Citation Nr: 1322261 Decision Date: 07/11/13 Archive Date: 07/18/13 DOCKET NO. 07-21 533 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a right knee disability, to include as secondary to a service-connected left knee disability. 2. For the period prior to April 26, 2010, entitlement to a compensable disability rating for residuals of a left pectoralis major rupture (left shoulder disability). 3. For the period beginning on April 26, 2010, entitlement to a disability rating in excess of 10 percent for a left shoulder disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Juliano, Counsel INTRODUCTION The Veteran served on active duty from September 1985 to September 2005. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating decision of the Department of Veterans Affairs (VA) regional office (RO) located in Houston, Texas that granted service connection for the Veteran's left shoulder disability and assigned a noncompensable rating, effective October 1, 2005, and from a January 2008 rating decision that denied service connection for a right knee disability. An August 2010 rating decision granted a higher 10 percent rating for the Veteran's left shoulder disability, effective April 26, 2010. As this did not constitute a full grant of the benefit sought on appeal, this matter remains before the Board. See AB v. Brown, 6 Vet. App. 35 (1993). In February 2011, the Veteran testified before the undersigned Veterans Law Judge at a Travel Board hearing at the RO located in Houston, Texas. A transcript of the proceeding has been associated with the claims file. In December 2012, the Board remanded these matters for further development. Such development has been completed and associated with the claims file, and these matters are returned to the Board for further review. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran has a right knee disability that is related to his active service, or that was caused or aggravated by his service-connected left knee disability; arthritis was not shown within one year of discharge. 2. For the entire period on appeal, the Veteran's left shoulder disability is manifested by limitation of flexion to 155 to 160 degrees, limitation of abduction to 55 to 160 degrees, painful motion due to cramping, and x-ray evidence of mild degenerative arthritis; there is no objective evidence of ankylosis, loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, or uncertainty of movement. CONCLUSIONS OF LAW 1. Service connection for a right knee disability, to include as secondary to a service-connected left knee disability, is not warranted; nor may service connection be presumed. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. For the period prior to April 26, 2010, the criteria for an initial rating of 10 percent have been met, but no more. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.40, 4.71a (Diagnostic Code 5302) (2012). 3. For the beginning on April 26, 2010, the criteria for an initial rating in excess of 10 percent have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.40, 4.71a (Diagnostic Code 5302) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) With regard to the Veteran's claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5102, 5103(a), 5103A, 5106 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is generally required to "notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided . . . that is necessary to substantiate the claim." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). As part of that notice, VA must "indicate which portion of that information and evidence, if any, is to be provided by the claimant and which portion, if any, the Secretary . . will attempt to obtain on behalf of the claimant." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). With regard to the Veteran's initial rating claim, the Board notes that where service connection has been granted and an initial rating has been assigned, the claim of service connection has been more than substantiated, as it has been proven. As such, 38 U.S.C.A. § 5103(a) notice is no longer required since the purpose that the notice was intended to serve has been fulfilled. The Veteran bears the burden of demonstrating any prejudice from defective (or nonexistent) notice with respect to the downstream elements. See Goodwin v. Peake, 22 Vet. App. 128 (2008). That burden has not been met in this case. Neither the Veteran nor his representative alleges such prejudice in this case. With regard to the Veteran's claim for service connection for a right knee disability, the Board finds that August 2007 and February 2013 notice letters fully satisfied the notice requirements. The August 2007 letter explained what information or evidence was necessary to substantiate the Veteran's claim, what evidence he was responsible for submitting to VA, and which evidence VA would obtain. The August 2007 letter also explained how VA assigned disability ratings and effective dates. See Dingess v. Nicholson, 19 Vet. App. 473, 490-491 (2006). Pursuant to the Board's December 2012 remand directive, the February 2013 notice letter was sent to the Veteran explaining how to substantiate a claim for secondary service connection. Therefore, in light of the above, the Board finds that these letters satisfied the notice requirements of the VCAA. Although this last notice was subsequent to the initial denial of the claim, the claim was subsequently readjudicated in the March 2013 supplemental statement of the case, such that any issue as to the timeliness of the latter notice is harmless. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant notification letter followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). In short, the Board finds that the Veteran has been adequately notified of the information and evidence necessary to substantiate his claim. The Board also concludes that VA's duty to assist has been satisfied. The Veteran's service treatment records, VA treatment records, and private treatment records are all in the claims file. The Veteran has not referenced any outstanding records for VA to obtain relating to his claim. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of a veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). With regard to the Veteran's right knee service connection claim, the Veteran was provided with a VA examination in April 2010. He was previously provided with a September 2007 VA examination relating to his left knee. In December 2012, the Board remanded the Veteran's claim so that he could be provided with a new VA examination to address secondary service connection. Pursuant to the Board's remand directive, the Veteran was provided with another VA examination in March 2013 that addressed secondary service connection. The Board notes that the April 2010 and March 2013 VA examiners interviewed the Veteran, elicited a history from him, examined him, and provided thorough and adequate reasoning for their conclusions. Therefore, the Board finds that the April 2010 and March 2013 VA examination reports contain sufficient information to decide the Veteran's claim. With regard to the Veteran's left shoulder rating claim, he was provided with a VA examinations in August 2005 and April 2010. In December 2012, the Board remanded the Veteran's claim so that he could be provided with a new VA examination to address limitation of motion (with regard to the skeletal/joint rating criteria) as well as the muscular criteria. Pursuant to the Board's remand directive, the Veteran was provided with two new VA examinations in March 2013 - one for muscle injuries and one skeletal/joints. The April 2010 and March 2013 VA examination reports reflect that the examiners personally reviewed the claims file, examined the Veteran, and provided sufficient detail to rate the Veteran under the applicable diagnostic criteria. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's disability since he was last examined. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. VAOPGCPREC 11-95. The Board finds the above VA examination reports are thorough, complete, and adequate upon which to base a decision with regard to the Veteran's claim. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537. As a final matter, the Board finds that there has been substantial compliance with all of the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). As shown above, pursuant to the Board's December 2012 remand directive, the Veteran was provided with a February 2013 notice letter explaining how to substantiate a claim for secondary service connection with regard to his right knee claim. Also, pursuant to the Board's December 2012 remand directive, he was provided with a new March 2013 VA examination to address secondary service connection for his right knee claim, which examination report answered all of the questions posed by the Board. Also, pursuant to the Board's December 2012 remand directive, he was provided with two new March 2013 VA examinations for his left shoulder disability in order to address the muscle injury criteria as well as the skeletal/joint rating criteria in 38 C.F.R. § 4.71a. Therefore, in light of the above, the Board finds there was substantial compliance under Stegall. II. Analysis A. Right Knee The Veteran served on active duty from September 1985 to September 2005. He claims that he has a right knee disability that is related to service or, in the alternative, as secondary to his service-connected left knee disability. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110 (West 2002). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2012). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Where a veteran served continuously for 90 days or more during a period of war or during peacetime service after December 31, 1946, service connection may be allowed on a presumptive basis for certain listed chronic conditions, including arthritis, if the disability becomes manifest to a compensable degree within one year after the veteran's separation from service. 38 U.S.C.A. §§ 1101(3), 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Alternatively, a "disability which is proximately due to or the result of a service-connected disease or injury shall be service connected." 38 C.F.R. § 3.310(a) (2012). "Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence." 38 C.F.R. § 3.310(b) (2012); Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran's service treatment records are silent as to any right knee complaints. An August 2005 VA examination report (ordered relating to other claims) reflects that the right knee's appearance was normal, range of flexion was to 140 degrees, extension was to zero degrees, and the joint was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The drawer test and McMurray's test were within normal limits, and no diagnosed condition was found. Post-service treatment records from the Kelly Air Force Base (Kelly Clinic) dated in May 2006 and June 2006, within one year of discharge, likewise reflect no diagnosed right knee condition. A June 2006 record specifically notes that a musculoskeletal examination was performed, including a range of motion evaluation of all extremities, which was normal except for a diagnosed left pectoralis minor sprain. More than one year post-service, an April 2007 radiology report from the Kelly Clinic reflects an impression of mild arthrosis of both knees, with changes to the left tibia tuberosity likely a sequelae of remote Osgood-Schlatter disease. Also, a March 2008 radiology report from the WHMC reflects findings of bilateral knee degenerative arthrosis. The Veteran was provided with a September 2007 VA examination, albeit the Board notes that it is not entirely clear whether it was ordered based on the Veteran's separately adjudicated left knee rating claim. The examiner noted the Veteran's reported history of having been diagnosed with arthritis for 20 years, that he had injured his knee jumping out of a deuce, and that he reported experiencing symptoms of weakness, stiffness, giving way, lack of endurance, and fatigability. It was also noted that he reported pain for 20 years. Again, however, the Board notes that it is not entirely clear whether the above history and symptomatology relate to the Veteran's service-connected left knee only, his right knee, or both. It is clear, however, that the VA examiner performed an examination of both knees. Examination of the right knee revealed no edema, effusion, weakness, tenderness, redness, heat, subluxation, guarding of movement, locking pain, genu recurvatum, or crepitus. Range of flexion was noted as normal (140 degrees of flexion and zero degrees of extension). Range of motion was noted as not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The medial and lateral collateral ligaments stability test was within normal limits, and the medial and lateral meniscus test was within normal limits. No diagnosed right knee condition was recorded. An April 2010 VA examination report reflects that the Veteran reported that he believed that he had right knee arthritis with an onset "over time." He further opined that it was due to standing and web gear use over many years. He reported experiencing pain and stiffness. Examination of the right knee revealed no bumps consistent with Osgood-Schlatters disease, no crepitation, no mass behind the knee, no grinding, no instability, no patellar abnormality, no meniscal abnormality, no abnormal tendons or bursae, although a click was noted. Range of motion was noted as flexion to 120 degrees, and normal extension to zero degrees. No additional limitations were noted after three repetitions. The examiner noted that April 2007 x-rays revealed mild arthrosis of both knees. A diagnosis of mild arthrosis of both knees was recorded, and an otherwise stable right knee joint. The examiner opined that the Veteran's right knee condition was not caused by his service. The examiner reasoned that the Veteran's service treatment records were silent as to any right knee complaints, the first record of complaint post-service was in his own May 2007 statement (other than the noted April 2007 x-ray). The Veteran was provided with another VA examination in March 2013 per the Board's December 2012 remand in order to address his theory of entitlement based on secondary service connection. The March 2013 VA examination report reflects that the Veteran reported an onset of symptoms 10 or 5 years prior to separation. The examiner noted that radiographs 18 months post-service revealed arthrosis of both knees and left tibial tubercle Osgood-Schlatter disease. The Veteran reported symptoms of right knee "crushing," stiffness, and a "mashed" sensation. Range of motion was noted as flexion to 135 degrees and extension to zero degrees, with no objective evidence of pain, and no additional limitation of motion after repetitive testing. Right knee strength was 5/5. The Lachman test, posterior drawer test, and medial-lateral instability testing were all normal for both knees. No meniscal condition was noted, and no x-ray evidence of patellar subluxation. The examiner did acknowledge that the April 2007 and March 2008 x-ray reports documented arthritis in both knees. The VA examiner opined that the Veteran's right knee condition was not caused or aggravated by his service-connected left knee. The examiner explained that the Veteran's knees had no instabilities and his gait was stable. The examiner noted that there was no insult trauma or other injury shown in the records. As a preliminary matter, there is no x-ray evidence of arthritis of the right knee within one year of the Veteran's separation from service. While the Board acknowledges that the Veteran has reported symptomatology since service, the Board finds that arthritis is of the nature of conditions that requires verification by radiological records and is not capable of lay observation. See, e.g., 38 C.F.R. § 4.71a, Diagnostic Code 5003. Also, the Board acknowledges that the Veteran's sister, in her May 2008 statement, wrote that she is a radiology technician and that she looked at the Veteran's right knee in service and opined that it had Osgood-Schlatters. Again, however, the Board notes that her physical inspection of the Veteran's knee does not constitute radiological evidence, i.e., an x-ray, of the Veteran's right knee so as to confirm arthritis - even if she was or is a radiology technician. Therefore, in light of the above, the Board finds that service connection on a presumptive basis for right knee arthritis is not warranted. With regard to the Veteran's theory of entitlement to service connection on a direct basis, the Board finds the above opinion of the April 2010 VA examiner to be the most probative evidence of record with regard to whether the Veteran has a current right knee disability that is related to service. The VA examiner reviewed the claims file, interviewed the Veteran, examined him, and provided a thorough rationale for his conclusions. The Board notes that the April 2010 VA examiner's opinion is not contradicted by any other competent medical evidence of record, except with regard to the May 2008 statement from the Veteran's sister, a radiological technician, which is addressed below and which the Board ultimately finds less probative than the opinions of the VA examiners (as explained below). The Board acknowledges that the Veteran has reported, to differing extents, experiencing right knee pain since service. The Board notes, however, that this report is contradicted by the above noted August 2005 VA examination report and subsequent 2006 Kelly Clinic records, which the Board finds tends to diminish the credibility of the Veteran's account. The Board again acknowledges a May 2008 statement from the Veteran's sister, a radiology technician, in which she reported that during the Veteran's service (while he was home) she observed his knees and told him that he probably had "Osgood-Slaughters" knee. While the Board does acknowledge that she has radiology training and experience, the Board ultimately finds that her opinion that the Veteran had Osgood-Schlatters of the right knee in service is outweighed by the fact that the Veteran's service treatment records for 20 years are silent as to any complaints of any right knee problems whatsoever, as well as the fact that the Veteran's right knee on VA examination in August 2005 was found to be normal, and again in June 2006 it was found to be normal as noted above. The Board also acknowledges a May 2008 statement from the Veteran's mother in which she reports that the Veteran had complained about knee problems since 1998. Again, however, the Board finds that the probative value of her lay history is greatly outweighed by the fact that the Veteran's right knee was found on physical examination to be normal in August 2005 and June 2006. For these reasons, the Board finds that direct service connection is not warranted. With regard to the Veteran's theory of entitlement to service connection as secondary to his service-connected left knee disability, the Board finds the opinion of the March 2013 VA examiner to be the most probative evidence of record with regard to whether the Veteran has a current right knee disability that was caused or aggravated by his service-connected left knee disability. The March 2013 VA examiner reviewed the claims file, interviewed the Veteran, examined him, and provided a thorough rationale for his conclusions. Furthermore, his opinion is not contradicted by any other competent evidence of record. To the extent that the Veteran relates his right knee condition to his service-connected left knee disability, the Board notes that the Veteran, while competent to report certain symptomatology, is not competent as a lay person to opine as to whether his right knee arthritic condition is etiologically related to or aggravated by his left knee condition, which requires medical expertise in this particular case. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In sum, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for a right knee disability; the benefit of the doubt rule is not for application. B. Left Shoulder The Veteran seeks a higher initial rating for his service-connected muscle disability. Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7 (2012). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. See 38 U.S.C.A. § 5107(b) (West 2002). Where, as in the instant case, an appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). For rating purposes, the skeletal muscles of the body are divided into 23 muscle groups in 5 anatomical regions: six muscle groups for the shoulder girdle and arm (diagnostic codes 5301 through 5306); three muscle groups for the forearm and hand (diagnostic codes 5307 through 5309); three muscle groups for the foot and leg (diagnostic codes 5310 through 5312); six muscle groups for the pelvic girdle and thigh (diagnostic codes 5313 through 5318); and five muscle groups for the torso and neck (diagnostic codes 5319 through 5323). 38 C.F.R. § 4.55(b) (2012). For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c) (2012). A "slight" disability of affected muscles is characterized under 38 C.F.R. § 4.56(d) as a simple wound of muscle without debridement or infection. History and complaint include service department record of superficial wound with brief treatment and return to duty; with healing with good functional results. No cardinal signs or symptoms of muscle disability. Objective findings include minimal scar, no evidence of fascial defect, atrophy, or impaired tonus; no impairment of function or metallic fragments retained in muscle tissue. A "moderate" disability of muscles is characterized under 38 C.F.R. § 4.56(d) as follows: a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. History and complaint include service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the muscles. Objective findings include entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. A "moderately severe" disability of muscles is characterized under 38 C.F.R. § 4.56(d) as follows: a through-and-through or deep open penetrating wound by a small high velocity missile or a large low-velocity missile, with debridement, prolonged infection, or sloughing of the soft parts, and intermuscular scarring. History and complaint include service department record or other evidence showing hospitalization for a prolonged period for treatment of a wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability and, if present, evidence of inability to keep up with work requirements. Objective findings include entrance and exit scars indicating a track of a missile through one or more muscle groups. Objective findings should also include indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared to a sound side. Tests of strength and endurance compared with sound side should demonstrate positive evidence of impairment. A "severe" muscle disability is characterized under 38 C.F.R. § 4.56(d) as resulting from a through-and-through or deep-penetrating wound due to high velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, with intermuscular binding and scarring. History and complaint include service department record or other evidence showing hospitalization for a prolonged period for treatment of the wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries and, if present, evidence of inability to keep up with work requirements. Objective findings include ragged, depressed, and adherent scars indicating wide damage to muscle groups in missile track, palpation showing loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with corresponding muscle of the uninjured side indicate severe impairment of function. 38 C.F.R. § 4.56(d) (2012). It should be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain on use and weakness causing additional disability beyond that reflected on range of motion measurements. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran's left shoulder disability is currently assigned a noncompensable rating for the period prior to April 26, 2010 under Diagnostic Code 5302, and a 10 percent rating thereafter. See 38 C.F.R. § 4.73 (2012). The Veteran seeks higher initial ratings. The Veteran's left shoulder disability is presently evaluated under 38 C.F.R. § 4.73, Diagnostic Code 5302, Muscle Group II, which involves the depression of the arm from vertical overhead to hanging at the side (1/2); downward rotation of scapula (3/4); 1 and 2 act with Group III in forward and backward swing of the arm. Extrinsic muscles of shoulder girdle: (1) Pectoralis major II (costosternal); (2) latissimus dorsi and teres major (teres major, although technically an intrinsic muscle, is included with latissimus dorsi); (3) pectoralis minor; (4) rhomboid. Ratings for the dominant limb are provided as follows: 40 percent for severe disability; 30 percent for moderately severe disability; 20 percent for moderate disability; and noncompensable for slight disability. The Veteran was provided with VA examinations in August 2005, April 2010, and March 2013. The August 2005 VA examination report reflects that the Veteran suffered from a left pectoralis rupture 14 years prior due to weight lifting. The examiner noted that the wound was "superficial," the Veteran did not receive any treatment in the field, and he was able to return to his original service duty at the time of the injury at full duties. The degree of destruction was noted as involving a total tear of muscle from the tendon. The Veteran reported currently experiencing loss of strength, weakness, easy fatigability, pain, impairment of coordination, and inability to control movement well. He also noted deformity, cramping when lifting heavy objects or otherwise straining, and intermuscular scarring complications. It was noted that the Veteran was not receiving any treatment for the condition. He reported that he was not able to keep up with his work requirements because of the inability to lift heavy objects. Examination revealed that the Veteran is right hand dominant, and that the muscle group affected was II. Palpation revealed no loss of deep fascia or muscle substanance and no impairment of muscle tone. There were no signs of lowered endurance or impaired coordination; strength was noted as 4/5. The examiner noted that the Veteran's muscle injury did not affect the particular body part function that it controls. No muscle herniation was noted, and it was noted that it did not involve any tendon, bone, joint, or nerve damage. A diagnosis of left pectoralis major rupture was recorded. The examiner opined that the effect of the Veteran's condition on his usual occupation was minimal (even when combined with several other conditions). The April 2010 VA examination report reflects that the Veteran reported that he could not use his left pectoralis muscle because it cramps with motion. Physical examination revealed no intermuscular scarring, normal function in terms of comfort, endurance, and strength sufficient to perform activities of daily living, no residual nerve damage, tendon damage, or bone damage, no muscle herniation, no loss of deep fascia or muscle substance, and no motion of any joint affected by muscle disease or injury. Findings of pectoralis muscle retraction were noted. A diagnosis of left pectoralis muscle tear was recorded. The examiner noted that the Veteran's occupation was that of a security guard for the past two to five years, and that he had lost no time on the job due to his left shoulder condition, although acknowledging that pain and disfigurement had some impact on his occupational functioning. With regard to the Veteran's usual daily activities, the examiner noted that it had a severe effect on his chores, and prevented him from exercising and playing sports. In March 2013, the Veteran underwent two VA examinations relating to his left shoulder disability - one for muscle injuries, and one for joint injuries. The March 2013 VA examination report (Muscle Injuries) reflects a diagnosis of muscle group II injury of the left pectoralis major tendon near complete rupture myotendinous junction, chronic. The examiner noted that the injury did not involve a penetrating wound like a gunshot wound, nor a non-penetrating muscle injury, such as a muscle strain, Achilles tendon, or torn quadriceps muscle. The examiner noted that the Veteran's symptoms involved muscle cramping. The examiner noted the history of the injury as involving a muscle tear of the pectoralis major in November 1994 while lifting weights. He was noted as right hand dominant. The examiner noted that the Veteran's muscle injury did not affect muscle substance or function. Specifically, the examiner noted that none of the cardinal signs and symptoms of muscle injury were present, i.e., no loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c) (2012). Muscle strength testing was 5/5 (normal) for all affected muscle groups. No muscle atrophy was noted. The examiner acknowledged the August 2006 radiology report showing an impression of a near complete rupture of the pectoralis major tendon at its myotendinous junction, chronic in appearance, mild fatty atrophy of the pectoralis major muscle fibers adjacent to the torn tendon, and mild acromioclavicular osteo arthritis. The March 2013 VA examination report (Shoulder and Arm Conditions) reflects a diagnosis was recorded (since 2010) of rotator cuff tear, tendonopathy biceps, SLAP tear, moderate acromioclavicular degenerative arthritis, stable joint. The examiner noted, however, that the Veteran "only points out the pectoralis insertion pain left arm at the arm pit. I showed a diagram of the pectoralis and he agrees that the area of pain and discomfort is not the shoulder. Asymptomatic shoulder." Range of motion was noted as left shoulder flexion to 160 degrees, and abduction to 160 degrees, with no objective evidence of pain. The examiner noted that although the Veteran was able to perform repetitive testing in the prone position to 155 to 160 degrees, he would not forward flex or abduct past 90 degrees while standing due to complaints of cramping, which the examiner noted was contradictory (indicating it was not credible). No other functional loss after repetitive testing was noted. No localized pain or tenderness to palpation was noted, no guarding, muscle strength was 5/5, no ankylosis was found, the Hawkins impingement test was negative, no history of subluxation or recurrent subluxation was noted, no malunion, nonunion, or dislocation of the clavicle or scapula was noted. The examiner noted that a December 2010 MRI report reflected an impression of tears of the infraspinatus, supraspinatus, and subscapularis tendons, tendonopathy of the biceps tendon, a SLAP tear, an abnormal glenohumeral ligament suspicious for a chronic partial thickness tear, and mild to moderate acromioclavicular degenerative arthritis with evidence of active inflammation. The examiner opined that the Veteran's disability did not affect his ability to work. The Board notes that the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2Vet. App. 625, 629 (1992). The Board notes that Diagnostic Code 5302, Muscle Group II, specifically contemplates muscle injuries of the "pectoralis major," as the Veteran's disability has been repeatedly termed in the medical evidence. As shown above, however, none of the cardinal signs and symptoms are shown in the medical evidence of record, except to the extent that the Board acknowledges the Veteran's subjective reports of pain due to cramping. In that regard, the RO granted the higher 10 percent rating for the period beginning on April 26, 2010 (the date of the April 2010 VA examination) to take into account the Veteran's complaints of pain under the provisions of 38 C.F.R. § 4.40. The Board does acknowledge that the Veteran has reported experiencing muscle pain since service. Therefore, resolving doubt in favor of the Veteran, the Board will grant the 10 percent rating under Diagnostic Code 5302 for painful motion for the entire period on appeal. The Veteran is not entitled to a higher rating under Diagnostic Code 5302, which provides a 20 percent rating for "moderate" muscle injury generally involving two or more of the cardinal signs and symptoms of muscle injury. The Board points out that the August 2005 VA examiner specifically opined that the Veteran's muscle injury did even not affect the particular body part function that it controls. The April 2010 VA examiner noted that no motion of any joint was affected by his muscle injury. Likewise, the March 2013 VA examiner noted that while the Veteran had some pain near his left armpit, his left shoulder itself was generally asymptomatic, except for certain inconsistent range of motion findings. The VA examiners noted muscle strength as 5/5. Therefore, as two or more of the cardinal signs and symptoms of muscle injury are not shown, the Board finds that entitlement to the next higher, 20 percent moderate rating under Diagnostic Code 5302 is not warranted for any period on appeal. As noted above, the March 2013 VA joints examination was obtained to address the musculoskelatal rating criteria in the event that the Veteran might be entitled to a higher rating under the musculoskeletal rating criteria in 38 C.F.R. § 4.71a. In that regard, the Board notes that Diagnostic Code 5201 provides a 20 percent rating for limitation of motion to the shoulder level (90 degrees). For the reasons discussed above, however, the Board finds that the Veteran's range of motion for the entire period on appeal was flexion to 155 to 160 degrees and extension to zero degrees. Therefore, as limitation of motion to shoulder level is not found for the entire period on appeal, entitlement to a higher rating under Diagnostic Code 5201 is not shown. Also, no ankylosis is shown, such that no rating under Diagnostic Code 5200 is warranted. No rating is warranted under Diagnostic Code 5202 as no malunion, dislocations, nonunion, or guarding of movement of the humerus is shown. A higher rating is not warranted under Diagnostic Code 5203 as there is no nonunion or malunion of the clavicle or scapula. While the Board acknowledges radiographic evidence of arthritis in the Veteran's left shoulder as well as his complaints of painful motion, Diagnostic Code 5003 only provides a maximum 10 percent rating for degenerative arthritis confirmed by x-ray of a major joint without otherwise compensable limitation of motion for the entire period on appeal. See 38 C.F.R. § 4.71a (2012). The Board points out that separate ratings may not be awarded for joint and muscle group injuries because the evaluation of joints already includes consideration of weakened movement due to factors such as muscle injury. 38 C.F.R. § 4.45 (2012). Accordingly, the assignment of separate ratings for limitation of motion and muscle injuries affecting the left shoulder would amount to impermissible pyramiding. 38 C.F.R. § 4.14 (2011). Therefore, in light of the above, the Board finds that for the period prior to April 26, 2010, entitlement to a higher 10 percent initial rating for the Veteran's left shoulder disability is warranted under Diagnostic Code 5302; for the period beginning on April 26, 2010, entitlement to an initial rating in excess of 10 percent disabling under Diagnostic Code 5302 is not warranted. The Board has considered whether referral for an extraschedular rating is appropriate. "The determination of whether a claimant is entitled to an extraschedular rating under 38 C.F.R. § 3.321(b) is a three-step inquiry. . . 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. . ." Thun v. Peake, 22 Vet App 111, 115 (2008) (citing Fisher v. Principi, 4 Vet.App. 57, 60 (1993), and Floyd v. Brown, 9 Vet.App. 88, 95 (1996)). "Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. . .[I]f the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun at 115. "[I]n the second step of the inquiry, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant'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')." Thun at 115-116. "When an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating." Thun at 116. With respect to the first prong of Thun, the Board finds that the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's left shoulder disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's left shoulder disability with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology as discussed above. As such, an extraschedular rating is not appropriate. In sum, the preponderance of the evidence is in favor of a higher 10 percent initial rating for the period prior to April 26, 2010, and against a rating in excess of 10 percent thereafter. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for a right knee disability is denied. For the period prior to April 26, 2010, entitlement to a 10 percent disability rating for a left shoulder disability is granted, subject to regulations applicable to the payment of monetary benefits. For the period beginning on April 26, 2010, entitlement to a disability rating in excess of 10 percent disabling for a left shoulder disability is denied. ____________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs