Citation Nr: 1314766 Decision Date: 05/03/13 Archive Date: 05/15/13 DOCKET NO. 03-21 539 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for residuals of a left shoulder injury. 2. Entitlement to an initial rating in excess of 10 percent for chondromalacia of the right knee. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD David S. Ames, Counsel INTRODUCTION The Veteran served on active duty from June 1968 to January 1993. 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 St. Petersburg, Florida (RO). This case was remanded by the Board in August 2007 and September 2008 for additional development. In August 2009, the Board denied the Veteran's claims. He appealed the denial of these claims to the United States Court of Appeals for Veterans Claims (Court). In a July 2011 Memorandum Decision, the Court vacated the part of the Board's decision that denied initial disability ratings in excess of 10 percent for residuals of a left shoulder injury and chondromalacia of the right knee, and remanded those matters to the Board for readjudication. This case was then once again remanded by the Board in March 2012 for additional development. FINDINGS OF FACT 1. The medical evidence of record shows that the Veteran's left shoulder disability was initially manifested by pain, fatigue, weakness, guarding, and limitation of left shoulder motion to, at most, 165 degrees of flexion, 150 degrees of abduction, 82 degrees of internal rotation, and 78 degrees of external rotation. For the period on and after April 17, 2012, the Veteran was found to have limitation of left shoulder motion to, at most, 90 degrees of flexion, 80 degrees of abduction, 78 degrees of external rotation, and 82 degrees of internal rotation. 2. The medical evidence of record shows that the Veteran's right knee disability is manifested by pain, swelling, stiffness, decreased endurance, crepitus, grinding, mild varus deformity, weakness, and limitation of motion to, at most, 80 degrees of flexion and 5 degrees of extension. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for residuals of a left shoulder injury have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5201 (2012). 2. The criteria for a rating of 20 percent, but not higher, for residuals of a left shoulder injury, as of April 17, 2012, have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5201 (2012). 3. The criteria for an initial rating in excess of 10 percent for chondromalacia of the right knee 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). 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 claims with an adjudication of the claims 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 letters dated in August 2003, March 2006, July 2006, August 2006, December 2006, August 2007, and October 2008. 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) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's 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 claims. 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). Further, the Veteran was provided an opportunity to set forth his contentions at a Travel Board hearing in January 2007 before the undersigned Veteran's Law Judge (VLJ). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that the RO Decision Review Officer or VLJ who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the undersigned VLJ identified the issues on appeal. The VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Therefore, not only were the issues "explained in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claims," were also fully explained. See Bryant, 23 Vet. App. at 497. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and the Board can adjudicate the claims based on the current record. Thus, VA has satisfied its duty to notify the Veteran and had satisfied that duty prior to the adjudication in the January 2013 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 (Schedule), found in 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 military 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; 38 C.F.R. § 4.1 (2012). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (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; 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, 34 (1999). The appeal of the Veteran's left shoulder and right knee claims are based on the assignment of initial ratings following initial awards of service connection for residuals of a left shoulder injury and chondromalacia of the right knee. 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, 126 (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. Id. Left Shoulder Service connection for residuals of a left shoulder injury was granted by a January 2002 rating decision and a noncompensable rating was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5201, effective February 1, 1993. In the selection of 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 disorder, under Diagnostic Code 5299, was the service-connected disorder, and limitation of motion of the arm, under Diagnostic Code 5201, was a residual condition. Subsequently, an October 2007 rating decision assigned a 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5201-5010, effective February 1, 1993. The hyphenated diagnostic code in this case indicates that limitation of motion of the arm, under Diagnostic Code 5201, was the service-connected disorder, and traumatic arthritis, under Diagnostic Code 5010, was a residual condition. In an April 1993 VA general medical examination report, the Veteran reported previous right shoulder complaints, but did not comment on any left shoulder complaints. After physical examination, the diagnoses included degenerative joint disease of the acromioclavicular joint. A July 1994 private medical report stated that, on examination, the Veteran's left shoulder was tender over the acromioclavicular joint, but he had a full range of motion. There was no evidence of subluxation of the humeral heads in the anterior and posterior directions. Following x-ray examination, the relevant diagnosis was left shoulder acromioclavicular joint osteoarthritis. In a January 1995 private medical report, the Veteran stated that he could not lift very heavy objects without pulling both shoulders. On evaluation, he reported experiencing pain. On physical examination, the Veteran had left shoulder range of motion to 165 degrees of flexion, 150 degrees of abduction, 82 degrees of internal rotation, and 78 degrees of external rotation. He had left shoulder discomfort with lifting more than 40 pounds. The examiner stated that the Veteran was not able to work in overhead positions. A second January 1995 private medical report stated that the Veteran had left shoulder acromioclavicular joint osteoarthritis. On testing, the Veteran had deficits in left shoulder flexion and abduction, but average strength. He also had decreased endurance in the upper extremities. The examiner opined that the Veteran's various disabilities did not significantly limit his functional abilities. In a February 1999 VA joints examination report, the Veteran complained of chronic left shoulder pain. On physical examination, the Veteran had left shoulder range of motion to 165 degrees of flexion, 180 degrees of abduction, 90 degrees of internal rotation, and 90 degrees of external rotation. There was pain on all ranges of motion, but no tenderness over the left acromioclavicular joint. He had normal left shoulder strength and impingement sign was negative. On x-ray examination, the Veteran's left shoulder was normal. The impression was residuals of left shoulder injury; history of tendonitis and degenerative changes of acromioclavicular joint. A February 1999 VA skin examination report stated that the Veteran's arms had a circular range of motion of approximately 180 degrees, with pain in the upper range, as well as lateral motion of approximately 90 degrees. In an August 2007 VA joints examination report, the Veteran complained of left shoulder pain, stiffness, decreased range of motion, and weakness, but denied swelling, locking, instability, subluxation, or dislocation. He reported experiencing daily flare-ups with increased activities, with each flare-up lasting for several minutes. On physical examination, there was tenderness over the anterior portion of the left shoulder joint, without gross deformity or swelling noted. The Veteran had a left shoulder range of motion to 170 degrees of flexion, 170 degrees of abduction, 90 degrees of internal rotation, and 90 degrees of external rotation. There was pain associated with the range of motion. On repetitive motion, there was increased pain, fatigue, and weakness, but no lack of endurance or change in the range of motion. The examiner stated that additional limitations due to flare-ups could not be determined without resorting to mere speculation. On x-ray examination, the Veteran's left shoulder was normal. The diagnosis was left shoulder impingement syndrome with objective findings of early decrease in range of motion. The examiner opined that there were no objective findings that indicated that the Veteran's left shoulder limited his ability to work or maintain substantially gainful employment. A February 2012 private medical report gave a diagnosis of bilateral shoulder pain. A February 2012 private magnetic resonance imaging report stated that, after views of the Veteran's left shoulder, the impression was acromioclavicular osteoarthritis, supraspinatous and bicipital tendinopathy, and superior and posterior labral tear with a 3 millimeter paralabral cyst. In an April 2012 VA shoulder and arm examination report, the Veteran complained of left shoulder pain. The report stated that the Veteran was ambidextrous. The Veteran stated that flare-ups did not impact his functional impairment. He had left shoulder range of motion to 115 degrees of flexion, with pain at 90 degrees, and 110 degrees of abduction, with pain at 80 degrees. Following repetitive motion, the Veteran's left shoulder range of motion remained the same. His functional impairment was listed as reduced movement and pain on movement. The Veteran had pain and guarding of the left shoulder, with slightly reduced left shoulder strength, but no ankylosis. The Veteran was positive for left rotator cuff condition testing. He had a history of mechanical symptoms on the left, but no history of recurrent dislocation/subluxation of the glenohumeral/scapulohumeral joint. The Veteran was unable to perform crank apprehension and relocation tear testing. The Veteran was reported to have acromioclavicular joint arthritis, but he did not have malunion or nonunion of the clavicle or scapula, or dislocation. There was tenderness on palpation of the acromioclavicular joint. Cross-body adduction test was negative. The Veteran had not had a total shoulder replacement and was reported to have not had arthroscopic or other shoulder surgery. He did not have any scars related to his left shoulder condition. Degenerative arthritis was documented on imaging studies. The functional impact of the Veteran's left shoulder condition was difficulty with work involving overhead activities and lifting heavy objects. The examiner opined that the Veteran's left shoulder disability had moderate functional impact. The medical evidence of record shows that the Veteran's left shoulder disability was initially manifested by pain, fatigue, weakness, guarding, and limitation of left shoulder motion to, at most, 165 degrees of flexion, 150 degrees of abduction, 82 degrees of internal rotation, and 78 degrees of external rotation. For the period on and after April 17, 2012, the Veteran was found to have limitation of left shoulder motion to, at most, 90 degrees of flexion, 80 degrees of abduction, 78 degrees of external rotation, and 82 degrees of internal rotation. The Board notes that the April 2012 VA shoulder and arm examination report stated that the Veteran was ambidextrous. However, previous evidence of record shows that the Veteran is right-handed. Therefore, for rating purposes, his left shoulder is considered his minor or non-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 left 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. In addition, there is no medical evidence of record that the Veteran's left shoulder has ever been ankylosed or that he has ever experienced impairment of the humerus. 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 5200, 5202 (2012). The record shows that the Veteran has received a diagnosis of left shoulder arthritis following x-ray examination. However, such findings, combined with the limitation of motion elicited, would warrant no more than a 10 percent rating under 38 C.F.R § 4.71a , Diagnostic Codes 5003, 5010. See also 38 C.F.R. § 4.45 (2012). Under Diagnostic Code 5201, limitation of motion of the minor arm at shoulder level warrants a 20 percent rating, limitation of motion of the minor arm midway between the side and shoulder level warrants a 20 percent rating, and limitation of motion of the minor arm to 25 degrees from the side warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5201. 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 the motion of the Veteran's left arm was ever limited to shoulder level, even with consideration of pain on motion, prior to April 17, 2012. Accordingly, an initial rating in excess of 10 percent is not warranted for the Veteran's left shoulder disability under Diagnostic Code 5201. 38 C.F.R. § 4.71a, Diagnostic Code 5201. However, the April 2012 VA shoulder and arm examination report stated that the Veteran's left shoulder range of motion was limited by pain to 90 degrees of flexion and 80 degrees of abduction. Accordingly, the medical evidence of record shows that the Veteran's left arm has been limited to shoulder level for the period on and after April 17, 2012. As such, a 20 percent rating is warranted for the Veteran's left shoulder disability for the period on and after April 17, 2012. Id. However, a rating in excess of 20 percent is not warranted at any point during the period on appeal, as the medical evidence of record does not show that the Veteran's left arm has ever been limited to 25 degrees from his side. The Veteran has reported left shoulder pain on use, a contention which is substantiated by the medical evidence of record. However, the April 2012 VA shoulder and arm examination report specifically measured the Veteran's pain and those findings have resulted in the grant of a 20 percent rating for the period on and after April 17, 2012. There is no evidence of record which indicates that the Veteran's left shoulder pain ever limited his left arm range of motion to shoulder level or below prior to April 17, 2012, or that it has since limited his left arm to 25 degrees from his side. 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 left shoulder pain or other symptoms which caused additional limitations sufficient to warrant an initial rating in excess of 10 percent or a rating in excess of 20 percent for the period on and after April 17, 2012. 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 further staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's left shoulder symptoms, the evidence shows no distinct periods of time when his symptoms have varied to such an extent that ratings in excess of those assigned herein would be warranted for under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012); Fenderson, 12 Vet. App. 119. 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, 22 Vet. App. 111. 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 left shoulder disorder inadequate. The Veteran's left shoulder disorder was rated under 38 C.F.R. § 4.71a, Diagnostic Code 5201, the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's left shoulder disability is manifested by pain, fatigue, weakness, guarding, and limitation of left shoulder motion to the degrees listed above. 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 ratings assigned herein for his left shoulder disorder. Ratings in excess of the ratings assigned herein 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 ratings assigned herein for the Veteran's left shoulder disorder reasonably describe the Veteran's disability level and symptomatology and, therefore, the schedular ratings assigned herein are 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 left shoulder does not cause an impact on his occupational abilities beyond that contemplated by the ratings assigned herein. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.71a, Diagnostic Code 5201. In reaching this decision, the Board finds that the preponderance of the evidence of record shows that the Veteran's left shoulder disability does not meet the criteria for ratings in excess of those assigned herein. Therefore, the claim for increased ratings beyond those assigned herein is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Right Knee Service connection for chondromalacia of the right patella was granted by a January 2002 rating decision and a noncompensable rating was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5010, effective February 1, 1993. The hyphenated diagnostic code in this case indicates that an unlisted musculoskeletal disorder, under Diagnostic Code 5299, was the service-connected disorder, and traumatic arthritis, under Diagnostic Code 5010, was a residual condition. Subsequently, an October 2007 rating decision assigned a 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5010, effective February 1, 1993. An April 1993 VA general medical examination report stated that, on physical examination, the Veteran's knees appeared to be normal with no crepitation, swelling, joint laxity, or tenderness. The Veteran had bilateral knee range of motion to 135 degrees of flexion and 0 degrees of extension. In a July 1994 private medical report, the Veteran complained of difficulty rising from a squat, crepitation, and a grinding sensation. On physical examination, the Veteran had right knee range of motion to 135 degrees of flexion and 0 degrees of extension. There was some swelling of the right knee which was associated with chondromalacia. The diagnosis was bilateral knee chondromalacia of the patella. In a December 1994 private medical report, the Veteran complained of knee catching, stiffness, and giving way. On examination, the examiner stated that the Veteran's chondromalacia appeared mild. In a January 1995 private medical report, the Veteran stated that he could not squat for more than several minutes due to knee pain. On evaluation, he reported experiencing pain and feeling like his right knee was going to give out. On physical examination, the Veteran's right knee range of motion was within normal limits. He was able to walk .87 mile in 31 minutes, and reported experiencing right knee pain. A second January 1995 private medical report stated that, on testing, the Veteran had average right knee strength. He did have decreased endurance in the lower extremities. In a February 1999 VA joints examination report, the Veteran complained of right knee discomfort. On physical examination, a distal neurovascular examination was normal. There was no pain on motion, but he had slight patellofemoral crepitance noted on motion. There was tenderness to palpation about the patellofemoral joint, as well as a positive patella grind test. No ligamentous instability was noted and McMurray's testing was negative. On x-ray examination, the Veteran's right knee was normal. The impression was bilateral chondromalacia of the patella. A February 1999 VA skin examination report stated that the Veteran's knees were restricted by approximately 50 percent in flexion. In a February 2002 private medical report, the Veteran complained of severe right knee pain and stated that he was unable to squat. On physical examination, there was crepitus noted on palpation of the right knee. The assessment was severe bilateral knee pain. In a second February 2002 private medical report, the Veteran complained of right knee pain, buckling, popping, and hyperextending, but denied swelling or locking. On x-ray examination, the Veteran's right knee was unremarkable except for slight lateral patellar subluxation. On physical examination, the Veteran had a full right knee range of motion without pain. Lachman's, McMurray's, and patellar apprehension tests were negative. There was no varus or valgus instability, joint line tenderness, tenderness over the pes insertion, Baker's cyst, or aneurysm, but there was effusion. An August 2002 private medical report stated that the Veteran had severe osteoarthritis of the knees. In an August 2004 private medical report, the Veteran complained of right knee pain, swelling, and severe popping. On physical examination, the Veteran had right knee range of motion to 125 degrees of flexion and 0 degrees of extension. There was a palpable tender plicae and popping of the plicae with flexion and extension of the knee, which was painful. There was also some patellofemoral crepitus, but the Veteran's neurovascular status was normal and there was no instability. X-ray examination of the right knee showed no fractures, dislocations, or degenerative changes. In a December 2005 private medical report, the Veteran complained of right knee pain. On physical examination, the Veteran's right knee medial plica was palpably tender, but without effusion. He had a near full right knee range of motion. The impression was bilateral symptomatic pathologic plica. A January 2006 private medical report stated that, on physical examination, the Veteran's right knee was quite tender over the plica with popping. After magnetic resonance imaging, the impression was plica right knee. A June 2006 private medical report stated that the Veteran was proceeding with surgical intervention of the right knee. On physical examination, there was tenderness over the palpable right medial plica band as well as mild tenderness over the right medial joint line. There was no effusion, varus instability, or valgus instability. Anterior drawer, posterior drawer, and Lachman's tests were negative. A distal neurovascular examination was normal. The impression was symptomatic pathologic plica and possible medial meniscus tear, right knee. A second June 2006 private medical report stated that the Veteran was three days post-operative from a right knee arthroscopy and was doing well with minimal pain. On physical examination, the right knee showed a surgical incision which was well approximated with intact sutures. There was trace effusion and the range of motion was near full with extension to approximately 100 degrees. A distal neurovascular examination was normal. The impression was post-operative arthroscopy of the right knee. In a July 2006 private medical report, the Veteran complained of right knee popping and pain which increased with prolonged sitting, as well as an inability to squat or kneel. On physical examination, the Veteran had well-healed right knee surgical scars, though there was some mild hypertrophic scarring of the medial arthroscopy portal site. There was trace effusion, but the Veteran had near full range of motion and a distal neurovascular examination was normal. The impression was post-operative arthroscopy, right knee, with grade 2 chondromalacia of the patella. In an August 2006 private medical report, the Veteran complained of pain and crepitus in the right knee. On physical examination, there was some crepitus with flexion and extension, but the knee was otherwise stable and the neurovascular status was normal. X-ray examination showed no fractures, dislocations, or degenerative changes. The impression was chondromalacia and post-operative arthroscopy of the right knee. Four separate September 2006 private medical reports stated that the Veteran was seen for right knee injections. The various physical examinations showed no effusion, stable distal neurovascular examination, and no evidence of infection or synovitis. In an October 2006 private medical report, the Veteran complained of right knee pain and difficult walking down stairs, kneeling, and squatting. The impression was arthroscopically documented chondromalacia of the right knee. A November 2006 private medical report stated that the Veteran had severe degenerative joint disease. However, on physical examination, the Veteran had a full range of motion in the extremities. In a January 2007 private medical report, the Veteran complained of right knee pain. On physical examination, there was minimal right knee swelling and the Veteran had a full range of motion. X-ray examination showed no fractures, dislocations, or significant worsening of his early degenerative joint disease. The impression was arthroscopically documented chondromalacia of the right knee. In a February 2007 private medical report, the Veteran complained of right knee pain. In an August 2007 VA joints examination report, the Veteran complained of right knee pain, stiffness, decreased range motion, and popping. He reported experiencing some instability, but denied locking, subluxation, or dislocation. On physical examination of the right knee, there was no gross swelling or deformity, but there was tenderness noted over the patella and along the medial aspect of the joint space. The Veteran had right knee range of motion to 112 degrees of flexion and 0 degrees of extension. There was no abnormal motion noted with valgus and varus stress testing and anterior and posterior drawer signs were negative. McMurray's sign was positive on the medial aspect of the joint space and there was a positive grind test. The examiner stated that additional limitations due to flare-ups could not be determined without resorting to mere speculation. On x-ray examination, the Veteran's right knee was normal. The diagnosis was right knee, post medial meniscus tear with objective findings of decreased function. The examiner opined that there was no evidence of any instability or ankylosis, but the Veteran had functional limitation of range of motion that limited him in any occupation requiring persistent mobility. In a February 2012 private medical report, the Veteran complained of right knee pain and stiffness. On physical examination, there was a slight right knee varus deformity and a positive valgus stress test which showed some laxity in the medial compartment. Varus stress, anterior drawer, and Lachman's tests were negative. The Veteran had minimal knee effusion and right knee range of motion to 120 degrees of flexion and 0 degrees of extension. The Veteran did not have any discomfort with range of motion when sitting, but did have a painful gait pattern favoring his right leg. There was muscle weakness specifically of the quads and hamstrings, in part due to knee effusion which was caused by arthritis, which led to long-term weakness. The Veteran did not have any endurance and McMurray testing elicited some pain over the medial joint line, but no definitive pop was palpated. After magnetic resonance imaging, the impression was right knee significant osteoarthritis. An April 2012 VA knee and lower leg examination report gave a diagnosis of right knee osteoarthritis. The Veteran denied experiencing flare-ups that impacted the function of the knee or lower leg. He had right knee range of motion to 110 degrees of flexion, with pain at 80 degrees, and 5 degrees of extension without pain. Following repetitive motion, the Veteran's right knee range of motion remained the same. His functional impairment was listed as reduced movement, pain on movement, swelling, deformity, and mild varus of the right knee. There was pain on palpation with slightly reduced right knee strength. However, the Veteran's right knee was normal on all instability testing and there was no evidence of patellar subluxation/dislocation. The Veteran did not have shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. He had experienced a right meniscal tear with frequent episodes of joint pain and effusion, for which he had received a meniscectomy in June 2006. However, there were no residual symptoms of that meniscectomy. The Veteran had not had a total knee replacement and did not have any scars related to his right knee disability. The examiner stated that the functional impact of the Veteran's right knee condition was that he had difficulty kneeling, squatting, or standing for more than 10 to 15 minutes at a time; sitting for more than 30 to 60 minutes at a time; and walking more than 100 yards at a time. The examiner opined that the Veteran's right knee disability was moderate in severity and resulted in moderate functional limitation. 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. 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. 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. 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, swelling, stiffness, decreased endurance, crepitus, grinding, mild varus deformity, weakness, and limitation of motion to, at most, 80 degrees of flexion and 5 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. 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; 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 April 2012 VA knee and lower leg examination report specifically measured the Veteran's painless range of 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, 25 Vet. App. 32. 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; DeLuca, 8 Vet. App. 202. 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, and there were no symptoms from the removal or dislocation of semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262 (2012); VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56704 (1998). The record shows that the Veteran has received a diagnosis of right knee arthritis following x-ray examination. However, such findings, combined with the limitation of motion elicited, would warrant no more than a 10 percent rating under 38 C.F.R § 4.71a , Diagnostic Codes 5003, 5010. See also 38 C.F.R. § 4.45. 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, the preponderance of the medical evidence of record shows that any subluxation or lateral instability the Veteran experiences is sufficiently rare as to not warrant characterization as recurrent. Specifically, the Board notes that the February 2002 private medical report found that the Veteran had slight lateral patellar subluxation, while the February 2012 private medical report found that the Veteran had a positive valgus stress test which showed some laxity in the medial compartment. However, the February 2002 private medical report also stated that there was no varus or valgus instability while the February 2012 private medical report stated that there was no varus instability. In addition, the Board notes that these are the only two medical reports which indicate the presence of any right knee subluxation or instability over the entire 20 year period on appeal. Furthermore, the Veteran was specifically found to have no joint laxity or instability on examination in April 1993, February 1999, June 2006, August 2007, and April 2012. In particular, the April 2012 VA knee and lower leg examination report found that the Veteran's right knee was normal on all instability testing and there was no evidence of patellar subluxation/dislocation. Accordingly, the preponderance of the medical evidence of record demonstrates that any right knee subluxation or instability that the Veteran did experience was extremely rare and was not a normal manifestation of the Veteran's right knee disability. As such, the Board finds that the preponderance of the evidence of record demonstrates that any subluxation or lateral instability the Veteran experiences is sufficiently rare as to not warrant characterization as recurrent. 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. The medical evidence of record also shows that the Veteran has had a surgical scar on his right knee that was related to his service-connected right knee disorder. However, a separate compensable evaluation is not warranted for any scar that currently exists, as there is no evidence of record that the scar has ever been at least six square inches in area, unstable, or painful. See 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7804 (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; 38 C.F.R. § 3.344; Fenderson, 12 Vet. App. 119. 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, 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, swelling, stiffness, decreased endurance, crepitus, grinding, mild varus deformity, weakness, and limitation of motion to, at most, 80 degrees of flexion and 5 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 does not cause an impact on his occupational abilities beyond that contemplated by the ratings assigned herein. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. In reaching this decision, the Board finds that the preponderance of the evidence of record shows that the Veteran's chondromalacia of the right knee does not meet the criteria for a rating in excess of 10 percent. Therefore, the claim is denied. Gilbert, 1 Vet. App. 49; Massey, 7 Vet. App. 204. ORDER An initial rating in excess of 10 percent for residuals of a left shoulder injury, prior to April 17, 2012, is denied. A rating of 20 percent, but not higher, for residuals of a left shoulder injury, as of April 17, 2012, is granted. An initial rating in excess of 10 percent for chondromalacia of the right knee is denied. ____________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs