Citation Nr: 1335887 Decision Date: 11/05/13 Archive Date: 11/13/13 DOCKET NO. 10-16 909 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to increases in the "staged" (0 percent prior to February 12, 2013 and 30 percent from that date) ratings assigned for posttraumatic stress disorder (PTSD) (previously rated as dyssomnia). 2. Entitlement to increases in the "staged" (10 percent prior to February 12, 2013 and 20 percent from that date) ratings assigned for left shoulder degenerative joint disease (DJD). 3. Entitlement to increases in the "staged" (10 percent prior to February 12, 2013 and 20 percent from that date) ratings assigned for postoperative right shoulder DJD. 4. Entitlement to increases in the "staged" (10 percent prior to February 12, 2013 and 20 percent from that date) ratings assigned for a right knee disability. 5. Entitlement to a rating in excess of 10 percent for a left knee disability. 6. Entitlement to increases in the "staged" (10 percent prior to February 12, 2013 and 20 percent from that date) ratings assigned for lumbar spine DJD and degenerative disc disease (DDD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Young, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from May 1986 until he retired in July 2008. These matters are before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision by a Department of Veterans Affairs (VA) regional office (RO) that, in pertinent part, granted service connection for the disabilities at issue and assigned 0 percent ratings for each, effective August 1, 2008. An interim (February 2010) decision review officer decision increased the ratings for left shoulder DJD to 10 percent, postoperative right shoulder DJD to 10 percent, a right knee disability to 10 percent, a left knee disability to 10 percent, and lumbar spine DJD and DDD to 10 percent, each effective August 1, 2008. The Veteran had not expressed satisfaction with the ratings assigned, therefore, the appeal continued. See AB v. Brown, 6 Vet. App. 35 (1993). In August 2012, a Travel Board hearing was held before the undersigned. A transcript of the hearing is associated with the claims file. In October 2012, the Board remanded these matter for additional development. An interim (February 2013) rating decision increased the rating for PTSD (previously dyssomnia) to 30 percent, left shoulder DJD to 20 percent, postoperative right shoulder DJD to 20 percent, a right knee disability to 20 percent, and lumbar spine DJD and DDD to 20 percent, each effective February 12, 2013. Since the Veteran has not expressed satisfaction with those ratings, the appeal continues. The February 2013 rating decision also granted service connection for radiculopathy of the left and right lower extremities (as neurological manifestations of the service-connected low back disability) and assigned a separate 20 percent rating for each, effective February 12, 2013. The Veteran has not expressed disagreement with that determination, and those ratings are not before the Board. FINDINGS OF FACT 1. Prior to February 12, 2013, the Veteran suffered from insomnia which did not interfere with his social or occupational functioning; occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication was not shown. 2. From February 12, 2013, the Veteran's PTSD is not shown to have been manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships or other symptoms of similar gravity. 3. Prior to February 12, 2013, the Veteran's left (minor) shoulder DJD was not shown to be manifested by arm motion limited to shoulder level; from that date, it is not shown to have been manifested by motion limited to 25 degrees from the side. 4. Prior to February 12, 2013, the Veteran's right (major) shoulder DJD was not shown to have been manifested by arm motion limited to shoulder level; from that date it is not shown to have been manifested by arm motion limited to midway between the side and shoulder level. 5. Prior to February 12, 2013, the Veteran's right knee disability was not manifested by extension limited to 15 degrees, flexion limited to 30 degrees; or compensable limitations of both extension and flexion; subluxation and/or lateral instability were not shown; from that date it has been manifested by dislocated semilunar cartilage of the knee with frequent episodes of locking, pain, and effusion into the joint, but not by flexion limited to 15 degrees or extension limited to 20 degrees; subluxation and/or lateral instability are not shown. 6. At no time under consideration is the Veteran's left knee disability shown to have been manifested by extension limited to 15 degrees or flexion limited to 30 degrees; subluxation and/or lateral instability are not shown. 7. Prior to February 12, 2013 was the Veteran's lumbar spine disability was not shown to have been manifested by limitation of thoracolumbar spine forward flexion to 60 degrees or less; by limitation of combined range of motion to 120 degrees or less; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; separately ratable neurological symptoms and/or incapacitating episodes of disc disease were not shown; from that date, the Veteran's lumbar spine disability is not shown to have been manifested by forward flexion of the thoracolumbar spine limited to 30 degrees or less or by favorable ankylosis of the entire thoracolumbar spine; separately ratable neurological symptoms (other than radiculopathy of left and right lower extremities) and/or incapacitating episodes of disc disease are not shown. CONCLUSIONS OF LAW 1. A compensable rating for PTSD prior to February 12, 2013 and a rating for PTSD in excess of 30 percent from that date are not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code (Code) 9410 (2013). 2. Ratings for left shoulder DJD in excess of 10 percent prior to February 12, 2013 and/or in excess of 20 percent from that date are not warranted. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Codes 5003, 5010, 5201 (2013). 3. Ratings for right shoulder DJD in excess of 10 percent prior to February 12, 2013 and/or in excess of 20 percent from that date are not warranted. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Codes 5003, 5010, 5201 (2013). 4. Ratings for a right knee disability in excess of 10 percent prior to February 12, 2013 and/or in excess of 20 percent from that date are not warranted. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Codes 5258, 5261 (2013). 5. A rating for a left knee disability in excess of 10 percent is not warranted. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Code 5261, (2013). 6. Ratings for lumbar spine DJD and DDD in excess of 10 percent prior to February 12, 2013 and/or in excess of 20 percent from that date are not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a Code 5237 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claims. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper 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 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). As the rating decision on appeal granted service connection for the disabilities at issue [dyssomnia (now PTSD), bilateral shoulder, bilateral knee, and lumbar spine disabilities], and assigned disability ratings and an effective date for the awards, statutory notice had served its purpose, and its application was no longer required. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). A February 2010 statement of the case (SOC), and February 2013 supplemental SOC properly provided notice on the "downstream" issues of entitlement to increased initial ratings, and readjudicated the matters after the Veteran had opportunity to respond. It is not alleged that the Veteran is prejudiced by a notice defect. See Goodwin v. Peake, 22. Vet. App. 128 (2008). The Veteran's service treatment records are associated with his claims file, and pertinent postservice treatment records have been secured. He was afforded VA examinations in June 2008 and in February 2013, and a Travel Board hearing, before the undersigned, in August 2012. At the hearing the Veteran was advised of what is needed to substantiate his claims; his testimony reflects that he is aware of what is necessary. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis The Board notes that all of the evidence in the record, with an emphasis on the evidence relevant to this appeal, has been reviewed. The Veteran's physical claims file and Virtual VA have been reviewed. (At present there are no pertinent documents in Virtual VA.). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two ratings applies, 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. In every instance where the schedule does not provide a 0 percent rating for a diagnostic code, a 0 percent rating will be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. With any form of arthritis, painful motion is a factor to be considered. 38 C.F.R. § 4.59. Traumatic arthritis is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Code 5010. 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 rating will be assigned where there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent rating will be assigned where 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. 38 C.F.R. § 4.71a, Code 5003. In a claim for an increased rating, "staged" ratings may be warranted if the claim involves the initial rating assigned with a grant of service connection. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). PTSD (previously dyssomnia) The September 2008 rating decision granted service connection for dyssomnia (recurring sleep problems/insomnia), rated 0 percent, effective August 1, 2008. Because there is no specific diagnostic code for dyssomnia, the RO rated the disorder by analogy to an anxiety disorder, under the General Rating Formula for Mental Disorders (General Rating formula), Code 9410, (other and unspecified neurosis). Under the General Rating Formula a 0 percent rating is warranted when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Code 9410. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Veteran has been assigned Global Assessment of Functioning (GAF) scores for his mental disorder, to include PTSD. Scores ranging from 81 to 90 denote absent or minimal symptoms (e.g., mild anxiety before an examination), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). Scores ranging from 71 to 80 denote that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g. temporarily falling behind in schoolwork). Scores ranging from 61 to 70 reflect mild symptoms (e.g., depressed mood and some insomnia) OR some difficulty in social, occupational or school functioning (e.g., occasional truancy or theft within the household) but generally functioning pretty well, has some meaningful interpersonal relationships. Lesser scores reflect increasingly more severe levels of mental impairment. See 38 C.F.R. § 4.130 [incorporating by reference VA's adoption of the American Psychiatric Association DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, 4th Edition (DSM-IV) for rating purposes]. Prior to February 12, 2013 Prior to February 12, 2013 (and from the effective date of the grant of service connection in 2008), the Veteran's dyssomnia (now PTSD) symptoms are not shown to have more nearly approximated the criteria for a compensable (10 percent) rating. The pertinent evidence for that period of time consists primarily of the report of a June 2008 pre-discharge VA (fee basis) psychiatric examination; at that time the Veteran reported that he had been having sleep problems for the past two to three years. He denied any problems with snoring or restless leg movements. He stated that he was able to concentrate; and denied suicidal thoughts and any problems with psychosis, obsessive-compulsive symptoms, mania, anxiety or panic attacks. His appetite, energy and enjoyment of life were good; he had been married for 20 years and had four daughters. He stated that his relationship with his parents is good. On mental status examination the examiner noted that the Veteran was appropriately dressed, groomed and pleasant. He showed no signs of psychomotor agitation or retardation. His mood was described as euthymic. His affect was full and appropriate. His speech was normal in tone, rate and content. His thoughts appeared to be organized and logical. There was no evidence of psychosis, and he denied suicidal or homicidal ideas. He was a reliable historian. Suspiciousness and panic attacks were not shown. Concentration was normal. He had no difficulty with performing activities of daily living. He was capable of establishing and maintaining effective work and social relationships. He had no difficulty understanding simple or complex commands. He did not appear to be a threat or danger to himself or others. Cognitively he was alert and oriented in all three spheres. He could recall three out of three objects immediately and two out of three objects at one and five minutes. Serials sevens were done without error. He could recall six digits forwards and four digits backwards. He had a good fund of knowledge. Proverb interpretation was abstract. He showed good judgment and insight with regard to his problems. The diagnosis under Axis I was terminal insomnia which does not interfere with social or occupational functioning. He therefore met the criteria for a dyssomnia, not otherwise specified. His GAF score was 85. The examiner noted that the Veteran drives his automobile without fear, difficulty or legal restriction, and did not have a history of having been disoriented in time or space. In addition, he noted that the Veteran's condition does not affect his functioning in his usual occupation or his activities of daily living. At the August 2012 Travel Board hearing, the Veteran testified that he had Ambien prescribed for insomnia and it had a negative impact on his ability to function; therefore he stopped taking it. He stated that he has nightmares, which (he thought) contributed to his inability to sleep. To warrant a 10 percent rating under the General Rating Formula the evidence must show occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. Such is not shown prior to February 12, 2013. The June 2008 VA examiner diagnosed insomnia which he opined did not interfere with social or occupational functioning. He assigned a GAF score of 85, which reflects there are no symptoms or minimal symptoms present, good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, and/or no more than everyday problems or concerns. The Veteran reported that his energy and enjoyment of life were good. He had good relationships with family members, including his wife and children. He was able to concentrate and denied any problems with psychosis, obsessive-compulsive symptoms, and mania, anxiety or panic attacks. He stated that he had medication prescribed for insomnia, but stopped taking it because it negatively impacted on his ability to function. The disability picture presented shows that the Veteran's psychiatric disability was essentially asymptomatic, and is not one consistent with the criteria for a 10 percent rating in the General Rating Formula. Hence, such rating is not warranted. From February 12, 2013 On February 12, 2013 VA examination to evaluate the Veteran's dyssomnia, the examiner noted that during the course of the interview, it became clear that the Veteran's sleep problems were symptoms of PTSD, which had never been diagnosed. The February 2013 VA examiner diagnosed PTSD under Axis I. Based on the examiner's assessment of the Veteran's mental functioning (at the time of the examination) the RO increased the rating for the disability (now recognized as PTSD) to 30 percent, effective February 12, 2013. Accordingly, the focus is on whether manifestations of the Veteran's PTSD meet or approximate the criteria for a rating in excess of the 30 percent. The February 2013 VA examination report notes that the Veteran's GAF score was 70. The examiner specifically found there was occupational and social impairment due to mild or transient symptoms which decreased work efficiency and his ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran reported that he first started to have problems with sleep in the mid 2000's, and that insomnia and trouble sleeping had been a chronic problem for him since. He tried Ambien while still in the military, which he took for one week; he stated "I didn't like how it made me feel." No other mental health treatment was reported. He reported that he has intrusive memories of past traumatic events and there are times when nightmares wake him. He reported avoidance of trauma-related stimuli and emotional numbing. He stated that his mood is flat and numb. He reported occasional problems with sad mood, but denied that those moods last for longer than a day or so. His energy levels were good. There was no helplessness or hopelessness. He admitted to feeling detached from people. He had not kept up with his old friends. He has been married for almost 25 years. He is close to his wife and can talk to her about personal things. He has good relationships with his four daughters. He also has a few friends ("a couple of guys at work"). However, he stated that he "does tend to keep to himself." He talked periodically to his sister, but they were not really close. He spent his free time working. He liked to garden and work around the house. He went out with his wife only occasionally. He was working full-time as a defense contractor, a position he has held for the past four years. He denied having any problems at work. He also denied symptoms of anger or irritability. There was no exaggerated startle response. His concentration was fair. He stated that he had a hard time remembering basic things, such as names and directions. He denied hypervigilance. There were no suicidal or homicidal ideations. He reported occasional problems with anxiety; physical symptoms of anxiety last for only a minute or so. He worried about providing for his wife and children. While the examiner noted essentially that the Veteran's symptoms had increased, since the 2008 VA examination, (providing the basis for the increase in the rating to 30 percent), the examiner did not find that there was reduced reliability and productivity due to PTSD symptoms. As far as the listed symptoms in the criteria for a 50 percent rating, flat affect, impairment of short- and long-term memory and disturbances of mood were noted on examination. However, his PTSD symptoms did not satisfy the other criteria as there were no findings of circumstantial, circumlocutory, or stereotyped speech, panic attacks, difficulty in understanding complex commands, impaired judgment and abstract thinking, or difficulty in establishing and maintaining effective work and social relations. While all (or even most) of the symptoms listed in the criteria for a 50 percent rating need not be shown to warrant such rating, the end result has to be reduced reliability and productivity due to the symptoms shown. Here, such is not the case. The Veteran reported having friends at work, and that he was not having any problems at work. He also has a good relationship with his wife of nearly 25 years, and his four daughters. Such level of functioning is inconsistent with a rating in excess of 30 percent. Furthermore the GAF score assigned (70) reflects mild symptoms or some difficulty in social or occupational functioning but generally functioning pretty well with some meaningful interpersonal relationships, and does not provide a separate basis for an increased rating. Viewing the evidence of record in its entirety, the Board finds that the preponderance of the evidence is against a finding that the criteria for a 50 percent rating are met (or approximated) for this period of time when all the manifestations are considered. See Mauerhan, 16 Vet. App. 436. Therefore, such rating is not warranted. Bilateral Shoulder Disability Shoulder disability is rated under Codes 5200 to 5203. [Because the Veteran is right arm dominant, the right shoulder disability is rated as the major joint.] As the Veteran is not shown to have ankylosis of the shoulder, Code 5200 does not apply. And as the Veteran does not have non-union, fibrous union, malunion, or dislocations of the shoulder, Codes 5202, 5203 likewise do not apply. Under Code 5201 (for limitation of shoulder motion), the minimum schedular rating of 20 percent is warranted where there is limitation of motion of an arm at the shoulder level. Limitation of major arm motion to midway between the side and shoulder level warrants a 30 percent rating. Limitation of minor arm motion to midway between the side and shoulder level warrants a 20 percent rating. Limitation of major arm motion to 25 degrees from side warrants a 40 percent rating. Limitation of minor arm motion to 25 degrees from side warrants a 30 percent rating. 38 C.F.R. § 4.71a. Normal forward flexion of a shoulder is from 0 to 180 degrees, normal abduction of a shoulder is from 0 to 180 degrees, normal external rotation is from 0 to 90 degrees, and normal internal rotation is from 0 to 90 degrees. 38 C.F.R. § 4.71. Plate I. Arthritis of both shoulders has been diagnosed, and the shoulder disabilities are rated based on limitation of motion. 38 C.F.R. § 4.71a, Code 5003. The shoulder joint is considered a major joint. See 38 C.F.R. § 4.45(f). November 2007 x-rays showed findings of left acromioclavicular (AC) joint arthritis. There was no evidence of fracture or dislocation. Mild degenerative arthrosis of the glenohumeral joint was noted. MRI [magnetic resonance imaging] of the left shoulder showed mild diffuse supraspinatus/infraspinatus tendinosis, mild subcoracoid bursitis including extension into the rotator cuff interval consistent with rotator cuff interval injury, mild osteoarthritic degeneration, includes minimal osteophytosis at the anterior aspect of the humeral head, small subchondral cystic degeneration of the humeral head anteromedially, and mild AC joint degeneration involving a predominantly flat type I acromion. The impressions were SLAP [superior labral anteroposterior (shoulder lesion)] II lesion and a "GLAD" lesion, probable rotator cuff interval injury with an associated mild subcoracoid, bursitis, and mild AC joint degeneration. X-rays of the right shoulder showed abnormal widening of the AC joint, suggesting chronic AC separation and/or old trauma, sequelae of prior trauma and/or arthritis of the right AC joint. Otherwise, there were no acute findings. MRI of the right shoulder showed AC joint widening and fragmentation which appeared chronic with the AC joint space measuring 1.3cm consistent with AC chronic ligamentous injury, mild to moderate diffuse supraspinatus/infraspinatus conjoined tendinosis, SLAP II lesion with an associated paralabral cystic fluid extension measuring approximately 1.2cm with involvement of the subcoracoid recess, and mild superior subluxation of the humeral head relative to the glenoid. The impressions were SLAP II lesion and anterior labral tear, mild/moderate supraspinatus/infraspinatus tendinosis, and chronic AC ligamentous injury with AC joint widening and AC joint bony fragmentation. On June 2008 pre-discharge VA (fee basis) general medical examination, the Veteran reported that he had a torn rotator cuff diagnosed in service in 2003. He reported symptoms of weakness, stiffness, swelling, giving way, lack of endurance, locking, fatigability, and pain, which was constant, crushing and aching, elicited by physical activity and relieved by rest. He stated that when the pain is at its worse, his functional impairment results in an inability to perform normal activities. On physical examination there were no gross abnormalities in form or function of the upper extremities. There was no detectable alteration in form or function of either shoulder. There was no sign of edema, effusion, weakness, tenderness, redness, heat or abnormal movement. No fixed position was identified. There was normal strength and the range of motion of both shoulders was flexion and abduction to 180 degrees, and external and internal rotation was to 90 degrees. Pain, weakness, lack of endurance, fatigue or incoordination had no further impact on the range of motion after repetitive use. Motor and sensory functions were normal. X-rays of the right shoulder showed postoperative and arthritic changes, otherwise negative examination. X-rays of the left shoulder showed degenerative joint disease, otherwise negative examination. The diagnoses were no pathology was identified on physical examination to render a diagnosis, postoperative and arthritic changes of the right shoulder, otherwise negative examination; and degenerative joint disease of the left shoulder, otherwise negative examination. The examiner noted further that during the examination the Veteran was able to walk with a normal gait, sit with a normal posture, stand from a sitting or lying position, undress, dress, lace his shoes in the sitting position, go on and off the examining table without distress. There was an inconsistent disparity between the range of motion observed while the Veteran was engaged in such activities and his performance during physical examination when he was asked to carry out specific motions. He drove his automobile without fear, difficulty or legal restriction. The examiner indicated that the Veteran's shoulder disability did not affect functioning in his usual occupation or in activities of daily living. At the August 2012 Travel Board hearing, the Veteran testified that his MRI in service showed that his left shoulder disability is more severe than that found on (fee basis) VA examination. On February 2013 VA (shoulder and arm) examination, the Veteran reported that his bilateral shoulder pain started gradually in the late 1990's. There was no trauma or surgery. There was prolonged walking with heavy body armor. He stated that he has constant bilateral should pain that is a dull throbbing pain (4-5/10). He stated that raising his arms, and heavy lifting made the pain worse (10/10); it was improved with limited activities, Motrin, and rest). He denied any dislocations of either shoulder. He was noted to be right-arm dominant. He reported that when he has flare-ups of shoulder pain he has to stop using his shoulders and avoid activities that require raising his arms. Right shoulder flexion was to 85 degrees, and abduction was to 80 degrees. Left shoulder flexion was to 80 degrees and abduction was to 85 degrees. There was no additional limitation in range of motion of the shoulders and arms following repetitive use testing. Right shoulder internal rotation was to 40 degrees with pain at 40 degrees, and no change after 3 repetitions. Right shoulder external rotation was to 55 degrees with pain at 55 degrees, and no change after 3 repetitions. Left shoulder internal rotation was to 40 degrees with pain at 40 degrees, and no change after 3 repetitions. Left shoulder external rotation was to 40 degrees with pain at 40 degrees, and no change after 3 repetitions. Functional impairment of the shoulders included less movement than normal and pain on movement. There was localized tenderness or pain on palpation of the joint, soft tissue or biceps tendon of the shoulders. There was no guarding. He had normal muscle strength of the shoulders. The shoulders were not ankylosed. He had a positive Hawkins' Impingement Test, bilaterally (forward arm flex to 90 degrees with the elbow bent to 90 degrees). Pain on internal rotation indicates a positive test, and may signify rotator cuff tendonopathy or tear. Empty-can test (abduct arm to 90 degrees and forward flex 30 degrees) was negative. External rotation/infraspinatus strength test (arm at side with elbow flexed 90 degrees, external rotations against resistance) was negative (weakness indicates a positive test, and may be associated with infraspinatus tendonopathy or tear). Lift-off subscapular test (internal rotation of arm behind lower back, pushes against examiner's hand) was negative (weakness indicates a positive test, and may indicate subscapularis tendonopathy or tear). There was no history of recurrent dislocation (subluxation) of the glenohumeral joint. There was no AC joint condition or any other impairment of the clavicle or scapula; nor was there tenderness on palpation of the AC joint. There were no surgeries or scars associated with the shoulders. X-rays of the right shoulder showed some separation of the AC joint, some degenerative changes of the glenohumeral joint, and no fracture. The diagnoses were bilateral shoulder SLAP II lesion, right shoulder labral tear, left shoulder bursitis, right shoulder tendonitis, left AC joint DJD, and right shoulder DJD. Prior to February 12, 2013 Left (minor) Shoulder The preponderance of the evidence is against a rating in excess of 10 percent for the Veteran's left shoulder DJD for the period prior to February 12, 2013. To warrant a 20 percent rating for the left shoulder under Code 5201, there must be limitation of arm motion at the shoulder level. Prior to February 12, 2013, the Veteran had left arm motion well above the shoulder level, to 180 degrees (as shown on VA examination in June 2008). The June 2008 VA examination report also revealed there were no additional limitations due to pain or on use on range of motion testing; and pain, weakness, lack of endurance, fatigue or incoordination had no further impact after repetitive use. Consequently, DeLuca factors do not present a basis for an increase in the rating. . The 10 percent rating assigned for the period prior to February 12, 2013 recognizes that the Veteran has painful motion of the left shoulder with limitation less than compensable under Code 5201 (see 38 C.F.R. § 4.71a, Code 5003). There are no left shoulder symptoms/impairments of function shown or alleged that are not fully encompassed by the criteria for the 10 percent rating assigned. In summary, prior to February 12, 2013 the schedular criteria for a 20 percent rating for the left shoulder disability were not met (or approximated), and such rating was not warranted. Right (major) Shoulder The preponderance of the evidence is also against a rating in excess of 10 percent for the Veteran's right shoulder DJD for the period prior to February 12, 2013. To warrant a 20 percent rating for the right shoulder under Code 5201, there must be limitation of arm motion at the shoulder level. Prior to February 12, 2013, the Veteran had right arm motion well above the shoulder level, to 180 degrees as found on June 2008 VA examination. The June 2008 VA examination also found no additional limitations due to pain/on use on range of motion testing; and pain, weakness, lack of endurance, fatigue or incoordination had no further impact after repetitive use. Consequently, DeLuca factors do not present a basis for an increase in the rating. The 10 percent rating assigned for the period prior to February 12, 2013 recognizes that the Veteran has painful motion of the right shoulder with limitation less than compensable under Code 5201. There are no right shoulder symptoms/impairments of function shown or alleged that are not fully encompassed by the criteria for the 10 percent rating assigned. In summary, prior to February 12, 2013 the schedular criteria for a 20 percent rating for right shoulder disability were not met (or approximated), and such rating was not warranted. From February 12, 2013 Left (minor) Shoulder From February 12, 2013 a rating in excess of 20 percent is not warranted for the left shoulder disability because at no time since that date is left shoulder motion shown to have been limited to 25 degrees from the side, even with such factors as pain and use considered. The February 2013 VA examiner found flexion of the left shoulder to 80 degrees and abduction to 85 degrees. While the Veteran has some functional loss and/or functional impairment of the shoulder due to less movement than normal and/or pain on movement, these do not rise to the level of equivalency to limitation to 25 degrees from the side. Consequently, DeLuca factors do not present a basis for an increase in the rating. The evidentiary record also does not show any manifestations of, or functional impairment due to a left shoulder disability not encompassed by the schedular criteria for the 20 percent rating assigned for the period from February 12, 2013. In summary, from February 12, 2013 the schedular criteria for the next higher, 30 percent, rating for left shoulder disability are not met (or approximated), and such rating is not warranted. Right (major) Shoulder A rating in excess of 20 percent is not warranted for the right shoulder disability because at no time during the period from February 12, 2013 is right shoulder motion shown to be limited (due to the service-connected disability) to midway between side and shoulder level, even with such factors as pain and use considered. Significantly, the February 2013 VA examiner found flexion of the left shoulder to 85 degrees and abduction to 80 degrees. While the Veteran has some functional loss and/or functional impairment of the right shoulder due to less movement than normal and/or pain on movement, these do not rise to the level of equivalency to limitation to midway between the side and shoulder. Consequently, DeLuca factors do not present a basis for an increase in the rating. The evidentiary record does not show any manifestations of, or functional impairment due to a right shoulder disability that are not encompassed by the schedular criteria for the 20 percent rating assigned for the period from February 12, 2013. In summary, from February 12, 2013 the schedular criteria for the next higher, 30 percent, rating for right shoulder disability are not met (or approximated), and such rating is not warranted. Bilateral Knee Disability The rating schedule provides for a 10 percent rating for slight recurrent subluxation or lateral instability of the knee, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Code 5257. Dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint warrants a 20 percent rating. 38 C.F.R. § 4.71a, Code 5258. Flexion of the leg limited to 45 degrees warrants a 10 percent rating, flexion limited to 30 degrees warrants a 20 percent rating, and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Code 5260. Extension limited at 10 degrees warrants a 10 percent rating, extension limited at 15 degrees warrants a 20 percent rating, extension limited at 20 degrees warrants a 30 percent rating, extension limited at 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Code 5261. Flexion of the knee to 140 degrees is considered full and extension at 0 degrees is considered full. See 38 C.F.R. § 4.71, Plate II. VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9-98, (August, 1998). Moreover, the General Counsel has also held that separate ratings under 38 C.F.R. § 4.71a, Code 5260 (limitation of flexion of the leg) and under Code 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004 (September 2004). Consideration of other diagnostic codes for rating knee disability (5256, 5259, 5262, 5263) is inappropriate in this case as the Veteran's bilateral knee disabilities do not include the pathology required in the criteria for those Codes (ankylosis, removal of semilunar cartilage, malunion or nonunion of tibia or fibula, or genu recurvatum). 38 C.F.R. § 4.71a. STRs include a November 2005 MRI of the right knee, which showed findings corresponding with a subchondral cyst or small osteochondral defect. The impression was possible tear posterior horn medial meniscus, torn posterior cruciate ligament, and large joint effusion. A November 2007 MRI of the right knee revealed small bilateral osteochondral defects with predominant involvement of the posterior aspect of the right medial femoral condyle, mild/moderate intrinsic mucoid degenerative changes of the medial menisci bilaterally and small right sided medial meniscal radial tear of its body, small bilateral effusion and mild bilateral degeneration including cartilaginous thinning and right sided superior patellar enthesophytosis, chronic mild/moderate medial collateral ligamentous right sided tear, partial tear, and mild partial tear of the left sided lateral collateral ligament. A November 2007 MRI of the left knee revealed a small radial tear of the medial meniscus, and mild intrinsic mucoid degeneration of the posterior horn of the medial meniscus. The lateral meniscus and cruciate ligaments were intact. There was minimal joint effusion. There was mild thickening and increased fluid sensitive signal in the medial collateral ligament consistent with mild medial collateral ligamentous tear. The patellar cartilage was intact. On June 2008 pre-discharge (fee basis) VA examination, the Veteran reported that he had torn ligaments of the knees (as a result of airborne operations) diagnosed in November 2005. He reported symptoms of weakness, stiffness, swelling, giving way, lack of endurance, locking, fatigability and pain in both knees, described as crushing, aching, burning and sharp, with a severity of 7/10. He had braces prescribed and physical therapy for both knees. He stated that he was no longer able to perform normal movements due to his bilateral knee disability. On physical examination, his knees were within normal limits. There was no edema, effusion, weakness, tenderness, redness, heat or abnormal movement. There was no evidence of recurrent subluxation, locking pain, joint effusion or crepitus. No fixed position was identified. The range of motion was within normal limits with flexion to 140 degrees and extension at 0 degrees. There was no varus/valgus instability. Drawer's and McMurray's tests were negative. Pain, weakness, lack of endurance, fatigue or incoordination had no further impact on the range of motion after repetitive exercise. Motor and sensory functions of the lower extremities were normal. Right and left knee reflexes were present and equal. X-rays of the right knee showed early DJD with mild patellar spurring, probable osteochondritis dissecans lesion in the right medial femoral condyle. X-rays of the left knee show mild patellar spurring and spurring of the tibial spines, otherwise negative. The diagnoses were no pathology was identified on physical examination to render a diagnosis; early degenerative joint disease of the right knee with mild patellar spurring, probable osteochondritis dissecans lesion in the right medial femoral condyle, and mild patellar spurring and spurring of the tibial spines of the left knee, otherwise negative, by x-rays. The examiner noted further that during the examination the Veteran was able to walk with a normal gait, sit with a normal posture, stand from a sitting or lying position, undress, dress, lace his shoes in the sitting position, and go on and off the examining table without distress. There was an inconsistent disparity between the range of motion observed while the Veteran was engaged in such activities and his performance during physical examination when he was asked to carry out specific motions. He drove his automobile without fear, difficulty or legal restriction, and there is no history of disorientation in time or space. In addition, he noted that the Veteran's condition does not affect his functioning in his usual occupation or his activities of daily living. At the August 2012 Travel Board hearing, the Veteran testified that he wears metal braces on both legs due to his bilateral knee disability. He indicated that consideration should have been given for instability in his case. On February 2013 VA examination, the Veteran reported that during a parachute drop in service he tore his posterior cruciate ligament in the right knee and since then the right knee has been limited. Pain occurred with prolonged standing, and walking up stairs. He stated that he has instability and giving way (which can be triggered when walking on an uneven pavement). He had bilateral knee braces prescribed in 2006/2007. He has intermittent locking of the right knee. Pain in the right knee was moderate to severe, and could be associated with swelling that lasted a day and was relieved with rest, Motrin, and limited activity. He limited his exercise to avoid flare-ups. Range of motion testing revealed right knee flexion to 95 degrees (objective evidence of painful motion began at 95 degrees), extension was to 10 degrees (objective evidence of painful motion began at 10 degrees). He had left knee flexion to 100 degrees (objective evidence of painful motion began at 100 degrees), extension was to 5 degrees (objective evidence of painful motion began at 5 degrees). There was additional limitation in range of motion and functional loss and/or functional impairment of both knees, manifested by less movement than normal and pain on movement. The Veteran had tenderness or pain to palpation for joint line or soft tissues of both knees. Muscle strength for both knees was 5/5. The joint stability, and posterior instability tests were normal for both knees. Medial-lateral instability was normal for both knees. There was no history of patellar subluxation/dislocation. There also was no evidence that he had ever had shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. It was shown that he had right meniscal tear, and frequent episodes of joint pain and effusion. The examiner referred to the 2007 right and left knee MRI reports. It was noted that the Veteran's bilateral knee disability limited his ability to deploy overseas (he is a government contractor) and results in bilateral knee pain with prolonged sitting. The diagnoses were right knee posterior cruciate ligament tear, medial collateral ligament tear, medial meniscal tear, and patellar enthesophytosis, left knee lateral collateral ligament tear, and bilateral degenerative changes of the meniscus and internal derangement. Right Knee Prior to February 12, 2013 For the period prior to February 12, 2013 the Veteran's right knee disability is rated 10 percent under Code 5261 (limitation of extension). The June 2008 VA examination report, which covers that period, found motion from 0 to 140 degrees (or full). Accordingly, prior to February 12, 2013 a rating for right knee disability in excess of 10 percent under Code 5260 or Code 5261 (or based on a combination of ratings under these two codes) is not warranted. The Board has also considered the possibility of a separate rating for subluxation/instability which may be awarded where there is both (x-ray evidence) arthritis and instability of a knee. See VAOPGCPREC 23-97 (1997). However, despite the Veteran's August 2012 hearing testimony (that essentially alluded to his wearing of knee braces as an indication that there is instability of the knee), subluxation or lateral instability was not noted in the STRs or on the 2008 pre-discharge VA examination. The examiner in 2008 specifically noted there was no evidence of recurrent subluxation. Without any objective evidence of such, the Veteran's statements that allude to instability of the knee are self-serving and lack probative value. Consequently, a separate compensable rating for instability would be inappropriate. Additional factors that could provide a basis for an increase have been considered; however, it is not shown that the Veteran has any loss of knee function beyond that currently compensated. 38 C.F.R. §§ 4.40 , 4.45; Deluca, 8 Vet. App. at 206. Notably, the current rating under Code 5261 specifically encompasses limitation of motion due to pain. In summary, prior to February 12, 2013 the schedular criteria for the next higher, 20 percent, rating for right knee disability were not met (or approximated), and such rating is not warranted. From February 12, 2013 For the period from February 12, 2013 the Veteran's right knee disability is rated 20 percent under Code 5258 (dislocated semilunar cartilage). The Board notes that the Veteran's right knee disability was previously rating under Code 5261 (limitation of extension). By February 2013 rating decision the RO found that the Veteran's right knee disability warranted an increased (20 percent) rating for semilunar cartilage of the right knee (Code 5258). 20 percent is the highest schedular evaluation allowed for dislocated semilunar cartilage of the knee with frequent episodes of locking, pain, and effusion into the joint. Hence, a higher rating under Code 5258 is not warranted. The Board has considered an increased (30 percent) rating for limitation of flexion (Code 5260), or limitation of extension (Code 5261) for the period from February 12, 2012, and finds that the 2013 VA examination report does not show limitation of right knee flexion limited to 15 degrees, or limitation of extension limited to 20 degrees. The February 2013 VA examination report noted right knee flexion to 95 degrees and extension to 10 degrees. Accordingly, from February 12, 2013 a rating for right knee disability in excess of 20 percent under Code 5260 or Code 5261 (or based on a combination of ratings under these two codes) is not warranted. The Board has also considered a separate rating for severe recurrent subluxation or lateral instability (Code 5257) and finds that such rating is not warranted because recurrent subluxation or lateral instability was not found on February 2013 VA examination. The examiner specifically noted there was no evidence or history of recurrent patellar subluxation/dislocation. Additional factors that could provide a basis for an increase have been considered; however, for the period from February 12, 2013 it is not shown that the Veteran has any loss of right knee function beyond that currently compensated. 38 C.F.R. §§ 4.40, 4.45; Deluca, 8 Vet. App. at 206. In summary, from February 12, 2013 the schedular criteria for the next higher, 30 percent, rating for right knee disability are not met (or approximated), and such rating is not warranted. Left Knee In a September 2008 rating decision service connection was granted for the Veteran's left knee patellar spurring and spurring of the tibial spines, rated 0 percent, effective August 1, 2008 (the day following discharge from service). An interim (February 2010) rating decision increased the rating for the left knee disability to 10 percent (also effective August 1, 2008), under Code 5261 (limitation of extension) based upon the evidence showing the Veteran's left knee joint was affected by painful motion. The evidence does not support the award of a higher (20 percent) rating for the Veteran's left knee disability. STRs and VA examination reports do not show compensable limitation of left knee extension to or left knee flexion even with consideration of factors such as pain and use (repetitive motion). Notably, the 2008 VA examination report found no limitation of extension or flexion; and on February 2013 examination left knee extension was to 5 degrees, and flexion was to 95 degrees (both noncompensable). Accordingly, a rating in excess of 10 percent for left knee disability under either Code 5260 or Code 5261 (or based on a combination of ratings under these two codes) is not warranted. The Board has also considered whether a separate rating for left knee disability is warranted under Code 5257 for subluxation/instability. However, despite the Veteran's August 2012 hearing testimony (that essentially alluded to the wearing of knee braces as an indication that there is instability of the knee), subluxation or lateral instability was not found on STRs or on the 2008 pre-discharge VA examination or the February 2013 VA examination. The examiners in 2008 and 2013 specifically noted there was no evidence of recurrent subluxation. Without any objective evidence of such, the Veteran's statements that allude to instability of the knee are self-serving and lack probative value. Consequently, a compensable rating for instability is not warranted. Additional factors that could provide a basis for an increase have also been considered; however, it is not shown that the Veteran has any loss of left knee function beyond that currently compensated. 38 C.F.R. §§ 4.40 , 4.45; Deluca, 8 Vet. App. at 206. Notably, the current rating under Code 5261 specifically encompasses limitation of motion due to pain. The Board has considered whether a staged increased rating might be warranted; however, at no time during the appeal period is there a showing of disability warranting a rating in excess of 10 percent under the schedular criteria. See Fenderson, 12 Vet. App. 119. In summary, the schedular criteria for the next higher, 20 percent, rating for left knee disability are not met (or approximated) at any time during the appeal period, and such rating is not warranted. Lumbar Spine Disability The September 2008 rating decision granted service connection for DJD and DDD of the lumbar spine (claimed as thoracic and lumbar spine condition with neurological symptoms) and assigned a 0 percent rating effective August 1, 2008. A February 2010 rating decision increased the rating for DJD and DDD of the lumbar spine to 10 percent with the same (August 1, 2008) effective date. In February 2013 the RO increased the rating for DJD and DDD of the lumbar spine to 20 percent effective February 12, 2013. The Veteran's service connected lumbar spine DJD and DDD, is rated under Code 5237 (lumbosacral strain). Lumbosacral strain is rated under the General Rating Formula for Rating Diseases and Injuries of the Spine (General Rating Formula). Given the November 2007 x-ray findings of DDD at L5-S1 with disc height loss and vacuum disc phenomenon, the Veteran's lumbar spine disability may alternatively be rated under Code 5243 (for intervertebral disc syndrome (IVDS) - although such has not been specifically diagnosed), which is rated under the General Rating Formula or based on incapacitating episodes, whichever is more favorable to the Veteran. 38 C.F.R. § 4.71a. Under the General Rating Formula, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply: a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion for the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine limited to 30 degrees or less; or where there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. There are several notes following the General Rating Formula criteria, which provide: (1) Associated objective neurological abnormalities are to be rated separately under an appropriate diagnostic code. (2) For purposes of VA compensation, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateroflexion is 0 to 30 degrees, and left and right lateral rotation is 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateroflexion, and left and right rotation. The normal combined range of the thoracolumbar spine is to 240 degrees. (3) In exceptional cases, an examiner may state that, because of age, body habitus, neurological disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in the regulation. 38 C.F.R. § 4.71a. For ratings based on incapacitating episodes of IVDS, a 10 percent rating is warranted for incapacitating episodes having a total duration of at least one week but less than 2 weeks, during the past 12 months. A 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks, but less than four weeks, during the past 12 months. A 40 percent rating is warranted for incapacitating episodes if such episodes had a total duration of at least four weeks but less than six weeks, during the past 12 months. A 60 percent (maximum) rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. Note (1) following Code 5243 provides that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. November 2007 STRs show x-ray findings of lumbar spine degenerative disc and joint disease involving L4-5 and L5-S1. On June 2008 pre-discharge VA examination, the Veteran reported that DDD was diagnosed in 1988 (via MRI). He complained of low back stiffness, weakness, numbness, pain and erectile dysfunction. He stated that his low back pain was aching, oppressing and sharp with a severity of 7/10, elicited by physical activity and relieved by rest. He did not report any incapacitation with bedrest required. He stated that he was unable to sit for more than 30 minutes due to his low back disability. On physical examination of the thoracolumbar spine, there was no evidence of radiating pain on movement, muscle spasm or tenderness. The straight leg raise test was negative, bilaterally. There was no fixed position of the lumbar spine; and range of motion was within normal limits. Flexion was to 90 degrees, extension to 30 degrees, and right and left lateral flexion and rotation were all to 30 degrees. Pain, weakness, lack of endurance, fatigue or incoordination did not impact range of motion after repetitive use. There was symmetry in appearance and spinal motion. Inspection of the spine revealed that the position of the head and curvature of the spine were within normal limits. X-rays of the lumbosacral spine showed disc disease, greatest at L5-S1 and, to a lesser extent, L4-5 with mild facet DJD at L5-S1, otherwise negative. Neurological examination of the peripheral nerves did not reveal any evidence of neuralgia, neuritis, or paralysis. There was no detectable alteration in sensory perception or motor supply. Motor strength was 5/5 in all muscle groups. His urinary and genital functions were undisturbed. The examiner noted that review of the history and physical examination did not identify an IVDS as evident by bowel or bladder dysfunction. The diagnoses were status post traumatic injury to thoracic and lumbar spine with paresthesia, condition resolved without complications. No current pathology identified on physical examination to render a diagnosis. Disc disease, greatest at L5-S1 and, to a lesser extent, L4-5 with mild facet DJD at L5-S1, otherwise negative, by x-rays. At the August 2012 Travel Board hearing, the Veteran testified that the evidence shows he has DDD involving his low back, and also indicates that while there is no evidence of IVDS, he has back and neck pain, compressed discs, and numbness in his legs associated with the low back. On February 2013 VA examination, the Veteran reported having low back pain since the 1990's and that he currently has mild dull 3-4/10 low back pain. He stated that prolonged sitting, bending, and heavy lifting make the pain worse. He was told that his discs will slip out of normal alignment and "swell out" with no specific triggers. He has limited range of motion and pain that improves in a couple of days with rest. He had not seen a medical care provider for his low back disability since his discharge from the military. He had full bladder and bowel control. He had intermittent numbness, tingling, and bilateral leg pain with flares lasting a few seconds. Range of motion testing revealed forward flexion to 55 degrees (with painful motion beginning at 40 degrees), extension to 15 degrees (no change with painful motion), right lateral flexion to 20 degrees, left lateral flexion to 25 degrees, and right and left lateral rotation to 30 degrees. There was no objective evidence of painful motion with lateral flexion and rotation. The Veteran did not have additional limitation in range of motion of the thoracolumbar spine following repetitive-use testing. Functional loss and/or functional impairment were manifested by less movement than normal, pain on movement, and he has to stand after prolonged sitting due to back pain. He had normal muscle strength (5/5), and no muscle atrophy. Reflex and sensory examinations were normal. Moderate radiculopathy affected his right and left lower extremities. There were no other neurologic abnormalities shown, including IVDS. He did not use any assistive devices [to ambulate]. The examiner cited to the November 2007 x-rays which showed DDD and DJD involving L4-5 and L5-S1. Prior to February 12, 2013 For the period prior to February 12, 2013 the Veteran's lumbar spine disability is rated 10 percent under Code 5237. The record pertaining to this period does not show (nor is alleged) that forward flexion of the thoracolumbar spine was limited to 60 degrees or less, that combined range of motion of the thoracolumbar spine was 120 degrees or less; or that there was muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour as to warrant the next higher (20 percent) rating under Code 5237. On June 2008 pre-discharge VA examination thoracolumbar forward flexion was to 90 degrees, there was no increase in impairment of function with repetitive testing (i.e., on use); combined range of motion was 240 degrees, and there was no muscle spasm. Consequently, a rating in excess of 10 percent under the General Rating Formula was not warranted. There were no separately ratable neurological symptoms (on neurological evaluation no abnormalities were reported). Furthermore, there were no reports of incapacitating episodes of IVDS, and the spine was not ankylosed. As there is no evidence, or allegation, that the Veteran has ever had an incapacitating episode (bed rest prescribed by a physician), rating based on such episodes would be inappropriate. Additional factors that could provide a basis for an increase have also been considered; however, it is not shown that the Veteran has any functional loss beyond that compensated prior to February 12, 2013. 38 C.F.R. §§ 4.10, 4.40, 4.45; DeLuca, 8 Vet. App. at 205. Significantly, the June 2008 examiner found that pain, weakness, lack of endurance, fatigue or incoordination did not impact range of motion after repetitive use. In summary, prior to February 12, 2013 there was no basis in the factual evidence for the assignment of a schedular rating in excess of 10 percent. Consequently, the next higher (20 percent) rating under the General Rating Formula criteria is not warranted prior to February 12, 2013. From February 12, 2013 For the period from February 12, 2013 the Veteran's lumbar spine disability is rated 20 percent under Code 5237. The record during that period does not show (nor is it alleged) that forward flexion of the thoracolumbar spine was limited to 30 degrees or less, or that there is favorable ankylosis of the entire thoracolumbar spine as to warrant the next higher (40 percent) rating under Code 5237. On February 2013 VA examination thoracolumbar forward flexion was to 55 degrees, (there was no additional limitation in range of motion of the thoracolumbar spine following repetitive-use testing) and there was no evidence of ankylosis of the spine. A February 2013 rating decision assigned separate 20 percent ratings each for radiculopathy of the left and right lower extremities as neurological symptoms of the service-connected lumbar spine disability. [Those ratings are not at issue herein.]. No other neurological symptoms are shown and a further separate rating for such symptoms is not warranted. Furthermore, there were no reports of incapacitating episodes of IVDS. As there is no evidence, or allegation, that the Veteran has ever had an incapacitating episode (bed rest prescribed by a physician), rating based on such episodes would be inappropriate. Additional factors that could provide a basis for an increase have also been considered; however, it is not shown that the Veteran has any functional loss beyond that being currently compensated. 38 C.F.R. §§ 4.10, 4.40, 4.45; DeLuca, 8 Vet. App. at 205. Significantly, the February 2013 examiner found impairment of function with repetitive testing (i.e., on use) manifested by less movement than normal and pain on movement. However, such did not cause a degree of impairment (equivalent to flexion limited to 30 degrees, or ankylosis) sufficient to warrant a 40 percent rating. In summary, from February 12, 2013 there was no basis in the factual evidence for the assignment of a schedular rating in excess of 20 percent. Consequently, the next higher (40 percent) rating under the General Rating Formula criteria is not warranted from February 12, 2013. The Board has also considered whether referral for extraschedular consideration is warranted. There is no objective evidence or allegation in the record of symptoms and/or impairment due to the Veteran's service-connected PTSD, bilateral shoulder disability, bilateral knee disability and lumbar spine disability that are not encompassed by the "staged" ratings assigned (other than for a left knee disability). The functional impairment shown (e.g., that he has less movement than normal and pain on movement See February 2013 VA examination report) is encompassed by the criteria for the schedular ratings assigned. Therefore, those criteria are not inadequate, and referral for extraschedular consideration is not warranted. 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111 (2008). Finally, the Veteran works full-time as a defense contractor and has held that position for four years (see February 2013 VA PTSD examination); it is not alleged that his service-connected disabilities render him unemployable. Thus, the matter of a total disability rating based on individual unemployability due to service-connected disabilities is not raised by the record. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). ORDER A compensable rating for PTSD prior to February 12, 2013 and a rating in excess of 30 percent from that date are denied. Ratings for left shoulder DJD in excess of 10 percent prior to February 12, 2013 and in excess of 20 percent from that date are denied. Ratings for right shoulder DJD in excess of 10 percent prior to February 12, 2013 and in excess of 20 percent from that date are denied. Ratings for a right knee disability in excess of 10 percent prior to February 12, 2013 and in excess of 20 percent from that date are denied. A rating in excess of 10 percent for a left knee disability is denied. Ratings for lumbar spine DDD and DJD in excess of 10 percent prior to February 12, 2013 and in excess of 20 percent from that date are denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs