Citation Nr: 1335153 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 08-26 969 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to an increased rating for left shoulder bursitis, rated as 10 percent disabling prior to September 1, 2010; 100 percent disabling from September 1, 2010 to November 1, 2010; and 10 percent disabling from November 1, 2010 to October 19, 2011. 2. Entitlement to a rating in excess of 30 percent disabling for left shoulder bursitis, from October 19, 2011. 3. Entitlement to an increased rating for right shoulder bursitis, rated as 20 percent disabling prior to December 1, 2010; 100 percent disabling from December 1, 2010 to February 1, 2011; and as 20 percent disabling from February 1, 2011 to October 19, 2011. 4. Entitlement to a rating in excess of 30 percent disabling for right shoulder bursitis from October 19, 2011. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from July 1976 to September 1994. These matters come before the Board of Veterans' Appeals (Board) from an October 2007 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Wichita, Kansas. During the pendency of the appeal, the RO effectuated a July 2010 Board decision and assigned a rating of 20 percent disabling for the Veteran's right shoulder effective from December 11, 2006. In a January 2013 rating decision, the RO granted temporary 100 percent evaluations for the left and right shoulders, and subsequent evaluations of 30 percent from October 19, 2011 for each shoulder. The Board finds, based on the clinical evidence of record, as discussed in further detail below, that this portion of the Veteran's claim should be separated from the earlier time period and remanded for further development. In December 2008, the Veteran testified before a Decision Review Officer in Wichita, Kansas. A transcript of that hearing is of record. These matters were most recently before the Board in September 2011, when the Board remanded the Veteran's claims for further development pursuant to an order by the United States Court of Appeals for Veterans Claims (Court) in conjunction with a Joint Motion for Remand. The issues have now returned to the Board for further appellate consideration. The Board finds that there has been substantial compliance with its remand. During the pendency of the appeal, the Veteran was originally represented by the Georgia Department of Veterans Services. In February 2013, the Disabled American Veterans submitted a post remand brief on behalf of the Veteran. In June 2013, the Veteran submitted a VA Form 21-22 appointing any American Legion VSR to act on his behalf. In September 2013, The American Legion submitted an informal hearing presentation brief on behalf of the Veteran. Based on the most recent VA Form 21-22 and the September 2013 brief, the Board finds that The American Legion is the Veteran's representative in these matters. The issues of entitlement to ratings in excess of 30 percent disabling for left shoulder bursitis and in excess of 30 percent disabling for right shoulder bursitis from October 19, 2011 are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to October 19, 2011, the Veteran's left shoulder disability was manifested by complaints of pain on motion, occasional swelling, stiffness, and weakness; objectively, his left arm had flexion to greater than the shoulder level with no evidence of nonunion of the clavicle with loose movement, or impairment of the humerus. 2. Prior to October 19, 2011, the Veteran's right shoulder disability was manifested by complaints of pain on motion, occasional swelling, stiffness, and weakness; objectively, his right arm had flexion to greater than midway between the side and shoulder, with no evidence of nonunion of the clavicle with loose movement, or impairment of the humerus. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent disabling prior to September 1, 2010, and from November 1, 2010 to October 19, 2011 for left shoulder disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5200 - 5203 (2013). 2. The criteria for a rating in excess of 20 percent disabling prior to December 1, 2010 and from February 1, 2011 to October 19, 2011 for right shoulder disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5200 - 5203 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided in April 2007 and July 2008. VA has a duty to assist the appellant in the development of the claims. The claim file includes VA and private medical records and correspondence, and the statements of the Veteran in support of the claims. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. VA examinations/opinions were obtained in 2007 and 2011. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that, taken as a whole, the Veteran has been afforded adequate VA examinations/opinions. The examiners considered the full history of the disabilities. The reports include clinical examinations, diagnostic testing, and the Veteran's reported symptoms. The reports provide findings relevant to the criteria for rating the disabilities at issue. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008), Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (citing Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012). The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal Criteria Rating Disabilities in general Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Rating musculoskeletal disabilities 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 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. 38 C.F.R. §§ 4.40 and 4.45 (2013), see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2013). The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. Id. § 4.45. Pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss. Pain may cause a functional loss but itself does not constitute functional loss; rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). Rating the Shoulder Shoulder disabilities are rated under Codes 5200 to 5203. Under DC 5201 for limitation of motion of the major arm, a 20 percent rating is assigned for limitation of motion at shoulder level. A 30 percent rating is assigned for limitation of motion to midway between side and shoulder level on the major side. A 40 percent rating is assigned for limitation of motion of the arm to 25 degrees from side on the major side. Under DC 5201 for limitation of motion of the minor arm, a 20 percent rating is assigned for limitation of motion at shoulder level. A 20 percent rating is assigned for limitation of motion to midway between side and shoulder level on the minor side. A 30 percent rating is assigned for limitation of motion of the arm to 25 degrees from side on the minor side. Normal range of motion in the shoulder is from 0 to 180 degrees of forward elevation (flexion) and 0 to 180 degrees of shoulder abduction. See 38 C.F.R. § 4.71a, Plate I. The Federal Circuit recently held that the plain language of 38 C.F.R. § 4.71a confirms that a veteran is only entitled to a single disability rating under diagnostic code 5201 for each arm that suffers from limited motion at the shoulder joint. The diagnostic code does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to "limitation of motion of" the arm. Yonek v. Shinseki, __ F.3d __, No. 2012-7120, 2013 WL 3368972, slip op. at 4. (Fed. Cit. July 8, 2013). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence pertinent to the claims on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. The Veteran's left and right shoulder disabilities have each been rated under DC 5019-5203. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2013). DC 5019 pertains to bursitis, and is to be rated based upon limitation of motion of the affected joint, as is the same for degenerative arthritis. DC 5203 pertains to impairment of the clavicle and scapula. As the shoulder is the joint affected in this case, DC 5201, which contemplates limitation of arm motion, is also applicable. 38 C.F.R. § 4.71a. The rating criteria provide different ratings for the minor arm and the major arm. The Veteran has indicated (in various treatment records and on VA examination) that he is right-handed; therefore, the Board will apply the ratings and criteria for the major arm to the right shoulder disability, and the ratings and criteria for the minor arm for the left shoulder disability. 38 C.F.R. § 4.69 (2013). The Veteran filed a claim for an increased rating for his shoulders in December 2006. Left shoulder bursitis, rated as 10 percent disabling prior to September 1, 2010; 100 percent disabling from September 1, 2010 to November 1, 2010; and 10 percent disabling from November 1, 2010 to October 19, 2011 Prior to September 1, 2010 and from November 1, 2010 to October 19, 2011 The Veteran would be entitled to a rating in excess of 10 percent prior to September 1, 2010 under DC 5200 if he had ankylosis, under DC 5201 if he had limitation of motion at the shoulder level, under DC 5202 if he had humerus impairment with recurrent dislocation, fibrous union, nonunion, malunion with moderate or marked deformity, or loss of head, or under DC 5203 if he had dislocation or nonunion with loose movement of the scapula. Clinical records from December 2005 to January 2007 from Dr. R. Lochamy are associated with the claims file. The December 2005 record reflects that the Veteran was seen as a new patient. The reports reflect diagnoses of fatigue, polyuria, polydipsia, hypertension, a sleep disorder, erectile dysfunction, and GAD. The reports are negative for complaints of, or treatment for, the Veteran's shoulders. A September 2006 VA primary care nurse practitioner note reflects that the Veteran was seen to establish care at the Topeka VAMC. The record reflects that the Veteran reported chronic joint pains in the elbows and knees. The report is negative for any complaints with regard to the shoulders. A December 4, 2006 VA social worker record reflects that the Veteran reported that he wished to make a claim to have his rating increased. He stated that his shoulder pain "is getting worse". He also stated that at times he cannot button up his shirt and that it is a struggle to get on a pullover shirt. In May 2007, the Veteran's then fiancé submitted a statement that the Veteran's bilateral bursitis was so bad some days that she would have to button the Veteran's shirt or tie his shoes for him. She stated that he took Aleve and went to the chiropractor, but that he found little relief from the pain. She also stated that the Veteran had had "these problems the entire 8 1/2 years I've known him." As discussed below, the Veteran has reported that flare-ups which require assistance with buttoning his shirt occur once a month. On August 2007 VA examination, the Veteran reported constant left shoulder pain, with weakness, stiffness, and occasional swelling. He also reported that his shoulders locked up sometimes. He treated the pain with Aleve as needed and also used a heating pad at night. He had reported flare-ups occurring once a month lasting for one full day, with intense pain, which made him unable to button his shirt or carry objects in front of him. He denied any dislocation of the shoulders or inflammatory arthritis. He reported that he missed work "off and on" due to shoulder pain and was limited in his ability to complete outdoor yard work. He denied any use of slings or braces. Physical examination of the left shoulder in August 2007 revealed passive forward flexion and abduction to 180 degrees, or normal. Active forward flexion was to 135 degrees with pain at 115 degrees. Active abduction was to 140 degrees, with pain that developed at 115 degrees. External rotation was 75 degrees passively, and to 70 degrees actively, with pain developing at 58 degrees. Internal rotation was to 60 degrees, passively, and to 45 degrees actively, with pain at 30 degrees. After repetitive motion, forward flexion was to 137 degrees, which was actually an increase in 2 degrees. Thus, a rating in excess of 10 percent is not warranted based on the 2007 examination report. X-ray examination revealed bilateral arthritic changes in the acromioclavicular joint. The diagnosis was right and left shoulder degenerative joint disease. In December 2008, the Veteran testified before a Decision Review Officer, stating that he treated his shoulder pain with Aleve, which he took three to four times per day. He testified that he is treated approximately twice a year, in addition to regularly scheduled appointments. He reported that his job required him to use his shoulders seventy percent of the time lifting pieces of equipment, usually weighing 15 to 20 pounds. He testified that because of these duties, he experienced constant shoulder pain, and had had to ask for assistance at times. He stated that he had taken 40 hours of leave in the past four months due strictly to his shoulders; however, he also testified that he has not been able to take time off in the last six months to seek treatment because he works "all the time" with a construction crew. He reported that on occasion he needed help taking his shirt off after work due to pain and fatigue. He stated that he was limited in how far he could reach when showering, and also had trouble getting things which are heavy down from the cabinet, and that he asks for assistance. He testified that he does not have trouble shaving. He sometimes asked for assistance in yard work. He had pain when lifting his arms out to the sides. He reported that he started to notice swelling in his shoulders more frequently, about twice per week. He reported that he does not sleep well at night because he has to reposition his arms. (The Board notes that the Veteran has also stated that he has sleep difficulties due to sleep apnea and anxiety with insomnia.) In a statement dated in November 2008, the Veteran's friend, S. stated that the Veteran experienced pain in his shoulders, elbows, and back, which made it difficult for him to sleep at night, and that it was difficult for the Veteran to ask for help or to admit that he experienced pain. Friends of the Veteran are competent to report what the Veteran has told them and what they actually witness; however, they are not competent to report the actual level of pain which the Veteran experiences. The claim file contains a May 2009 VA examination report for the Veteran's elbows which reflects that he reported that he had to quit his job two weeks earlier, in April 2009, due to chronic daily bilateral elbow pain. The record does not reflect that he had to quit work due to his shoulder disabilities. October 2009 VA clinical records reflect that the Veteran reported chronic bilateral shoulder pain that is worsening. He declined physical therapy but stated that he "would like it documented in his chart that this pain is worsening." The record further reflects that there were no severe limitations in range of motion or severe deformities, but that the Veteran had diffuse pain to palpation in shoulders. It was noted that he uses over-the-counter NSAIDs (nonsteroidal anti-inflammatory drugs) for pain. A November 2009 MRI revealed bilateral AC tendon impingement as well as bilateral supraspinatus tendon tears. The Veteran agreed to a course of physical therapy. A January 2010 VA clinical record reflects that degenerative joint disease was noted in x-ray on both shoulders. Records from the Cantrell Center for Physical Therapy and Sports Medicine are associated with the claims file. They reflect treatment from March to April 2010. Prior to the beginning of therapy, the Veteran reported that he always has difficulty dressing, opening a tight or new jar, carrying objects over 10 pounds, gardening or yard work, recreational activities, and sleeping through the night due to his injury. The records also note that he had impingement of both shoulders, and sleep apnea. After therapy, the Veteran reported that in addition, to the above noted "always" difficulties, he also had difficulty placing an object overhead, performing heavy household chores, carrying a laundry basket, shopping bag, briefcase, or handbag, and washing, brushing or blow drying his hair. He also noted that writing legibly for an extended period of time and toilet care were difficult. The claim file includes an April 15, 2010 Discharge Summary from the Cantrell Center. It reflects that the Veteran was referred to therapy for bilateral shoulder pain. It was noted that he "demonstrated signs and symptoms unlikely to truly benefit from therapy. He demonstrated weakness and loss in motion and possible rotator cuff pathology with impingement as well." His average pain was noted to be an 8 to 9 out of 10. He had 118 to 120 degrees of flexion. (A review of the worksheets from the provider indicates that it was 118 degrees for the right shoulder and 120 degrees for the left shoulder.) A May 2010 VA record reflects that shoulder injections at the Dublin VA were minimally effective. A June 2010 private record from Kinnebrew Orthopedic and Sports Medicine reflects that the Veteran presented for initial evaluation of shoulder pain. It was noted that the onset of the shoulder pain has been gradual and has been occurring in a persistent pattern for years. The pain was described as moderate and characterized as a dull aching, which was aggravated by physical activity, overhead activity, lifting, and repetitive use. Upon examination, the Veteran had mild tenderness, no swelling, normal sensation, and soft tissue tension and texture. Pain was reported to be worse at night due to turning over while sleeping. Pain was reportedly relieved by heat and use of NSAIDs. The June 2010 record, as well as a July 2010 and August 2010 records, note that the biceps load test was positive, the empty can test was positive and the Speed's test was positive for the left shoulder. The biceps load test and empty can test were positive for the right shoulder. The following ranges of motion were noted for both shoulders: Glenohumeral movement: painful arc from 90 degrees to 180 degrees Extension: 45 degrees Flexion: 180 degrees Glenohumeral abduction: 180 degrees In June 2010 handwritten correspondence from the Veteran's spouse, she, states that she has known the Veteran for 10 years and worked with him for seven years. She indicated that his depression has kept him from doing home improvement on his home. (She noted that he has a 100 year old home with a beautiful lawn with flowers and roses). She also stated that he had worked on the restoration of a 1967 Mustang with his son until a decrease in energy and interest after VA appointments and medication changes like Xanax, Cialis, and [Zolpidem]. Notably, she did not indicate that it was his shoulders that prevented the home improvement work or car restoration. A November 4, 2010 private clinical report is of record. It reflects that the Veteran was nine weeks post surgery and that his pain was described as mild. Examination of the left shoulder revealed normal sensation, normal deep tendon reflexes and coordination, no instability, no subluxation or laxity, and that the Veteran was neurovascularly intact. The pain upon examination was characterized as moderate. Range of motion testing was limited due to apprehension and guarding. A January 2011 VA record reflects that the Veteran was currently receiving Percocet for the private sector and was engaged in physical therapy. A May 2011 VA examination report reflects that the Veteran reported giving way, stiffness, weakness, decreased speed of joint motion, and weekly flare-ups which were moderate in severity and hours in duration. He denied instability, incoordination, dislocation, subluxation, locking and effusion. He stated that precipitating factors for flare-ups were reaching over the head, washing the hair, and lifting greater than one pound. Upon examination, he had the following ranges of motion for both shoulders: Flexion to 180 degrees Abduction to 180 degrees Left internal rotation to 90 degrees Left external rotation to 90 degrees There was no objective evidence of pain with active motion. X-rays reflected no acute fraction or dislocation. The Veteran had degenerative changes in the left acromioclavicular joint. The glenohumeral joint was intact. It was noted that there were no significant effects on occupation or daily activities. Thus, a rating in excess of 10 percent is not warranted based on the 2011 examination report. A May 2011 VA clinical record reflects that the Veteran reported constant left shoulder pain which was a 7/10, was dull, and nothing improved or worsened it. Bursitis is rated under DC 5019, which states that it will be rated on limitation of motion of the affected parts as degenerative arthritis. Degenerative arthritis is rated under DC 5003. DC 5003 provides that when limitation of motion of a specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. 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, the disability is rated based on x-ray evidence. The Board has considered which appropriate diagnostic code would provide the Veteran with the highest rating. DC 5200 is not applicable because the Veteran has not had ankylosis of the scapulohumeral articulation. In addition, DC 5201 does not provide the Veteran with a higher rating because he did not have limitation of motion of the arm at the shoulder level or less (90 degrees or less). As noted above, the Veteran had active forward flexion to 135 degrees with pain at 115 degrees, and active abduction to 140 degrees, with pain that developed at 115 degrees in August 2007. In April 2010, the Veteran had 118 to 120 degrees of flexion. In June, July, and August 2010, the Veteran had flexion to 180 degrees. In May 2011, the Veteran had flexion to 180 degrees and abduction to 180 degrees with no objective evidence of pain with active motion and no significant effects on occupation or daily activities. Thus, a compensable rating is not warranted under DC 5200 or 5201. The Board acknowledges the Veteran's statements that during at times, and during a flare-up, he had to struggle with certain activities such as putting on a pullover shirt, buttoning his shirt, tying his shoes, carrying objects in front of him, placing objects overhead, dealing with his hair, and writing legibly for an extended period of time. Such limitations of motion; however, are adequately compensated in the 10 percent evaluation and do not rise to the level of severity which would warrant a higher evaluation. The Veteran's complaints of difficultly washing his hair, putting on a pullover shirt, and reaching overhead items do not reflect limitation of motion to a 90 degree level. Importantly, the findings on examination reflect that his range of motion is not limited to the shoulder level. The Veteran has also stated that sometimes, it feels like his shoulder is locking; however, the clinical evidence does not reflect a finding of ankylosis or adhesive capsulitis. As the diagnostic codes which pertain to the shoulder and arm (DCs 5200-5201) do not provide the Veteran with a compensable rating for the left shoulder on the basis of limitation of motion, he has been granted a 10 percent rating under DC 5003. Under DCs 5003 and 5019, a 20 percent evaluation is not warranted unless X-ray evidence shows involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. The shoulder is considered a single major joint. In addition, such evaluations are warranted when there is no limitation of motion. In the Veteran's case, he does have some limitation of motion. Thus, he is not entitled to a rating greater than the current 10 percent rating under this code. In addition, DC 5202 is not applicable because the evidence does not reflect malunion of the humerus, and DC 5203 is not applicable because the evidence does not reflect nonunion of the clavicle or scapula with loose movement. The Board has determined that the Veteran is entitled to no more than a 10 percent disability rating for a left shoulder disability under the applicable shoulder and arm criteria. The Board is required to consider the effect of pain and weakness when rating a service-connected disability on the basis of limitation of motion. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board finds that the effect of pain and weakness on the basis of limitation of motion has been considered because although VA examination, treatment records, and testimony have shown that the Veteran experiences pain on motion and flare-ups on activity, there is no evidence to suggest that the functional loss is the equivalent to loss of motion to 90 degrees or less on the left side or of ankylosis of the shoulder. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2013), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Entitlement to an increased rating for right shoulder bursitis, rated as 20 percent disabling prior to December 1, 2010; 100 percent disabling from December 1, 2010 to February 1, 2011; 20 percent disabling from February 1, 2011 to October 19, 2011 Much of the evidence noted above pertains to both the left and right shoulder; thus, it need not be repeated below, although it has been considered. The Veteran would be entitled to a rating higher than 20 percent prior to December 1, 2010 under DC 5201 if he had limitation of motion of the arm limited to midway between side and shoulder level or to 25 degrees from the side, under DC 5200 if he had ankylosis of the scapulohumeral articulation, or under DC 5202 if he had recurrent dislocation at the scapulohumeral joint with frequent episodes and guarding of all arm movements, fibrous union, or nonuse of false flail joint, loss of head of humerus. Physical examination of the right shoulder in August 2007 revealed passive forward flexion and abduction to 180 degrees, or normal. Active forward flexion was to 135 degrees with pain at 70 degrees. Active abduction was to 145 degrees, with pain that developed at 100 degrees. External rotation was 80 degrees passively, and to 75 degrees actively, with pain developing at 70 degrees. Internal rotation was to 60 degrees, passively, and to 60 degrees actively, with pain at 55 degrees. After repetitive motion, forward flexion was to 122 degrees, which was a decrease in 13 degrees. X-ray examination revealed bilateral arthritic changes in the acromioclavicular joint. The diagnosis was right and left shoulder degenerative joint disease. A higher evaluation is not warranted based on the examination report. A November 2009 MRI revealed bilateral AC tendon impingement as well as bilateral supraspinatus tendon tears. The Veteran agreed to a course of physical therapy. A January 2010 VA clinical record reflects that degenerative joint disease was noted in x-ray on both shoulders. A May 2010 VA record reflects that shoulder injections a the Dublin VA were minimally effective. An August 26, 2010 record reflects that the Veteran had glenohumeral painful arc from 90 to 180 degrees. Extension was to 45 degrees, flexion was to 180 degrees. Impingement test was positive on the right and Neer impairment was positive on the right. A February 16, 2011 physical therapy note from Cantrell Center reflects that the Veteran was seen on December 30. 2010 for status post right rotator cuff repair. It was noted that his current range of motion was 170 degrees of flexion and 180 degrees of abduction. His strength was within normal limits. It was further noted as follows: "[the Veteran] has responded well to physical therapy. He is independent and pain free with all functional activities. He is being discharged to his home exercise program." A February 22, 2011 Kinnebrew Orthopedic and Sports Medicine record reflects that the Veteran was seen for his right shoulder. It was noted that "there are no reported problems. The pain is described as none." Upon clinical examination, it was noted that there was "mild" pain. Right shoulder range of motion testing was limited due to apprehension. Correspondence dated in March 2011 from Kinnebrew Orthopedics and Sports Medicine reflects that the Veteran as treated for right shoulder cuff tear, biceps tendon tear and AC joint arthritis. It further reflects that the Veteran "underwent an arthroscopy of the right shoulder to repair the issues on December 1, 2010. He has been seen multiple times since the surgery for follow up and has been in physical therapy as well. He was last seen in my office on February 22, 2011 in which he was released from my care." An April 2011 VA record reflects that the Veteran complained of right shoulder pain for one month which was a 5 to 8 out of 10. The pain was improved with Aleve and the right shoulder pain is worsened by movement. It was noted that he had had surgery on December 1, 2011. A May 31, 2011 primary care physical note reflects that the Veteran reported right shoulder pain for one month which was an 8 out of 10 sharp and it felt as though the right shoulder is going to come out of place. The pain was improved with Aleve. It was noted that he had had surgery in December. The Veteran reported that he has decreased range of motion of both shoulders to the point that he was unable to wash or comb his hair. He stated that he is unable to sleep due to pain in his shoulders. A June 2011 VA record reflects that the Veteran had surgery on the right shoulder in December and had been receiving physical therapy with excellent results until the end of February when he felt a "pop" in this right shoulder resulting in pain and loss of motion. He reported that he is unable to perform overhead activities due to pain and that he tries to keep his arm at his side due to a feeling of dislocation with abduction and adduction. X-ray reports from May 11, 2011 revealed no acute fracture or dislocation in the shoulder joints, and mild degenerative joint disease of the acromioclavical joint. A July 2011 VA physical therapy record reflects right shoulder pain which was a 7 out of 10. The Veteran reported that it "just feels like something wants to pop out." Range of motion of the right shoulder was 100 degrees of flexion, 110 degrees of abduction. His right shoulder strength was grossly 3- out of 5. August 2011 VA records reflect that the Veteran reported pain as 7 out of 10 in the right shoulder and that his shoulder felt as if it was going to pop out of the joint, particularly with showering and grooming. His strength was grossly 3 - to 3 out of 5. An August 4, 2011 VA record reflects that he had 90 degrees of forward flexion and 115 degrees of abduction upon initial assessment. He was noted to currently have 90 degrees of forward flexion and 85 degrees of abduction. August 11, 2011 VA physical therapy record reflects 100 degrees of flexion and 110 degrees of abduction. An August 31, 2011 VA occupational therapy discharge note reflects that the Veteran had 90 degrees of forward flexion and 85 degrees of abduction. In sum, the clinical record reflects right arm active forward flexion to 135 degrees with pain at 70 degrees, and abduction to 145 degrees, with pain that developed at 100 degrees in August 2007, flexion to 118 in April 2010, flexion to 180 degrees in June, July, and August 2010, 170 degrees of flexion and 180 degrees of abduction in December 2010 (pain free with all functional activities and mild pain), flexion and abduction to 180 degrees each in May 2011 with no objective evidence of pain. Flexion of 100 degrees and abduction of 110 degrees in July 2011. In August 2011, he had between 90 and 100 degrees forward flexion and 85 to 115 degrees of abduction. Thus, a higher rating for limitation of motion is not warranted because the Veteran does not have limitation of motion of the arm midway between the side and shoulder level, or 45 degrees. The Board also acknowledges the Veteran's statements that sometimes his right shoulder feels like it wants to pop out; however, there has been no actual dislocation. He has also stated that sometimes, it feels like it is locking; however, the clinical evidence does not reflect a finding of ankylosis or adhesive capsulitis. DC 5200 is not applicable because the Veteran has not had ankylosis of the scapulohumeral articulation. In addition, DC 5202 is not applicable because the evidence does not reflect malunion of the humerus, and DC 5203 is not applicable because the evidence does not reflect nonunion of the clavicle or scapula with loose movement. The Board has also considered whether a separate rating is warranted for the Veteran's scars or other symptoms of his service-connected right shoulder disability, but finds that such a separate rating is not warranted. The October/November 2011 VA examination report notes that the Veteran had two one centimeter scars and one 1.5 centimeter scar on the right shoulder. The scars were linear, superficial, stable, and nonpainful. Thus, a separate rating for scars under DCs 7801-7805 is not warranted. An October/November 2011 VA examination report reflects sensation testing to light touch was normal. Deep tendon reflexes were normal. Tinel testing was negative. Radial, median, ulnar, musculocutaneous, circumflex, long thoracic, upper radicular, middle radicular, and lower radicular nerves were all normal. Thus, a separate rating for nerve symptoms under DCs 8510-8719 is not warranted. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2013), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Extra-schedular - left and right shoulders Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extra-schedular disability rating would be warranted based upon a finding that 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 would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). The Board acknowledges the Veteran's statements that at times, and during a flare-up, he has had to struggle with certain activities (e.g. dressing, reaching items, writing). The Veteran's inability to adequately perform these activities is considered in the rating criteria because the criteria are based on limitation of motion (i.e. that certain activities are prevented when the Veteran's arm limitation is limited due to pain, fatigue, and other symptoms.) The Diagnostic Codes allow for compensation for various degrees of limitation of motion. In addition, the evidence that the Veteran may have sleep difficulty due to his shoulder pain does not warrant referral for an extraschedular evaluation. Pain on motion, whether moving the arm intentionally or unintentionally while sleeping, or attempting to sleep, is considered with regard to limitation of motion. Referral for consideration of an extra-schedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to an increased rating for left shoulder bursitis, rated as 10 percent disabling prior to September 1, 2010, and 10 percent disabling from November 1, 2010 to October 19, 2011, is denied. Entitlement to an increased rating for right shoulder bursitis, rated as 20 percent disabling prior to December 1, 2010, and as 20 percent disabling from February 1, 2011 to October 19, 2011, is denied. REMAND From October 19, 2011 An October 2011 VA examination, with a report dated in November 2011, is of record. It reflects that the Veteran did not have ankylosis; however, it also reflects poor muscle strength and that the Veteran was unable to perform the Hawkin's Impingement Test, the empty-can test, the external rotation/infraspinatus strength test, and the lift-off subscapularis test. The report also reflects, in pertinent part, as follows: Veteran presents walking with arm straight down by his sides and stiffly against this body only bending at the elbow. There were no obvious deformities noted. There was no report of pain upon palpation of the clavicle or scapula areas nor was there any objective evidence of pain upon palpation of these mentioned areas. He was observed to have 10 degrees of abduction to both arms while taking off and putting on his sleeveless pullover shirt during which time there was observed facial grimace of pain. Veteran refused to perform active range of motion with the left shoulder as he kept it snuggly tucked against his side. . . . --veteran refused to allow this examiner to perform passive range of motion for bilateral shoulder due to guarding and pain. -- veteran became tearful during examination. Based on examination and review of available documentation veteran has severe pain in both shoulders worse on the left. He has Severe AC Joint Degenerative Change and possible recurrent full thickness rotator cuff tear Per Dr. [W.B.], Radiologist, as seen on 10/31/2011 MRI of left shoulder. Thus explains veteran's resistance to active or passive range of motion of the left upper extremity. Based on the Veteran's inability to perform testing, the Board finds that another VA examination is warranted to determine the current extent of the Veteran's disability. Accordingly, the case is REMANDED for the following action: 1. Request the appellant to identify all providers (VA and private) from whom he has received treatment for his shoulders from October 19, 2011, and complete and return a provided VA Form 21-4142, Authorization and Consent to Release Information, for each provider identified. After obtaining completed VA Forms 21-4142, the AOJ should attempt to obtain all identified pertinent medical records, to include including all VA records. 2. Schedule the Veteran for a VA examination to determine the extent of his service-connected shoulder disabilities. Perform all necessary diagnostic tests, and report all clinical manifestations in detail. The examiner should provide an opinion, if reasonably possible, as to whether the Veteran's reports of pain and inability to perform repetitive testing are consistent with the objective diagnostic findings (i.e. x-ray, MRI, drawer tests, etc.) and service-connected clinical diagnoses. 3. After undertaking any other development deemed appropriate, the RO should readjudicate the issues on appeal from October 19, 2011. If a benefit sought on appeal is not granted, the RO should issue a supplemental statement of the case and provide the Veteran and his representative with an appropriate opportunity to respond. The case should then be returned to the Board for further appellate consideration as warranted. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs