Citation Nr: 1323688 Decision Date: 07/25/13 Archive Date: 08/06/13 DOCKET NO. 09-21 599 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an increased disability rating for spondylosis of the lumbar spine with recurrent strain, currently evaluated as 10 percent disabling. 2. Entitlement to an increased disability rating for impingement syndrome, status-post surgical repair of the left shoulder, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Hallie E. Brokowsky, Counsel INTRODUCTION The Veteran served on active duty from November 1979 to December 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The Board notes that, pursuant to his request in his June 2009 substantive appeal, the Veteran requested a hearing before the Board; however, in May 2010, the Veteran withdrew the Board hearing request. As such, the Board will proceed with its review on the present record. See 38 C.F.R. § 20.704(d), (e) (2012). The Virtual VA claims file has been reviewed. FINDINGS OF FACT 1. Spondylosis of the lumbar spine with recurrent spasm is manifest by pain, spasm and limitied motion. Functinal flexion is better than 60 degrees. 2. Impingement syndrome, status-post surgical repair of the left shoulder, most closely approximates malunion of the scapula, with pain. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for spondylosis of the lumbar spine with recurrent spasm disease are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5295-5239 (2012). 2. The criteria for a disability rating in excess of 10 percent for impingement syndrome, status-post surgical repair of the left shoulder, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5203 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this case, the agency of original jurisdiction (AOJ) issued notice letters, dated in April 2008 and December 2008, to the Veteran. These letters explained the evidence necessary to substantiate the Veteran's claims for increased ratings, as well as the legal criteria for entitlement to such benefits. The letters also informed him of his and VA's respective duties for obtaining evidence. The AOJ decision that is the basis of this appeal was decided after the issuance of an initial, appropriate VCAA notice. As such, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA also has a duty to assist a veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The claims file contains the Veteran's available service treatment records, reports of VA and private post-service treatment, and the Veteran's own statements in support of his claims. The Veteran was afforded VA examinations responsive to the claims for increased disability ratings. The Board has reviewed the examination reports, and finds that they are adequate for the purpose of deciding the issues on appeal. The examination reports contain all the findings needed to rate the Veteran's service-connected spondylosis of the lumbar spine and impingement syndrome of the left shoulder, including history and clinical evaluation. The Veteran's appeal for higher evaluations for the spondylosis of the lumbar spine and impingement syndrome of the left shoulder, is distinguished from the facts in Proscelle v. Derwinski, 2 Vet. App. 629, 633 (1992), where no VA examination was provided during the rating claim, and a veteran specifically stated that his disability "has increased in severity [such] that I rate a higher disability," constituting at least both some assertion by the veteran and some evidence of worsening of disability since the last VA examination. Proscelle, 2 Vet. App. at 632. In the Veteran's case currently on appeal to the Board, there is no evidence of worsening of the Veteran's disabilities since the 2010 VA examinations, including no assertion by the Veteran of worsening since the last VA examination. The Veteran here does not assert that his spondylosis of the lumbar spine and impingement syndrome of the left shoulder worsened since the June 2010 VA examination; he merely asserts entitlement to higher disability evaluations. The Veteran has not submitted evidence of worsening, and the evidence of record, including the medical evidence reflecting on the severity of the disabilities on appeal, does not suggest that these disabilities worsened since the most recent VA examinations, or since VA treatment records in 2010. As there is no evidence of worsening since the last VA examination, a remand for a new VA examination is not warranted, and is not required by the VCAA. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (mere passage of time does not require VA to provide a new medical examination); VAOPGCPREC 11-95 (interpreting that a new examination is appropriate when there is an assertion of an increase in severity since the last examination). The Veteran has been afforded adequate examinations on the issues decided herein. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Additionally, the Veteran has not alleged that any examination is inadequate to decide the claims being adjudicated herein, so the examinations are presumed to have been adequate. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of the opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). The Board has reviewed the Veteran's statements and medical evidence of record and concludes that there is no outstanding evidence with respect to the Veteran's claims. For these reasons, the Board finds that the VCAA duties to notify and assist have been met. Legal Criteria for Increased Disability Evaluations Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where the veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In addition, when assessing the severity of a musculoskeletal disability that, as here, is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Analysis for Increased Disability Evaluations Spondylosis of the Lumbar Spine with Recurrent Strain Lumbosacral and cervical spine disabilities are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine ("general rating formula"). 38 C.F.R. § 4.71a, DCs 5237-5242. Intervertebral disc syndrome (IVDS) is rated under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. See 38 C.F.R. § 4.71a, DC 5243. According to the general rating formula, a 10 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees, but not greater than 235 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. A 20 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 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. A 40 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is to be assigned for unfavorable ankylosis of the entire thoracolumbar spine. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, entire thoracolumbar spine, or entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 68 Fed. Reg. 51,443, Note (5) (Aug. 27, 2003). The Formula for Rating IVDS Based on Incapacitating Episodes provides for ratings from 10 to 60 percent based on the frequency and duration of incapacitating episodes, defined in Note 1 as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. The maximum 60 percent schedular rating is warranted for incapacitating episodes having a total duration of at least 6 weeks during the previous 12 months. The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note 1 provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Note 2 provides that, for VA compensation purposes, the combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. Note 4 provides that range of motion measurements are to be rounded to the nearest five degrees. Note 5 defines unfavorable ankylosis as a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note 6 provides that disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The Veteran's spondylosis of the lumbar spine, with recurrent strain is evaluated as 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5239. The Veteran was initially afforded a VA examination in May 2008. According to that report, the Veteran complained of low back pain on a daily basis; he denied radiation of the pain, but stated that his pain was incapacitating once in the prior year. His flare-ups are precipitated by activity and his work as a truck driver. Physical examination showed moderate pain on motion. Flexion was to 80 degrees, extension was to 20 degrees, lateral flexion was to 20 degrees bilaterally, and lateral rotation was to 30 degrees bilaterally. There was end range pain, but motion was not additionally limited by pain upon repetitive motion. There was mild mid-lumbar spinal tenderness, straight leg raising was to 45 degrees, and he had decreased motor strength in flexion of the left knee. He also had decreased sensation to the dorsum and lateral aspect of his left leg and foot; knee and ankle reflexes were 2+. X-rays showed minimal spurring at L4-5. The diagnosis was degenerative joint disease of the lumbar spine. Private treatment records from Pinetree Family Practice, dated October 1998 through July 2008, shows treatment for muscle spasms and joint pain. The Veteran was most recently afforded a VA examination in June 2010. The Veteran again complained of daily low back pain, worse with activity, but without radiation. He denied any incapacitating episodes requiring physician prescribed bed rest in the prior year. The Veteran denied flare-ups and stated that his activities of daily living were not affected. The Veteran reports using a back brace. Upon examination, he had flexion to 75 degrees, extension was to 10 degrees, lateral flexion was to 20 degrees bilaterally, and lateral rotation was to 35 degrees bilaterally. There was pain throughout the range of motion, but his range of motion was not additionally limited following repetitive use. There was diffuse tenderness to palpation, without spasm. Straight leg raising was negative and he had normal and symmetric deep tendon reflexes. Sensation was decreased in the left leg. Gait was normal. X-rays showed degenerative joint disease of the lumbar spine with spurring at L4-5. The diagnosis was degenerative joint disease of the lumbar spine. The Veteran has been assigned a 10 percent evaluation for his low back disability. The 10 percent evaluation contemplates pain on motion. It is also consistent with limitation of flexion to 61 degrees. In order to warrant a higher evaluation, there must be the functional equivalent of limitation of flexion to 60 degrees or less, or a combined range of motion not greater than 120 degrees or abnormal gait or contour. Here, the Veteran has complained of pain, decreased ability lift heavy objects and sleep impairment. After a review of the lay and medical evidence, the Board finds that the Veteran's current 10 percent disability rating is most appropriate for the Veteran's spondylosis of the lumbar spine, with recurrent strain, for the entire rating period on appeal, and that a higher, compensable rating is not warranted. 38 C.F.R. § 4.7. The objective evidence of record indicates that the Veteran's spondylosis of the lumbar spine was productive of pain with combined range of motion of the thoracolumbar spine limited to 200 degrees at the May 2008 VA examination. The Veteran's thoracolumbar strain was productive of no worse than forward flexion to 75 degrees at his June 2010 VA examination; extension was to 10 degrees and lateral rotation and flexion were to at least 20 degrees. Likewise, he had normal gait and negative straight leg testing. Reflexes and strength testing were normal. X-rays showed spurring at L4-5, consistent with degenerative joint disease, but without evidence of intervertebral fractures. Private treatment records dated October 1998 through July 2008 show complaints of back pain, and the June 2010 showed tenderness to palpation. He had pain on motion, but no additional limitation of motion due to pain. Thus, applying the facts to the criteria set forth above, the Veteran remains entitled to no more than a 10 percent evaluation for his service-connected spondylosis of the lumbar spine, with recurrent strain under the General Rating Formula for Diseases and Injuries of the Spine. The Board has considered whether additional functional impairment due to factors such as pain, weakness and fatigability demonstrate additional limitation of motion or function to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca at 206-07. To the extent that the Veteran claims that his pain upon motion is the equivalent of limited motion, the Board finds that the Veteran's subjective complaints of pain have been contemplated in the current rating assignment, as the current ratings are based on the objectively demonstrated reduced motion; the May 2008 and June 2010 VA examination reports indicate that the Veteran complained of pain, but physical examination did not demonstrate any additional limitations in response to pain, including incoordination, weakness, or fatigability. Therefore, the objective indications are that the Veteran's symptoms do not result in any additional functional limitation to a degree that would support a rating in excess of the current disability rating; the evidence reveals a disability picture most approximating a 10 percent evaluation, even with consideration of whether there was additional functional impairment due to DeLuca factors. See Mitchell, supra. In reaching this determination, the Board has considered the lay pleadings. However, the pleadings, even when accepted as true, do not establish that the appellant's motion is functional limited to 60 degrees or less or that the combined range of motion is less than 120 degrees. No evidence suggests that there is an abnormality of the spinal contour or an abnormal gait due to spasm or guarding. Further, the evidence does not show favorable or unfavorable ankylosis of the entire thoracolumbar spine during either of the rating periods on appeal. The evidence also does not show that the Veteran's spondylosis of the lumbar spine, with recurrent strain has been productive of incapacitating episodes for the entire rating period on appeal. Although the Veteran reported experiencing an incapacitating episode at the May 2008 VA examination, there is no indication that it required bed rest by a physician and treatment by a physician. Moreover, at the June 2010 VA examination, the Veteran explicitly denied that he had incapacitating episodes requiring bed rest by a physician and treatment by a physician. The neurological examinations at these examinations showed decreased strength and sensation in the left lower extremity due to his service-connected spondylosis of the lumbar spine; the Veteran was granted service connection for neurological deficits of the left lower extremity in a September 2008 rating decision, and assigned a separate 20 percent disability evaluation, effective April 3, 2008. However, as the Veteran is separately evaluated for his neurological deficits of his left lower extremity, it is not for consideration here. Impingement Syndrome, Status-Post Surgical Repair of the Left Shoulder 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 (2012). Diagnostic Code 5200 provides that ankylosis of the scapulohumeral articulation is to be rated as follows: favorable ankylosis, with abduction to 60 degrees, can reach mouth and head, 30 percent for the major shoulder and 20 percent for the minor shoulder; intermediate ankylosis, between favorable and unfavorable, 40 percent for the major shoulder and 30 percent for the minor shoulder; unfavorable ankylosis, abduction limited to 25 degrees from side, 50 percent for the major shoulder and 40 percent for the minor shoulder. A Note provides that the scapula and humerus move as one piece. 38 C.F.R. § 4.71a. Diagnostic Code 5201 provides that limitation of motion of the arm at the shoulder level is rated 20 percent for the major shoulder and 20 percent for the minor shoulder; limitation of motion of the arm midway between the side and shoulder level is rated as 30 percent for the major shoulder and 20 percent for the minor shoulder; limitation of motion of the arm to 25 degrees from the side is rated as 40 percent for the major shoulder and 30 percent for the minor shoulder. 38 C.F.R. § 4.71a. Diagnostic Code 5202 provides ratings for other impairment of the humerus. Malunion of the humerus with moderate deformity is rated as 20 percent for the major shoulder and 20 percent for the minor shoulder; malunion of the humerus with marked deformity is rated as 30 percent for the major shoulder and 20 percent for the minor shoulder. Recurrent dislocations of the humerus at the scapulohumeral joint, with infrequent episodes, and guarding of movement only at the shoulder level, are rated as 20 percent for the major shoulder and 20 percent for the minor shoulder; recurrent dislocations of the humerus at the scapulohumeral joint, with frequent episodes and guarding of all arm movements, are rated as 30 percent for the major shoulder and 20 percent for the minor shoulder. Fibrous union of the humerus is rated as 50 percent for the major shoulder and 40 percent for the minor shoulder. Nonunion of humerus (false flail joint) is rated as 60 percent for the major shoulder and 50 percent for the minor shoulder. Loss of head of the humerus (flail shoulder) is rated as 80 percent for the major shoulder and 70 percent for the minor shoulder. 38 C.F.R. § 4.71a. Diagnostic Code 5203 provides ratings for other impairment of the clavicle or scapula. Malunion of the clavicle or scapula is rated as 10 percent for the major shoulder and 10 percent for the minor shoulder. Nonunion of the clavicle or scapula without loose movement is rated as 10 percent for the major shoulder and 10 percent for the minor shoulder; nonunion of the clavicle or scapula with loose movement is rated as 20 percent for the major shoulder and 20 percent for the minor shoulder. Dislocation of the clavicle or scapula with loose movement is rated as 20 percent for the major shoulder and 20 percent for the minor shoulder. Diagnostic Code 5203 provides an alternative rating based on impairment of function of the contiguous joint. 38 C.F.R. § 4.71a. The Veteran's impingement syndrome, status-post surgical repair of the left shoulder, is evaluated as 10 percent disabling, pursuant to the provisions of 38 C.F.R. § 4.71a, DC 5203. In this case, documents of record establish that the Veteran is right handed; the Veteran reported that his dominant hand is his right hand at the May 2008 and June 2010 VA examinations. See 38 C.F.R. § 4.69 (2012). At the May 2008 VA examination, the Veteran complained of left shoulder pain, which interfered with his sleep. The Veteran reported pain and instability on overhead activities, as well as flare-ups that are weather and activity related. He denied using any assistive devices. Physical examination was negative for tenderness to palpation of the acromioclavicular joint. He had abduction to 170 degrees, forward flexion to 170 degrees, external rotation to 80 degrees, and internal rotation to 80 degrees; there was end range pain on motion, but his range of motion was not additionally limited by repetitive use. Impingement testing was normal. There was some popping and crepitus on motion, and there was decreased supraspinatus strength. X-rays were normal. The diagnosis was impingement syndrome and prior surgery of the left shoulder. As previously noted, private treatment records from Pinetree Family Practice, dated October 1998 through July 2008, shows treatment for muscle spasms and joint pain. Range of motion of the shoulders was noted as being good. A report from Anderson Radiology indicates that an MRI of the Veteran's left shoulder was negative for rotator cuff tear, but showed minimal subacromial-subdeltoid bursitis, with post-surgical changes of the shoulder. The June 2010 VA examination report indicates that the Veteran complained of daily left shoulder pain, increasing with activity and overhead movement. He also complained of occasional instability, but denied any effect on activities of daily living. He also denied experiencing flare-ups. Physical examination showed that the Veteran had abduction to 115 degrees, flexion to 120 degrees, external rotation to 70 degrees, and internal rotation to 50 degrees. There was pain throughout the range of motion, but without additional limitation of motion upon repetitive use. There was positive impingement sign in the left shoulder, with normal stability and normal strength. There was tenderness to palpation over the supraspinatus tendon in the subacromial bursa area. X-rays were normal. After a review of the lay and medical evidence, the Board finds that the Veteran's disability picture is most consistent with his current 10 percent disability rating for his impingement syndrome, status-post surgical repair of the left shoulder. The objective evidence shows that, throughout the rating period on appeal, the Veteran did not have malunion or nonunion of the left clavicle or scapula. According to the May 2008 and June 2010 VA examination reports, the Veteran had impingement, but range of motion was no worse than forward flexion to 120 degrees, active abduction to 115 degrees, and rotation to 50 degrees internal and 70 degrees external on VA examination in June 2010. The Board has also considered whether he has additional functional loss - beyond that objectively shown - due to his pain, or because of weakness, premature or excess fatigability, incoordination, etc. See DeLuca v. Brown, 8 Vet. App. 202 (1995), citing 38 C.F.R. §§ 4.40, 4.45, and 4.59. However, the fact that the Veteran experienced pain, even if experienced throughout the range of motion on examination, does not by itself warrant a higher rating under the diagnostic codes providing ratings for limitation of motion. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, it is the functional limitation, i.e., the additional limitation of motion, caused by pain or the other DeLuca factors that must be considered in determining whether a higher rating is warranted, and there is no objective indication that the Veteran's symptoms result in any additional functional limitation to a degree that would support a rating in excess of the current 10 percent rating for his left shoulder. The May 2008 and June 2010 VA examiners noted that joint function on the left was not additionally limited, after repetitive use, by fatigue, weakness, lack of endurance, or incoordination, despite complaints of pain. The current disability evaluation contemplates the Veteran's complaints, as well as any limitation of motion due to pain. There was no evidence of fracture or dislocation upon x-ray in June 2010. Further, the evidence also shows no nonunion, fibrous union, or loss of the head of the humerus. As such, the Board is precluded from assigning a disability rating in excess of 10 percent for impingement syndrome, status-post surgical repair of the left shoulder under Diagnostic Codes 5202 or 5203. Lay Pleadings One function of the Board is to consider the lay evidence and pleadings. However, other than that recorded during medical evaluations, the record is remarkably lacking in substantive pleadings from the Veteran or the representative. Under the circumstances, the medical evidence is more probative than any implied pleadings or lay evidence. The Board has considered the December 2008 pleading from the Veteran. We accept as credible that pain and that he does not trust the range of motion. However, neither the lay nor medical evidence suggests that shoulder motion is functionally limited to shoulder level or below. Although he has a fear of it popping out, the more probative medical evidence establishes that he does not have dislocations. Extraschedular Considerations As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If 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. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms of the Veteran's spondylosis of the lumbar spine and impingement syndrome of the left shoulder are fully contemplated by the applicable rating criteria. As shown above, the criteria include symptoms, each of which were addressed in the VA examination report and treatment records and which provided the basis for the disability ratings that have been assigned. The Veteran has no complaints other than pain as a result of each disability, which was clearly considered in the range of motion testing that was carried out and which serves as the basis for his assigned disability rating for his spondylosis of the lumbar spine and impingement syndrome of the left shoulder. In any event, the evidence does not reflect that there has been marked interference with employment, frequent hospitalization, or that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. The Veteran alleged that spondylosis of the lumbar spine and impingement syndrome of the left shoulder interferes with his ability to work, but he did not indicate that he had to miss any time from work due to his spondylosis of the lumbar spine and impingement syndrome of the left shoulder. According to the Veteran, his spondylosis of the lumbar spine and impingement syndrome of the left shoulder slow his productivity, but have no other impact on his employment as a truck driver. Therefore, referral for consideration of extraschedular ratings for the spondylosis of the lumbar spine and impingement syndrome of the left shoulder is not warranted. 38 C.F.R. § 3.321(b)(1). In the absence of exceptional factors associated with spondylosis of the lumbar spine and impingement syndrome of the left shoulder, the Board finds that the criteria for submission for assignment of extraschedular ratings pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Entitlement to a disability evaluation in excess of 10 percent for spondylosis of the lumbar spine with recurrent strain is denied. Entitlement to a disability evaluation in excess of 10 percent for impingement syndrome, status-post surgical repair of the left shoulder, is denied. ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs