Citation Nr: 1318129 Decision Date: 06/04/13 Archive Date: 06/11/13 DOCKET NO. 09-18 902A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Atlanta, Georgia THE ISSUE 1. Entitlement to a rating in excess of 20 percent for recurrent dislocation of the right shoulder with subacromial bursitis and degenerative changes from December 6, 2005 to June 15, 2010. 2. Entitlement to a rating in excess of 30 percent for recurrent dislocation of the right shoulder with subacromial bursitis and degenerative changes beginning on August 1, 2010. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Suzie S. Gaston, Counsel INTRODUCTION The Veteran served on active duty from August 1968 to August 1972. This matter comes before the Board of Veterans' Appeals (hereinafter Board) on appeal from a June 2007 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland, which continued a 20 percent disability rating for recurrent dislocation of the right shoulder with subacromial bursitis and degenerative changes. Subsequently, in a September 2007 rating decision, the RO confirmed and continued the 20 percent disability rating for the service-connected recurrent dislocation of the right shoulder with subacromial bursitis and degenerative changes. The Veteran perfected a timely appeal to that decision. In a December 2010 rating decision, the Atlanta, Georgia RO assigned a temporary 100 percent evaluation based on surgical or other treatment necessitating convalescence, effective June 16, 2010 to July 31, 2010. The rating decision also assigned a 30 percent evaluation for recurrent dislocation of the right shoulder with subacromial bursitis and degenerative changes from August 1, 2010, forward. Because this is not the highest possible rating available under the rating schedule for this disability, and because the Veteran has not indicated that he is content with the 30 percent rating, the appeal continues. See AB v. Brown, 6 Vet. App. 35, 39 (1993). In February 2012, the Board remanded the case for further evidentiary development. The Appeals Management Center (AMC) completed the requested development and issued a supplemental statement of the case (SSOC) in October 2012. Review of the record reflects substantial compliance with the Board's Remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT 1. During the period from December 6, 2005 to June 15, 2010, the Veteran's right shoulder disorder was manifested by shoulder pain, weakness, stiffness, and slight limitation of motion, but without functional loss that equates to limitation of motion to 25 degrees from the side. The Veteran's right shoulder bursitis was not shown to have limitation of motion midway between the side and shoulder level and was not manifested by ankylosis of the scapulohumeral articulation; impairment of the humerus involving recurrent dislocation at the scapulohumeral joint, malunion, fibrous union, false flail joint, or flail shoulder; or impairment of the scapula or clavicle. 2. Beginning August 1, 2010, the Veteran's right shoulder impingement was manifested by subjective complaints of chronic constant pain, weakness, stiffness, giving way, locking and tenderness; objective findings showed instability, weakness, tenderness, guarding of movement, and limitation of motion of the right arm, more than midway between the side and the shoulder level. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for recurrent dislocation of the right shoulder with subacromial bursitis and degenerative changes were not met during the period from December 6, 2005 to June 15, 2010. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4 .10, 4.71a, Diagnostic Codes 5299-5201 (2012). 2. Beginning August 1, 2010, the criteria for a rating in excess of 30 percent for recurrent dislocation of the right shoulder with subacromial bursitis and degenerative changes have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp 2012); 38 C.F.R. §§ 3.157, 3.321, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5299-5201 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist. The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim; and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims has held that VCAA notice should be provided to a claimant before the initial RO decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice is provided after the initial decision, such a timing error can be cured by subsequent readjudication of the claim, as in a statement of the case (SOC) or SSOC. Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In this case, VA satisfied its duty to notify by means of a letter dated in January 2007 from the RO to the Veteran which was issued prior to the RO decisions in June 2007 and September 2007. Additional letters were issued in February 2012 and May 2012. Those letters informed the Veteran of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. Accordingly, the requirements the Court set out in Pelegrini have been satisfied. The Board finds that the content of the above-noted letters provided to the Veteran complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. Regarding the duty to assist, the Veteran was provided an opportunity to submit additional evidence. It also appears that all obtainable evidence identified by the Veteran relative to the claim decided herein has been obtained and associated with the claims file, and that neither he nor his representative has identified any other pertinent evidence not already of record that would need to be obtained for a proper disposition of this claim. It is therefore the Board's conclusion that the Veteran has been provided with every opportunity to submit evidence and argument in support of his claim, and to respond to VA notice. The Veteran has been afforded VA examinations on the issue decided herein. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The examinations were conducted by medical professionals who reviewed the medical records, solicited history from the Veteran, and provided information necessary to decide the issue addressed in this decision. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). Accordingly, the Board finds that VA has satisfied its duty to notify and assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence under the VCAA. Therefore, no useful purpose would be served in remanding these matters for yet more development. Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the Veteran. The Court has held that such remands are to be avoided. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). II. Factual Background. By a rating action in August 1973, the RO granted service connection for recurrent dislocation of the right shoulder; a 0 percent disability rating was assigned, effective August 5, 1972. In January 1974, the RO increased the evaluation for the right shoulder disorder from 0 percent to 10 percent, effective August 5, 1972. Subsequently, in a July 2004 rating action, the RO increased the evaluation for the right shoulder disorder from 10 percent to 20 percent, effective January 21, 2004. The Veteran's claim for an increased rating for his right shoulder disorder (VA Form 21-4138) was received in December 2006. Submitted in support of the claim were VA progress notes dated from May 2005 to September 2006. These records show that the Veteran received follow up evaluation and treatment for his right shoulder disorder. An orthopedic consultation note, dated in May 2006, indicates that the Veteran was seen for evaluation of right shoulder pain. It was noted that he had had pain and crepitus as well as some cramping sensation in his right shoulder since 1969. He stated that he had not any treatments to his shoulder since that time. He denied any symptoms which extend beyond the elbow; he also denied any neck pain. On examination, his right shoulder range of motion both active and passively was full. He had some tenderness to palpation over the AC joint. He had a positive cross-body adduction test. He had a negative near and Hawkins test. He had some discomfort with supraspinatus strength testing. He had no pain with internal and external rotation. X-ray study, dated in April 2006, revealed mild degenerative joint disease in the acromioclavicular joint; there were no other significant bony abnormalities. The pertinent diagnosis was AC degenerative joint disease. When seen in September 2006, it was noted that the Veteran was offered cortisone injection in May 2006 but declined. He was seen requesting a cortisone injection in the right shoulder. He reported that this condition is not affecting his lifestyle at this time, but would like to have some type of treatment to relieve this pain. He was not currently taking any pain medication. He rated the severity of the pain as 5 out of 10 at the worst. On examination, it was noted that he had pain on elevation of the right arm at the 75 degree level. He had tenderness on palpation over the AC joint on the right. The assessment was right shoulder impingement and right shoulder acromioclavicular degenerative joint disease. The Veteran was afforded a VA compensation examination February 2007. At that time, the Veteran indicated that he dislocated his right shoulder only once while in the Marine Corps; it was reduced conservatively without surgery. Over the years he has continued to have discomfort in the shoulder. It was noted that he underwent one arthroscopic debridement of calcium deposit in 1993. He also received a steroid injection in the right shoulder in September 2006 at the Baltimore VA. It was reported that the Veteran is self-employed IT personnel. On examination, the right shoulder had a forward flexion to 170 degrees, abduction to 160 degrees, external rotation to 80 degrees, and internal rotation to 70 degrees. He had discomfort between 100 to 170 degrees abduction and forward flexion. There was no loss of motion on repetitive maneuvers. X-ray examination is CPRS that revealed degenerative arthritis. The pertinent diagnosis was right shoulder impingement syndrome. The examiner stated that the Veteran had limitation lifting heavy weight and doing above shoulder activity from right dominant upper extremity. However, there was no evidence of additional limitation either due to pain, weakness, fatigue, lack of endurance after repetitive motion, incoordination or flare-up. There was no evidence of adverse impact on activities of daily living, personal grooming, hygiene, transportation, or his current occupation as an IT personnel. Received in August 2008 were VA progress notes dated from June 2008 through August 2008. These records do not reflect any complaints of or treatment for the right shoulder disorder. The Veteran was afforded another VA examination in September 2008. He reported problems with weakness, stiffness, lack of endurance and locking. It was noted that he did not have any swelling, heat, redness, giving way, fatigability or dislocation. The Veteran also reported having pain in the right shoulder which occurs constantly; he noted that the pain travels to the lower back. The Veteran described the pain as crushing, burning, aching and sharp; he described the intensity of the pain as a 10 out of 10. The Veteran noted that the pain is relieved by heating pads. Examination of the right shoulder revealed a level scar at the right shoulder measuring 4 cm x 0.3 cm; the scar had hypopigmentation of less than 6 square inches. There was no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, inflammation, edema, keloid formation, hyperpigmental or abnormal texture. It was noted that the Veteran is right hand dominant. There was tenderness and guarding on movement of the right shoulder. The right shoulder showed no signs of edema, effusion, weakness, redness or heat; there was no subluxation. Range of motion in the right shoulder revealed a forward flexion of 0 degrees to 150 degrees, with pain occurring at 100 degrees; abduction was from 0 degrees to 130 degrees, with pain occurring at 90 degrees; external rotation was from 0 to 40 degrees, with pain occurring at 10 degrees; and internal rotation was 0 to 40 degrees, with pain occurring at 10 degrees. The examiner noted that the joint function was additionally limited by pain after repetitive use; however, the joint function was not additionally limited by fatigue, weakness, lack of endurance and incoordination. There was no additional limitation in degree. Motor function in the right arm was within normal limits and sensory function was within normal limits. Reflexes in the right upper extremity revealed biceps jerk of 1+ and triceps of 1+. The pertinent diagnosis was changed from right shoulder dislocation to right shoulder strain; the examiner stated that there was no dislocation found on examination and the x-ray was normal. The subjective factors were pain and stiffness, and the objective factors were decreased range of motion with pain and normal x-ray. Received in May 2009 were VA progress notes dated from March 2007 to April 2009. These records do not reflect any complaints of or treatment for the right shoulder disorder. Received in June 2009 were private treatment reports dated from May 2009 to June 2009 which show that the Veteran received physical therapy treatment for constant sharp pain in the right shoulder. When seen in June 2009, a splint was applied to the right shoulder and the Veteran was placed on limited duty, with restrictions that included no lifting, pulling or pushing more than 15 pounds with the right extremity. Received in January 2010 were VA progress notes dated from June 2008 through January 2010. These records do not reflect any complaints of or treatment for the right shoulder disorder. Records from Piedmont Hospital show that the Veteran was seen in June 2010 for evaluation of his right shoulder; he was diagnosed with right shoulder impingement, partial tear. A subsequent operative report indicates that the Veteran sustained an injury at work to his right shoulder, and preoperative MRI revealed acromioclavicular arthritis and evidence of anterolateral acromial spur with bursal changes. He failed conservative measures. The Veteran underwent right shoulder arthroscopy with glenohumeral joint debridement of synovitis and fraying; arthroscopic biceps tenotomy and tendodesis; arthroscopic subacromial decompression and bursectomy; and arthroscopic distal clavicle excision. On the occasion of a VA examination in June 2010, the Veteran reported problems with weakness, stiffness, giving way, lack of endurance, locking, fatigability, tenderness and pain. It was noted that he did not have any swelling, heat, redness, deformity, drainage, effusion, subluxation or dislocation. The Veteran reported experiencing flare-ups often lasting 24 hours; he rated the intensity of the right shoulder pain as a 10. He noted that the flare-ups are precipitated by physical activity and work and they are alleviated by rest. The Veteran reported difficulty standing and walking; he also noted limited swing of his arm. It was noted that the Veteran was not receiving any treatment for his shoulder condition. It was reported that the Veteran had arthroscopic surgery on the right arm, but he was not experiencing any residual symptoms. The Veteran stated that it is very difficult to perform his usual occupation. On examination, it was noted that the Veteran was right hand dominant. There was no scar based on the skin examination. There was tenderness and guarding on movement of the right shoulder. The right shoulder showed no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, malalignment and drainage; there was no subluxation. There was no ankylosis of the right shoulder. Range of motion in the right shoulder revealed a forward flexion of 0 degrees to 80 degrees, with pain occurring at 75 degrees; abduction was from 0 degrees to 60 degrees, with pain occurring at 55 degrees; external rotation was from 0 to 65 degrees; and internal rotation was 0 to 90 degrees. The examiner noted that the joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. The examiner noted that the pertinent diagnosis is bilateral shoulder strain, status post right shoulder dislocations with bursitis and degenerative changes. The objective factors are restrictive range of motion and tenderness; there was no visible scar on examination. The Veteran was afforded another VA examination in October 2010, in order to evaluate the right shoulder disorder following his June 2010 surgery. At that time, the Veteran reported problems with weakness, stiffness, giving way, lack of endurance, locking, tenderness and pain. He denied any swelling, heat, redness, fatigability, deformity, drainage, effusion, subluxation or dislocation. The Veteran reported experiencing flare-ups once each day which usually last up to 24 hour; he rated the intensity of the right shoulder pain as a 7. He stated that the flare-ups occurred spontaneously; he noted that they are alleviated by Oxycodone. The Veteran indicated that, during the flare-ups, he experiences pain and limitation of motion of the joint. The Veteran reported difficulty standing and walking; he also noted that he can't swing his arms as he walks due to pain. The Veteran related that he underwent surgery for his right shoulder in June 2010, and the residuals of the surgery include persistent pain in the right shoulder. He stated that his condition has not resulted in any incapacitation in the past 12 months. It was noted that the Veteran works in a hospital and his duties include pulling medical files; the Veteran noted that the shoulder pain may eventually cause him to lose his job. On examination, it was noted that there was a scar precisely located right shoulder anterior midline deltoid muscle; it was a vertical scar secondary to the shoulder surgery. This was a linear scar; it measured 5 cm by 0.5 cm. The scar was not painful on examination. There was no skin breakdown. It was a superficial scar with no underlying tissue damage. Inflammation was absent. Edema was absent. There was no keloid formation. The scar was not disfiguring; it did not limit the Veteran's motion. There was no limitation of function due to the scar. There was a scar precisely located right shoulder over the lateral deltoid muscle area vertical in nature from the shoulder surgery. This was a linear scar. The entire scar measured 2 cm by 0.5 cm. The scar was not painful on examination. There was no skin breakdown. This was a superficial scar with no underlying tissue damage. Inflammation was absent; edema was absent. There was no keloid formation. The scar was not disfiguring; it did not limit the Veteran's motion. There was no limitation of function due to the scar. There was a scar precisely located right shoulder superior area adjacent to the acromioclavicular junction. The scar was horizontal in nature; it was from the arthroscopic surgery. This was a linear scar. The entire scar measured 1 cm by 0.5 cm. The scar was not painful on examination. There was no skin breakdown. This was a superficial scar with no underlying tissue damage. Inflammation was absent; edema was absent. There was no keloid formation. The scar was not disfiguring; it did not limit the Veteran's motion. There was no limitation of function due to the scar. Examination of the right shoulder revealed instability, weakness, tenderness and guarding of movement. The shoulder showed no signs of edema, abnormal movement, effusion, redness, heat, deformity, malalignment or drainage. There was no subluxation. There was no ankylosis. Range of motion in the right shoulder revealed a forward flexion of 0 degrees to 90 degrees, with pain occurring at 90 degrees; abduction was from 0 degrees to 40 degrees, with pain occurring at 40 degrees; external rotation was from 0 to 45 degrees, with pain occurring at 45 degrees; and internal rotation was 0 to 45 degrees, with pain occurring at 45 degrees. The examiner noted that repetitive range of motion of the right joint was not possible due to the severity of pain on range of motion. Muscle strength was 3/5 in the right forearm, biceps and triceps area. A neurological examination was normal for the right upper extremity. Pulses were 2+ on the right brachial, antecubital, radial and ulnar arteries. The examiner noted that the Veteran's diagnosis was changed to status post right shoulder arthroscopic surgery for chronic dislocation with degenerative joint disease and biceps tendinosis, and subacromial bursitis with residual scars. The effect of the condition on the Veteran's usual occupation is his occupation in pulling medical records at a hospital and this requires that he pulls 170 charts per day. This is highly repetitive work and is inhibited due to the constant right shoulder pain. He cannot do heavy lifting as well. The effect of the condition on the Veteran's daily activity is any strenuous activity such as lifting and repetitive activity to involve the right hand is prohibited, such as yard work, or heavy lifting in house hold chores. During a VA examination in March 2012, it was noted that the Veteran reinjured his right shoulder in a job related incident in 2010; he underwent surgical debridement and biceps tenodesis in June 2010. The Veteran reported flare-ups 2 to 3 times a week which last between 20 to 30 minutes. Range of motion in the right shoulder revealed a flexion to 180 degrees, with no objective evidence of painful motion. Abduction was to 155 degrees, with pain starting at 155 degrees. The Veteran was able to perform repetitive use testing. There was no additional limitation in degree. Functional impairment included less movement than normal and pain on movement. There was no tenderness, but he had guarding on movement of the right shoulder. Muscle strength testing was 5/5. There was no ankylosis. There was no subluxation. The pertinent diagnosis was status post debridement and biceps tenodesis, right shoulder. The examiner stated that the Veteran has no evidence of scapulohumeral deformity, recurrent dislocation, or fibrous union. He has no evidence of a false flail joint or flail shoulder. The examiner noted that the Veteran has a 3 cm anterior right shoulder operative scar and a 1 cm scar laterally and superiorly; all scars are well healed and non-tender. They do not affect any right shoulder function. Received in May 2012 were treatment reports from Dr. Randall D. Alexander, dated from June 2009 through October 2010. These records show that the Veteran received clinical attention and treatment for chronic right shoulder pain. When seen in June 2009, the Veteran reported a two week history of stiffness and pain in the right shoulder and right thumb. On examination, he had some tenderness in the right shoulder and painful stiffness at the limits of motion. X-rays of the right shoulder revealed no fracture, dislocation or degenerative change. The impression was right shoulder and arm pain which was exacerbated by work activities. In September 2009, the Veteran reported persistent pain in the right shoulder; it was noted that an MRI of the shoulder showed a small partial thickness rotator cuff tear and evidence of impingement. He stated that an injection given in June 2009 did not give him relief. Examination revealed positive impingement of the right shoulder and positive tenderness at the limits of motion in the shoulder. The impression was right shoulder rotator cuff partial tear and impingement, which has not responded to conservative treatment. III. Legal Analysis. Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. See 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. Part 4 (2012). 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history, and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the entire recorded history, and that each disability must be considered from the point of view of the Veteran's working or seeking work. Separate diagnostic codes identify the various disabilities. 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. 38 C.F.R. § 4.7. Otherwise, the lower rating is to be assigned. The requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based upon a single, incomplete, or inaccurate report and to enable VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Moreover, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Court has held that evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 (2012) and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45 (2012). See DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. See 38 C.F.R. § 4.40 (2012). The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. See 38 C.F.R. § 4.45 (2012). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert at 54. The Veteran's current right shoulder disorder, recurrent dislocation with subacromial bursitis with degenerative changes has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5201. Diagnostic Code 5201 provides for limitation of motion of the arm. 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. 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. A. Right Shoulder-December 6, 2005 to June 15, 2010. After a careful review of the evidence of record, the Board finds that the Veteran's right shoulder disorder is appropriately evaluated as 20 percent disabling prior to June 15, 2010. The Board notes that, during the period from December 6, 2005 through June 15, 2010, the objective medical evidence of record did not reflect any findings of limitation of motion of the arm to midway between the side and shoulder level so as to warrant a 30 percent disability rating under Diagnostic Code 5201. In this regard the Board notes that, in considering the Veteran's complaints of pain, weakness, stiffness, lack of endurance and locking, prior to June 15, 2010, the medical evidence of record, including the February 2007 VA examination report, the May and June 2009 private medical reports, the September 2008 VA examination report, and the June 2010 VA examination, demonstrates that his right shoulder was productive of pain and limitation of motion of the arm, at worst, with forward flexion to 75 degrees, abduction to 55 degrees, external rotation to 65 degrees and internal rotation to 90 degrees with pain throughout range of motion. As such, limitation of motion, though present, does not rise to the level meeting the requirements set forth in Diagnostic Code 5201. Additionally, none of the VA examinations or medical records prior to June 15, 2010 has shown that the Veteran's right shoulder is ankylosed. He retains useful, but painful motion; therefore, the shoulder is not ankylosed, and an increased rating under Diagnostic Code 5200 is not warranted. Moreover, the medical evidence has consistently shown no deformity. Therefore, a higher, 30 percent rating is not warranted under Diagnostic Code 5202, malunion with marked deformity. Further VA medical records are negative for shoulder dislocations. As such, the Veteran cannot be said to have suffered from recurrent dislocations during this time period. There is also no evidence of frequent guarding at all movements. Therefore, a higher 30 percent rating under Diagnostic Code 5202 is not warranted. A higher rating under Diagnostic Code 5202 is also not warranted based upon loss of head of humerus (flail shoulder), nonunion of humerus (false flail joint), or fibrous union of the humerus because the evidence fails to show such diagnoses or complaints. Each of the ratings under Diagnostic Code 5203 is 20 percent or less; therefore, the Veteran cannot receiving a rating in excess of 20 percent under this code. 38 C.F.R. § 4.71a, Diagnostic Code 5203. In sum, the evidence does not warrant the assignment of a rating in excess of 20 percent for the Veteran's right shoulder dislocation prior to June 15, 2010. With regard to establishing loss of function due to pain, it is necessary that complaints be supported by adequate pathology and be evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. The Board finds that the effects of pain reasonably shown to be due to the Veteran's right shoulder disability are contemplated in the 20 percent rating assigned during the period in question. There is no indication that pain, due to disability of the right shoulder, causes functional loss greater than that contemplated by the 20 percent evaluation assigned. 38 C.F.R. § 4.40, 4.45; DeLuca v. Brown. B. Right Shoulder-Beginning on August 1, 2010. With regard to the time period beginning on August 1, 2010, the Board notes that the objective medical evidence of record does not reflect any findings of limitation of motion of the arm to 25 degrees from the side so as to warrant a 40 percent disability rating under Diagnostic Code 5201. In this regard, the Board notes that, in considering the Veteran's complaints of pain, weakness, stiffness, giving way, lack of endurance, locking, and tenderness, beginning August 1, 2010, the medical evidence of record, including the October 2010 and March 2012 VA examinations, demonstrates that his right shoulder disorder was productive of pain and limitation of motion of the arm with forward flexion to 90 degrees, abduction to 40 degrees, external rotation to 45 degrees, and internal rotation to 45 degrees in October 2010. The examiner noted that repetitive range of motion of the right joint was not possible due to severity of pain on range of motion. However, the March 2012 VA examination reflects nearly full range of motion in the right shoulder, with flexion to 180, and abduction to 155 degrees; and the examination found no additional limitation of function found on repetitive use although painful movement was noted. The pain associated with such ranges of motion was not so severe as to approximate ankylosis. The Veteran has difficulty and pain with lifting and carrying activities, as well as with certain daily living activities; however, his right shoulder joint is not ankylosed. As such, a rating in excess of 30 percent under Diagnostic Codes 5200 and 5202 are not for application. The Board has also considered whether there are other appropriate diagnostic codes for application. However, as the Veteran's service-connected right shoulder does not reflect malunion of the humerus or recurrent dislocation of the shoulder or a loss of the head of the humerus, nonunion or fibrous union of the humerus, or ankylosis of the scapulohumeral articulation at any time during the pendency of the appeal, Diagnostic Codes 5200, 5202 and 5203 do not apply. As previously noted, each of the ratings under Diagnostic Code 5203 is 20 percent or less; therefore, the Veteran cannot receiving a rating in excess of 30 percent under this code. 38 C.F.R. § 4.71a, Diagnostic Code 5203. Even considering the Veteran's subjective complaints as outlined above, the medical evidence of record does not reflect any additional limitation of motion demonstrated upon repetitive motion that would support higher evaluation for the period beginning August 1, 2010. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2012); see also 38 C.F.R. §§ 4.45, 4.59 (2012). In considering the right shoulder disability picture as a whole, even considering any additional loss of motion resulting from pain due to flare-ups (in terms of degrees), the Board does not find that a rating in excess of 30 percent rating is warranted under any diagnostic code for the time period beginning on August 1, 2010. In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the assignment of an even higher rating, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Ordinarily, the Schedule will apply unless there are exceptional or unusual factors, which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular rating is warranted upon a finding that "the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b) (1) (2012). The schedular evaluations in this case are not shown to be inadequate. Ratings in excess of those assigned are provided in the rating schedule, but the medical evidence reflects that the criteria for a higher rating are not present with respect to the right shoulder disorder as discussed above. Consequently, the evidence does not demonstrate that the right shoulder disorder markedly interferes with employment. Further, there is no evidence that the Veteran has been hospitalized due to his service-connected right shoulder disorder. There is no indication that the Veteran experienced any symptoms not contemplated by the rating criteria during the claim periods in question. Therefore, referral for consideration of an extraschedular evaluation is not warranted. 38 C.F.R. § 3.321 (2012). ORDER Entitlement to a rating in excess of 20 percent for recurrent dislocation of the right shoulder with subacromial bursitis and degenerative changes, during the period from December 6, 2005 to June 15, 2010, is denied. Entitlement to a disability rating in excess of 30 percent for recurrent dislocation of the right shoulder with subacromial bursitis and degenerative changes beginning on August 1, 2010 is denied. ____________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs