Citation Nr: 1325357 Decision Date: 08/09/13 Archive Date: 08/13/13 DOCKET NO. 06-36 481 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to an initial compensable rating prior to July 27, 2007, and in excess of 10 percent thereafter for left shoulder rotator cuff tear and impingement status post repair and decompression. 2. Entitlement to an initial rating in excess of 10 percent for retracted tear of the long head of the left biceps tendon. 3. Entitlement to an initial compensable rating for residual scar of the left upper extremity. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Fussell, Counsel INTRODUCTION The Veteran served on active duty from December 1972 to August 1976, and from November 1978 to March 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2005 decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The case is currently under the jurisdiction of the RO in Indianapolis, Indiana. In the May 2005 rating decision, the RO granted service connection for left shoulder rotator cuff tear and impingement, status post repair and decompression, with a noncompensable disability rating, effective April 1, 2005. In a June 2008 rating action, the RO increased the evaluation for the service-connected left shoulder disability to 10 percent, effective July 27, 2007. Therefore, the issue is characterized as shown on the title page of this decision. In April 2010, the Veteran testified at a hearing before a Veterans Law Judge (VLJ) in Washington, D.C. A transcript of the hearing is associated with the claims folder. In an August 2010 decision, the Board denied the Veteran's claim for an increased rating for a right knee disability and remanded his claim for a higher initial rating for his left shoulder disability for additional development. This matter came to the Board again in March 2012 and was remanded to allow the Veteran the opportunity to provide testimony before a new VLJ, since the April 2010 VLJ was no longer employed by the Board. In November 2012, the Veteran testified, via video-conference, before the undersigned VLJ. A transcript of the hearing is associated with the claims folder. The Board again remanded this case in January 2013 for further development. The Board also referred five additional issues to the agency of original jurisdiction (AOJ) for adjudication. Such issues were (1) entitlement to a separate rating for surgical scars of the left shoulder; (2) entitlement to an increased rating for sinusitis; (3) entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU); (4) an increased rating for a heart condition; (5) an increased rating for sleep apnea; (6) service connection for restless leg syndrome; and (7) service connection for reactive airway disease/asthma. Thereafter, a May 8, 2013 rating decision granted service connection for a retracted tear of the long head of the left biceps tendon due to left shoulder rotator cuff tear and impingement status post repair and decompression, which was assigned an initial 10 percent rating, effective March 25, 2013; granted service connection for a scar of the left upper extremity, due to left shoulder rotator cuff tear and impingement status post repair and decompression, which was assigned an initial noncompensable rating, effective March 25, 2013; denied a rating in excess of 50 percent rating for obstructive sleep apnea; denied a rating in excess of 30 percent rating for a heart condition (sinus arrhythmias); and denied a compensable rating for sinusitis. Additionally, entitlement to a TDIU rating remained denied. Also, service connection for restless leg syndrome, right shoulder arthritis, reactive airway disease, also claimed as asthma, was denied. Subsequently, a May 22, 2013, rating decision granted an earlier effective date of July 27, 2007, for service connection and the initially assigned 10 percent rating for a retracted tear of the long head of the left biceps tendon. With respect to the issues of entitlement to an initial rating in excess of 10 percent for retracted tear of the long head of the left biceps tendon and entitlement to an initial compensable rating for residual scar of the left upper extremity, the Board finds that it has jurisdiction over them as ancillary to the Veteran's claim of entitlement to higher initial ratings for his left shoulder rotator cuff tear and impingement status post repair and decompression. In this regard, such separate ratings were assigned to compensate the Veteran for additional manifestations of his left shoulder rotator cuff tear and impingement status post repair and decompression. Moreover, with respect to the issue of entitlement to an initial rating in excess of 10 percent for retracted tear of the long head of the left biceps tendon, the May 22, 2013, rating decision specifically informed the Veteran that such issue was ancillary to the issue on appeal and is regarded as inextricably intertwined with the appellate issue. He was also advised that no further action on his part was necessary. Therefore, the Board finds that such issues are part and parcel of the Veteran's claim for higher initial ratings for his left shoulder rotator cuff tear and impingement status post repair and decompression and, as such, has taken jurisdiction over them. Regarding the remaining issues addressed in the May 8, 2013, rating decision, the record before the Board does not reflect that the Veteran has initiated an appeal by filing a notice of disagreement. Therefore, at this time, the Board does not have jurisdiction over them. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file reveals VA treatment records dated through April 2013, which were considered in the May 2013 supplemental statement of the case, and a copy of the November 2012 Board hearing transcript. FINDINGS OF FACT 1. For the entire appeal period, the Veteran's left shoulder rotator cuff tear and impingement status post repair and decompression is manifested by pain, stiffness, tenderness, and crepitus resulting in slight limitation of motion, but does not result in functional loss that more nearly approximates ankylosis of the scapulohumeral articulation, limitation of arm motion to the shoulder level or lower, or impairment of the humerus, clavicle, or scapula. 2. For the entire appeal period, the Veteran's retracted tear of the long head of the left biceps tendon affects muscle substance or function in that there is a small step-off detectable on deep palpation of the proximal left biceps and occasional loss of power, weakness, lowered threshold of fatigue, and fatigue-pain, resulting in an inability to keep up with work requirements pertaining to repetitive heavy lifting, but does not result in functional loss more nearly approximating a moderately severe or severe muscle disability. 3. For the entire appeal period, the Veteran's residual scar of the left upper extremity is asymptomatic and not of a size to warrant a compensable rating. CONCLUSIONS OF LAW 1. For the entire appeal period, i.e., since April 1, 2005, the criteria for an initial 10 percent rating, but no higher, for left shoulder rotator cuff tear and impingement status post repair and decompression have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5099-5024 (2012). 2. For the entire appeal period, i.e., since April 1, 2005, the criteria for an initial 10 percent rating, but no higher, for retracted tear of the long head of the left biceps tendon have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.14, 4.73, Diagnostic Code 5305 (2012). 3. For the entire appeal period, i.e., since April 1, 2005, the criteria for an initial noncompensable rating, but no higher, for residual scar of the left upper extremity have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.14, 4.118, Diagnostic Code 7805 (2008), (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's 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 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA 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. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. The Board observes that the Veteran has appealed with respect to the propriety of the initially assigned ratings for his left shoulder disability from the original grant of service connection. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). In this case, the Veteran's claim for service connection for his left shoulder disability was granted and an initial rating was assigned in the May 2005 rating decision on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned rating, no additional 38 U.S.C.A. § 5103(a) notice is required because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Relevant to the duty to assist, the Veteran's service treatment records as well as post-service VA and private treatment records have been obtained and considered. An attempt was made to obtain Social Security Administration records; however, in May 2009, VA was advised that no such records existed. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Veteran was also afforded a VA examination in January 2005, July 2007, November 2011, and March 2013 in conjunction with the claims on appeal. While the Veteran had alleged at his April 2010 and November 2012 Board hearings that the first three examinations did not adequately consider the "DeLuca" factors (in evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. See DeLuca v. Brown, 8 Vet. App. 202 (1995)), the record reflects that the January 2005, July 2007, and November 2011 VA examinations did, in fact, consider additional symptoms resulting in functional loss, to include limitation of motion of the left shoulder. In this regard, the January 2005 examiner noted discomfort on forced passive forward flexion past 160 degrees. Additionally, the July 2007 examiner considered range of motion findings with respect to pain, tenderness, crepitus, discomfort, and loss of strength, fatigue, pain, and incoordination after repetitions of movement. Finally, the November 2011 VA examiner considered the impact of flare-ups, pain on motion, and repetitive use testing. Moreover, the Veteran was afforded another VA examination in March 2013 and has not alleged that such was inadequate with respect to the "DeLuca" factors. The Veteran further claimed that the first three examinations did not adequately address his alleged impairment with respect to his muscle. Therefore, he was afforded a VA muscle injury examination in March 2013 in addition to the VA orthopedic examination. Regarding the March 2013 VA examinations, neither the Veteran nor his representative has alleged that such is inadequate for rating purposes. Moreover, the Board finds that the four examinations of record are adequate in order to evaluate the Veteran's service-connected left shoulder disabilities as they include an interview with the Veteran, a review of the record, and a full physical examination, addressing the relevant rating criteria pertaining to all manifestations of the Veteran's left shoulder disability, to include those pertaining to orthopedic disabilities, muscular disabilities, and scarring. Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's initial rating claims and no further examination is necessary. In April 2010 and November 2012, the Veteran was provided an opportunity to set forth his contentions during hearings before a Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, both Board hearings focused on the elements for claim substantiation, i.e., evidence of a greater degree of disability. The issue on appeal was identified and the representative and the VLJs specifically elicited testimony from the Veteran as to his the relevant clinical history. The hearings focused on the Veteran's history, current treatment, and symptomatology as to the service-connected disability for which he seeks a higher rating. While the Veteran indicated that he did not currently receive treatment for his left shoulder disability, the VLJs twice remanded the case in order to afford the Veteran additional VA examinations that considered all of the manifestations of his left shoulder disability. Moreover, neither the Veteran nor representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) nor have they identified any prejudice in the conduct of the Board hearings. By contrast, the hearings focused on the elements necessary for claim substantiation and the Veteran demonstrated actual knowledge of the elements necessary to substantiate his claim for a higher initial rating for his left shoulder disability. As such, the Board finds that, consistent with Bryant, the VLJs complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. As indicated previously, this case was remanded in August 2010, March 2012, and January 2013, the Board remanded the case for additional development. In this regard, the August 2010 and January 2013 remands directed that the Veteran be afforded VA examinations so as to determine the current nature and severity of his left shoulder disability. Such examinations were conducted in November 2011 and March 2013 and addressed the Board's relevant inquiries. Additionally, the March 2012 remand directed that the Veteran be afforded his requested video-conference hearing before a new VLJ as the VLJ who had previously heard his case in April 2010 was no longer employed by the Board. Such hearing was held in November 2012. Therefore, the Board finds that the AOJ has substantially complied with the August 2010, March 2012, and January 2013 remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Background A March 1997 service treatment record noted that the Veteran had a history of an acromioclavicular separation in 1981 while playing softball. A general medical examination at the time of an Aeromedical Consultation in December 2002 revealed minimal limitation of motion of the left shoulder at the extreme of movement but, otherwise, there was full range of motion. An April 2002 operative report shows that the Veteran underwent left shoulder arthroscopy with subacromial decompression and rotator cuff repair. He had persistent left shoulder pain since 1989, including while weight-lifting. He had not had an episode of subluxation or dislocation. His pain had progressively worsened. He had physical therapy. Recent examinations were significant for impingement. The operative diagnosis was rotator cuff tear of the supraspinatus and a complete retracted tear of the long head of the biceps tendon. Left shoulder X-rays in January 2005 revealed a small orthopedic device or screw within the lateral aspect of the humeral head, probably representing an anchor for repair of a tendon. Otherwise, the bony structures and the shoulder joint appeared normal. The acromioclavicular joint was unremarkable. A January 2005 VA pre-discharge examination noted that the Veteran had begun having left shoulder disability, including pain, in the early 2000s. He would awaken at night with left shoulder pain. In April 2002 he had a rotator cuff repair with subacromial decompression, bursectomy, and biceps tenotomy. He still had some intermittent discomfort when lying on his left side, but the symptoms had improved after the surgery. He had some feelings of stiffness but, overall, his left shoulder had improved quite a bit and did not cause daily pain. On physical examination, left shoulder forward flexion was to 160 degrees, and abduction was to 150 degrees. There was no significant tenderness. He had a negative impingement sign. He had some discomfort on forced passive forward flexion past 160 degrees. External rotation was to 60 degrees. External rotational strength was 5/5. The 3 cms. postoperative left shoulder scar was healed and nontender. The pertinent assessment was left shoulder rotator cuff tear and impingement, status post repair, and decompression. On a VA general medical examination conducted later in January 2005, it was noted that the Veteran continued to play basketball with others of his own age. On physical examination, he undressed and redressed without difficulty. He reported that he was right-handed. On examination of his extremities, his radial pulse in his left upper extremity was normal. Neurologically, he had normal coordination. There was no motor or sensory loss on his left side. Deep tendon reflexes in the upper extremities were 2+. On a VA general medical examination conducted for TDIU purposes on July 27, 2007, the Veteran reported that his medical conditions were not the primary reason for his unemployment. He further indicated that there had been no significant changes. After service, he had worked as a volunteer for several months. For about 3 months, he had worked as an intern and was paid some wages. He took some classes in construction management and wanted to be a general contractor, but was not currently employed. He reported that he was right-handed. Neurologically, he appeared to be normal. On VA orthopedic examination conducted on July 27, 2007, in conjunction with the Veteran's TDIU claim, the Veteran reported having had left shoulder pain since 2001, although records showed he had had such pain since 1986. A November 2001 left shoulder MRI had revealed a type-1 acromion, increased soft tissue, and degenerative changes in the acromioclavicular region and capsular effusion. He also had bursitis and periarticular tear of the anterior aspect of the supraspinatus tendon with predisposition to impingement at the acromioclavicular joint level. The surgeon performing the left shoulder operation had noted difficulties finding the biceps tendon. There appeared to be a stump off of the superior labrum, which was mobile, and some subchondral bone was exposed. There was no evidence of the long end of the biceps. Currently, the Veteran reported continuing to have left shoulder pain, especially when lying on his left side. His symptoms were attenuated by the 2002 surgery but since he had started working for Habitat in 2005 he could not use his left arm very well and was easily fatigued. He had thought that he could work 1 or 2 days a week, rather than 5 days, because his work at that time involved heavy lifting. Prior to that, he was in Iraq in June 2004 but on his return in December, and through March, he was not very active and did not really feel a lot of issues related to left shoulder pain. It was only during heavy construction work that he started having more difficulties from fatigue and pain. He denied using any braces or applying heat or any ultrasound treatment. He had not been hospitalized for his left shoulder. He was right-handed. On physical examination, left shoulder forward flexion was preserved from zero (0) to 160 degrees, actively, and on passive flexion it was up to 180 degrees without any significant pain or tenderness. Shoulder abduction was to 160 degrees without any limitation. There was some crepitus and mild discomfort for the last 30 degrees but he was able to do 5 repetitions of movement without any loss of strength, fatigue, pain, or incoordination. Internal and external left shoulder rotation were preserved. Overall, left arm strength was 5/5 and there was no muscle atrophy. The postoperative scar was nontender and mobile. A comparison of a July 2007 left shoulder X-ray to X-rays in 2004 revealed no acute fracture or dislocation, and the glenohumeral joint space was maintained. The examiner's assessment was that no major limitation of range of motion was found, but there was considerable pain on heavy lifting. The Veteran's strength was also fairly preserved, although he claimed that on prolonged heavy lifting and doing heavy construction work he became easily fatigued. However, the latter was difficult to determine based on the regular physical examination which was performed. At the April 2010 Board hearing, it was averred that the Veteran had limited strength and frequent pain in the left shoulder. He testified that, since service, he had spent time building homes for Habitat and was doing some general work flipping houses. Performing work such as handing drywall or plywood caused pain in the biceps, creating a sensation as if the muscle were tearing. These objects weighed about 30 lbs. and repeated lifting caused pain. For the past 18 months he had worked for the U.S. State Department in Iraq and, so, during that time had not been doing construction work, i.e., for about two or more years. He was no longer doing contract work and was currently home from Iraq and would not return until September. While in Iraq, he was a deputy team leader of an embedded provincial reconstruction team of about 26 people, but was not performing any actual physical construction work. The Veteran testified that, when he finally returned stateside in September 2010, he intended for he and his wife to operate a small construction company involved in flipping houses and occasionally building houses as the economy permitted. As to pain on repetitive movement, the Veteran could not recall how many repetitions of moving drywall would cause left shoulder pain. He had a 3 inch postoperative left shoulder scar. The Veteran had taken 800 milligrams of Motrin three times daily for his service-connected knee disability and also for low back disability. His left shoulder surgery had been in April 2002, at which time the bursa was removed and the acromion was shaved, and, as a result, range of motion of the left shoulder was fine. However, he was told that the left shoulder was worn out from the inside out. The tendon had worn out due to scraping against the acromion and damaging the muscle with resultant atrophy and detached tendon. It was not contended that the Veteran had limited left shoulder motion but, rather, that he had pain and fatigue on repetitive motion. On VA examination in August 2011 in conjunction with a TDIU claim, as to his left shoulder, the Veteran reported that he was having problems dressing himself. His course since onset had been stable. He took medication, Ibuprofen 800 mgs. every 6 hours, as needed, without side effects. As to his musculoskeletal system, he had complaints of weakness or fatigue. He reported having severe pain, stiffness, and limited motion of the left shoulder. The symptoms worsened with weather changes and increased activities caused a flare-up. Ibuprofen helped relieve his pain, as did making frequent positional changes. However, he reported not having any additional limitation of motion or other functional impairment during a flare-up. Neurologically, the Veteran had symptoms of coldness, a feeling of heaviness, fatigability, and aching of the left upper extremity. He had no history of weakness or paralysis. He had no history of poor coordination. Muscle strength was 5, but he had tenderness of the left shoulder. Left shoulder forward flexion and abduction were to 160 degrees, internal rotation was to 30 degrees, and external rotation was to 90 degrees. There was no objective evidence of pain on active motion and there was no additional limitation of motion after repetitive motion. Reflexes in both upper extremities were 1+. There was decreased sensation in the left upper extremity from the upper arm to the wrist, but sensation to vibration, position, and light touch were normal and there were no dysesthesias. It was observed that the Veteran's usual occupation was in construction. He had been self-employed flipping houses for less than one year and had not lost any time from work. After service, he had work for a time with the U.S. State Department. It was reported that the Veteran shoulder disability caused no effects on his usual occupation or any resulting work problems and there were no effects of this problem on his usual daily activities. On VA examination in November 2011, the Veteran reported being ambidextrous. He felt that he had decreased use of the left arm due to weakness, fatigue, and cramping. He sometimes had a sensation of tearing in his biceps area in an area that was not surgically repaired. He stated that he did not routinely have discomfort when getting dressed, but did when he had to pull on a flight suit, as he had tried out an old one last week. The Veteran reported having shoulder pain only with certain positions in range of motion. He had pain in the biceps area with such motion as lifting and with stretching. His taking 800 mgs. of Ibuprofen, as needed, helped but did not fully provide relief. The Veteran indicated that his son was a registered nurse and had taught the Veteran some exercises which had helped both shoulders. He did not report that flare-ups impacted the function of the shoulder. He denied having left shoulder flare-ups with weather changes. Left shoulder flexion was to 180 degrees, with pain beginning at 175 degrees. Left shoulder abduction was to 180 degrees and there was no objective evidence of painful motion. He was able to perform repetitive-use testing with 3 repetitions. He had no additional limited shoulder motion after repetitive-use testing. It was also reported that the Veteran did not have any functional loss or functional impairment of the shoulder. He did not have localized tenderness or pain on palpation of the joints, soft tissues or biceps tendon of the shoulder and there was no guarding of the shoulder. Left shoulder strength was 5/5 in abduction and forward flexion. There was no ankylosis. Hawkin's impingement test (forward flexion to 90 degrees with the elbow bent to 90 degrees with pain on internal rotation) was positive and might signify rotator cuff teninopathy or tear of the "right" but not the left shoulder. The "Empty-can test" was negative. However, external rotation/infraspinatus strength test was positive in each shoulder, and could be associated with infraspinatus tendinopathy or tear. There was a history of mechanical symptoms, e.g., clicking, catching, in the left shoulder, but no history of recurrent subluxations of the glenohumeral or scapulohumeral joints. He was able to flex both biceps and had no pain with palpation to the bicep area when flexed or relaxed. There was slight atrophy of the left biceps, compared to the right. Clicking in the left shoulder was noted with passive range of motion. It was noted that diagnostic testing had not revealed degenerative or traumatic arthritis. His shoulder disorder impacted his ability to work because he had found putting on flight suits to be difficult due to shoulder and biceps pain. It also interfered with his ability to lift, due to pain in the biceps area. At the November 2012 Board hearing, the Veteran testified that a physician had informed him that it appeared that his left shoulder had been worn from the inside out and an MRI had revealed bursitis. Surgically, he had been unable to reattach a long tendon of the head of the biceps, because it was atrophied, but the surgeon had removed the bursa. He had undergone rehabilitation, which had been reasonably successful. The shoulder only catched partially and he only sometimes had pain. The Veteran stated that he was able to use his left shoulder satisfactorily, such as performing five repetitions during an examination. After retiring from the military, he had continued his education and gotten another degree, in civil engineering and construction management but that work was difficult because any type of weight or repetitive motions wore his muscles out quickly. His son, a nurse, had given him some physical therapy exercises to perform. He had not had any dislocations of the left shoulder. Upon questioning by the presiding VLJ, the Veteran stated that he had atrophy in the left biceps area due to an unattached tendon and, so, had decreased strength in his left arm. The Veteran further testified that he had difficulty lifting weight over his head. With repetitions his range of motion of the left shoulder decreased, particularly if lifting weights. He had not had left shoulder surgery since 2002 nor had it been recommended. He took Motrin regularly. He was not currently working, although he had a contractor's license. He bought and repaired rental properties and occasionally sold them. The Veteran's left shoulder impacted him when doing construction work on houses, such as drywall work, which was something he really could not do any more. His primary problems with the left shoulder were lack of endurance and fatigue, as well as episodic pain. As to the separate ratings of a noncompensable disability level and a 10 percent disability level, his symptoms had remained pretty much the same since his service discharge, with no real spike in his symptoms in 2007. On VA orthopedic examination in March 2013, it was reported that the Veteran had bursitis, impingement, and rotator cuff tear of the left shoulder. He had begun having trouble with the left shoulder in about 2001, with pain when lifting weights. Following surgery in 2002, he had not had treatment. He was right-handed. He did not report having flare-ups which impacted the function of the left shoulder. On examination, forward flexion of the left shoulder was to 160 degrees with no objective evidence of painful motion. Abduction was to 175 degrees, also without objective evidence of painful motion. Left shoulder forward flexion was equal to that of the right shoulder but left shoulder abduction was only 5 degrees less than in the right shoulder. He was able to perform repetitive-use testing with 3 repetitions, following which range of motion in forward flexion and in abduction was the same as prior to repetitions and it was specifically stated that he had no additional limitation of motion after repetitive-use testing. The examiner reported that the Veteran had functional loss or functional impairment of the left shoulder and arm, in that he had less motion than normal. He also had localized tenderness or pain on palpation of the soft tissue or biceps tendon in each shoulder but had no guarding of either shoulder. Strength in forward flexion and in abduction was 5/5, bilaterally. There was no ankylosis of the glenohumeral or scapulohumeral joints. Hawkin's impingement test, "Empty-can" test, external rotation/infraspinatus strength test, and lift-off subscapular tests were negative. There was a history of mechanical symptoms, e.g., clicking or catching in the left shoulder but no history of recurrent dislocations, i.e., subluxations, of the glenohumeral or scapulohumeral joints. There was no tenderness on palpation of the acromioclavicular joint. As a residual of his past left shoulder surgery he had occasional catching or grinding, decreased strength, and fatigue. Imaging studies had revealed both degenerative and traumatic arthritis. His left shoulder condition impacted his ability to work due to decreased strength and fatigue when doing construction work. It was noted that X-rays indicated minimal degenerative changes of the acromioclavicular joints. It was also observed that the Veteran had a surgical scar, but such was not painful and/or unstable, or greater than 39 square centimeters. The Veteran was also afforded a VA examination in March 2013 as to the muscles in his left shoulder. It was noted that he had a retracted tear of the long head of the left biceps tendon. It was again observed that he was right-handed. The Veteran had an injury of Muscle Group 5 (V) on the left, the flexor muscles involving the biceps, or brachialis, or brachioradialis. He had never had an injury of the muscle groups of the forearm or hand. He did not have a history of an extensive muscle hernia or any muscle, without other injury of a muscle. He had no known fascial defects from the muscle injury. The muscle injury affected muscle substance or function in that there was a small step-off detectable on deep palpation of the proximal left biceps without tenderness or loss of function on examination. However, he had occasional loss of power and occasional weakness, as well as occasional lowered threshold of fatigue and fatigue-pain. However, there was no impairment of coordination or uncertainty of movement. He had normal strength in both shoulders in abduction, elbow extension, wrist flexion and extension. There was no muscle atrophy. There was no impairment of function such that he would be equally well served by amputation with prosthesis. His muscle injury impacted his ability to work, such as resulting in an inability to keep up with work requirements, specifically he had difficulty with repetitive heavy lifting. III. Initial Rating Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the appellant's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating an appellant's service-connected disabilities. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994) (the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. 38 C.F.R. § 4.69. In the instant case, the Board finds that the Veteran is right hand dominant. While he reported that he was ambidextrous at the November 2011 VA examination, the preponderance of the evidence reflects that he is, in fact, right-handed. Therefore, as the disabilities of his left shoulder pertain to this nondominant side, the ratings for the minor side will be applied. The Board observes that a May 2005 rating decision granted service connection for the Veteran's left shoulder rotator cuff tear and impingement status post repair and decompression effective April 1, 2005, the day after his discharge from service. Separate service connection for his retracted tear of the long head of the bicep tendon and residual scar of the left upper extremity was not made effective until July 27, 2007, and March 25, 2013, respectively. However, as the Veteran has continuously pursued his appeal with respect to the propriety of the initially assigned rating for his left shoulder disability and the latter two issues are part and parcel of such claim, the Board finds that the appeal period for all three disabilities begins as of April 1, 2005. A. Left Shoulder Rotator Cuff Tear and Impingement Status Post Repair and Decompression The Veteran's left shoulder rotator cuff tear and impingement status post repair and decompression has been assigned a noncompensable rating, effective April 1, 2005, and a 10 percent rating, effective July 27, 2007, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5099-5024. In this case, the hyphenated Diagnostic Code indicates the use of an analogous rating using the criteria of the second part. See 38 C.F.R. § 4.27. Specifically, the RO determined that the Veteran's disability did not fit the criteria of the Diagnostic Codes which rate specific shoulder disabilities and applied the criteria of Diagnostic Code 5024, which addresses tenosynovitis, by analogy. Diagnostic Code 5024 provides that tenosynovitis is rated on limitation of motion of the affected part as degenerative arthritis, which is addressed in Diagnostic Code 5003. In general, disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. Diagnostic Code 5003 provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X- ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Normal forward elevation of a shoulder (flexion) as well as normal abduction (movement of the arm away from the side) are to 180 degrees. Normal internal and external rotation are to 90 degrees. 38 C.F.R. § 4.71, Plate 1. Under 38 C.F.R. § 4.71a, DC 5200, ankylosis of the scapulohumeral articulation (which moves as one piece), when in a favorable position, with abduction to 60 degrees, and ability to reach the mouth and head is retained, a 20 percent evaluation for the minor extremity is warranted. When in an intermediate position between favorable and unfavorable, a 30 percent rating is warranted for the minor extremity. When in an unfavorable position, with abduction limited to 25 degrees from the side, a 40 percent evaluation is assigned for the minor extremity. Ankylosis is immobility and consolidation of a joint due to disease, injury or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992) (memorandum decision); Nix v. Brown, 4 Vet. App. 462, 465 (1993); and Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Diagnostic Code 5201, which provides for a minimum 20 percent rating with limitation of motion of the shoulder of the major or minor extremity at shoulder level; and a 20 percent rating for limitation of motion of the shoulder of the minor extremity midway between the side and shoulder level; and a 30 percent rating when limitation of motion of the shoulder of the minor extremity is limited to 25 degrees from the side. In Lineberger v. Brown, 5 Vet. App. 367, 370 (1993) the Court noted that as the minimum 20 percent rating for limited shoulder motion, it should be clarified whether that rating is a result of limitation of motion of abduction only, or whether both limitation of motion of flexion and abduction are required. However, in Mariano v. Principi, 17 Vet. App. 305, 317-18 (2003) the Court clarified that for a 20 percent rating under Diagnostic Code 5201 the applicable plane of motion was not to be measured by limitation of motion of abduction alone to the shoulder level because 38 C.F.R. § 4.71, Plate I listed both abduction and forward elevation (flexion) as shoulder-arm movements. Diagnostic Code 5201 did not specifically identify the plane of motion (although Diagnostic Code 5200 did refer to abduction), and the title of Diagnostic Code 5201 was "Arm, limitation of motion of" and appeared to be generic without specifying limitation based solely on abduction. The Court left open the question of whether the ratings in Diagnostic Code 5201 required limitation in all planes or limitation in any one plane but the Court noted that it would be very difficult to satisfy Diagnostic Code 5201 if limitation were required in all planes. So, here, the Board concludes that for rating under Diagnostic Code 5201 the limitation of motion may be in any one plane of motion, e.g., abduction or forward elevation (flexion). However, if there is limitation of motion in more than one plane, separate ratings for limited motion in each plane are not assignable under Diagnostic Code 5201 because that Diagnostic Code refers to limitation of motion in a generic sense. See Yonek v. Shinseki, No. 2012-7120, slip op. (Fed.Cir. July 8, 2013); --- F3d. --- ; 2013 WL 3368972. Under 38 C.F.R. § 4.71a, Diagnostic Code 5202, a minimum 20 percent is warranted for impairment of the humerus, regardless of whether the major or minor extremity is affected, when there is either malunion with moderate deformity or when there are recurrent dislocations of the scapulohumeral joint which are infrequent and there is guarding of movement only at the shoulder level. Under 38 C.F.R. § 4.71a, Diagnostic Code 5203, malunion of the clavicle or scapula, or nonunion without loose movement, of the major or minor extremity warrants a 10 percent evaluation (or impairment may be rated on the basis of impaired function of a contiguous joint). Nonunion with loose movement, or dislocation, of the clavicle or scapula of the major or minor extremity warrants a 20 percent evaluation (or impairment may be rated on the basis of impaired function of a contiguous joint). As indicated previously, the Veteran has been assigned a noncompensable rating prior to July 27, 2007, and a 10 percent rating thereafter for the orthopedic manifestations of his left shoulder disability. However, for the reasons discussed herein, the Board finds that an initial 10 percent rating, but no higher, for the entire appeal period, i.e., since April 1, 2005, is warranted. A review of the evidence of record reflects that, for the entire appeal period, the Veteran's left shoulder rotator cuff tear and impingement status post repair and decompression is manifested by pain, stiffness, tenderness, and crepitus resulting in slight limitation of motion, but does not result in functional loss that more nearly approximates ankylosis of the scapulohumeral articulation, limitation of arm motion to the shoulder level or lower, or impairment of the humerus, clavicle, or scapula. In this regard, service treatment records reflect that the Veteran had minimal limitation of motion of the left shoulder with pain and stiffness. Additionally, in January 2005, he had some discomfort on forced passive forward flexion past 160 degrees. Likewise, post-service records reveal the Veteran's complaints of left shoulder pain, especially when lying on his left side. Additionally, in July 2007, it was noted that the Veteran had some crepitus and mild discomfort for the last 30 degrees of motion. In August 2011, the Veteran reported severe pain, stiffness, and limited motion of the left shoulder. Tenderness was also noted on examination. Additionally, at his Board hearings, he testified to frequent pain in the left shoulder and fatigue on repetitive motion. Furthermore, the evidence demonstrates slight limitation of motion of the left shoulder. As indicated previously, normal forward elevation of a shoulder (flexion) as well as normal abduction (movement of the arm away from the side) are to 180 degrees. Normal internal and external rotation are to 90 degrees. In January 2005, forward flexion was to 150 degrees and external rotation was to 60 degrees. Likewise, in July 2007, forward flexion and abduction was to 160 degrees on active range motion. In August 2011, left shoulder forward flexion and abduction were to 160 degrees, internal rotation was to 30 degrees, and external rotation was to 90 degrees. Additionally, in March 2013, the Veteran had forward flexion of the left shoulder to 160 degrees and abduction to 175 degrees. Additionally, at such time, left shoulder abduction to 5 degrees less than that of the right shoulder. The Veteran has also testified that there was no change in his level of disability after discharge from his active service and that the left shoulder disorder had been stable in the level of severity. Therefore, as the orthopedic manifestations of the Veteran's left shoulder result in pain, stiffness, tenderness, and crepitus resulting in slight limitation of motion for the entire appeal period, i.e., since April 1, 2005, the Board finds that an initial 10 percent rating is warranted. See Burton, supra. However, the Board further determines that an initial rating in excess of 10 percent is not warranted as the Veteran's left shoulder disability does not result in functional loss more nearly approximating ankylosis of the scapulohumeral articulation, limitation of arm motion to the shoulder level or lower, or impairment of the humerus, clavicle or scapula, even when considering functional loss under 38 C.F.R. §§ 4.40 and 4.45. See DeLuca, supra; Mitchell, supra. In this regard, as discussed previously, while the Veteran's left shoulder disability results in mild limitation of motion, there is no evidence that such is limited to the shoulder level or lower, or results in ankylosis. Furthermore, the evidence is entirely negative for any loss of the head, nonunion, fibrous union, dislocation, or malunion of the humerus, clavicle or scapula. Therefore, a higher or separate rating under the Diagnostic Codes pertaining to the evaluation of the shoulder and arm is not warranted. Furthermore, while March 2013 X-rays revealed minimal degenerative changes of the acromioclavicular joints, a higher or separate rating is not warranted under Diagnostic Code 5003. Specifically, as the Veteran has already been awarded a 10 percent rating based on painful, limited motion, assigning a separate 10 percent rating under Diagnostic Code 5003 would constitute pyramiding as he would be compensated twice for the same symptomatology. 38 C.F.R. § 4.14; Esteban, supra. Moreover, as there is no X-ray evidence of involvement of two or more major joints, a 20 percent rating is not warranted under Diagnostic Code 5003. Therefore, the Board finds that the Veteran is entitled to an initial rating of 10 percent, but no higher, for left shoulder rotator cuff tear and impingement status post repair and decompression for the entire appeal period, i.e., since April 1, 2005. B. Retracted Tear of the Long Head of the Left Biceps Tendon The Veteran's retracted tear of the long head of the left biceps tendon has been assigned a 10 percent rating, effective July 27, 2007, pursuant to 38 C.F.R. § 4.73, Diagnostic Code 5305. Diagnostic Code 5305 addresses injuries to Muscle Group V, which pertains to elbow supination (1) (long head of biceps is stabilizer of shoulder joint) and flexion of elbow (1, 2, 3). Such encompasses to the flexor muscles of the elbow: (1) biceps, (2) brachialis, and (3) brachioradialis. Regarding the ratings pertaining to the minor/nondominant side, a severe injury to Muscle Group V warrants a 30 percent rating; a moderately severe injury warrants a 20 percent rating; a moderate injury warrants a 10 percent rating; and a slight injury warrants a noncompensable rating. The factors to be considered in evaluating disabilities residual to healed wounds involving muscle groups are set forth in 38 C.F.R. §§ 4.55, 4.56. For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c). The type of injury associated with a moderate muscle disability is a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. A history with regard to this type of injury includes service department record or other evidence of in-service treatment for the wound and record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objective findings include entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue, some loss of deep fascia or muscle substance or impairment of muscle tonus, and loss of power or lowered threshold of fatigue when compared to the sound side. The type of injury associated with a moderately severe muscle disability is a through and through or deep penetrating wound by a small high-velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. A history with regard to this type of injury should include prolonged hospitalization in service for treatment of wound, consistent complaints of cardinal signs and symptoms of muscle disability, and, if present, evidence of inability to keep up with work requirements. Objective findings should include entrance and (if present) exit scars indicating the track of the missile through one or more muscle groups, and indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side. Tests of strength and endurance compared with sound side should demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). The type of injury associated with a severe muscle disability is a through and through or deep penetrating wound by a small high-velocity missile or large or multiple low-velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, and intermuscular binding and scarring. A history with regard to this type of injury should include prolonged hospitalization in service for treatment of wound, consistent complaints of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Objective findings should include ragged, depressed, and adherent scars indicating wide damage to muscle groups in missile track, and indications on palpation of loss of deep fascia, muscle substance, or soft flabby muscles in wound area. Also, muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side should indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X- ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of missile; (B) adhesion of scar to one of the long bones, scapula, pelvic bone, sacrum, or vertebrae, with epithelial sealing over the bone, rather than true skin covering in an area where bone is normally protected by muscle; (C) diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (D) visible or measurable atrophy; (E) adaptive contraction of an opposing group of muscles; (F) atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; and (G) induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d)(4) . For the entire appeal period, i.e., since April 1, 2005, the Board finds that the Veteran's retracted tear of the long head of the left biceps tendon affects muscle substance or function in that there is a small step-off detectable on deep palpation of the proximal left biceps and occasional loss of power, weakness, lowered threshold of fatigue, and fatigue-pain, resulting in an inability to keep up with work requirements pertaining to repetitive heavy lifting, but does not result in functional loss more nearly approximating a moderately severe or severe muscle disability. Therefore, the Board concludes that an initial 10 percent, but no higher, for the entire appeal period is warranted. In this regard, the Veteran's service treatment records reflect that he underwent surgery for a rotator cuff tear of the supraspinatus and a complete retracted tear of the long head of the biceps tendon. Post-service records reflect that, in July 2007, the Veteran reported experiencing fatigue in using his left bicep and indicated that, upon prolonged heavy lifting and doing heavy construction work, he became easily fatigued. In August 2011, the Veteran reported tenderness of the left shoulder. On examination in November 2011, he indicated that he had decreased use of the left arm due to weakness, fatigue, and cramping. He also stated that he had a sensation of tearing in the biceps area and pain in the biceps area with motion when lifting and stretching. On examination, testing revealed possible rotator cuff teninopathy or tear. There was slight atrophy of the left biceps when compared to the right. At the March 2013 VA joints examination, the Veteran had localized tenderness or pain on palpation of the soft tissue or biceps tendon and it was noted that, as a residual of his past shoulder surgery, he had occasional catching or grinding, decreased strength, and fatigue. Additionally, at the March 2013 VA muscles examination, it was determined that the Veteran had an injury of Muscle Group V on the left, the flexor muscles involving the biceps, or brachialis, or brachioradialis. The muscle injury affected muscle substance or function in that there was a small step-off detectable on deep palpation of the proximal left biceps without tenderness or loss of function on examination. The Veteran also had occasional loss of power and occasional weakness, as well as occasional lowered threshold of fatigue and fatigue-pain. The examiner also indicated that the muscle injury impacted his ability to work, resulting in an inability to keep up with work requirements, in that he had difficulty with repetitive heavy lifting. Moreover, the March 2013 VA examiner determined that the Veteran's retracted tear of the long head of the biceps tendon was clearly documented at the time of the Veteran's shoulder surgery for full thickness rotator cuff tear in 2002 and is often associated with such rotator cuff disease. Therefore, the Board finds that the Veteran's injury to muscle group V has been present since his military service, an initial 10 percent rating is warranted as for the entire appeal period, i.e., since April 1, 2005. However, the Board finds that the Veteran's disability of muscle group V does not more nearly approximate a moderately severe or severe muscle injury and, thereafter, an initial rating in excess of 10 percent is not warranted. In this regard, at the July 2007 VA examination, while the Veteran complained of fatigue and pain, such was only in relation to when he was doing heavy construction work. Additionally, left arm strength was 5/5 and there was no muscle atrophy. Likewise, muscle strength was 5 and reflexes in both upper extremities were 1+ at the August 2011 VA examination. In November 2011, there was no localized tenderness or pain on palpation of the soft tissues or biceps tendon. Left shoulder strength was 5/5 in abduction and forward flexion at the November 2011 and March 2013 examinations. Additionally, at the March 2013 VA examination, there was no impairment of coordination or uncertainty of movement. Furthermore, he had normal strength in both shoulders in abduction, elbow extension, wrist flexion and extension. There was no muscle atrophy and there was no history of an extensive muscle hernia or any muscle, without other injury of a muscle. He had no known fascial defects from the muscle injury. There was no impairment of function such that he would be equally well served by amputation with prosthesis. Based on the foregoing, the Board finds that there is no evidence during service of a through and through or deep penetrating wound by a small high-velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. Furthermore, there is no indication that the Veteran's treatment during service included prolonged hospitalization. Additionally, while he has complained of fatigue, pain, and weakness associated with his muscle disability, such complaints are not consistent. Rather, they were only in relation to heavy lifting or heavy construction work. Likewise, while such resulted in an inability to keep up with work requirements, such was only noted to be in relation to repetitive heavy lifting. Additionally, there is no objective evidence an indication on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side. Finally, there is no evidence that tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. Consequently, the Veteran's manifestations of his retracted tear of the long head of the left biceps tendon do not more nearly approximate a moderately severe muscle group injury. Likewise, there is no evidence of the type of injury, type of history, or objective findings associated with a severe muscle group injury. Therefore, the Board finds that the Veteran is entitled to an initial rating of 10 percent, but no higher, for retracted tear of the long head of the left biceps tendon for the entire appeal period, i.e., since April 1, 2005. C. Residual Scar of the Left Upper Extremity The Veteran's residual scar of the left upper extremity has been assigned a noncompensable rating, effective July 27, 2007, pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7805. As indicated previously, the Board has found that the Veteran's claim regarding higher or separate ratings for his left shoulder disability had been pending since April 1, 2005. While a separate rating for his residual scar was not granted until March 25, 2013, and the schedular rating criteria pertaining to the skin were amended effective October 23, 2008, the Board finds that there is no prejudice to him in the Board proceeding with a decision at this time as Diagnostic Code 7805 essentially remained unchanged by the amendments. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2012); 67 Fed. Reg. 49590-49599 (July 31, 2002). Specifically, Diagnostic Code 7805 (2008) provides that a scar should be rated on the limitation of function of the affected part. Similarly, Diagnostic Code 7805 (2012) provides that a scar's disabling effects not considered under Diagnostic Codes 7800 (scars on the head, face, or neck), 7801 (deep and nonlinear scars of certain sizes), 7802 (superficial and nonlinear scars of certain sizes), and 7804 (stable or painful scars) should be rated under an appropriate diagnostic code. Other Diagnostic Codes in effect both prior to and as of October 2008 provide for compensable ratings for symptomatic scars or scars of certain sizes. The evidence of record reflects that the Veteran underwent surgery to his left shoulder during service that resulted in a scar. In January 2005, such scar was described as three centimeters and was noted to be healed and nontender. Additionally, on examination in July 2007, such scar was noted to be nontender and mobile. In March 2013, it was noted that the Veteran had a surgical scar, but such was not painful and/or unstable, or greater than 39 square centimeters. Therefore, as the Veteran's residuals scar of the left upper extremity has been present for the entire appeal period, i.e., since April 1, 2005, but is asymptomatic and not of a size to warrant a compensable rating, the Board finds that an initial noncompensable rating, but no higher, for residual scar of the left upper extremity is warranted as of April 1, 2005. D. Other Considerations The Board observes that, at the August 2011 VA examination, reflexes in both upper extremities were 1+ and there was decreased sensation in the left upper extremity from the upper arm to the wrist, but sensation to vibration, position, and light touch were normal and there were no dysesthesias. Likewise, motor examination was normal. Moreover, all other examinations failed to reveal any neurologic impairment of the left upper extremity. Specifically, in January 2005, radial pulse was normal, he had normal coordination, there was no motor or sensory loss on the left side, and deep tendon reflexes were 2+. Furthermore, on examination in July 2007, he appeared to be normal neurologically. The remainder of the medical and lay evidence is similarly negative for any complaints, treatment, or findings referable to neurologic impairment associated with the Veteran's left shoulder rotator cuff tear and impingement status post repair and decompression. Therefore, the Board finds that the preponderance of the evidence is against a finding that a separate rating is warranted for neurological impairment associated with such disability. In making its determinations in this case, the Board has also carefully considered the Veteran's contentions with respect to the nature of his service-connected disabilities at issue and notes that her lay testimony is competent to describe certain symptoms associated with these disabilities. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and has been contemplated by the disability ratings that have been assigned. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disabilities at issue. As such, while the Board accepts the Veteran's testimony with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected conditions at issue. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected left shoulder disabilities; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disabilities is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. In general, the schedular disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The application of such schedular criteria was discussed in great detail above. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). An extra-schedular disability rating is warranted 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 that application of the regular schedular standards would be impracticable. Id. The Court has held that the Board is precluded by regulation from assigning an extra-schedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected disabilities with the established criteria found in the rating schedule. The Board finds that the Veteran's symptomatology is fully addressed by the rating criteria under which such disabilities are rated. In this regard, the manifestations of the Veteran's left shoulder disability have been assigned three separate ratings under different diagnostic codes in order to address all symptoms, to include orthopedic, muscular, and scarring symptomatology. Specifically, the Veteran's 10 percent rating for left shoulder rotator cuff tear and impingement status post repair and decompression contemplates the Veteran's symptoms resulting in functional loss related to his limitation of shoulder movement. Moreover, his 10 percent rating for retracted tear of the long head of the left biceps tendon contemplates his symptoms resulting in functional loss related to the decreased strength in his biceps muscle. Finally, he has been awarded a noncompensable rating for asymptomatic scarring as a result of his in-service surgery. There are no additional symptoms of the Veteran's left shoulder disabilities that are not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disabilities. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of the issues decided herein for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for total disability rating for compensation based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. During the course of the Veteran's claims, a claim for TDIU was considered and denied by the RO in August 2007 and May 2013 rating decisions. The Veteran has not appealed such decisions. Such adjudications reflects the permissive bifurcation of the initial rating claims from the TDIU claim. See Roebuck v. Nicholson, 20 Vet. App. 307, 315 (2006) (acknowledging that the Board can bifurcate a claim and address different theories or arguments in separate decisions); Holland v. Brown, 6 Vet. App. 443, 447 (1994) (holding that "it was not inappropriate" for the Board to refer a TDIU claim to the RO for further adjudication and still decide an increased-ratings claim). Moreover, while acknowledging the Rice decision, in Locklear v. Shinseki, 24 Vet. App. 311 (2011), the Court held that it is permissive for VA to address a claim for TDIU independently of other claims, including increased rating and service connection claims. Id. at 315. Given the foregoing, the Board concludes that the TDIU claim was separately adjudicated and not perfected for appellate review. Accordingly, the Board does not have jurisdiction over the claim and need not refer or remand the matter. In conclusion, the Board finds that the criteria for initial ratings in excess of 10 percent, 10 percent, and 0 percent for left shoulder rotator cuff tear and impingement status post repair and decompression, retracted tear of the long head of the left biceps tendon, and residual scar of the upper left extremity, respectively, have not been met. In denying such increased initial ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. ORDER For the entire appeal period, i.e., since April 1, 2005, an initial 10 percent rating, but no higher, for left shoulder rotator cuff tear and impingement status post repair and decompression is granted, subject to the laws and regulations governing the award of monetary benefits. For the entire appeal period, i.e., since April 1, 2005, an initial 10 percent rating, but no higher, for retracted tear of the long head of the left biceps tendon is granted, subject to the laws and regulations governing the award of monetary benefits. For the entire appeal period, i.e., since April 1, 2005, an initial noncompensable rating, but no higher, for residual scar of the left upper extremity is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs