Citation Nr: 1315565 Decision Date: 05/10/13 Archive Date: 05/15/13 DOCKET NO. 03-02 004 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE 1. Entitlement to a rating in excess of 20 percent for left shoulder residuals of acromioplasty (shoulder condition), claimed as arthritis, to include an initial rating in excess of 10 percent earlier than June 12, 2012. 2. Entitlement to a rating in excess of 20 percent for right shoulder residuals of acromioplasty (shoulder condition), claimed as arthritis, to include an initial rating in excess of 10 percent earlier than June 12, 2012. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Andrea Johnson, Associate Counsel INTRODUCTION The Veteran had active military service from February 1986 to April 2000. This appeal comes to the Board of Veterans' Appeals (Board) from a November 2012 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. This claim was previously denied by the Board in December 2008, however this determination was set aside by the Court of Appeals for Veterans Claims (Court) in October 2011. In May 2012 the Board remanded this issue for further development, and in November 2012 the RO granted an increased rating to 20 percent in each shoulder. This issue has now returned to the Board for adjudication. The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to ensure a total review of the evidence. FINDINGS OF FACT 1. Prior to June 12, 2012 the evidence of record demonstrated the Veteran was able to move both his arms above shoulder level. 2. At no time during the course of the Veteran's appeal has it been shown that his bilateral shoulder condition prevented him from raising his arm to midway between his side and shoulder level. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent in each shoulder, earlier than June 12, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1, 4.2, 4.7, 4.27, 4.40, 4.45, 4.59, 4.71a Diagnostic Codes 5200-5203 (2012). 2. The criteria for a rating in excess of 20 percent in each shoulder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1, 4.2, 4.7, 4.27, 4.40, 4.45, 4.59, 4.71a Diagnostic Codes 5200-5203 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. In Fenderson v. West, 12 Vet. App. 119, 126 (1999), the Court noted a distinction between an appeal involving the veteran's disagreement with the initial rating assigned at the time a disability is service connected. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is propriety of the initial evaluations assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson, 12 Vet. App. at 126. In June 2000, the Veteran filed for service connection for his bilateral shoulder condition. During the course of his appeal the RO granted his claim and assigned an initial 10 percent rating in both shoulders, with a staged increased rating to 20 percent is each shoulder effective June 12, 2012. As such, the Board will first consider whether a rating in excess of 10 percent for his bilateral shoulder condition is warranted earlier than June 2012, and then will consider whether a rating in excess of 20 percent for his bilateral shoulder condition is warranted. The RO rated his right shoulder condition under Diagnostic Code 5299-5203 and his left shoulder condition under Diagnostic Code 5009-5201. 38 C.F.R. § 4.71a. In the selection of diagnostic codes 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. Diagnostic Code 5299 refers generally to orthopedic disabilities and is not associated with any specific rating criteria. See 38 C.F.R. §§ 4.27, 4.71a. Diagnostic Code 5009 provides that other types of arthritis should be rated as rheumatoid arthritis, Diagnostic Code 5002. 38 C.F.R. § 4.71a. Diagnostic Code 5002 provides that chronic residuals of rheumatoid arthritis, such as limitation of motion or ankylosis, should be rated under the appropriate diagnostic code for the specific joints involved, here in left shoulder. However, as will be discussed below, the Board finds that Veteran's primary complaint in each shoulder is pain and limited motion. Therefore, the Board finds that Diagnostic Code 5009-5201, the rating of the chronic residuals of arthritis based on limitation of motion, is appropriate for both shoulders. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 degrees to 180 degrees, abduction from 0 degrees to 180 degrees, external rotation from 0 degrees to 90 degrees, and internal rotation from 0 degrees to 90 degrees. 38 C.F.R. § 4.71, Plate I. Diagnostic Codes 5200 through 5203 relate to the shoulder and will each be addressed in turn. 38 C.F.R. § 4.71a. Diagnostic Code 5200 provides that ankylosis of the scapulohumeral articulation is to be rated as follows: favorable ankylosis, with abduction to 60 degrees, can reach mouth and head, 30 percent for the major shoulder and 20 percent for the minor shoulder; intermediate ankylosis, between favorable and unfavorable, 40 percent for the major shoulder and 30 percent for the minor shoulder; unfavorable ankylosis, abduction limited to 25 degrees from side, 50 percent for the major shoulder and 40 percent for the minor shoulder. A Note provides that the scapula and humerus move as one piece. 38 C.F.R. § 4.71a. Diagnostic Code 5201 provides that limitation of motion of the arm at the shoulder level is rated 20 percent for the major shoulder and 20 percent for the minor shoulder; limitation of motion of the arm midway between the side and shoulder level is rated as 30 percent for the major shoulder and 20 percent for the minor shoulder; limitation of motion of the arm to 25 degrees from the side is rated as 40 percent for the major shoulder and 30 percent for the minor shoulder. 38 C.F.R. § 4.71a. Diagnostic Code 5202 provides ratings for other impairment of the humerus. Malunion of the humerus with moderate deformity is rated as 20 percent for the major shoulder and 20 percent for the minor shoulder; malunion of the humerus with marked deformity is rated as 30 percent for the major shoulder and 20 percent for the minor shoulder. Recurrent dislocations of the humerus at the scapulohumeral joint, with infrequent episodes, and guarding of movement only at the shoulder level, are rated as 20 percent for the major shoulder and 20 percent for the minor shoulder; recurrent dislocations of the humerus at the scapulohumeral joint, with frequent episodes and guarding of all arm movements, are rated as 30 percent for the major shoulder and 20 percent for the minor shoulder. Fibrous union of the humerus is rated as 50 percent for the major shoulder and 40 percent for the minor shoulder. Nonunion of humerus (false flail joint) is rated as 60 percent for the major shoulder and 50 percent for the minor shoulder. Loss of head of the humerus (flail shoulder) is rated as 80 percent for the major shoulder and 70 percent for the minor shoulder. 38 C.F.R. § 4.71a. Diagnostic Code 5203 provides ratings for other impairment of the clavicle or scapula. Malunion of the clavicle or scapula is rated as 10 percent for the major shoulder and 10 percent for the minor shoulder. Nonunion of the clavicle or scapula without loose movement is rated as 10 percent for the major shoulder and 10 percent for the minor shoulder; nonunion of the clavicle or scapula with loose movement is rated as 20 percent for the major shoulder and 20 percent for the minor shoulder. Dislocation of the clavicle or scapula with loose movement is rated as 20 percent for the major shoulder and 20 percent for the minor shoulder. Diagnostic Code 5203 provides an alternative rating based on impairment of function of the contiguous joint. 38 C.F.R. § 4.71a. All evidence of record has been reviewed and considered, and the relevant evidence is summarized below. In June 2000 the VA received the Veteran's claim for benefits for arthritis in each shoulder. In August 2000 the Veteran was provided with a VA examination regarding his bilateral shoulder condition. X-rays were conducted and revealed each shoulder was in normal condition and failed to demonstrate any evidence of soft calcification, joint abnormalities, or any other osseus or soft tissue abnormalities. The examiner noted a scar on each shoulder caused by the Veteran's previous surgeries. Muscle strength of upper extremities was 5 out of 5, with motor function, sensory, and reflex within normal limits. The examiner opined the Veteran's bilateral shoulder condition had resolved and found no diagnosis. Range of motion testing was also conducted and revealed the Veteran had normal range of motion in both shoulders. However, the Veteran experienced pain in his right shoulder with flexion at 90 degrees. The examiner found the Veteran did not experience any additional DeLuca (a case which, indidentially, involved a shoulder disability) factors in his right shoulder, providing evidence against this claim. Although the results of this exam provide some evidence that the Veteran was not experiencing a shoulder disability at this time, based on a benefit of the doubt the Veteran has been awarded a 10 percent impairment bilaterally for his shoulder condition during this period. 38 C.F.R. § 3.102. In May 2002 the Veteran sought treatment at a VA facility for his chronic shoulder pain. The medical professional noted his left shoulder had mild restriction in abduction. In April 2003 the Veteran was provided with an additional VA examination of his shoulder condition. The veteran reported that he had intermittent problems with his shoulders, specifically pain with overhead lifting. Range of motion testing was performed and revealed the Veteran's right shoulder had flexion to 130 degrees, abduction to 110 degrees, external rotation to 80 degrees, internal rotation to 75 degrees, adduction to 35 degrees, and extension to 20 degrees. His left shoulder had flexion to 130 degrees, abduction to 110 degrees, external rotation to 80 degrees, internal rotation to 70 degrees, adduction to 25 degrees, and extension to 20 degrees. As such, this testing revealed the Veteran experienced some limitation of range of motion. The x-rays taken showed postoperative decompression of the AC joint but the AC joint was not decompressed and was normal. The examiner diagnosed chronic tendonitis of the shoulders treated by surgical decompression. The Board finds this examination provides evidence the Veteran was experiencing a shoulder disability at the time, however, as will be discussed below, the Board finds the evidence does not establish a disability in excess of 10 percent bilaterally. The Veteran was again provided with an additional VA examination in August 2004. At this time, the Veteran reported that his left shoulder was worse than his right. He stated that his left shoulder abduction maneuver resulted in a "pop" and that the soreness limited his motion. He reported he could not sleep on either side. The Veteran stated that his right shoulder always hurt and that the pain was aggravated by raising his arms to his sides or his frontal body. The right shoulder had a dull pain and was aggravated by quick motion. He denied fracture, dislocation, subluxation or instability. The Veteran stated that he had weakness and impaired endurance of the right shoulder. He reported that grooming and using the toilet aggravated the right shoulder, as well as overhead activity. The Veteran stated that repetitive motion aggravated his left shoulder. He also reported stiffness and tightness with soreness of the left shoulder. The Veteran reported activities such as reaching, cutting the grass, hanging pictures aggravated both shoulders. The exam showed no edema or swelling. The right shoulder had a 6 cm, nontender, residual scar. No deltoid atrophy was present and the AC joint subdeltoid was nontender. The left shoulder showed a 9 cm residual scar. No edema or swelling was noted. Forward flexion of the left shoulder was to 145 degrees, abduction to 150 degrees, extension to 40 degrees, and external rotation to 45 degrees. There was arc pain motion on forward flexion from 95 to 135 degrees and with abduction from 90 to 150 degrees. No fatigue, weakness, impaired endurance, or lack of coordination was noted, providing more evidence against this claim. Right shoulder forward flexion was to 45 degrees, abduction to 50 degrees, extension to 45 degrees, and external rotation to 60 degrees. However, pain was noted with forward flexion from 100 to 140 degrees and abduction at 115 to 150 degrees. As such, it appears that there are typographical mistakes in the report as the flexion range of motion measurements show 45 degrees while the Veteran had pain to 140 degrees, and as the abduction measurement shows 50 degrees with pain to 150 degrees. It does not make sense that the Veteran experienced pain beyond his range of motion. Furthermore, both previous and subsequent testing revealed the Veteran had much greater range of motion in his right shoulder than 45 to 50 degrees. The Board therefore suspects the range of motion for his right shoulder may not have been correctly noted (particularly in light of a review of the evidence as a whole, including the Veteran's own statements), and therefore less probative weight is afforded to this diagnostic testing in regards to his right shoulder. The left shoulder showed a 9 cm. residual scar. No edema or swelling was noted. Forward flexion of the left shoulder was to 145 degrees, abduction to 150 degrees, extension to 40 degrees, and external rotation to 45 degrees. There was arc pain motion on forward flexion from 95 to 135 degrees and with abduction from 90 to 150 degrees. No fatigue, weakness, impaired endurance, or lack of coordination was noticed, providing more evidence against this claim. The Veteran reported deeper sensation aggravating both shoulders. The Hawkins cross arm test of the shoulders was significant for impingement. The AP view indicated hypertrophy of the distal clavicle AC joint with reduction and narrowed space of the right shoulder. The external and internal views indicated proximal humerus greater tuberosity increase in nodularity and sclerosis of the attachment of the supraspinatus. The left shoulder AC joint showed no significant pathology. AP view internal and external showed slight knobbiness of the greater tuberosity of the left proximal humerus. The acromial humeral height of the left shoulder was 1.18 cm. as compared with the right shoulder at 1.19 cm. The examiner diagnosed residual impingement of the right shoulder secondary to acromioclavicular joint arthritis and Mumford procedure without subluxation or instability. The left shoulder was diagnosed with residuals of acromioplasty without subluxation or instability. Neurological testing revealed muscle strength 5 of 5 and reflexes of +2 (normal) in each arm. The examiner opined there was no clinical evidence of peripheral neuropathy. As discussed above, this examination is afforded limited probative value in relation to the Veteran's right shoulder due to an apparent typographical error in the Veteran's right shoulder range of motion. In regards to the Veteran's left shoulder, this exam suggests he had increased range of motion since previous testing, proving limited evidence against his claim. The Veteran began physical therapy for his left shoulder pain in September 2005. The Veteran reported that pain onset the previous year and had progressively worsened. He reported his pain was 1 out of 10 at rest, 9 with movement. The Veteran reported working as a supervisor at a plant. Range of motion testing showed his right shoulder was grossly within functional limits, while his left shoulder had forward flexion to 120 degrees with pain, abduction to 70 degrees with pain, exterior rotation to left ear and interior rotation to left hip with pain. The right shoulder strength was 4+, while left shoulder was 4 with flexion and interior rotation, 4- with abduction and exterior rotation. Sensation was intact to light touch. Hawkins and supraspinatus tests were both positive. The Veteran was given strengthening exercises and told to return to physical therapy once a week for the following four weeks. In March 2006 the Veteran again sought treatment for his bilateral shoulder pain at a VA facility. He complained of chronic, dull, and continuous shoulder pain, severity level 3. The Veteran reported his pain was relieved by rest. The registered nurse noted strong upper extremities, providing more evidence against this claim. The treatment records establish that this same month the Veteran was involved in a car wreck which lead to concussion, low back pain, neck pain, and right leg pain. The Veteran has not alleged, and the medical record does not establish, this wreck contributed to or aggravated his bilateral shoulder condition. In December 2007 the Veteran was provided with an additional VA examination. The Veteran reported that lifting or squeezing his hands together increased his bilateral shoulder pain, right more than left. The Veteran denied flare-ups and reported that overhead activity aggravated his right shoulder. He stated that he practiced avoidance, benign neglect, and was careful to avoid pain. Activities such as making the bed and cutting grass aggravated his shoulders and exacerbated his condition. The Veteran also reported driving irritated his left shoulder and arm rest pressure on the right irritated the right shoulder. He stated that lifting at work also irritated his shoulders. As for sleeping, the left shoulder was fine, but he had pain in the right shoulder. He reported a stabbing sensation in the right shoulder, but no subjective symptoms in the left. On examination, the scars on both shoulders were noted, as well as decreased muscular build. No swelling was noted and the Veteran indicated that his shoulders were nontender. During digital pressure he was nontender. There was no atrophy of the deltoid. The acromioclavicular joints were nontender as were the subdeltoid. Forward flexion of the right shoulder was to 135 degrees, abduction to 130 degrees, extension to 35 degrees, external rotation to 90 degrees, and internal rotation to 40 degrees. There was arc pain motion on forward flexion from 70 to 135 degrees. There was no additional limitation with repetitive motion secondary to pain, fatigue, weakness, or lack of endurance other than the arc pain motion. Forward flexion of the left shoulder was to 130 degrees, abduction to 155 degrees, extension to 45 degrees, external rotation to 90 degrees, and internal rotation to 65 degrees. There was no additional limitation with repetitive motion secondary to pain, fatigue, weakness, or lack of endurance, providing more evidence against this claim. The right shoulder had a positive apprehension, Hawkins, cross-arm for impingement. All other tests for the right and left shoulders were negative. Based on the foregoing the examiner diagnosed bilateral stable joint acromioplasty. In November 2008 the Veteran testified in a hearing before the Board. The Veteran reported that he experienced pain and cracking noise in his shoulders. He testified that some days he couldn't reach the top of the board in his classroom due to his shoulder condition and must have a student help him write up high. He stated he could life approximately two pounds from a low height, but he had difficulty lifting from up high. The Veteran also reported he took painkillers to manage his condition. In February 2011 the Veteran returned to a VA facility for further treatment of his shoulder condition. He reported chronic pain in both shoulders and feeling like his right shoulder would 'lock up.' The physician noted decreased range of motion in Veteran's right shoulder. The Veteran had normal strength in right shoulder, but was unable to actively flex. The physician noted the Veteran had partial left shoulder dislocation. She recommended physical therapy for the Veteran's shoulders. The physician noted the Veteran's shoulders were normal while sitting, but found his left AC joint was tender to palpation. Range of motion testing was conducted and in the Veteran's left shoulder revealed active flexion to 90 degrees, passive to 145 degrees; active abduction to 90 degrees, passive to 125 degrees; active external rotation to 55 degrees, passive to 65 degrees; and active internal rotation to 45 degrees, passive to 55 degrees. Right shoulder testing revealed active flexion to 145 degrees, active abduction to 145 degrees, active external rotation to 80 degrees, and active internal rotation to 75 degrees. In May 2011 the Veteran was seen by an orthopedic surgeon and reported increased shoulder pain, left more than right, especially with overhead motions. The Veteran described a nerve like pain in his left shoulder and achy symptoms in his right. Range of motion testing in right arm revealed flexion to 170 degrees, abduction to 160 degrees with pain at 90 degrees, external rotation of 80 degrees, and internal rotation to 75 degrees. The left shoulder revealed flexion to 160 degrees with pain beginning at 120 degrees, abduction to 150 degrees with pain at 90 degrees, external rotation to 80 degrees, and internal rotation to 75 degrees. Mild crepitus was noted in both shoulders, as well as some pain-related weakness on resisted abduction. X-rays were performed and minimal degenerative changes were noted in both acromioclavicular joints, while subacromial space was well preserved. The surgeon diagnosed degenerative labral tearing and impingement in the right shoulder, with biceps tendinopathy, impingement, and possible rotator cuff tear in the left shoulder. As such, the treatment records continued to reflect the Veteran had some shoulder impairment, primarily limited range of motion, however the evidence does not establish that the Veteran's condition had worsened at this time, providing more evidence against this claim. The Veteran returned in June 2011 and reported chronic bilateral shoulder pain and previous history of shoulder surgeries. He stated that for the past six months his left shoulder had gradually gotten worse. He reported his pain was 4 out of 10. The Veteran did not report instability symptoms in either shoulder. Range of motion testing in left shoulder revealed flexion to 165 degrees, abduction to 155 degrees, external rotation to 80 degrees, and internal rotation to 75 degrees. Right shoulder exhibited flexion to 160 degrees, abduction to 155 degrees, external rotation to 80 degrees, and internal rotation to 75 degrees. Muscle testing in left arm showed strength of 3 for flexion, abduction, extension, and external rotation, 3+ for internal rotation, 4 for triceps, and 4+ for biceps. Right shoulder showed 3+ strength in external rotation, 4- in flexion, abduction, and internal rotation, and 5 for extension, biceps, and triceps. The physician noted the Veteran showed characteristics consistent with subacromial impingement in the right shoulder, subacromial bursitis in the left. The Veteran was instructed on a home exercise plan to include range of motion and strengthening exercises. An MRI of both shoulders was also performed. Film of the left shoulder revealed degenerative changes bilaterally manifested by joint space narrowing, esteophytosis, capsular bulging with associated periarticular edema, and physical impingement of the supraspinatus tendon by the AC joint. The physician diagnosed supraspinatus tendinosis without evidence of rotator cuff tear, severe osteoarthritis of the ancromioclavicular joint with periarticular bone marrow edema, and subacromial subdeltoid bursitis. The MRI arthrogram of the right shoulder revealed degenerative changes of right AC joint manifested by mild subchondral cystic changes, capsular hypertrophy, and mild periarticular edema, as well as subcortical cystic changes at the insertion of the supraspinatous tendon. Physical impingement of the supraspinatus tendon by the AC joint was also revealed in the right shoulder. The physician also noted mild fraying of the bursal sided surface of the supraspinatus tendon without focal tear. The physician opined mild labral degenerative change without focal tear, mild supraspinatus tendinosis without significant rotator cuff tear, and acromioclavicular joint osteoarthritis with physical impingement upon the rotator cuff in the right shoulder. As discussed above, the Veteran was provided with an additional VA examination upon remand in June 2012. The examiner reviewed the Veteran's claims file and medical history, as well as personally interviewed the Veteran. He reported his medical history consistent with the record. The Veteran reported increased activities and certain movements triggered increased pain in both shoulders, as well as laying on either shoulder. Range of motion testing was performed and in the right shoulder revealed flexion to 90 degrees with pain beginning at 80 and abduction to 90 degrees with pain beginning at 80. Left shoulder revealed flexion to 80 degrees with pain beginning at 70 and abduction to 80 degrees with pain beginning at 70. The examiner noted the Veteran was unable to perform repetitive use testing due to his reported severe pain and impossibility of moving his shoulders any more. However, the examiner noted that no atrophy were present in either arm as would usually be seen when an extremity is not used secondary to severe pain. The examiner opined the Veteran did not have any functional loss or impairment in the shoulders or arms, providing highly probative evidence against the claims before the Board at this time. The Veteran exhibited localized tenderness, pain of palpation, and guarding of both shoulders. Muscle strength was rated at 5 out of 5 bilaterally. The Veteran did not have ankylosis of the shoulder. The examiner noted mechanical symptoms, such as clicking, in both shoulders. Tenderness upon palpation of the AC joint was noted in both shoulders. Scars were noted on both shoulders, but scars were not painful, unstable, or greater than 39 square centimeters. No imaging studies of the shoulder were performed. The examiner diagnosed the Veteran was osteoarthritis of both shoulders. The examiner also noted the Veteran exhibited a greater range of motion in May 2011, and the examiner therefore questioned the Veteran's valid participation in the examination. The examiner opined the Veteran's shoulder condition impacted his ability to work, noting the Veteran reported he was unable to move his upper extremities to complete his tasks as an art teacher. The Board notes that this most recent range of motion testing, from June 2012 reveals for the first time that the Veteran is only able to move his arm roughly even with his shoulder, showing flexion and abduction of 90 degrees in his right shoulder and 80 degrees in his left. Therefore, the Board finds that for the first time during the period on appeal the Veteran met the criteria for an increased 20 percent rating due to limitation of motion from his bilateral shoulder condition. A 20 percent rating is warranted under Diagnostic Code 5201 when the Veteran can only lift his arms to shoulder level. 38 C.F.R. § 4.71a. As such, the Board finds this rating is warranted effective June 2012, at best. In this regard, it is important for the Veteran to understand that not all evidence supports this finding, for reasons clearly cited above. Significant evidence indicates that the 20 rating is not warranted. However, in giving the Veteran the benefit of the doubt, and considering his complaints of pain, this evaluation may be justified, at this time. In this regard, the Board has considered the Veteran's occupation and that this condition may impact him more significantly than it would an average Veteran. The Board finds the Veteran is not entitled to a rating in excess of 20 percent at any point during the period on appeal based on impaired range of motion. Under Diagnostic Code 5201 a higher rating of 30 percent is not warranted unless the Veteran can only lift his arm to midway between side and shoulder level, or approximately flexion of 45 degrees. The Board finds the Veteran did not exhibit this limitation of motion at any point during the period on appeal. The Board notes that the August 2004 range of motion testing of the Veteran's right shoulder noted flexion of 45 degrees, however, as discussed above, the Board finds this result was likely due to a typographical error and is afforded little probative weight. This finding is totally inconsistent with event the Veteran's own statements regarding the nature and extent of his own disabilities. More persuasively, no other range of motion testing found the Veteran was limited to only raising his arm midway between his side and his shoulder during the entire period on appeal. As the Veteran consistently demonstrated an ability to raise his arm much higher than midway between his side and shoulder level, the Board finds a 30 percent rating under this code is not warranted at any point during the period on appeal. The Board also finds the Veteran was not entitled to the 20 percent rating at any point before June 2012 due to impaired range of motion. Diagnostic testing before June 2012 consistently demonstrated that the Veteran could move his arm higher than shoulder level, as evidenced by flexion and abduction consistently higher than 90 degrees. The Board notes as recently as June 2011 diagnostic testing revealed the Veteran had flexion of 165 degrees in his left shoulder and 160 degrees in his right, with abduction of 155 degrees bilaterally. This diagnostic testing revealed the Veteran could lift his arms higher than shoulder level through this time. As such, the Board finds a 20 percent rating based on limitation of motion is not warranted at any point before June 2012. Board also finds that the Veteran is not entitled to a higher rating under other diagnostic codes related to shoulder impairment during the period on appeal. Diagnostic Code 5200 relates to ankylosis of the shoulder. However treating physicians and examiners consistently noted the Veteran had no ankylosis of the shoulder throughout the period on appeal. This finding is supported by the most recent examination from June 2012 in which the examiner explicitly found the Veteran had no ankylosis of the shoulder. Therefore, the Board finds the Veteran is not entitled to a rating under this diagnostic code. Diagnostic Code 5202 relates to impairment of the humerous, including malunion, recurrent dislocation, nonunion, or flail shoulder. However, the medical evidence has been reviewed and does not establish the Veteran experienced any of these conditions at any point during the period on appeal. The most recent imaging of the Veteran's shoulders, the MRIs from June 2011, do not reveal any malunion of the humerus. As such, the Board finds a rating in excess of 20 percent is not warranted under this code for either shoulder. Finally, Diagnostic Code 5203 relates to impairment of the clavicle or scapula, including malunion, nonunion, and dislocation. However, such impairment was not noted in the medical evidence of record. As such, a rating under this code is also not warranted. In reaching this conclusion, the Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995) (a shoulder disability). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Additionally, painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. However, in this case the Board finds an additional rating under DeLuca is not warranted. In December 2007 the VA examiner specifically found that the Veteran did not experience any additional limitation with repetitive motion secondary to pain, fatigue, weakness, and lack of endurance. The most recent examiner, from June 2012, noted that the Veteran was not able to perform repetitive use testing due to reported severe pain. However, the examiner also noted that atrophy was not present in either arm as would usually be expected when an extremity is not used secondary to pain, suggesting the Veteran does not experience functional loss due to repetitive use. Regardless, while more recent testing did not explicitly state the Veteran was able to perform repetitive use testing without additional functional loss, it does not provide evidence that the Veteran experienced such loss. The Veteran reported that his shoulders caused him pain upon movement, but did not assert that repetitive use lead to loss of function. Although pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (emphasis added). Therefore, the Board finds the Veteran's pain alone does not entitle him to a higher disability evaluation than that warranted under the schedular criteria. In any event, without taking into consideration the Veteran's concerns, this evaluation could not be justified based on the objective record. The Board has also considered whether referral for consideration of an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a veteran is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. This means that 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 rating schedule for that disability. If the criteria reasonably describe the veteran's disability level and symptomatology, then the veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral is required. If the criteria do not reasonably describe the veteran's disability level and symptomatology, a determination must be made whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. In this case, the Board finds the schedular rating criteria reasonably describes the Veteran's symptomatology and disability level. The Veteran's primary complaints are pain and limited movement. The Board finds that the Veteran's range of motion and pain have been specifically completed by the rating criteria and the DeLuca factors. The Board has also considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. However, the Board finds that the evidence of record suggests the Veteran is still fully employed. As recently as June 2012 the Veteran reported he continued to work as an art teacher. The Board finds the Veteran's disability picture is not exceptional, and an extraschedular consideration is not required. In this regard, the Board has considered the Veteran's occupation and that this condition may impact him more significantly than it would an average Veteran in the evaluation of the 20 percent evaluation without which the objective medical evidence would provide significant evidence against the 20 percent evaluation, let alone a higher evaluation. The Board does note that treatment records reflect the Veteran was temporarily unemployed around the time of March 2006. However, nothing in the record suggested this period of unemployment was due to the Veteran's bilateral shoulder condition. Instead, treatment records from that time suggested the Veteran quit his job due to "racial slurs, MVA [motor vehicle accident], and inability to sleep." Thus, the Board finds that Rice is inapplicable since there is no evidence of unemployability due to the Veteran's service connected bilateral shoulder condition. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a veteran before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and must: (1) inform the veteran about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the veteran about the information and evidence that VA will seek to provide; and (3) inform the veteran about the information and evidence the veteran is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to service connection claims, a section 5103(a) notice should also advise a veteran of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In this case, the Veteran's claim for service connection for his shoulder condition was granted. He then appealed the downstream issue of the rating that had been assigned. Under these circumstances, since the original claim was granted, there are no further notice requirements under the aforementioned law with regard to that issue. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). VA and private treatment records have been obtained, as have service treatment records. Additionally, the Veteran was able to testify at a hearing before the Board. The Veteran was also provided with copious amounts of VA examinations (the reports of which have been associated with the claims file). The Board finds the VA examinations were thorough and adequate and provide a sound basis upon which to base a decision with regard to the Veteran's claim. The VA examiners personally interviewed and examined the Veteran, including eliciting a history from him, and provided the information necessary to evaluate his disability. Furthermore, neither the Veteran nor his representative has voiced any issue with the adequacy of the examinations. As discussed, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER The Veteran's claim for a rating in excess of 20 percent for left shoulder residuals of acromioplasty, to include an initial rating in excess of 10 percent earlier than June 12, 2012, is denied. The Veteran's claim for a rating in excess of 20 percent for right shoulder residuals of acromioplasty, to include an initial rating in excess of 10 percent earlier than June 12, 2012, is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs