Citation Nr: 1331411 Decision Date: 09/30/13 Archive Date: 10/02/13 DOCKET NO. 10-05 372 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for a right hip condition, including as secondary to service-connected left knee and hip disabilities. 2. Entitlement to service connection for left rotator cuff tendonitis, including as secondary to service-connected left knee and hip disabilities. 3. Entitlement to service connection for right rotator cuff tendonitis, including as secondary to service-connected left knee and hip disabilities. 4. Entitlement to a rating in excess of 10 percent for tendonitis, left hip. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. J. N. Driever INTRODUCTION The Veteran served in the U. S. Army Reserves from 1978 to 1998, including on various periods of active duty or active duty for training (ACDUTRA), including from August 1978 to November 1978, from April 1991 to September 1991, and from January 1992 to June 1992. These claims come before the Board of Veterans' Appeals (Board) on appeal of a June 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. Other than an Appellant's Brief, in which the Veteran's representative elaborates on prior substantive contentions, VA's paperless claims processing system (Virtual VA) includes no additional pertinent documents for consideration in support of these claims. In multiple written statements dated in 2009 and 2010, the Veteran appears to be raising claims for compensation under the provisions of 38 U.S.C.A. § 1151 for disability due to VA medical treatment (VA physician and physical therapist allegedly recommended exercising using the shoulders for cardiac benefit, resulting in bilateral rotator cuff tendonitis). The Board refers this matter to the RO for appropriate action. FINDINGS OF FACT 1. A right hip condition was not incurred in or aggravated by active service and is not proximately due to or the result of the Veteran's service-connected left knee and hip disabilities. 2. Left rotator cuff tendonitis was not incurred in or aggravated by active service and is not proximately due to or the result of the Veteran's service-connected left knee and hip disabilities. 3. Right rotator cuff tendonitis was not incurred in or aggravated by active service and is not proximately due to or the result of the Veteran's service-connected left knee and hip disabilities. 4. Tendonitis in the Veteran's left hip manifests as mild diffuse tenderness and limitation of flexion to 85 degrees with pain, not increased during flare-ups or on repetitive use, and intermittently necessitates the use of pain medication and an exercise machine. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right hip condition, including as secondary to service-connected left knee and hip disabilities, are not met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2012). 2. The criteria for entitlement to service connection for left rotator cuff tendonitis, including as secondary to service-connected left knee and hip disabilities, are not met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2012). 3. The criteria for entitlement to service connection for right rotator cuff tendonitis, including as secondary to service-connected left knee and hip disabilities, are not met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2012). 4. The criteria for entitlement to a rating in excess of 10 percent for tendonitis, left hip, are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1-4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5013-5253 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law that it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R."); and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet.App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet.App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet.App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law as well as the controlling decisions of the appellate courts. VA's Duties to Notify and Assist Upon receipt and prior to consideration of most applications for VA benefits, VA must satisfy certain procedural requirements outlined in the Veterans Claims Assistance Act of 2000 (VCAA) and its implementing regulations. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The United States Court of Appeals for Veterans Claims (Court) has mandated that VA ensure strict compliance with the provisions of the VCAA. Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA and its implementing regulations provide that VA is to notify a claimant and his representative, if any, of the information and medical or lay evidence not previously provided to the Secretary that is necessary to substantiate a claim. As part of the notice, VA is to specifically inform the claimant and his representative, if any, of which portion of the evidence the claimant is to provide and which portion of the evidence VA will attempt to obtain on the claimant's behalf. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012). When a claimant is trying to establish entitlement to service connection for a disability, the VCAA notice must apprise him of all five elements of the claim, including: (1) veteran status; (2) existence of disability; (3) a connection between service and disability; (4) degree of disability; and (5) effective date of disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Under section § 5103(a) and in claims for increased ratings, the Court initially required that VA notify the claimant that 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 and the effect that worsening has on the claimant's employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37, 43 (2008). The Court also held that, if the Diagnostic Code (DC) under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant. The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant DCs, 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 daily life. As with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation, including competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. Id. at 43-44. The Court of Appeals for the Federal Circuit (Federal Circuit), however, later held that the notice described in 38 U.S.C.A. § 5103(a) need not be veteran specific and that daily life evidence was not statutorily mandated. The Federal Circuit thus vacated the Court's decision to the extent it required notification of alternative DCs and the need to submit potential daily life information on the basis that such evidence was not needed for proper claims adjudication. Vazquez-Flores v. Shinseki, 580 F.3d 127 (Fed. Cir. 2009). Ideally, the RO should provide the claimant VCAA prior to its initial unfavorable decision on the claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). However, if the RO does not, or provides the notice in a timely manner but it is inadequate or incomplete, the RO can effectively cure this error by providing any necessary VCAA notice and then readjudicating the claim in a statement of the case (SOC) or supplemental SOC (SSOC). In such a case, the intended purpose of the notice is not frustrated, rather preserved, and the claimant is given ample opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U.S. Supreme Court has made clear that VCAA notice errors, even when shown to have occurred, are not presumptively prejudicial, instead, must be judged on a case-by-case basis. As the pleading party attacking the agency's decision, the Veteran has the burden of proof of not only establishing error but also, above and beyond that, of showing how it is unduly prejudicial, meaning outcome determinative of his claim, i.e., more than harmless. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). VA also has a duty to assist a claimant in obtaining evidence necessary to substantiate a claim, including, in certain cases, by offering a medical examination or obtaining a medical opinion, but such assistance is not required if there is no reasonable possibility that it would aid in substantiating the claim. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b), (c). Notice The RO provided the Veteran VCAA notice by letter dated May 2009. The RO sent this letter before initially adjudicating the Veteran's claims. The letter satisfies the timing and content requirements noted above. It informs the Veteran of the evidence needed to substantiate his claims and identifies the type of evidence that would best do so. It includes all necessary information on disability ratings and effective dates in the event service connection and/or an increased evaluation is granted. It identifies the evidence the RO requested and/or received in support of the Veteran's claims and the evidence it is responsible for securing. It indicates that the RO will make reasonable efforts to assist the Veteran in obtaining outstanding evidence provided he identifies its source(s), but that it is the Veteran's responsibility to ensure VA's receipt of all pertinent evidence. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of these claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir., 2004). He does not assert that VA failed to comply with VCAA's notice provisions. The RO also satisfied its duty to assist the Veteran in the development of these claims by trying to secure and associate with the claims file all documents the Veteran identified as being pertinent to his claims, including service and post-service private treatment records. The RO also afforded the Veteran VA examinations, and the reports of these examinations indicate the examiners were aware of the Veteran's relevant military, medical and post-military history, the claimed right hip and bilateral shoulder disabilities and the severity of the Veteran's left hip disability. When VA affords a claimant a VA examination or obtains a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Unless the claimant challenges the adequacy of the examination or opinion, however, the Board may assume, and need not affirmatively establish, the adequacy of the examination report and the competence of the examiner. Sickels v. Shinseki, 643 F.3d, 1362, 1365-66 (Fed. Cir. 2011) (holding that, although the Board is required to consider issues independently raised by the evidence of record, the Board is still entitled to assume the competency of a VA examiner and the adequacy of a VA opinion without demonstrating why the medical examiner's report is competent and sufficiently informed); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-1291 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged). Id. Even when the claimant challenges a VA examination or opinion, the Board may assume the competency of the VA medical examiner, including nurse practitioners, as long as, under 38 C.F.R. § 3.159(a)(1), he or she is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Cox v. Nicholson, 20 Vet. App. 563 (2007). The Veteran does not assert that there are any outstanding records that must be obtained in support of these claims. He also does not assert that the reports of the VA examinations are inadequate. Analyses Claims for Service Connection: When deciding claims, the Board is required to consider all potential bases of entitlement, including direct, presumptive and secondary. See Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). The Board is also required to address all arguments advanced by a claimant and/or theories under which entitlement to benefits sought may be awarded. See Robinson v. Peake, 21 Vet. App. 545, 552 (2008) (noting that the Board is required to consider all issues raised either by the claimant or reasonably by the evidence of record), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009). The Veteran argues that he incurred right hip and bilateral shoulder disabilities secondary to his service-connected left hip and left knee disabilities. The Veteran alleged in statements dated in February 2009, September 2009, October 2009 and February 2010, that his service-connected disabilities forced him to alter his gait, which in turn caused him to develop a right hip condition. In addition, he asserts that, due to his service-connected disabilities, he could not strengthen his cardiovascular system by using his legs so his physician advised him to use his shoulders for this purpose. He alleges that after undergoing physical therapy with this purpose in mind, he developed tendonitis in both shoulders. He asserts that his physician and physical therapist have since told him to stop using his shoulders to exercise. Considering these lay statements in conjunction with all other pertinent evidence in the claims file and applicable law and regulations, the Board finds that the preponderance of the evidence is against a grant of each of these claims. The Veteran has not been diagnosed with a right hip disability and his bilateral rotator cuff tendonitis is not related to his active service or, as alleged, his service-connected left knee and left hip disabilities. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval or air service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). Mere symptoms alone, including pain, without a diagnosed or identifiable underlying malady or condition, do not in and of themselves constitute a ratable disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), appeal dismissed in part and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Active military service includes active duty, any period of ACDUTRA during which a claimant becomes disabled or dies due to injury or disease incurred in or aggravated in the line of duty, and any period of inactive duty training (INACDUTRA), during which a claimant becomes disabled or dies due to injury incurred in or aggravated in the line of duty or from an acute myocardial infarction, cardiac arrest, or a cerebrovascular accident that occurred during such training. 38 U.S.C.A. §§ 101(21), (24), 106 (West 2002); 38 C.F.R. § 3.6(a), (d) (2012). Reserve and National Guard service generally means ACDUTRA and INACDUTRA. ACDUTRA is full time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505. 38 U.S.C.A. § 101(22) (West 2002); 38 C.F.R. § 3.6(c) (2012). Basically, this refers to the two weeks of annual training, sometimes referred to as "summer camp," which each Reservist or National Guardsman must perform each year. It can also refer to the Reservist's or Guardsman's initial period of training. INACDUTRA includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505. 38 U.S.C.A. § 101(23) (West 2002); 38 C.F.R. § 3.6(d) (2012). Basically, this refers to the twelve four-hour weekend drills that each Reservist or National Guardsman must perform each year and is sometimes referred to as "weekend warrior" training. These drills are deemed to be part-time training. Generally, an individual who has only Reserve or National Guard service (ACDUTRA or INACDUTRA with no active duty) is not a Veteran as legally defined. In the context of service connection claims, for example, this means that the presumption of soundness upon entry into service and the presumptive service connection provisions of 38 C.F.R. § 3.307, applicable to active duty, do not apply to ACDUTRA or INACDUTRA. 38 U.S.C.A. §§ 1111, 1112, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Service connection on a presumptive basis is thus not available where the only service performed is ACDUTRA or INACDUTRA. See Smith v. Shinseki, 24 Vet. App. 40 (2010); Biggins v. Derwinski, 1 Vet. App. 474, 476-78 (1991). To prevail on the issue of service connection, there must be competent evidence of: (1) a current disability; (2) in-service occurrence or aggravation of a disease or injury; and (3) a nexus between the in-service injury or disease and the current disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Once evidence is determined to be competent, its credibility must be evaluated. Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency, a legal concept focusing on whether testimony may be heard and considered, and credibility, a factual determination focusing on the probative value of the evidence); see also Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994) (in rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises or authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). In certain instances, however, a lay statement may be deemed competent and adequate to support a claim for service connection by substantiating the occurrence of lay-observable events or a disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence); Barr v. Nicholson, 21 Vet. App. 303 (2007) (layperson is competent to report disease with unique and readily identifiable features such as varicose veins); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). If a chronic disease is shown in service, subsequent manifestations of the same disease, however remote, are to be service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). When certain chronic diseases are at issue, including arthritis or any other disease enumerated at 38 C.F.R. § 3.309(a), see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), a claimant may establish entitlement to service connection based on a demonstration of continuity of symptomatology. Evidence of continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Continuity of symptomatology may be demonstrated by submitting evidence showing: (1) that a condition was "noted" during service; (2) post-service continuity of the same symptomatology; and (3) a nexus between the present disability and the post-service symptomatology. Savage v. Brown, 10 Vet. App. 488, 495-97; see also Hickson v. West, 12 Vet. App. 247, 253 (1999) (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection). Service connection may be granted for any disease diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Service connection may be presumed for certain medical conditions, including arthritis, if it is shown that a veteran served continuously for 90 days or more during a period of war or during peacetime after December 31, 1946, the condition manifested to a degree of 10 percent within one year from the date of discharge, and there is no evidence of record establishing otherwise. 38 U.S.C.A. §§ 1101, 1112(a), 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). Service connection may also be granted when a claimed disability is found to be proximately due to or the result of a service-connected disability, or when any increase in severity (aggravation) of a nonservice-connected disease or injury is found to be proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Veteran does not assert, nor do service treatment records show that the Veteran reported right hip or shoulder complaints, or received treatment for or was diagnosed with a right hip or shoulder disability during service, including any period of active duty or ACDUTRA. The Veteran also does not assert that the claimed disabilities are related to service. The Veteran injured his left knee during his 1998 period of ACDUTRA and, consequently, by rating decision dated April 1999, the RO granted the Veteran service connection for residuals of that injury. By rating decisions dated June 2005 and May 2006, based on alterations in posture, gait and body mechanics due to the left knee disability, the RO granted the Veteran service connection for left hip and low back disabilities secondary to the left knee disability. Service connection for the left knee, left hip and low back disabilities remain in effect. Since his 1992 period of service, the Veteran has received treatment for multiple medical complaints, particularly related to his service-connected disabilities. He has also undergone VA examinations, including in April 2005, May 2006, June 2009 and June 2010. Prior to 2009, however, no medical professional noted any right hip or bilateral shoulder abnormalities or diagnosed a right hip or shoulder condition. The Veteran first reported right shoulder complaints in January 2009, during a VA outpatient treatment visit. He first reported right hip and left shoulder complaints in June 2009 during a VA examination. In January 2009, he reported that he had been working out on a recumbent bike, but had to stop due to knee problems. He alleged that he then switched to a cardio machine for exercise, which necessitated the use of his upper body and arms, but was forced to stop using that machine due to shoulder pain. His physician diagnosed right shoulder pain due to rotator cuff tendonitis, aggravated by repetitive movement. In June 2009, the VA examiner diagnosed rotator cuff tendonitis of the left shoulder. However, X-rays of the right hip were normal and, according to the VA examiner, there was no right hip pathology on which to base a diagnosis. In June 2010, the Veteran again reported right hip pain, but the VA examiner did not diagnose a right hip condition. In June and July 2010, Scott Oswald, DC, submitted written opinions confirming the RO's previous finding that the Veteran's service-connected left knee disability had caused the Veteran to change his gait, leading to changes in his lumbopelvic region. However, neither opinion specifically mentions the Veteran's right hip or shoulders, includes a right hip diagnosis, or explains the cause of the bilateral shoulder complaints, to include whether they are related to any service-connected disability. The Veteran is competent to report right hip symptoms as reported by medical professionals. But in this case, because the Veteran has no special training or expertise in medicine, he is not competent to diagnose a medical condition or its etiology manifested by this symptom. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F. 3d at 1377. Pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute an actual ratable disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), appeal dismissed in part and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Medical professionals have addressed the etiology of the Veteran's shoulder conditions. As previously indicated and as alleged, in January 2009, a VA physician linked the Veteran's right rotator cuff tendonitis to the repetitive movement of a certain exercise machine he was using, not to any service-connected disability. Most importantly, during the VA examination that was conducted in June 2009, an examiner specifically ruled out a relationship between the right and left shoulder conditions and the Veteran's service-connected left knee and hip disabilities. The examiner considered the Veteran's report that, because of these service-connected disabilities, he could not do a cardiopulmonary workout using his lower extremities and overused his upper extremities, but the examiner found that there was no reason based on physical mechanics to link the shoulder conditions to the service-connected disabilities. The examiner further found that, although the primary care physician recommended using the upper body to work out and the Veteran developed these conditions as a result, the service-connected disabilities did not directly cause the shoulder conditions to develop. The Veteran claims that he is entitled to service connection for bilateral shoulder conditions on the basis that they developed secondary to his physician's and physical therapist's recommendations to work out using his arms. Indeed the medical evidence confirms that working out with his upper extremities caused the rotator cuff tendonitis to develop. This does not mean, however, that the tendonitis is proximately due to or the result of the Veteran's service-connected left knee and hip disabilities. Rather, because of these service-connected disabilities, the Veteran made a choice to work out using his upper extremities as recommended and disability resulted. The Veteran's assertion and the facts noted raise a claim for VA compensation based on VA treatment, a claim the Board refers to the RO above, in the Introduction section of this decision. The Veteran's assertions are the only evidence linking the bilateral shoulder conditions to service-connected disabilities. As previously indicated, the Veteran is competent to report that he developed right and left shoulder pain after working out as these are lay-observable facts, but, because he has no special training or expertise in medicine, he is not competent to attribute this pain to active service or a service-connected disability. In the absence of competent and credible evidence diagnosing a right hip disability and linking the Veteran's shoulder conditions to his service-connected disabilities, the Board finds that such conditions were not incurred in or aggravated by active service and are not proximately due to or the result of service-connected disabilities. Based on this finding, the Board concludes that the criteria for entitlement to service connection for these conditions are not met. A claimant is responsible for presenting evidence in support of his claim for benefits under laws administered by VA. VA is responsible for considering all such evidence, lay and medical. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA is to give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In each of these cases, the evidence is not in relative equipoise. The benefit-of-the-doubt rule is therefore not applicable. Claim for an Increased Evaluation The Veteran seeks an evaluation in excess of 10 percent for his left hip disability. He alleged in statements he submitted in February 2009, September 2009, October 2009 and February 2010 that this disability has increased in severity. He asserts that his left hip pain manifests at night, interferes with sleeping and exercising, and causes a lack of mobility. The Veteran asserts that the only reason he has good motion in his left hip is because he does stretching exercises regularly to remain flexible but that he has pain on movement. The Board has considered the Veteran's contentions in conjunction with all medical documents of record, and finds that the preponderance of the evidence is against the assignment of an evaluation in excess of 10 percent for the Veteran's left hip disability. Tendonitis in the Veteran's left hip manifests as mild diffuse tenderness and limitation of flexion to 85 degrees with pain, not increased during flare-ups or on repetitive use, and intermittently necessitates the use of pain medication and an exercise machine. Disability ratings are determined by evaluating the extent to which a service-connected disability adversely affects a Veteran's ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Where an award of service connection for a disability has been granted and the assignment of an initial rating for that disability is disputed, separate ratings may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). In claims for increases, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). A disability may require re-evaluation in accordance with changes in a Veteran's condition. In determining the level of current impairment, it is thus essential that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. 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. The examination on which an evaluation is based must adequately portray the anatomical damage, and the functional loss, with respect to all of these elements. The 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 innervation, 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. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. §§ 4.40, 4.45 (2012). As regards the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: less movement than normal; more movement than normal; weakened movement; excess fatigability; incoordination, impaired ability to execute skilled movements smoothly; and pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995) (holding that VA's review of a service-connected musculoskeletal disability must include an assessment of the functional impairment caused by that disability and that, if the service-connected disability involves a joint rated based on limitation of motion, adequate consideration must be given to functional loss due to pain under 38 C.F.R. § 4.40, and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45); see also Johnson v. Brown, 9 Vet. App. 7 (1996) (provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the DCs predicated on limitation of motion). With any form of arthritis, painful motion is an important factor. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Painful, unstable, or maligned joints due to healed injury are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012). A compensable rating under DC 5003 and § 4.59 for painful motion is assignable where arthritis is established by X-ray findings, even if there is no actual limitation of motion of the affected joint. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). In such a case, painful motion is considered limited motion even though a particular range of motion is possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). Limitation of motion may be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003 (2012). Consideration of 38 C.F.R. § 4.59 is not limited to cases involving arthritis, thereby providing for the possibility of a rating based on painful motion of a joint, regardless of whether the painful motion stemmed from joint or periarticular pathology. Burton v. Shinseki, 25 Vet. App. 1 (2011). Later that month, however, the Court explained that pain must actually affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination and endurance to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In other words, although pain may cause functional loss, pain, itself, does not constitute functional loss and is just one factor to be considered when evaluating functional impairment. Id. The RO granted the Veteran service connection for tendonitis, left hip, in a June 2005 rating decision. It assigned this disability a 10 percent evaluation pursuant to DC 5253. Hip disabilities are rated based on limitation of motion of the affected part, i.e., the thigh, pursuant to DCs 5251, 5252 and 5253. DC 5251 provides that a 10 percent evaluation is assignable when extension of the hip is limited to 5 degrees. DC 5252 provides that a 10 percent evaluation is assignable when flexion of the thigh is limited to 45 degrees. A 20 percent evaluation is assignable when flexion of the thigh is limited to 30 degrees. A 30 percent evaluation is assignable when flexion of the thigh is limited to 20 degrees. A 40 percent evaluation is assignable when flexion of the thigh is limited to 10 degrees. DC 5253 provides that a 10 percent evaluation is assignable for limitation of rotation, with an inability to toe-out in excess of 15 degrees or where there is limitation of adduction such that one cannot cross their legs. A 20 percent evaluation is assignable for limitation of abduction, where motion is lost beyond 10 degrees. 38 C.F.R. § 4.71a, DC 5251-5253. Also potentially applicable to this claim are DCs 5250, 5254 and 5255. DC 5250 provides for an evaluation of at least 60 percent for ankylosis of the hip. DC 5254 provides for an 80 percent evaluation for flail joint of the hip. DC 5255 provides for an evaluation of at least 10 percent for malunion or nonunion of the femur with knee or hip disability. 38 C.F.R. § 4.71a, DCs 5250, 5254, 5255 (2012). Normal range of motion of the hip is 0 degrees of extension to 125 degrees of flexion and 0 to 45 degrees of abduction. 38 C.F.R. § 4.71, Plate II (2012). Since 2005, the Veteran has received treatment for his left hip disability and undergone VA left hip examinations, but during treatment visits and examinations, no medical professional noted that this disability resulted in flexion of the thigh to 30 degrees or less, loss of abduction with no motion beyond 10 degrees, left hip ankylosis, a flail hip joint or malunion or nonunion of the femur. During the May 2006 VA examination, the Veteran reported frequent pain, which increased in severity during flare-ups, but he did not recall that the pain then caused any change in range of motion. The examiner confirmed pain, both on palpation and motion, and also noted extension and flexion from 0 to 130 degrees with pain, with no change on repetitive use, rotation in flexion outwardly from 0 to 40 degrees without pain and inwardly from 0 to 20 degrees with pain, abduction from 0 to 55 degrees, and adduction from 0 to 20 degrees. Medical professionals confirmed left hip pain during VA outpatient treatment visits dated since 2007. X-rays taken in July 2007 showed normal left hip and left buttocks despite the reports of hip pain and indicated that the pain might be atypical and radicular. In February 2008, a medical professional noted full, pain-free range of motion of the hip and indicated that the left hip/buttock pain was resolving. During a VA examination conducted in June 2009, the examiner noted some loss of motion of the left hip, but not such loss as would warrant the assignment of an evaluation in excess of 10 percent for the left hip disability. The Veteran had extension of the left hip from 0 to 20 degrees (normal being from 0 to 30 degrees), flexion of the left hip from 0 to 85 degrees (normal being from 0 to 125 degrees), normal abduction, external rotation from 0 to 45 degrees (normal being from 0 to 60 degrees), internal rotation from 0 to 30 degrees (normal being from 0 to 40 degrees), no pain with motion, normal strength, no additional functional limitation during flare-ups or on repetitive use, and a slight limp noted in VA treatment records as being due to the Veteran's service-connected back and/or left knee disability. During a VA examination conducted in June 2010, an examiner referred to x-rays showing minimal narrowing of the joint space, but no progression since 2007, and characterized the Veteran's left hip disability as stable during the last 12 months. The Veteran reported left hip pain that manifested in response to turning and which necessitated the use of medication and, occasionally, an exercise machine. He had mild, diffuse tenderness in the left lateral hip region, but greater range of motion of the left hip than he exhibited in June 2009. He also had no pain on motion, normal strength, and no additional functional loss, including limited motion, during flare-ups or on repetitive use. Given these findings, a schedular evaluation in excess of 10 percent is not assignable for the left hip disability under any pertinent DC noted above. In certain circumstances, a claimant may be assigned a higher initial or increased evaluation on an extraschedular basis. The question of whether such an evaluation may be assigned on such a basis is a component of a claim for a higher initial or increased evaluation. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign a rating on an extraschedular basis in the first instance, when the question is raised either by the claimant, or reasonably by the evidence of record, the adjudicator must specifically decide whether to refer the claim to the Chief Benefits Director of VA's Compensation and Pension Service under 38 C.F.R. § 3.321 for consideration of the matter. Barringer v. Peake, 22 Vet. App. 242 (2008). He is authorized to approve the assignment of an extraschedular evaluation if the claim "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) (2012). If the claimant or the evidence raises the question of entitlement to a higher initial or increased evaluation on an extraschedular basis, as a threshold matter, the Board must determine whether the evidence before VA presents such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. This requires comparing the level of severity and symptomatology of the service-connected disability with the established criteria found in the rating schedule pertaining to that disability. Thun v. Peake, 22 Vet. App. 111, 118 (2008). If the criteria reasonably describe the level of severity and symptomatology of the disability, the disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate and no referral is necessary. Id. If the criteria do not reasonably describe the level of severity and symptomatology of the disability, the disability picture is not contemplated by the rating schedule and the assigned schedular evaluation is inadequate. The Board must then determine whether the exceptional disability picture involves other related factors such as those outlined in 38 C.F.R. 3.321(b)(1) as "governing norms", including "marked interference with employment" and "frequent periods of hospitalization". Id. The Veteran has not raised, nor does the evidence raise the question of entitlement to an increased evaluation for a left hip disability on an extraschedular basis. Referral for consideration of this matter is thus not necessary. ORDER Service connection for a right hip condition, including as secondary to service-connected left knee and hip disabilities, is denied. Service connection for left rotator cuff tendonitis, including as secondary to service-connected left knee and hip disabilities, is denied. Service connection for right rotator cuff tendonitis, including as secondary to service-connected left knee and hip disabilities, is denied. A rating in excess of 10 percent for tendonitis, left hip, is denied. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs