codes for rating the left shoulder disability but finds that no other diagnostic code provides a basis for a higher rating at any point prior to November 12, 2005, as ankylosis, and impairment of the humerus, clavicle or scapula is not shown prior to that date. See 38 C.F.R. § 4.71a. The disability also was not shown to involve any factor(s) that warrant evaluation under any other provision(s) of VA's rating schedule. B. Rating From November 12, 2005 As indicated above, the Veteran's service-connected left shoulder disability is rated 20 percent disabling, effective November 12, 2005. The Board will proceed to determine if a rating higher than 20 percent is warranted at any point since November 12, 2005. The pertinent evidence consists of VA examination reports dated November 2005, April 2010, and October 2012, VA treatment records dated from 2006 to 2008, and lay statements submitted in support of the Veteran's claim. On VA examination in November 2005, the Veteran reported experiencing pain with excessive use, including any attempts to work above shoulder level or with his elbow away from his body. On objective examination, the VA examiner noted that the Veteran was able to disrobe without any apparent difficulty and that there was no evidence of swelling, deformity, or tenderness. The Veteran was able to demonstrate flexion to 90 degrees, abduction to 80 degrees, and internal and external rotation to 90 degrees. The VA examiner noted that, while there was significant deterioration in range of motion, x-rays and MRIs of the left shoulder were normal, with only complaints of pain with certain motions. The November 2005 VA examiner stated that despite the loss of motion at the examination compared with the previous examination, he would "tend to take today's readings with a grain of salt." He concluded that the deterioration was too significant for such a short period of time (under two years) and that the findings were unreliable since they were based on the Veteran's complaints of pain. He concluded that there had been no change in the Veteran's left shoulder disability since the previous examination. The impression was impingement syndrome of the left shoulder. The Veteran went to the emergency room for left shoulder and low back pain in May 2006, and objective examination revealed limitation of motion of the left shoulder, as the Veteran was unable to actively lift past shoulder level due to pain. There was, however, no pain with palpation or crepitus on examination. In accordance with the Board's January 2008 remand, the Veteran was afforded a VA examination in April 2010. At that time, he reported pain, weakness, instability, giving way, lack of endurance, swelling, heat, redness, tenderness, and stiffness of his left shoulder. The Veteran also reported flare-ups of left shoulder pain and additional limitation of motion that occurred once a month and lasted for six hours at a time. The examiner noted that the Veteran was hospitalized and had surgery in 2008. On examination, there was tenderness of the anterior, posterior, and lateral aspects of the left shoulder. The Veteran was able to demonstrate forward flexion from 0 to 110 degrees with pain throughout, abduction from 0 to 90 degrees with pain throughout, external rotation from 0 to 30 degrees with pain throughout, and internal rotation from 0 to 30 degrees with pain throughout. The examiner noted repetitive motion resulted in range of motion decreased to 90 degrees with increased pain. An X-ray of the left shoulder was interpreted as normal, and the impression was left shoulder strain. The Veteran was afforded another VA examination in October 2012, at which time he reported having continuous pain rated 2/10, with weekly flare-ups of pain rated 10/10 that last for eight hours. On examination, the Veteran was able to demonstrate flexion to 100 degrees, with evidence of painful motion with 80 degrees, and abduction to 80 degrees, including with pain. The VA examiner noted there was additional limitation of motion and painful motion following repetitive use, although repetitive testing revealed flexion limited to no less than 100 degrees and abduction limited to no less than 80 degrees. There was evidence of guarding, localized tenderness, and pain on palpation of the joints. There was also evidence of decreased strength in flexion and abduction. The VA examiner noted there was a scar on the left shoulder, but the scar was not painful on examination. VA treatment records are consistent with the other medical evidence of record, as they reflect that the Veteran's left shoulder disability is manifested by pain, limited motion, and difficulty lifting his left arm. Indeed, the treatment records consistently note that the Veteran is unable to actively lift his arm past shoulder level due to pain. See VA treatment records dated May 2006, August 2006, and June 2008. Otherwise, the VA treatment records show that the Veteran's range of motion is limited to no less than 110 degrees in flexion and 90 degrees in abduction. See October 2008 VA treatment record. Even after surgery on his left shoulder in November 2008, the Veteran was able to demonstrate flexion and abduction to 68 and 78 degrees, respectively. See December 2008 VA treatment record. Considering the pertinent evidence in light of the applicable legal authority, the Board finds that a rating higher than 20 percent for the Veteran's service-connected left shoulder disability is not warranted at any point since November 12, 2005. The medical evidence of record, shows that the Veteran's range of motion has been limited to no less than 68 and 78 degrees in flexion and abduction, respectively, including as a result of pain. Since November 12, 2005, there is no medical or other objective evidence of record that shows the Veteran's range of motion has been limited to less than 25 degrees, even considering functional impairment associated with repetitive use and pain. Indeed, range of motion testing during the November 2005 VA examination revealed left shoulder flexion to 90 degrees and abduction to 80 degrees, while the April 2010 VA examination report reflects the Veteran had left shoulder flexion and abduction to 110 and 90 degrees, respectively, with pain throughout, and that repetitive motion resulted in increased pain and flexion limited to no less than 90 degrees. Similarly, the October 2012 VA examination report reflects that the Veteran had left shoulder flexion to 100 degrees and abduction to 80 degrees, even with pain and after repetitive motion. As reflected above, while the objective evidence of record reflects that the Veteran's left shoulder disability has been manifested by limited range of motion, the objective evidence consistently reflects that the Veteran has demonstrated left shoulder movement to more than 25 degrees. Therefore, based on the foregoing, the Board finds that the Veteran's lay assertions regarding being unable to raise his arm between his side and shoulder are not considered credible and are not entitled to more weight than the objective findings rendered by trained medical professionals who have evaluated his service-connected left shoulder disability. Accordingly, for the period since November 12, 2005, the Board finds the most persuasive evidence of record does not support the assignment of a disability rating higher than 20 percent under DC 5201, as motion limited to less than 25 degrees is not shown in the evidence, including as a result of pain or repetitive use. In this context, the Board has considered sections 4.40 and 4.45 and DeLuca, supra, as the evidence shows the Veteran experiences pain while demonstrating movement in his left shoulder; however, the lay and medical evidence of record does not reflect that his pain has been so disabling to result in movement limited to less than 25 degrees - for the maximum 30 percent rating under DC 5201. The Board also finds that no other diagnostic code provides a basis for assignment of a rating higher than 20 percent at any point since November 2005. In this regard, there is no indication in the lay or medical evidence showing that the service-connected left shoulder disability is manifested by ankylosis of the scapulohumeral articulation, impairment of the humerus, or impairment of the clavicle or scapula. As such, Diagnostic Codes 5200, 5202, and 5203 are not applicable, and the service-connected left shoulder disability is also not shown to involve any other factor(s) that warrant consideration of any other provision(s) of VA's rating schedule. The Board has considered whether the Veteran may be assigned a separate, compensable rating for the scar on his left shoulder. The October 2012 VA examiner noted that there is a non-painful scar on the Veteran's left shoulder. There is no indication or allegation that the left shoulder scar is adherent and there is no objective evidence of pain with palpation to the scar. As such, and because there is no evidence or allegation of any symptomatology associated with the scar, or indication that the scar results in any limited function, assignment of a separate, compensable rating for the left shoulder scar is not warranted. See 38 C.F.R. § 4.118, DC 7803 to 7805. The Board again notes that the Veteran's own assertions, and those of his representative, have been considered. However, as noted, the Board finds that the lay assertions made in support of his claim for higher rating are not entitled to more weight than the objective findings rendered by trained medical professionals in evaluating the Veteran's left shoulder disability. See 38 C.F.R. § 3.159 (a)(1); see also Bostain, supra; Routen, supra. As indicated above, the persuasive evidence indicates that the Veteran's service-connected left shoulder disability more nearly approximates the level of disability contemplated by the 20 percent, but no higher rating assigned for the period beginning on November 12, 2005. C. Final Considerations The above determinations are based upon application of pertinent provisions of VA's rating schedule. Additionally, the Board finds that, at no point pertinent to this appeal has the Veteran's service-connected left shoulder disability reflected so exceptional or so unusual a picture as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b) (2012). There is a three-step analysis for determining whether an extra-schedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111, 115 (2008). First, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id. at 115-16; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalizations). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. at 116. In this case, the Board finds that the schedular criteria is adequate to rate the Veteran's service-connected left shoulder disability at all times pertinent to this appeal. Indeed, the rating schedule fully contemplates the described symptomatology, including the Veteran's painful, limited motion, and provides for ratings higher than that assigned based on more significant functional impairment. Significantly, there is no medical indication or argument that the applicable criteria are otherwise inadequate to rate the disability. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For all the foregoing reasons, the Board finds that there is no basis for any further staged rating for the service-connected left shoulder disability, pursuant to Fenderson, and that the claims for higher ratings prior to and since November 12, 2005, must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of any higher rating at any pertinent point, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (2012). ORDER An initial, compensable rating for impingement syndrome of the left shoulder, prior to November 12, 2005, is denied. A rating in excess of 20 percent for impingement syndrome of the left shoulder, from November 12, 2005, is denied. REMAND Review of the record reveals that the RO/AMC has not completed the development requested in the April 2011 Board remand with respect to the claims for service connection on appeal. Indeed, neither the paper claims file nor paperless claims file reflects that a physician has provided the additional nexus opinions requested with respect each of the disabilities for which service connection is sought. The United States Court of Appeals for Veterans Claims has held that compliance by the Board or the RO with remand instructions is neither optional nor discretionary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Here, the Board finds that the directives in the April 2011 remand were not substantially complied with, necessitating another remand. Accordingly, as directed by the Board in April 2011, the Veteran's entire claims file should be forwarded to the physician who examined the Veteran and prepared the April 2010 examination report for an addendum opinion. The RO should only arrange for the Veteran to undergo further examination if the prior examiner is not available, or another examination of the Veteran is deemed warranted. If a further examination is scheduled, the Veteran is hereby advised that failure to report to the scheduled examination, without good cause, may result in denial of the claims for service connection (as the original claims will be considered on the basis of the evidence of record). See 38 C.F.R. § 3.655 (2012). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. If the Veteran fails to report to any scheduled examination, the RO should obtain and associate with the claims file (a) copy(ies) of the notice(s) of the date and time of the examination sent to him by the pertinent VA medical facility. Prior to obtaining further medical opinion in these claims, to ensure that all due process requirements are met, and that the record before the physician is complete, the RO should also give the Veteran another opportunity to present information and/or evidence pertinent to the claims for service connection remaining on appeal. The RO's letter to the Veteran should explain that he has a full one-year period for response. See 38 U.S.C.A. § 5103(b)(1) (West 2002); but see 38 U.S.C.A. § 5103(b)(3) (West Supp. 2012) (amending the relevant statute to clarify that VA may make a decision on a claim before the expiration of the one-year notice period). Thereafter, the RO should obtain any additional evidence for which the Veteran provides sufficient information and, if necessary, authorization following the procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties to notify and assist imposed by the VCAA. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the RO of the responsibility to ensure full VCAA compliance. Hence, in addition to the actions requested above, the RO should also undertake any other development or notification action deemed warranted by the VCAA prior to adjudicating the claims for service connection on appeal. Accordingly, these matters are hereby REMANDED for the following action: 1. Send the Veteran and his representative a letter requesting that the Veteran provide sufficient information, and if necessary, authorization to obtain any additional evidence pertinent to the service connection claims on appeal that is not currently of record. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). If the Veteran responds, assist him in obtaining any additional evidence identified by following the current procedures set forth in 38 C.F.R. § 3.159. All records and responses received should be associated with the claims file. If any records sought are not obtained, the RO should notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 2. After all records and/or responses from each contacted entity have been associated with the claims file, the Veteran's entire claims file, to include as complete copy of this REMAND, should be forwarded to the examiner who examined the Veteran in April 2010 for an addendum opinion. The opinion should address the following: Feet - Whether it is at least as likely as not (there is a 50 percent or greater probability) that the Veteran's pre-existing pes planus (1) increased in severity during any of the Veteran's verified periods of service; and, if so, (2) whether the increase in severity represented the natural progression of the condition or aggravation (permanent worsening of the disability in question). Knees - With respect to each knee, whether current disability is at least as likely as not the result of disease or injury incurred in or aggravated during the Veteran's active duty service from March 2003 to March 2004. If the prior examiner is not available, or another examination of the Veteran is deemed warranted, arrange for the Veteran to undergo VA orthopedic examination, by an appropriate physician, to obtain a medical opinion responsive to the questions posed above. The entire claims file, to include a complete copy of this REMAND, must be furnished to the examiner, and the examination report should reflect consideration of the Veteran's documented medical history and assertions. In rendering the requested opinions, the physician should consider and discuss all service treatment records, as well as all post-service medical evidence-to particularly include the April 2004 VA examination report-as well as the Veteran's assertions. The physician should set forth all examination findings (if any), along with the complete rationale for the conclusions reached, in a printed (typewritten) report. 3. If the Veteran fails to report to any scheduled examination, obtain and associate with the claims file a copy of any notice(s) of the date and time of the examination sent to the Veteran by the pertinent VA medical facility. 4. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App. 268 (1998). 5. After completing the requested actions, and any additional notification and/or development deemed warranted, readjudicate the claims for service connection for right knee disability, for left knee disability, and for flat feet, in light of pertinent evidence and legal authority. 6. If any benefit sought on appeal remains denied, furnish to the Veteran and his representative an appropriate SSOC that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication, and it is not the Board's intent to imply whether the benefits requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). This REMAND must be afforded expeditious treatment. The law requires that all claims remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs