Citation Nr: 1318008 Decision Date: 06/03/13 Archive Date: 06/11/13 DOCKET NO. 05-31 129 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent prior to January 9, 2012 for right shoulder degenerative joint disease. 2. Entitlement to a rating in excess of 20 percent on and after January 9, 2012 for right shoulder degenerative joint disease. 3. Entitlement to a rating in excess of 10 percent prior to April 26, 2005 for cervical spine degenerative joint disease. 4. Entitlement to a rating in excess of 20 percent from April 26, 2005 to January 8, 2012 for cervical spine degenerative joint disease. 5. Entitlement to a rating in excess of 30 percent on after and January 9, 2012 for cervical spine degenerative joint disease. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD G. Wasik, Counsel INTRODUCTION The Veteran served on active duty from December 1972 to November 1975 and from October 1985 to August 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2004 rating decision from the Department of Veterans Affairs (VA) Regional Office in Montgomery, Alabama (RO). Specifically, in August 2003, the Veteran submitted a claim of entitlement to a rating in excess of 10 percent for his service-connected cervical spine degenerative joint disease. He also submitted a claim of entitlement to service connection for right shoulder degenerative joint disease. In September 2004, the 10 percent rating assigned to the Veteran's cervical spine degenerative joint disease was maintained, while service connection for right shoulder degenerative joint disease was granted and a 10 percent rating was assigned thereto, effective August 25, 2003. The Veteran perfected an appeal seeking a higher rating for his cervical spine degenerative joint disease and a higher initial rating for his right shoulder degenerative joint disease. In a July 2007 rating decision, the rating assigned to the Veteran's cervical spine degenerative joint disease was increased to 20 percent, effective April 26, 2005. In June 2009 and December 2011, the Board remanded the Veteran's increased rating claims for further development. Subsequent to the second Board remand, in an August 2012 rating decision, the rating assigned to the Veteran cervical spine degenerative joint disease was increased to 30 percent, effective January 9, 2012. Moreover, the rating assigned to the Veteran's right shoulder degenerative joint disease was increased to 20 percent, also effective January 9, 2012. Following the issuance of an August 2012 supplemental statement of the case, the Veteran's claims were remitted to the Board for further appellate review. FINDINGS OF FACT 1. Prior to January 9, 2012, the service-connected right shoulder degenerative joint disease was manifested by complaints of pain and limitation of motion but the preponderance of the competent evidence demonstrates that the Veteran was able to move his arm above his shoulder. 2. From January 9, 2012 and thereafter, the service-connected right shoulder degenerative joint disease was manifested by complaints of pain but the Veteran was able to move his arm more than 45 degrees in abduction (limitation of motion was not limited to midway between the arm and shoulder). 3. Prior to April 26, 2005, the service-connected cervical spine degenerative joint disease was productive of moderate limitation of motion of the cervical spine. 4. From April 26, 2005 to January 9, 2012, the service-connected cervical spine degenerative joint disease was manifested by complaints of pain and limitation of motion but the Veteran was able to forward flex his spine to more than 15 degrees and severe limitation of motion of the cervical spine was not demonstrated. 5. From January 9, 2012 forward, the service-connected cervical spine degenerative joint disease was manifested by complaints of pain and limitation of motion but there was no ankylosis. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating of 10 percent prior to January 9, 2012 for right shoulder degenerative joint disease, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5201 (2012). 2. The criteria for entitlement to a rating in excess of 20 percent on and after January 9, 2012 for right shoulder degenerative joint disease, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5201 (2012). 3. The criteria for entitlement to a rating 20 percent prior to April 26, 2005 for cervical spine degenerative joint disease, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5290 (2002), Diagnostic Code 5237 (2012). 4. The criteria for entitlement to a rating in excess of 20 percent from April 26, 2005 to January 9, 2012 for cervical spine degenerative joint disease, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5290 (2002), Diagnostic Code 5237 (2012). 5. The criteria for entitlement to a rating in excess of 30 percent on after and January 9, 2012 for cervical spine degenerative joint disease, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5237 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100 , 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his/her representative, if applicable, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) ; Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Further, in Dingess v. Nicholson, the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, VA is required to review the evidence presented with the claim and to provide the claimant with notice of what evidence not previously provided will help substantiate his/her claim. 19 Vet. App. 473 (2006); see also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the claimant of what is required to establish service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. The Board finds that the VCAA duty to notify was satisfied by letters sent to the Veteran in January 2004, March 2006 and July 2009. The claims were readjudicated after the notifications, the most recent readjudication is documented in the March 2013 supplemental statement of the case. Therefore, the Board finds that VA has fulfilled its duty to notify under the VCAA. VA has also satisfied its duty to assist the Veteran at every stage of this case. All available VA and private medical records identified by the Veteran are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claims. The Veteran has not indicated that there is any pertinent outstanding evidence which has not been obtained. VA examinations with respect to the claims were conducted and the reports of the VA examinations have been associated with the claims file. The Board finds reports of the VA examinations are sufficient to accurately adjudicate the current claims. The examiners who conducted the most recent examinations had access to and reviewed the evidence in the claims file and also physically examined the Veteran. The Veteran's self-reported medical history was recorded. Range of motion testing was conducted including repetitive range of motion testing and the results were reduced to writing in a form the Board can utilize in making the determinations below. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4) . VA has also assisted the Veteran and his representative throughout the course of this appeal by providing them with statements of the case and supplemental statement of the case, as appropriate, which informed them of the laws and regulations relevant to his claims. For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Increased rating criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In Fenderson, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a Veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2007). Under Diagnostic Code 5010, traumatic arthritis is rated. This provision directs the Board to rely on Diagnostic Code 5003, which addresses degenerative arthritis, when evaluating arthritic disorders. Under Diagnostic Code 5003, traumatic arthritis is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. When there is some limitation of motion, but which is noncompensable under a limitation-of-motion code, a 10 percent rating may be assigned with involvement of a major joint. 38 C.F.R. § 4.71a , Diagnostic Codes 5003, 5010. Limitation of motion of the arm is evaluated under Diagnostic Code 5201. Ratings assigned pursuant to this code may differ depending on whether the extremity at issue is considered the major (dominant) extremity or the minor (non-dominant) extremity. As the Veteran in the case at hand is right-handed, his right shoulder condition affects his major extremity, and will be evaluated accordingly. Under Diagnostic Code 5201, limitation of motion of the major extremity at the shoulder level warrants a 20 percent rating. Limitation of motion of the major extremity midway between the side and shoulder level warrants a 30 percent rating. Where motion of the major extremity is limited to 25 degrees from the side, a 40 percent rating is warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5201. For reference, standard ranges of shoulder motion are forward elevation (flexion) and abduction each from 0 to 180 degrees (with shoulder level at 90 degrees); and external and internal rotation each to 90 degrees. See 38 C.F.R. § 4.71, Plate I. During the pendency of this appeal, regulatory changes amended the VA Schedule for Rating Disabilities, 38 C.F.R. Part 4, including the criteria for rating disabilities of the spine. Effective September 26, 2003, VA revised the criteria for rating general diseases and injuries of the spine. 68 Fed. Reg. 51,454 (Aug. 27, 2003). Disabilities and injuries of the spine are currently evaluated under 38 C.F.R. § 4.71a, Diagnostic Codes 5235 through 5243. Because the Veteran filed his current claim in August 2003 the Board is required to consider the claim in light of both the former and revised schedular criteria in order to determine whether a higher rating is warranted for his neck disability. If application of the revised regulation results in a higher rating, the effective date for the higher disability rating can be no earlier than the effective date of the change in the regulation. 38 U.S.C.A. § 5110(g). Prior to the effective date of the change in the regulation, the Board can apply only the prior version of the regulation. Under former Diagnostic Code 5290, in effect prior to September 26, 2003, severe limitation of motion of the cervical spine is evaluated as 30 percent disabling. Moderate limitation of motion is evaluated as 20 percent disabling. Slight limitation of motion merits a 10 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5290 (2002). Under the revised criteria, effective September 26, 2003, a General Rating Formula for Diseases and Injuries of the Spine provides that, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. Unfavorable ankylosis of the entire cervical spine warrants a 40 percent evaluation. Forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine warrants a 30 percent evaluation. Forward flexion greater than 15 degrees but not greater than 30 degrees or the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis warrants a 20 percent evaluation. Forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height warrants a 10 percent rating. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (2012). When rating diseases and injuries of the spine, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. Id. at Note (1). Normal range of motion of the cervical spine is 45 degrees of flexion; 45 degrees of extension; 45 degrees of right and left lateral flexion; and 80 degrees of right and left rotation. 38 C.F.R. § 4.71a, Plate V. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3. Entitlement to an initial rating in excess of 10 percent prior to January 9, 2012 and entitlement to a rating in excess of 20 percent on and after January 9, 2012 for right shoulder degenerative joint disease Factual background In August 2003, the Veteran submitted a claim of entitlement to service connection for a right shoulder disorder. In September 2004, the RO granted service connection for degenerative joint disease of the right shoulder and assigned a 10 percent rating effective from August 2003. On VA examination in April 2004, the Veteran reported decreased range of motion in his right shoulder. Physical examination revealed that the range of motion of the shoulder was 80 degrees of posterior flexion, 90 degrees of anterior flexion, 90 degrees of internal rotation and 30 degrees of external rotation. Abduction was to 120 degrees. The pertinent diagnosis was degenerative joint disease of the right shoulder with moderate loss of function due to pain. Mild loss of function from decreased range of motion. The primary problem was pain and range of motion was nearly normal. At the time of a May 2004 examination, the range of motion of the shoulder was determined to be external rotation to 70 degrees and internal rotation to 75 degrees. At the time of an April 2005 VA examination, the Veteran reported chronic pain in his shoulder exacerbated by mowing the lawn, repetitive use, and reaching. He also reported some associated dislocation and subluxation intermittently. He denied flares. Range of motion was forward flexion from 0 to 130 degrees, abduction range of motion was form 0 to 110 degrees, internal rotation was from 0 to 40 degrees and external rotation was from 0 to 70 degrees. Tenderness was present at the acromioclavicular joint but no crepitance was found. The pertinent assessment was right shoulder degenerative joint disease with mild to moderate impairment. In January 2007, the Veteran received an injection for treatment of right shoulder bursitis/tendonitis. On VA examination in September 2009, the Veteran reported he experienced pain with certain movements or activities like raking or doing yard work and limited motion. He reported he was unable to swim any more. The condition had become progressively worse. The Veteran reported no deformity but there was instability. Pain, stiffness and weakness were also reported. He reported that his shoulder dislocated one to three times per month. He had flares of joint disease every two to three weeks lasting one to two days with severe symptoms. Physical examination revealed right flexion was from 0 to 110 degrees, right abduction was from 0 to 90 degrees; right internal rotation was from 0 to 30 degrees and left external rotation was from 0 to 70 degrees. There was objective evidence of pain following repetitive motion but no additional limitations were present after three repetitions of range of motion testing. No joint ankylosis was present. The diagnosis was degenerative joint disease of the right shoulder. A VA examination of right shoulder was conducted in April 2011. The Veteran reported right shoulder dislocation four to five times per month. He was able to put his shoulder back into place himself. He had intermittent moderate right shoulder pain which flared with dislocations. Muscle strength was 5/5 in the upper extremities. No ankylosis was present and there were no other objective joint abnormalities. Range of motion for right flexion was from 0 to 170 degrees; right abduction was from 0 to 170 degrees; right internal rotation was from 0 to 90 degrees and right external rotation was from 0 to 90 degrees. There was objective evidence of pain following repetitive motion but there was no additional limitations in the range of motion after three repetitions. The pertinent diagnosis was recurrent right shoulder subluxation. A VA shoulder examination was conducted in January 2012. The Veteran reported he had daily constant right shoulder pain. The pain was severe. He experienced flares of pain once or twice per day lasting a few minutes at which time he could not lift his arm above his head. Range of motion was conducted with flexion to 85 degrees and abduction to 50 degrees. Objective evidence of painful motion began at 0 degrees for both. Repetitive testing did not result in any additional limitation of motion. Repetitive testing resulted in less movement than normal, weakened movement and pain on movement. No ankylosis was present. Hawkins's impairment test, empty can test and lift-off subscapularis test were all negative. There was a reported history of subluxation with infrequent episodes in the right shoulder. Crank apprehension and relocation tester was negative. The Veteran did not have any acromioclavicular joint condition or any other impairment of the clavicle or scapula. Cross-body testing was negative. The examiner opined that the disability would limit the Veteran's ability to lift and carry objects above his head as well as duties of a very physical nature. The diagnosis was right shoulder arthritis. Analysis The Board finds that a rating in excess of 10 percent is not warranted for the service-connected right shoulder disorder prior to January 2012 based on limitation of motion of the shoulder under Diagnostic Code 5201. To warrant a greater level of compensation during this time period, the evidence must demonstrate that the motion of the Veteran's shoulder is limited to shoulder level or less. The greatest level of impairment of the motion of the right shoulder is documented at the time of the September 2009 VA examination when abduction was determined to be 90 degrees. Significantly, none of the other range of motion testing conducted during the pertinent time period documents this level of impairment. All the other range of motion testing conducted prior to and subsequent to September 2009 indicate that the Veteran was able to move his arm above shoulder level (over 90 degrees). No clinical records associated with the claims file document an inability to raise the arm above shoulder level. The Board finds the pertinent evidence of record more nearly approximates a 10 percent rating for the right shoulder disability prior to January 2012. The Board finds a rating in excess of 20 percent is not warranted for the service-connected right shoulder disability from January 2012 to the present under Diagnostic Code 5201. In order to warrant an increased rating for this time period, the evidence must demonstrate that the motion of the right arm is limited to midway between the side and shoulder level. On VA examination in January 2012, the Veteran was able to abduct his shoulder to 50 degrees. This range of motion does not equate to limitation of motion of the arm to approximately 45 degrees or less or midway between the side and the shoulder. There is no objective evidence of record which demonstrates that the Veteran was able to move his arm less than midway between the shoulder and his side during the pertinent time period. The Board finds that an increased rating for the right shoulder disability is not warranted at any time upon consideration of pain on use and during flares. Where testing was conducted to determine if the Veteran experienced additional limitation of motion upon repetitive use, it was found that there would be increased pain but no decrease in the range of motion. It is observed that the Veteran reported, at times, that the entire range of motion of his shoulder was painful. However, the Veteran was always able to move his shoulder. The Court has held that pain alone does not constitute a functional loss under VA regulations which evaluate disabilities based upon loss of motion. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that "the plain language of the regulation is unambiguous that, although pain may cause a functional loss, pain itself does not constitute functional loss"). The evidence of painful motion noted during the course of the appeal has been considered in awarding the compensable evaluations assigned. The fact that the Veteran experienced pain with all motion at times does not equate to a lack of motion of the right shoulder. After reviewing the totality of the relevant evidence, the Board concludes that the preponderance of the evidence is against an increased rating at any time during the appeal period. It follows that there is not a state of equipoise of the positive evidence with the negative evidence to permit a more favorable determination pursuant to 38 U.S.C.A. § 5107(b). Entitlement to a rating in excess of 10 percent prior to April 26, 2005, entitlement to a rating in excess of 20 percent from April 26, 2005 to January 9, 2012 and entitlement to a rating in excess of 30 percent on after and January 9, 2012 for cervical spine degenerative joint disease. Factual background In August 2003, the Veteran submitted a claim of entitlement to an increased rating for his service-connected cervical spine disability. On VA examination in April 2004, the Veteran reported progressive neck pain since an in-service injury. Physical examination revealed the range of motion of the cervical spine was anterior flexion to 30 degrees, posterior flexion to 45 degrees, right rotation to 45 degrees, left rotation to 50 degrees, right lateral flexion to 30 degrees and left lateral flexion to 30 degrees. Neurologic examination was negative. The pertinent diagnosis was degenerative joint disease of the cervical spine. The examiner opined the Veteran examiner had moderate to severe loss of function due to pain and decreased range of motion. Range of motion decreased where pain begins. There were no signs of significant degenerative disc disease and no signs of radiculopathy. The combined range of motion of the cervical spine was 230 degrees. On VA examination in May 2004, the examiner noted that the range of motion he obtained was not different from the prior VA examination with very little decrease. The examiner observed that the difference in the range of motion was that cervical spine lateral flexion was to 10 degrees. The combined range of motion from this examination was 190 degrees. At the time of an April 2005 VA examination, the Veteran reported neck pain which was 10 out of 10 and exacerbated by any moving of the head. He reported associated popping and grinding. Pain radiated to both his shoulders. He had daily flares which lasted for hours. During flares, there was increased pain. Range of motion testing was conducted. It was determined that the range of motion at the time of the examination was extension from 0 to 10 degrees; flexion from 0 to 45 degrees; lateral flexion from 0 to 10 degrees bilaterally, and rotation from 0 to 45 degrees bilaterally. There was tenderness to the cervical spine on both sides with spasms. The pertinent diagnosis was cervical spine degenerative joint disease with moderate impairment. The combined range of motion was 165 degrees. In December 2005 the range of motion of the cervical spine was within normal limits but was labored and slow except for lateral flexion which was limited to the 50% range. The Veteran reported he experienced numbness down his legs and arms. A VA examination of cervical spine was conducted in April 2011. The Veteran reported constant severe neck pain along with stiffness and spasms. He had flares of pain which he estimated resulted in an additional limitation of motion of 75 percent. The condition had been progressively worsening. He also reported pain radiating to his right arm and flares of spinal disease. The frequency was weekly and the duration was hours during which time the pain was extreme. Physical examination revealed there was no ankylosis nor was there evidence of fracture of one or more vertebral bodies. The range of motion was flexion from 0 to 35 degrees; extension from 0 to 35 degrees; right lateral flexion from 0 to 25 degrees; left lateral flexion from 0 to 60 degrees; right lateral rotation from 0 to 60 degrees. There was objective evidence of pain on active range of motion. There was objective evidence of pain following repetitive motion but there was no additional limitation of motion. The pertinent diagnosis was cervical spine degenerative disc disease. At the time of a January 2012 VA examination of the cervical spine, the Veteran reported he experienced constant extreme pain in his neck. The pain would flare once or twice per week which lasted several minutes. During flares, he estimated his activities would be limited by 90 percent. Physical examination revealed that the range of motion was forward flexion to 25 degrees; extension was to 15 degrees; right lateral flexion was to 10; left lateral flexion was to 10 degrees; right and left lateral rotation was to 20 degrees. Objective evidence of pain was present throughout the entire range of motion testing. After repetitive testing there was no additional limitation of motion. The Veteran had less movement than normal, weakened movement, excess fatigability and pain on movement after repetitive testing. The diagnosis was cervical spine degenerative disc disease. Analysis Initially, the Board notes that, during the entire appeal period, there is no competent evidence documenting the presence of ankylosis of the spine, either favorable or unfavorable. The Veteran does not meet the schedular criteria for a 40 percent evaluation at any time. For the period prior to April 26, 2005, the competent probative evidence does not demonstrate that the restriction in the range of motion of the spine warranted a rating in excess of 10 percent. Physical examination failed to demonstrate that forward flexion was 30 degrees or less. The greatest level of impairment of forward flexion was recorded to be 45 degrees at the time of the April 2004 VA examination. The examiner who conducted the May 2004 examination did not quantify the extent of impairment of forward flexion other than noting that it was not different from the time of the prior examination. The Board finds that, at the time of the April 2004 VA examination, the evidence of record does not support a determination that the service-connected cervical spine disability was productive of moderate or severe limitation of motion of the cervical spine. The Board's determination is based on the fact that the combined range of motion in April 2004 was determined to be 230 degrees out of a possible 340 degrees. The Board finds that the Veteran is able to move is spine approximately two thirds of the normal combined range of motion. This equates to a finding that the service-connected spine disability was productive of only slight limitation of motion when evaluated the disability under the three step criteria of slight, moderate and severe. The Board notes the examiner who conducted the April 2004 VA examination found the Veteran had moderate to severe loss of function due to pain. This does not change the Board's determination. The Board observes that the words "slight", "moderate", and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just". 38 C.F.R. § 4.6. It should also be noted that use of descriptive terminology such as "mild" by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 U.S.C.A. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. The Board finds that a 20 percent evaluation is warranted for the cervical spine disability prior to April 26, 2005 based on a determination that the May 2004 VA examination report documents the presence of moderate limitation of motion of the cervical spine under Diagnostic Code 5290 in effect prior to September 23, 2003. In May 2004, the combined range of motion of the cervical spine was determined to be 190 degrees. This combined range of motion is slightly more than half of the normal combined range of motion of the cervical spine of 340 degrees. This equates to a finding that the service-connected spine disability was productive of moderate limitation of motion when evaluated the disability under the three step criteria of slight, moderate and severe. Based on the Board's reasoning, the combined range of motion for of the cervical spine requires restriction to approximately 1/3 or less of the normal combined range of motion to qualify as severe which would be approximately 113 degrees or less. This level of symptomatology is not demonstrated at any time prior to January 2012. From April 2005 to January 2012, the Board finds the evidence of record does not support a determination that the service-connected cervical spine disability warranted a rating in excess of 20 percent. A 30 percent rating requires the cervical spine disability to be productive of ankylosis of the cervical spine or limitation of forward flexion to 15 degrees or less or there must be evidence of severe limitation of motion of the cervical spine in order to warrant a rating in excess of 20 percent. The competent probative medical evidence does not support such a determination. As set out above, there is no competent evidence documenting the presence of ankylosis of the cervical spine at any time during the appeal period. The greatest level of impairment of forward flexion of the cervical spine during this time period was determined to be 35 degrees. The greatest level of impairment of the combined motion of the cervical spine was documented in 155 degrees in April 2011. The Board finds this level of impairment equates to, at most, moderate limitation of motion of the cervical spine. The Veteran is able to move his cervical spine more than 1/3 of the normal combined range of motion but less than 2/3rds. From January 2012 to the present, the service-connected cervical spine disability must be manifested by unfavorable ankylosis of the entire cervical spine in order to warrant an increased rating. This symptomatology is lacking and a rating in excess of 30 percent for the cervical spine disability is not warranted from January 9, 2012 to the present. The Board finds that an increased rating for the cervical spine disability is not warranted at any time upon consideration of pain on use and during flares. Where testing was conducted to determine if the Veteran experienced additional limitation of motion upon repetitive use, it was found that there would be increased pain but no decrease in the range of motion. It is observed that the Veteran reported, at times, that the entire range of motion of his cervical spine was painful. However, the Veteran was always able to move his spine. The Court has held that pain alone does not constitute a functional loss under VA regulations which evaluate disabilities based upon loss of motion. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that "the plain language of the regulation is unambiguous that, although pain may cause a functional loss, pain itself does not constitute functional loss"). The evidence of painful motion noted during the course of the appeal has been considered in awarding the compensable evaluations assigned. The fact that the Veteran experienced pain with all motion at times does not equate to a lack of motion of the cervical spine. The Board finds that an increased rating or separate rating is not warranted at any time for separate neurological abnormalities associated with the cervical spine. While the Veteran has reported the presence of pain and numbness, no health care professional has attributed these complaints to separate neurological abnormalities associated with the cervical spine. After reviewing the totality of the relevant evidence, the Board concludes that the preponderance of the competent probative evidence supports a determination that a 20 percent evaluation is warranted prior to April 26, 2005 but ratings in excess of this amount subsequent to this time are not warranted. It follows that there is not a state of equipoise of the positive evidence with the negative evidence to permit a more favorable determination pursuant to 38 U.S.C.A. § 5107(b) for increased ratings after April 26, 2005. Extraschedular consideration The Board has also considered whether the Veteran's disabilities present an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). 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. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Veteran has complained of pain and limitation of motion in his shoulder and cervical spine and the current rating criteria provide evaluations for these complaints. The current rating criteria also provide for additional or more severe symptoms than currently shown by the evidence; thus, the Veteran's disability picture is contemplated by the rating schedule, and the assigned schedular evaluations are, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. ORDER Entitlement to an initial rating in excess of 10 percent prior to January 9, 2012 for right shoulder degenerative joint disease is not warranted. The appeal is denied. Entitlement to a rating in excess of 20 percent on and after January 9, 2012 for right shoulder degenerative joint disease is not warranted. The appeal is denied. Entitlement to a 20 percent evaluation prior to April 26, 2005 for cervical spine degenerative joint disease is granted subject to the laws and regulations governing monetary awards. Entitlement to a rating in excess of 20 percent from April 26, 2005 to January 9, 2012 and entitlement to a rating in excess of 30 percent on after and January 9, 2012 for cervical spine degenerative joint disease is not warranted. The appeal is denied. ____________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs