Citation Nr: 1324663 Decision Date: 08/02/13 Archive Date: 08/13/13 DOCKET NO. 08-36 881 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for right hand numbness, to include as secondary to the service-connected posttraumatic stress disorder (PTSD) with alcohol abuse. 2. Entitlement to service connection for right foot numbness, to include as secondary to the service-connected PTSD with alcohol abuse. 3. Entitlement to service connection for left foot numbness, to include as secondary to the service-connected PTSD with alcohol abuse. 4. Entitlement to service connection for a right hip disorder. 5. Entitlement to service connection for a left hip disorder. 6. Entitlement to service connection for a right elbow disorder. 7. Entitlement to an initial disability rating in excess of 10 percent for left shoulder bursitis with acromioclavicular joint (AC) joint degenerative arthritis (non-dominant), prior to January 24, 2013. 8. Entitlement to an initial disability rating in excess of 20 percent for the left shoulder bursitis with AC joint degenerative arthritis (non-dominant), since January 24, 2013. 9. Entitlement to a disability rating in excess of 10 percent for the right knee cartilage damage with patellofemoral syndrome. 10. Entitlement to a disability rating in excess of 10 percent for the left knee disability with patellofemoral syndrome, status post arthroscopy. 11. Entitlement to a compensable disability rating for uterine fibroids, on an extraschedular basis only. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Shauna M. Watkins, Associate Counsel INTRODUCTION The Veteran had active military service from September 1984 to October 1997. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2006 rating decision by the U.S. Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which granted service connection for the left shoulder bursitis with AC joint degenerative arthritis, and assigned an initial disability rating of 10 percent, effective July 21, 2005. The Veteran continued to appeal for a higher initial disability rating. The remaining issues on appeal were also denied in the September 2006 rating decision. Subsequent to the September 2006 rating decision, jurisdiction over the case was transferred to the RO and Insurance Center in Philadelphia, Pennsylvania. In connection with this appeal the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in Washington, DC, in January 2011. A transcript of the hearing is associated with the claims file. In July 2011, the Board denied the issues of: (1) whether new and material evidence has been received to reopen a claim of entitlement to service connection for a respiratory disability, to include as due to undiagnosed illness; (2) whether new and material evidence has been received to reopen a claim of entitlement to service connection for a right shoulder disability; (3) whether new and material evidence has been received to reopen a claim of entitlement to service connection for a low back disability; (4) whether new and material evidence has been received to reopen a claim of entitlement to service connection for residuals of toxin exposure; (5) entitlement to service connection for a right hip disability; (6) entitlement to service connection for a left hip disability; (7) entitlement to service connection for a right elbow disability; (8) entitlement to a disability rating in excess of 30 percent for PTSD; and, (9) entitlement to a compensable disability rating for uterine fibroids. The Veteran appealed the Board's July 2011 decision to the U.S. Court of Appeals for Veterans Claims (Court). In November 2012, the Court issued a single judge memorandum decision. In the November 2012 decision, the Court affirmed the Board's decision regarding the new and material evidence claims, the PTSD claim, and the uterine fibroids claim on a schedular basis only. The Court then vacated the Board's July 2011 decision regarding the bilateral hips, right elbow, and uterine fibroids (on an extraschedular basis only). The Court remanded these issues back to the Board for further development. In July 2011, the Board also remanded the issues of entitlement to service connection for bilateral hand numbness and bilateral foot numbness, and entitlement to increased disability ratings for the bilateral knee and left shoulder disabilities, to the RO via the Appeals Management Center (AMC), in Washington, DC, for further development. Upon remand, in a January 2013 rating decision, the RO granted service connection for left ulnar nerve small fiber peripheral neuropathy (claimed as left hand numbness). To date, the Veteran has not appealed either the initial disability rating or effective date assigned for this claim. Therefore, that claim has been resolved. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (holding that where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement (NOD) must thereafter be timely filed to initiate appellate review of the claim concerning "downstream" issues, such as the compensation level assigned for the disability and the effective date); see, too, 38 C.F.R. § 20.200 (2012). Additionally, upon remand, the RO increased the initial disability rating for the service-connected left shoulder bursitis with AC joint degenerative arthritis to 20 percent disabling, effective January 24, 2013, the date of VA Medical Center (VAMC) treatment records that reflected findings sufficient to establish entitlement to a higher evaluation. The Veteran has continued to appeal, requesting an even higher rating. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993) (indicating that a Veteran is presumed to be seeking the highest possible rating unless he or she expressly indicates otherwise). This rating decision created staged ratings, and the appeal has been appropriately recharacterized on the title page. Since the most recent Supplemental Statements of the Case (SSOCs) in February 2010 and January 2013, the Veteran has submitted additional medical evidence. She has waived her right to have this evidence first considered by the RO in a statement dated in April 2013. 38 C.F.R. §§ 20.800, 20.1304 (2012). The Veteran's Virtual VA paperless claims file has been reviewed in preparing this decision and remand, along with her paper claims file. The issues of: (1) entitlement to a compensable disability rating for uterine fibroids, on an extraschedular basis only; (2) entitlement to service connection for a right hip disorder; (3) entitlement to service connection for a left hip disorder; and, (4) entitlement to service connection for a right elbow disorder, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC in Washington, DC. FINDINGS OF FACT 1. The Veteran's current peripheral neuropathy of the right hand is shown to be etiologically related to her service-connected PTSD with alcohol abuse. 2. The Veteran's current peripheral neuropathy of the right foot is shown to be etiologically related to her service-connected PTSD with alcohol abuse. 3. The Veteran's current peripheral neuropathy of the left foot is shown to be etiologically related to her service-connected PTSD with alcohol abuse. 4. Prior to January 24, 2013, the service-connected left shoulder bursitis with AC joint degenerative arthritis was manifested by, at worst, forward flexion limited to 155 degrees, abduction limited to 140 degrees, internal rotation limited to 80 degrees, and external rotation limited to 90 degrees, even with consideration of the Veteran's pain. 5. Since January 24, 2013, the service-connected left shoulder bursitis with AC joint degenerative arthritis has been manifested by forward flexion limited to 90 degrees, abduction limited to 120 degrees, internal rotation limited to 90 degrees, and external rotation limited to 90 degrees, even with consideration of the Veteran's pain. 6. Throughout the appeal, the service-connected right knee cartilage damage with patellofemoral syndrome has been manifested by slight recurrent subluxation or lateral instability with pain. 7. Throughout the appeal, the service-connected left knee disability with patellofemoral syndrome, status post arthroscopy, has been manifested by slight recurrent subluxation or lateral instability with pain. CONCLUSIONS OF LAW 1. Service connection for peripheral neuropathy of the right hand, as secondary to the service-connected PTSD with alcohol abuse, is established. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. Service connection for peripheral neuropathy of the right foot, as secondary to the service-connected PTSD with alcohol abuse, is established. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 3. Service connection for peripheral neuropathy of the left foot, as secondary to the service-connected PTSD with alcohol abuse, is established. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 4. Prior to January 24, 2013, the criteria for an initial rating in excess of 10 percent for the left shoulder bursitis with AC joint degenerative arthritis (non-dominant) are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5201 (2012). 5. Since January 24, 2013, the criteria for an initial rating in excess of 20 percent for the left shoulder bursitis with AC joint degenerative arthritis (non-dominant) are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5201 (2012). 6. The criteria for a rating in excess of 10 percent for right knee cartilage damage with patellofemoral syndrome is not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5257 (2012). 7. The criteria for a rating in excess of 10 percent for left knee disability with patellofemoral syndrome, status post arthroscopy, is not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5257 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. VA's Duties to Notify and Assist Regarding the service connection claims decided herein, the Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Here, the Board is granting the service connection claims for numbness of the extremities. Thus, there is no prejudice to the Veteran and no further discussion of the VCAA is required for these claims. The VCAA analysis below will only pertain to the remaining claims decided herein. Under applicable law, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record: (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and, (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the Agency of Original Jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Regarding the left shoulder claims, the RO sent the Veteran an initial duty-to-assist letter in September 2005. This letter addressed the Veteran's underlying claim of service connection for left shoulder pain. The increased rating claims flow downstream from a September 2006 rating decision, which initially established service connection for the left shoulder bursitis. The United States Court of Appeals for Veterans Claims (Court) held, in Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91(2006), that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Thus, because the notice provided before service connection was granted was legally sufficient, VA's duty to notify in this case is satisfied. See also Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008). Regarding the bilateral knee claims, prior to and following the initial adjudication of the Veteran's increased rating claims, letters dated in September 2005, August 2009, and September 2012 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, at 187. The Court held that to satisfy the first Quartuccio element for an increased-compensation claim, section 5103(a) compliant notice must meet a four part test laid out in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). The United States Court of Appeals for the Federal Circuit (Federal Circuit) overruled the Vazquez-Flores in part, striking claimant-tailored and "daily life" notice elements. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Thus modified, VA must notify the claimant that, 1) to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability, 2) a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment, and 3) provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. See Vazquez-Flores, 22 Vet. App. at 43, overruled in part sub. nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). This action was accomplished by the August 2009 notice letter to the Veteran regarding her increased rating claims for her bilateral knee disabilities. Although this letter was not sent prior to the initial adjudication of the Veteran's claims, this was not prejudicial to her, since the claims were readjudicated in the February 2010 and January 2013 SSOCs. See Prickett, 20 Vet. App. at 370. All the law requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (2012) (harmless error). In view of the foregoing, the Board finds that the Veteran was notified and aware of the evidence needed to substantiate her claims, as well as the avenues through which she might obtain such evidence, and of the allocation of responsibilities between herself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. For all of these reasons, the Board concludes that the appeal may be adjudicated without a remand for further notification. VA also has a duty to assist the Veteran in the development of the claims. This duty includes assisting the Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issues has been obtained. Her STRs, personnel records, Social Security Administration (SSA) disability benefits records, and post-service VA and private treatment records have been obtained. The Board does not have notice of any additional relevant evidence that is available but has not been obtained. She has been afforded VA examinations, and the reports of those evaluations contain all findings needed to properly evaluate her service-connected disabilities. 38 C.F.R. § 4.2 (2012). Furthermore, the Veteran was afforded a Board hearing in January 2011. A Board member has two duties at a hearing: (1) a duty to fully explain the issues still outstanding that are relevant and material to substantiating the claim, and (2) a duty to suggest that a claimant submit evidence on an issue material to substantiating the claim when the record is missing any evidence on that issue or when the testimony at the hearing raises an issue for which there is no evidence in the record. See 38 C.F.R. § 3.103(c)(2) (2012); Procopio v. Shinseki, No. 11-1253, 2012 WL 4882287 at 3 (Vet. App. Oct. 16, 2012) (citing Bryant v. Shinseki, 23 Vet. App. 488, 492, 496 (2010)). Here, during the Board hearing, the VLJ specifically noted the issues, in pertinent part, as "entitlement to increased ratings for . . . left shoulder bursitis, currently at 10 percent disabling, chondromalacia of the right and left knees, each evaluated as 10 percent disabling." See BVA hearing, pg. 2. The VLJ noted the elements of the claims that were lacking to substantiate the claims for benefits (i.e., service-connected disabilities more severe than currently rated). See BVA hearing, pg. 2. The VLJ then asked questions to ascertain whether the Veteran had submitted evidence in support of these claims. See BVA hearing, pg. 5, 17-19. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims. Id. Moreover, the Veteran has not asserted that VA failed to comply with the hearing requirements, nor identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the Veteran, through her testimony, demonstrated that she had actual knowledge of the elements necessary to substantiate her claims for benefits. As such, the Board finds that the VLJ complied with the aforementioned hearing duties, and that any error in notice provided during the Veteran's hearing constitutes harmless error. The Board is also satisfied as to substantial compliance with its July 2011 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). This included scheduling the Veteran for additional VA examinations for her increased rating claims, which she had in October 2012. The remand also included obtaining the Veteran's recent VA and private treatment records, which were obtained and associated with the claims file. Finally, the remand included readjudicating the claims, which was accomplished in the February 2013 SSOC. Thus, the Board finds that there has been substantial compliance with its remand directives. Id. For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's claims. Therefore, no further assistance to the Veteran with the development of evidence is required. II. Service Connection The Veteran also seeks service connection for numbness of her right hand and feet, to include as secondary to her already service-connected PTSD with alcohol abuse. To establish direct service connection, the record must contain: (1) medical evidence of a current disorder; (2) medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease; and, (3) medical evidence of a nexus between the current disorder and the in-service disease or injury. In other words, entitlement to service connection for a particular disorder requires evidence of the existence of a current disorder and evidence that the disorder resulted from a disease or injury incurred in or aggravated during service. 38 U.S.C.A. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including organic disease of the nervous system, such as peripheral neuropathy, will be presumed if they manifest to a compensable degree within one year following the active military service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). For the showing of a chronic disease in service (such as peripheral neuropathy), there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, evidence of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. Feb. 21, 2013). In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the service-connected disability and the current disorder. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition, the regulations provide that service connection is warranted for a disorder that is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected disability, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected disability, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary disorder, the secondary disorder shall be considered a part of the original disability. Id. The Board notes that 38 C.F.R. § 3.310 was amended, effective October 10, 2006. Under the revised § 3.310(b) (the existing provision at 38 C.F.R. § 3.310(b) was moved to sub-section (c)), any increase in severity of a non-service-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service-connected. In reaching this determination as to aggravation of a non-service-connected disorder, consideration is required as to what the competent evidence establishes as the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected disability), in comparison to the medical evidence establishing the current level of severity of the non-service-connected disease or injury. These findings as to baseline and current levels of severity are to be based upon application of the corresponding criteria under the Schedule for Rating Disabilities (38 C.F.R. part 4) for evaluating that particular non-service-connected disorder. See 71 Fed. Reg. 52,744-47 (Sept. 7, 2006). It appears as though the new regulatory amendment poses a new restriction on claimants. Nonetheless, because the Veteran's claims were pending before the regulatory change was made, the Board will consider the version of 38 C.F.R. § 3.310 in effect before the revision, as this version is more favorable to the Veteran. See generally VAOGCPREC 7-03 and VAOPGCPREC 3-00. The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a) (West 2002); Baldwin v. West, 13 Vet. App. 1 (1999); see 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding a material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); see 38 C.F.R. §§ 3.102. If the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. The Board will begin by addressing secondary service connection. As noted above, the first element of secondary service connection requires evidence of a current disorder. Here, current diagnoses have been established. In June 2006, the Veteran was afforded a VA general medical examination. At that time, the examiner diagnosed the Veteran with subjective numbness in both hands and both feet. A December 2012 electromyography (EMG) found that the Veteran had electrophysiological evidence of accessory in the left peroneal nerve. Additionally, in a VA addendum medical opinion dated in January 2013, following a review of the claims file, the VA examiner diagnosed the Veteran with small fiber peripheral neuropathy in response to the question of the Veteran's current diagnoses pertaining to her present hand and foot numbness. Thus, the Veteran has satisfied the first element of secondary service connection. As stated above, the second element of secondary service connection requires evidence of a service-connected disability. Here, the Veteran is currently service-connected for PTSD with alcohol abuse. Thus, the Veteran has satisfied the second element of secondary service connection. As previously mentioned, the third element of secondary service connection requires medical nexus evidence establishing a connection between the service-connected disability and the current disorder. Here, the only nexus opinions of record on the issue of secondary service connection are positive. With regard to the Veteran's claims of entitlement to service connection for numbness in the hands and feet, the Board notes that in June 2006, the Veteran was afforded a VA general medical examination. At that time, the examiner diagnosed the Veteran with subjective numbness in both hands and both feet, likely secondary to hyperventilation syndrome and alcohol abuse. The Veteran was afforded another VA examination in October 2012, but a medical opinion was not provided. Accordingly, in January 2013, the Veteran was provided a VA addendum medical opinion. Following a review of the claims file, to include the recent October 2012 VA examination, and a telephone interview with the Veteran, the VA examiner determined that the currently diagnosed small fiber peripheral neuropathy was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the Veteran first started noticing symptoms of her current peripheral neuropathy in 1993. The examiner noted that the Veteran described heavy usage of alcohol, beer mostly, between the years of 1992 and 2004. The examiner indicated that the Veteran entered the active military service in September 1984, and was first diagnosed with PTSD between 2004 and 2005. The examiner reasoned that the Veteran first started experiencing symptoms of small fiber peripheral neuropathy in 1993. Thus, based on the historical facts, the examiner found that the Veteran developed the peripheral neuropathy in 1993 secondary to alcohol abuse. Before 1993, based on the history provided, the examiner determined that the Veteran did not suffer from peripheral neuropathy symptoms. Therefore, based on the historical facts, clinical examination, and EMG results, the examiner concluded that it is at least as likely as not that the Veteran's current small fiber peripheral neuropathy is caused by the claimed excessive usage of alcohol between the years of 1992 and 2004 when the Veteran was in the active military service. The examiner added that the Veteran's current disorder of small fiber peripheral neuropathy will continue to show worsening with continued use of alcohol beyond its natural progression. The aforementioned medical opinions support the Veteran's claims for service connection for peripheral neuropathy of the right hand and feet on a secondary basis, that is, that the Veteran's currently diagnosed peripheral neuropathy of the right hand and feet are caused by her service-connected PTSD with alcohol abuse. The VA examiners found that the Veteran's current peripheral neuropathy was due to her alcohol abuse, which has been found to be service-connected and included in the Veteran's service-connected PTSD disability. There are no contrary medical opinions contained in the claims file. The Veteran's lay statements support these medical opinions. Thus, the Veteran's claims can be granted on a secondary service connection basis. Based on the foregoing, the Board finds that the evidence supports the Veteran's claims for service connection for peripheral neuropathy of the right hand and feet, as secondary to her service-connected PTSD with alcohol abuse. As the competent medical evidence of record etiologically links the Veteran's peripheral neuropathy of the right hand and feet to her service-connected PTSD with alcohol abuse, service connection for peripheral neuropathy of the right hand and feet is warranted. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). III. Left Shoulder Claims Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity in civil occupations. Separate DCs identify the various disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § Part 4. Where a Veteran appeals the initial rating assigned for a disability at the time that service connection for that disability is granted, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous . . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. The Veteran asserts that she is entitled to higher initial ratings for her service-connected left shoulder bursitis with AC joint degenerative arthritis, currently evaluated as 10 percent prior to January 24, 2013, and 20 percent since January 24, 2013, under DC 5201. 38 C.F.R. § 4.71a. At the October 2012 VA medical examination, the Veteran reported that she is right-handed. Therefore, her left shoulder disability affects her minor joint. DC 5201 provides that limitation of motion of the arm at the shoulder level is rated 20 percent for the minor shoulder. Limitation of motion of the arm midway between the side and shoulder level is also rated as 20 percent for the minor shoulder. Limitation of motion of the arm to 25 degrees from the side is rated as 30 percent for the minor shoulder. 38 C.F.R. § 4.71a. Normal range of motion of the shoulder is set forth in 38 C.F.R. § 4.71, Plate I (2012). Normal forward elevation, or flexion, is from 0 to 180 degrees. Normal shoulder abduction is also from 0 to 180 degrees. Normal external rotation and internal rotation are from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. Regarding DC 5201, the Federal Circuit recently issued a decision, in which the Federal Circuit found that, "The plain language of section 4.71a confirms that a Veteran is only entitled to a single disability rating under diagnostic code 5201 for each arm that suffers from limited motion at the shoulder joint. The diagnostic code does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to 'limitation of motion of' the arm." Yonek v. Shinseki, No. 10-3320, slip. op. at 4 (July 8, 2013 (U.S. Vet. App.). Further, the provisions of 38 C.F.R. § 4.40 state that a disability affecting 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. 38 C.F.R. § 4.40. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, at 592 (1991). Instead, in Mitchell, the Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The Board further notes that the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The Board will begin by addressing the initial 10 percent disability rating in effect prior to January 24, 2013. In applying the above law to the facts of the case, the Board finds that the Veteran is not entitled to an initial disability rating in excess 10 percent for her left shoulder disability, prior to January 24, 2013. Here, there is no evidence of limitation of motion of the arm at the shoulder level, limitation of motion of the arm midway between the side and shoulder level, or limitation of motion of the arm to 25 degrees from the side, to warrant a higher disability rating. 38 C.F.R. § 4.71a, DC 5201. Specifically, at a VA examination in June 2006, the Veteran's ranges of motion of the left shoulder were as follows: forward flexion to 180 degrees (normal) with mild pain that started and ended at 180 degrees; and, abduction to 180 degrees (normal) with mild pain that started at 160 degrees and ended at 180 degrees. In January 2007, the Veteran was seen by her private physician for treatment of her left shoulder disability. At that outpatient treatment visit, the Veteran had full range of motion of the left shoulder. She was diagnosed with a history of left shoulder pain. At the September 2009 VA examination, the Veteran's ranges of motion of the left shoulder were as follows: abduction to 180 degrees (normal) without any complaints of pain; forward flexion to 180 degrees (normal) without any complaints of pain; external rotation to 90 degrees (normal) without any complaints of pain; and, internal rotation to 80 degrees (normal is 90 degrees) without any complaints of pain. At a private outpatient treatment visit in April 2010, the Veteran's ranges of motion of the left shoulder were as follows: flexion to 155 degrees (normal is 180 degrees) with pain; abduction to 165 degrees (normal is 180 degrees) without complaints of pain; external rotation to 90 degrees (normal) without complaints of pain; and, internal rotation to 85 degrees (normal is 90 degrees) without any complaints of pain. At a May 2010 private outpatient treatment visit, the Veteran's flexion of the left shoulder was limited to 155 degrees with pain. The Veteran stated that her pain continues to be a large limiting factor in her completion of daily living activities and recreational activities. At VA outpatient treatment visits in March 2012 and September 2012, the Veteran's flexion and abduction of the left shoulder were normal (180 degrees), even with consideration of her pain. The Veteran was afforded another VA examination in October 2012. Her ranges of motion of the left shoulder were as follows: flexion to 180 degrees (normal) with objective evidence of painful motion beginning at 160 degrees; and, abduction to 180 degrees (normal) with objective evidence of painful motion beginning at 140 degrees. At a VA outpatient treatment visit in October 2012, the Veteran's flexion and abduction of the left shoulder were normal (180 degrees), even with consideration of her pain. The remaining VA and private treatment records do not provide contrary evidence. Accordingly, the Veteran is not entitled to an initial disability rating in excess 10 percent for her left shoulder disability, prior to January 24, 2013. There is no evidence of limitation of motion of the arm at the shoulder level, limitation of motion of the arm midway between the side and shoulder level, or limitation of motion of the arm to 25 degrees from the side, to warrant a higher disability rating, prior to January 24, 2013. 38 C.F.R. § 4.71a, DC 5201. In forming this decision, the Board has considered the Veteran's complaints of pain, in the left shoulder. However, the lay and objective medical evidence does not show that her symptoms result in additional functional limitation to the extent that the Veteran's disability would be more than 10 percent disabling under DC 5201 prior to January 24, 2013. Specifically, at the June 2006 VA examination, the Veteran complained of pain in her left shoulder with severe to very severe pain during a flare-up. The Veteran stated that the flare-ups of the left shoulder usually lasted about three hours and were usually relieved with a heat pad. The June 2006 VA examiner determined that the Veteran would not have any functional limitation or impairment following repetitive use of her left shoulder. At the September 2009 VA examination, the Veteran reported that, about twice a year, she developed intermittent pain in her left shoulder at a level of 5 on a scale of 0-10. The Veteran stated that the pain lasted about a day or two. The Veteran reported that she could not give any further information regarding any flare-ups from her left shoulder disability, as she did not have any limitations in her day-to-day activities because of the shoulder pain except for being careful. The September 2009 VA examiner found that the Veteran did not have any limitations in her ranges of motion of the left shoulder following repetitive motion. The VA examiner stated that DeLuca provisions could not be clearly delineated with any medical certainty; however, the examiner found that during flare-ups the Veteran might have mild limitations in her ranges of motion of the left shoulder. The examiner stated that the extent of these limitations could not be determined as it depended on the level of severity of the Veteran's pain and the activities she performed. At the October 2012 VA examination, the Veteran experienced intermittent anterior/superior shoulder pain on a daily basis. The Veteran described the pain as sharp in quality with intensity sometimes reaching a 7 on a scale of 1-10. The pain was exacerbated by overhead activity. The Veteran stated that her symptoms fluctuated but were relatively consistent, and thus she did not experience flare-ups. The Veteran denied that any flare-ups impact the function of her shoulder. Following repetitive motion of the left shoulder, the October 2012 VA examiner determined that the Veteran did not have additional limitation in ranges of motion of the left shoulder. The examiner found that the Veteran had functional loss, functional impairment, and/or additional limitation in the ranges of motion of the left shoulder following repetitive use - specifically, pain on movement. Given that the Veteran was able to achieve the aforementioned ranges of motion of the left shoulder on examination despite the presence of pain, the Board finds that additional compensation for pain is not warranted. Indeed, pain alone does not constitute a functional loss under VA regulations. See Mitchell, 25 Vet. App. at 32. An award of a higher rating cannot be based on speculation of the additional functional loss in terms of degrees during such flare-ups. Thus, the Board finds that the Veteran's painful limitation of motion and additional functional impairment, meets the impairment contemplated with a 10 percent rating throughout the entire appeal period and does not more nearly approximate functional impairment commensurate with a higher 20 percent rating, prior to January 24, 2013. Even when considering the Veteran's pain and functional impairment following repetitive motion, the evidence of record does not establish that she has the requisite limitation of motion of the left shoulder to warrant a higher disability rating. Accordingly, prior to January 24, 2013, the evidence of record does not support the assignment of a higher 20 percent disability rating for the left shoulder disability based on additional functional limitation following repetitive use or flare-ups of the joint. The Board will now address the initial 20 percent disability rating in effect since January 24, 2013. In applying the above law to the facts of the case, the Board finds that the Veteran is not entitled to an initial disability rating in excess of 20 percent for her left shoulder disability, since January 24, 2013. Here, there is no evidence of limitation of motion of the left arm to 25 degrees from the side, to warrant a higher disability rating. 38 C.F.R. § 4.71a, DC 5201. Specifically, since January 24, 2013, there are no VA examinations of record. On January 24, 2013, the Veteran was seen by the VAMC for physical therapy for her left shoulder. At that outpatient treatment visit, the forward flexion of her left shoulder was noted to be limited to 90 degrees (normal is 180 degrees) and her abduction was limited to 120 degrees (normal is 180 degrees). Her internal rotation and external rotation of the left shoulder were within normal limits. The Veteran reported constant pain and impaired functional mobility. The physical therapist found that the Veteran was able to tolerate all of the provided exercises without any given difficulty. Based on this evidence, the RO granted the Veteran an increased disability rating of 20 percent, effective January 24, 2013. There is no other pertinent medical evidence in the claims file dated on or after January 24, 2013, with the exception of the aforementioned January 24, 2013, treatment record. Accordingly, based on the January 24, 2013, medical record, the Veteran is not entitled to an initial disability rating in excess of 20 percent for her left shoulder disability, since January 24, 2013. There is no evidence of limitation of motion of the left arm to 25 degrees from the side, to warrant a higher disability rating of 30 percent, since January 24, 2013. 38 C.F.R. § 4.71a, DC 5201. In forming this decision, the Board has considered the Veteran's complaints of pain in the left shoulder. However, the lay and objective medical evidence does not show that her symptoms result in additional functional limitation to the extent that the Veteran's disability would be more than 20 percent disabling under DC 5271, since January 24, 2013. Given that the Veteran was able to achieve the aforementioned ranges of motion of the left shoulder despite the presence of pain, the Board finds that additional compensation for pain is not warranted. Indeed, pain alone does not constitute a functional loss under VA regulations. See Mitchell, 25 Vet. App. at 32. An award of a higher rating cannot be based on speculation of the additional functional loss in terms of degrees during such flare-ups. Thus, the Board finds that the Veteran's painful limitation of motion and additional functional impairment, meets the impairment contemplated with a 20 percent rating throughout the entire appeal period and does not more nearly approximate functional impairment commensurate with a higher 30 percent rating. Even when considering the Veteran's pain and functional impairment following repetitive motion, the evidence of record does not establish that she has limitation of motion of the left arm to 25 degrees from the side, to warrant a higher disability rating. Accordingly, the evidence of record does not support the assignment of a higher 30 percent disability rating based on additional functional limitation following repetitive use or flare-ups of the joint, since January 24, 2013. The Board has considered other DCs in an effort to determine whether the Veteran might be entitled to higher disability ratings under another Code throughout the entire appeal. In this regard, DC 5200 provides that ankylosis of the scapulohumeral articulation is to be rated as follows: favorable ankylosis, with abduction to 60 degrees and can reach mouth and head, is rated as 20 percent for the minor shoulder; intermediate ankylosis, between favorable and unfavorable, is rated as 30 percent for the minor shoulder; and, unfavorable ankylosis with abduction limited to 25 degrees from side, is rated as 40 percent for the minor shoulder. A Note provides that the scapula and humerus move as one piece. 38 C.F.R. § 4.71a, DC 5200. Throughout the entire appeal, the Veteran's left shoulder has not been ankylosed, as the Veteran had range of motion, albeit limited, in the left shoulder. Further, the October 2012 VA examiner specifically found that the Veteran's left shoulder joint was not ankloysed. The remaining medical evidence of record does not provide contrary evidence to that described above. 38 C.F.R. § 4.71a, DC 5200. DC 5202 provides ratings for other impairment of the humerus. Malunion of the humerus with moderate deformity is rated as 20 percent for the minor shoulder. Malunion of the humerus with marked deformity is also rated as 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 minor shoulder. Recurrent dislocations of the humerus at the scapulohumeral joint, with frequent episodes and guarding of all arm movements, are rated as 20 percent for the minor shoulder. Fibrous union of the humerus is rated as 40 percent for the minor shoulder. Nonunion of humerus (false flail joint) is rated as 50 percent for the minor shoulder. Loss of head of the humerus (flail shoulder) is rated as 70 percent for the minor shoulder. 38 C.F.R. § 4.71a, DC 5202. DC 5203 also provides ratings for other impairment of the clavicle or scapula. Nonunion of the clavicle or scapula with loose movement is rated as 20 percent for the minor shoulder. Dislocation of the clavicle or scapula with loose movement is rated as 20 percent for the minor shoulder. 38 C.F.R. § 4.71a, DC 5203. Here, the October 2012 VA examiner specifically found that the Veteran's left shoulder was not manifested by malunion, nonunion, or recurrent dislocations. The remaining medical evidence of record does not provide contrary evidence to that described above. 38 C.F.R. § 4.71a, DCs 5202, 5203. Thus, the Board finds that there are no other Codes under which the Veteran would be entitled to a higher disability rating at any time during the appeal. Furthermore, the Veteran's symptoms do not appear to have changed significantly during the initial rating periods so as to warrant further staged ratings. Fenderson, 12 Vet. App. at 126. The Board notes that in adjudicating a claim, the competence and credibility of the Veteran must be considered. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what she observes or experiences. For example, she is competent to report that she experiences certain symptoms, such as pain, and she is credible in this regard. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran's competent and credible belief that her disability is worse than the assigned ratings, however, is outweighed by the competent and credible medical examinations that evaluated the true extent of impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings. In sum, the preponderance of the evidence is against the assignment of an initial disability rating in excess of 10 percent prior to January 24, 2013, and in excess of 20 percent since January 24, 2013, for the service-connected left shoulder bursitis with AC joint degenerative arthritis (non-dominant) at any time during the appeal period. Thus, the claims are denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see Gilbert, 1 Vet. App. at 53. IV. Bilateral Knee Claims Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity in civil occupations. See 38 U.S.C.A. § 1155. Separate DCs identify the various disabilities. The assignment of a particular DC is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One DC may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which DC or codes are most appropriate for application in the Veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The Board observes that unappealed rating decisions of March 1999 and April 2001 granted service connection for the Veteran's bilateral knee disabilities. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the "present level" of the Veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where VA's adjudication of an increased rating claim is lengthy, a claimant may experience multiple distinct degrees of disability that would result in different levels of compensation from the time the increased rating claim was filed until a final decision on that claim is made. Thus, VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran asserts that she is entitled to disability ratings in excess of 10 percent for her right knee cartilage damage with patellofemoral syndrome and in excess of 10 percent for the left knee with patellofemoral syndrome, status post arthroscopy. These disabilities are currently rated at 10 percent under 38 C.F.R. § 4.71a, DC 5257. She seeks increased ratings. Under 38 C.F.R. § 4.71a, DC 5257, a 10 percent rating is warranted for recurrent subluxation or lateral instability which is productive of slight impairment of the knee. A 20 percent rating is warranted for recurrent subluxation or lateral instability that is productive of moderate impairment of the knee. The maximum 30 percent rating is warranted for recurrent subluxation or lateral instability that is productive of severe impairment of the knee. Id. The words "slight," "moderate" and "severe", as used in the various diagnostic codes, are not defined in VA's Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. In other words, the use of these descriptive terms is not altogether dispositive of the rating that should be assigned, but it is nonetheless probative evidence to be considered in making this important determination. 38 C.F.R. §§ 4.2, 4.6. In VAOPGCPREC 23-97 (July 1, 1997; revised July 24, 1997), VA's General Counsel held that a claimant who has arthritis and instability of the knee may be rated separately under DCs 5003-5010 (for the arthritis of the knee) and DC 5257 (for the instability of the knee) based on additional disability. 38 C.F.R. § 4.71a, DCs 5003, 5010, 5257 (2012). It was specified that, for a knee disability already rated under DC 5257, a claimant would have additional disability justifying a separate rating if there is limitation of motion under DC 5260 (flexion) or DC 5261 (extension). Hence, if a claimant has a disability rating under DC 5257 for instability of the knee and there is also X-ray evidence of arthritis and resulting limitation of motion, a separate rating is available under DCs 5003-5010. 38 C.F.R. § 4.71a. Under DC 5260, a noncompensable (0 percent) rating is warranted for flexion of the knee limited to 60 degrees. A 10 percent rating requires flexion of the knee limited to 45 degrees. A 20 percent rating is warranted for flexion of the knee limited to 30 degrees. A 30 percent rating is warranted for flexion of the knee limited to 15 degrees. 38 C.F.R. § 4.71a. Under DC 5261, a noncompensable (0 percent) rating is warranted for extension of the knee limited to 5 degrees. A 10 percent rating requires extension limited to at least 10 degrees. A 20 percent rating requires extension limited to 15 degrees. A 30 percent rating requires extension limited to 20 degrees. A 40 percent rating requires extension limited to 30 degrees. A 50 percent rating requires extension limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261 (2012). For comparison, normal range of motion in the knee is from 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II. It is also possible to receive separate ratings for limitation of flexion (DC 5260) and limitation of extension (DC 5261) for a disability of the same joint. See VAOPGCPREC 9-2004 (Sept. 17, 2004). The provisions of 38 C.F.R. § 4.40 state that a disability affecting 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. 38 C.F.R. § 4.40. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca, 8 Vet. App. at 202. Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell, 25 Vet. App. at 38-43; cf. Powell, 13 Vet. App. at 34; Hicks, 8 Vet. App. at 421; Schafrath, 1 Vet. App. at 592. Instead, in Mitchell, the Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The Board further notes that the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson, 9 Vet. App. 7 (1996). In applying the above law to the facts of the case, the Board finds that the Veteran is not entitled to higher disability ratings for her service-connected bilateral knee disabilities. Id. The Board notes that measurements taken at the VA examinations, which included consideration of the Veteran's pain, did not meet the criteria for the 20 percent ratings under DC 5257. 38 C.F.R. § 4.71a. Specifically, although the Veteran reported the use of knee sleeves/braces, instability and subluxation of the knees were not documented at the September 2009 and October 2012 VA examinations. At a private treatment visit in April 2010, the Veteran's knees were found to be stable following varus, valgus, and Lachman's stability tests. At a private treatment visit in May 2010, the Veteran was found to have "excellent" stability in her knees. The Board notes that at the June 2006 VA examination, the Veteran's lateral collateral ligament examination of each knee was positive and her drawer sign of each knee was positive; however, the examiner found that the Veteran had "mild" lateral deviation of the knees and "mild" anterior displacement. The Board also notes that a September 2005 VA outpatient treatment record documents that a magnetic resonance imaging (MRI) of the left knee found "moderate" chondromalacia. However, the VA physician found that the Veteran had good strength of her left knee, and ligamental laxity, instability, or subluxation were not reported at this VA outpatient treatment visit. The remaining VA and private treatment records do not provide contrary evidence. Thus, the evidence does not establish that the Veteran has recurrent subluxation or lateral instability that is productive of moderate impairment of either knee. Instead, the Board finds that Veteran's bilateral knee disabilities are best rated as slight (i.e., the 10 percent disability rating). Therefore, the Veteran is not entitled to increased disability ratings for her service-connected bilateral knee disabilities under 38 C.F.R. § 4.71a, DC 5257. The evidence of record also does not establish that the Veteran should be awarded a separate disability rating for her limitation of extension or limitation of flexion of the knees. 38 C.F.R. § 4.71a, DCs 5260, 5261. The evidence establishes that the Veteran does not have a noncompensable or compensable disability rating under the limitation of extension or limitation of flexion codes. Id. At the June 2006 VA examination, the Veteran's extension was 0 degrees (normal) and her flexion was 140 degrees (normal) bilaterally, without any complaints of pain or discomfort. At the September 2009 VA examination, the Veteran's extension was 0 degrees (normal) and her flexion was 145 degrees (normal) bilaterally, with complaints of pain. At the September 2009 VA examination, the Veteran's extension was 0 degrees (normal) and her flexion was 140 degrees (normal) bilaterally, with no objective evidence of painful motion. The private and VA treatment records do not provide contrary results. Thus, the Veteran is not entitled to a separate disability rating for her limitation of extension or limitation of flexion of the knees. She does not meet the requirements for a noncompensable or compensable disability rating under the limitation of motion codes for either knee. 38 C.F.R. § 4.71a, DCs 5260, 5261. The Board also finds that disability ratings higher than 10 percent are not warranted on the basis of functional loss due to the other factors discussed in DeLuca - namely, weakened movement, excess fatigability, or incoordination. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. at 204-08. It bears reiterating that the Veteran does not have sufficient limitation of flexion or extension in her knees, even when considering her pain, to warrant even the minimum compensable ratings of 10 percent under DCs 5260 or 5261. Thus, her current 10 percent ratings for her service-connected bilateral knee disabilities under DC 5257 are the means of compensating her for the additional impairment - including additional limitation of motion, from her chronic pain in the knees. Thus, she is already receiving the appropriate amount of compensation for the pain and other DeLuca factors. The remainder of the DCs pertaining to the knee and leg also do not justify a disability rating in excess of 10 percent for the service-connected bilateral knee disability. Taking the remaining codes in numerical order, DC 5256 is not applicable because there is no ankylosis of the Veteran's knees. The existence of ankylosis is not supported by the Veteran's ranges of motion. 38 C.F.R. § 4.71a. DC 5258 is applicable where there is cartilage, semilunar, dislocated, with frequent episodes of "locking" pain and effusion into the joint. At the October 2012 VA examination, the VA examiner found that the Veteran did not have meniscal dislocation, or frequent episodes of joint locking, joint pain, or joint effusion in her knees. The remaining medical evidence of record does not provide contrary evidence. Thus, this DC is not applicable. 38 C.F.R. § 4.71a. DC 5262 (describing malunion or nonunion) has also not been raised by the aforementioned medical evidence, as there were no structural abnormalities of the Veteran's knees noted at the VA examinations or in the associated X-rays. Specifically, at the October 2012 VA examination, the VA examiner found that, based on X-rays of the knees, there were no loose bodies or meniscal abnormalities in the Veteran's knees. X-rays taken at the September 2009 VA examination were normal for each knee. Thus, the Veteran is not entitled to higher disability ratings of 20 percent under DC 5258 or DC 5262. Additionally, the Veteran is already in receipt of 10 percent, which is the maximum schedular rating available under DC 5259 and DC 5263. 38 C.F.R. § 4.71a. Regarding DCs 5003 and 5010, private treatment records dated in May 2010 diagnose the Veteran with mild bilateral knee patellofemoral osteoarthirits based on a MRI that showed changes consistent with degenerative arthritis. As stated above, the limitation of motion of the knees does not even meet the requirements for a noncompensable rating under the appropriate DCs (i.e., DC 5260 and 5261). Under these circumstances, a higher rating of 20 percent is assigned for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. The May 2010 private MRI showing degenerative arthritis in the knees does not document the involvement of 2 or more major joints or 2 or more minor joint groups. The MRI only documents degenerative arthritis in the anterior compartment of each knee. Additionally, X-rays taken at the September 2009 and October 2012 VA examinations were normal and did not show evidence of degenerative arthritis or involvement of 2 or more major joints or 2 or more minor joint groups. Further, occasional incapacitating exacerbations were not documented at the examinations or in the medical evidence of record. 38 C.F.R. § 4.71a. Thus, these remaining DCs do not justify disability ratings in excess of 10 percent for the service-connected bilateral knee disabilities. 38 C.F.R. § 4.71a. Finally, the Board observes that the Veteran has scars associated with her service-connected bilateral knee disabilities, as shown on the October 2012 VA examination report. Specifically, at this examination, the scars were not painful or unstable, and the total area of all of the related scars was not greater than 39 square centimeters. The remaining medical evidence of record does not provide contrary evidence. Thus, the evidence of record does not establish, and the Veteran has not asserted, that these associated scars are painful, unstable (frequent loss of covering of skin over the scar), deep (associated with underlying soft tissue damage), or cause limitation of function of the affected part (the knees). The scars also cover an area of less than 144 square inches (929 square centimeters). Therefore, consideration of a separate compensable evaluation for the scars of the service-connected bilateral knee disabilities is not warranted. 38 C.F.R. Part 4, DCs 7801, 7802, 7803, 7804, 7805 (2012). (The Board observes that the rating criteria for scars under DCs 7800, 7801, 7802, 7803, 7804, and 7805 were revised, effective October 23, 2008. 73 Fed. Reg. 54708-12 (Sept. 23, 2008). However, the changes apply only to applications for benefits received by VA on or after October 23, 2008, or to claims where a Veteran requests review under the new criteria. Here, the Veteran's increased rating claims were filed in July 2005, and no such request for review under the new criteria has been made.) The Board has also considered whether staged ratings are appropriate in this case. See Hart, 21 Vet. App. at 505; Francisco, 7 Vet. App. 55 (1994). However, at no time during the relevant appeal period have the service-connected bilateral knee disabilities more nearly met or nearly approximated the criteria for a higher disability rating. Accordingly, staged ratings are not for application in the instant case. The Board notes that in adjudicating a claim, the competence and credibility of the Veteran must be considered. See Buchanan, 451 F.3d at 1331; Washington, 19 Vet. App. at 368-69. The Board acknowledges that the Veteran is competent to give evidence about what she observes or experiences. For example, she is competent to report that she experiences certain symptoms, such as pain, and she is credible in this regard. See, e.g., Layno, 6 Vet. App. at 465. The Veteran's competent and credible belief that her disabilities are worse than the assigned ratings, however, is outweighed by the competent and credible medical examinations that evaluated the true extent of impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings than the Veteran's lay statements. In sum, the preponderance of the evidence is against the assignment of disability ratings in excess of 10 percent for the service-connected right knee cartilage damage with patellofemoral syndrome and for the service-connected left knee with patellofemoral syndrome, status post arthroscopy, at any time during the appeal period. Thus, the claims are denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see Gilbert, 1 Vet. App. at 49. III. Extraschedular and TDIU Consideration The above determination is based on application of provisions of the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2012). However, the regulations also provide for exceptional cases involving compensation. Pursuant to § 3.321(b)(1) (2012), the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). If the evidence raises the question of entitlement to an extraschedular rating, 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. Therefore, initially, there must be a comparison between the level of severity and symptomatology of a Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria reasonably describe the claimant's disability level and symptomatology, then a Veteran's disability picture is contemplated by the rating schedule. The assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, 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"). Here, because the schedular ratings for the Veteran's service-connected left shoulder disability and bilateral knee disabilities fully address her symptoms, which include mainly pain, referral to the VA Under Secretary for Benefits or the Director of Compensation and Pension Service for consideration of an extraschedular evaluation is not warranted. As previously stated, the Veteran's pain has been considered and addressed by the VA examiners, particularly in light of the Veteran's ranges of motion and repetitive motion. However, even considering her pain, the evidence of record does not warrant higher disability ratings. Further, the evidence of record does not establish that, during the course of her appeal, her left shoulder disability and/or bilateral knee disabilities have prevented her from being employed or required frequent hospitalizations. Specifically, at the September 2009 VA examination, the VA examiner found that the Veteran could maintain her current sedentary-style employment with these service-connected disabilities. The examiner stated that the Veteran does not have any limitations in her day-to-day activities or sedentary activities. Further, at the October 2012 VA examinations, the VA examiners determined that the Veteran's service-connected left shoulder and bilateral knee disabilities do not impact her work. There are no contrary medical opinions of record, and the remaining medical evidence does not contradict these medical opinions. Thus, there is no evidence that the Veteran's service-connected disabilities on appeal cause impairment that is not contemplated by the schedular rating criteria or that renders impractical the application of the regular schedular standards. See Thun, 22 Vet. App. at 111. Accordingly, referral of this case for consideration of an extraschedular rating is not warranted. Id.; see also Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996). Finally, pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), a claim for a TDIU is considered part and parcel of an increased rating claim when the issue of unemployability is raised by the record. In this case, the issue of unemployability is not raised by the record. As described above, at the September 2009 and October 2012 VA examinations, the VA examiners found that the Veteran's service-connected left shoulder and bilateral knee disabilities do not prevent her from being employable. Therefore, consideration of a TDIU is not warranted. ORDER The claim for service connection for peripheral neuropathy of the right hand, as secondary to the service-connected PTSD with alcohol abuse, is granted. The claim for service connection for peripheral neuropathy of the right foot, as secondary to the service-connected PTSD with alcohol abuse, is granted. The claim for service connection for peripheral neuropathy of the left foot, as secondary to the service-connected PTSD with alcohol abuse, is granted. Entitlement to an initial disability rating in excess of 10 percent for left shoulder bursitis with AC joint degenerative arthritis (non-dominant), prior to January 24, 2013, is denied. Entitlement to an initial disability rating in excess of 20 percent for the left shoulder bursitis with AC joint degenerative arthritis (non-dominant), since January 24, 2013, is denied. Entitlement to a disability rating in excess of 10 percent for the right knee cartilage damage with patellofemoral syndrome is denied. Entitlement to a disability rating in excess of 10 percent for the left knee disability with patellofemoral syndrome, status post arthroscopy, is denied. REMAND Inasmuch as the Board regrets the additional delay of this appeal, a remand is required before the remaining claims can be properly adjudicated. Uterine Fibroids Claim The Board is precluded from assigning an extraschedular rating in the first instance. See Bagwell, 9 Vet. App. at 238-9; Floyd, 9 Vet. App. at 96. Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer, 22 Vet. App. at 242; see Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Court has further clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun, 22 Vet. App. at 111. First, the RO must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and is found inadequate, the RO or Board must determine whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran'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 VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. See Id. Throughout the appeal, the RO and the AMC have declined to refer this case to the VA Under Secretary for Benefits or to the Director of Compensation and Pension Service for consideration of this appeal on an extraschedular basis under the provisions of 38 C.F.R. § 3.321(b). However, the June 2006 and September 2009 VA examinations establish that the Veteran experiences postmenstrual bleeding, pelvic pain, and backache symptoms as a result of her service-connected uterine fibroids. These symptoms are not contemplated by the schedular criteria for uterine fibroids. 38 C.F.R. § 4.116, Diagnostic Code 7513 (2012). Accordingly, the Board finds that this issue must be referred to this authority for special consideration under 38 C.F.R. § 3.321(b). The Board, therefore, is compelled to remand the increased rating claim, on an extraschedular basis, for referral to the Director of the Compensation and Pension Service or other designate in accordance with 38 C.F.R. § 3.321(b) for consideration of whether this benefit is warranted on an extraschedular basis. Hips and Right Elbow Claims In the case of a disability compensation claim, VA's duty to assist includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Such an examination or opinion is necessary to make a decision on a claim if all of the lay and medical evidence of record: (1) contains competent evidence that the claimant has a current disorder, or persistent or recurrent symptoms of a disorder, and (2) indicates that the disorder or symptoms may be associated with the claimant's active military, naval, or air service, but (3) does not contain sufficient medical evidence for VA to make a decision on the claim. Id.; see McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The threshold for finding a link between the current disorder and the active military service is low for the purposes of obtaining a medical opinion. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. Here, the Veteran was afforded a VA examination in June 2006 and diagnosed with right elbow tendinitis and bilateral hip bursitis. The Veteran's STRs document that on a November 1990 Report of Medical History, the Veteran checked "yes" to the question of whether she experienced painful or trick shoulder or elbow. Additionally, on November 1995 and March 1997 Report of Medical Histories, the Veteran checked "yes" to the question of whether she experienced painful or trick shoulder or elbow and "yes" to the question of whether she experienced swollen or painful joints. The Veteran asserts that her current bilateral hip and right elbow disorders began during her active military service. There is no VA etiology medical opinion of record regarding whether these disorders on appeal were directly incurred during the Veteran's active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. As the record establishes the existence of current disorders and in-service documentation, a VA examination is required to determine the etiology of the disorders currently on appeal. See 38 C.F.R. § 3.159(c)(4); see also McLendon, supra. The Veteran is hereby notified that it is her responsibility to report for these examinations and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2012). Accordingly, the case is REMANDED for the following actions: 1. Refer the claim of entitlement to a compensable disability rating for uterine fibroids, on an extraschedular basis only, to the Director of Compensation and Pension Service, pursuant to the provision of 38 C.F.R. § 3.321(b), for consideration of whether this benefit is warranted on an extraschedular basis. 2. The RO/AMC shall ask the June 2006 VA examiner to provide an addendum opinion, or if the VA examiner determines that it is necessary, schedule the Veteran for a VA examination to ascertain the etiology of the Veteran's currently diagnosed right elbow tendinitis and bilateral hip bursitis. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. The examiner is requested to review all pertinent records associated with the claims file, and offer opinions addressing: i) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's right elbow tendinitis is related to her active military service? In forming the medical opinion, please consider the November 1990, November 1995, and March 1997 Report of Medical Histories. ii) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's current right hip bursitis is related to her active military service? In forming the medical opinion, please consider the November 1995 and March 1997 Report of Medical Histories. iii) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's current left hip bursitis is related to her active military service? In forming the medical opinion, please consider the November 1995 and March 1997 Report of Medical Histories. In forming his or her opinion, the examiner is asked to consider the Veteran's lay statements regarding the progression of the disorders, and comment on whether the Veteran's statements make sense from a medical point of view. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If medical literature is relied upon in rendering this determination, the VA examiner should specifically cite each reference material utilized. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. Copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file itself, must be made available to the examiner. 3. After the above actions have been completed, readjudicate the Veteran's claims of: (1) entitlement to a compensable disability rating for uterine fibroids, on an extraschedular basis only; (2) entitlement to service connection for a right hip disorder; (3) entitlement to service connection for a left hip disorder; and, (4) entitlement to service connection for a right elbow disorder. If the claims remain denied, issue to the Veteran a Supplemental Statement of the Case (SSOC). Afford her the appropriate period of time within which to respond thereto. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs