Citation Nr: 1338780 Decision Date: 11/25/13 Archive Date: 12/06/13 DOCKET NO. 07-35 776 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial higher rating for a left knee disorder, rated 10 percent disabling from June 24, 2005 to March 8, 2006; 100 percent disabling from March 9, 2006, to April 30, 2006; and 10 percent disabling since May 1, 2006. 2. Entitlement to an initial rating in excess of 10 percent for a right knee disorder. 3. Entitlement to an initial rating in excess of 10 percent for low back disorder from June 24, 2005, to November 8, 2007; and in excess of 20 percent from November 9, 2007. 4. Entitlement to an initial rating in excess of 10 percent for a left shoulder disability from June 24, 2005 to November13, 2011, and in excess of 20 percent from November 14, 2011. 5. Entitlement to an initial compensable rating for rhinitis. 6. Entitlement to an initial rating in excess of 30 percent for asthma. 7. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD S.J. Janec, Counsel INTRODUCTION The Veteran served on active duty from August 1979 to November 1979 and from February 2003 to June 2005, with additional service in the Army Reserves. This matter comes before the Board of Veterans' Appeals (Board) from an August 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, that granted service connection and assigned 10 percent disability ratings for bilateral knee disorders (degenerative joint disease of the left and right knee) and a left shoulder disorder (residuals of a partial rotator cuff tear and early osteoarthritis). That August 2005 RO rating decision also awarded noncompensable service connection for a low back disorder (degenerative joint disease and strain of the lumbosacral spine) and rhinitis (turbinate hypertrophy and chronic rhinitis, status post surgery). Following the issuance of that decision, the Veteran changed residences and her claims folder was transferred to the RO in Montgomery, Alabama. In a subsequent December 2006 decision, the RO awarded a temporary total rating under 38 C.F.R. § 4.30 for the Veteran's left knee disorder, effective from March 6, 2006, to April 30, 2006, and assigned a 10 percent rating for that disability, effective May 1, 2006. Thereafter, the RO issued a September 2007 decision that awarded an initial 10 percent rating for the Veteran's low back disorder, effective the date of service connection. Then, in a July 2010 decision, the RO assigned a 20 percent rating for that service-connected disability, effective November 9, 2007. However, as none of those awards represented a full grant of the benefits sought on appeal, the Veteran's claims remained in appellate status. AB v. Brown, 6 Vet. App. 35 (1993). Next, the Board acknowledges that April 2009 and September 2009 rating decisions denied the Veteran's claim for a total disability rating based on individual unemployability due to service-connected disability. She filed a timely notice of disagreement with respect to that issue and a statement of the case was prepared in July 2011. The Veteran did not submit a substantive appeal. However, her representative submitted correspondence, dated in August 2011, which the Board accepts as a timely substantive appeal of her total disability rating based on individual unemployability due to service-connected disability claim. The Board found that the claim had been effectively merged on appeal with the Veteran's left knee, right knee, low back, left shoulder, and rhinitis claims and the Board assumed jurisdiction over those issues as well. Additionally, after the Veteran had perfected her appeal for an initial compensable rating for rhinitis, she filed a separate claim for secondary service connection for asthma. The RO then issued a rating decision granting service connection and assigning a 30 percent rating asthma and rhinitis, effective July 17, 2008. Although the Veteran did not specifically appeal her asthma rating, the RO included it as an issue in the January 2011 and March 2011 supplemental statements of the case. Subsequent statements from the Veteran and her representative indicate that she considers both the rating for asthma and the rating for rhinitis to be on appeal. Accordingly, the Board found that the filing of a timely substantive appeal was waived with respect to the Veteran's asthma claim and the Board assumed jurisdiction over both issues. Percy v. Shinseki, 23 Vet. App. 37, 45 (2009); Gonzalez-Morales v. Principi, 16 Vet. App. 556, 557-58 (2003). In October 2011, the Board remanded the case for further evidentiary development. In a September 2012 rating decision, the RO granted a 20 percent rating for a left shoulder disability from November 14, 2011. In November 2007, the Veteran requested a personal hearing before a decision review officer at the RO. Such hearing was scheduled in February 2010. However, the Veteran subsequently canceled the hearing. The issues of entitlement to an initial rating in excess of 30 percent for asthma and total disability rating based on individual unemployability due to service-connected disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. Throughout the period on appeal (other than the post-convalescent temporary 100 percent rating period), the Veteran's left knee disability has been manifest by arthritis with noncompensable limitation of extension and flexion with complaints of pain on use; no instability has been clinically demonstrated by objective evidence. 2. Throughout the period on appeal, the Veteran's right knee disability has been manifest by arthritis with noncompensable limitation of extension and flexion with complaints of pain on use; no instability has been clinically demonstrated by objective evidence. 3. Prior to November 9, 2007, the Veteran's low back disability was manifested by slight limitation of motion of the thoracolumbar spine with pain on motion; from November 9, 2007, the disability was manifested by increased limitation of motion with pain on motion. 4. Prior to November 14, 2011, the Veteran's left (minor) shoulder disability was manifested by complaints of pain, with arm motion possible to above shoulder level, intact sensation, normal muscle strength, no impingement syndrome, and no dislocations shown on examinations; from November 14, 2011, the disability was manifest by complaints of pain with functional impairment compatible with arm motion possible to greater than 25 degrees from the side, and no dislocations shown on examinations. 5. The Veteran's allergic rhinitis is not manifested by polyps and does not result in greater than 50-percent obstruction of the nasal passage on both sides or complete obstruction of a nasal passage. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for a left knee disability have not been met June 24, 2005 to March 8, 2006 or from May 1, 2006. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5260, 5261 (2013). 2. The criteria for an initial rating in excess of 10 percent for a right knee disability have not been met during the appeal period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5260, 5261 (2013). 3. The criteria for a rating in excess of 10 percent prior to November 9, 2007, and in excess of 20 percent from November 9, 2007, for a low back disability were not met during the appeal period. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5242 (2013). 4. The criteria for a rating in excess of 10 percent prior to November 14, 2011, and in excess of 20 percent from November 14, 2011, for a left (minor) shoulder disability were not met during the appeal period. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5201 (2013). 5. The criteria for an initial compensable rating for allergic rhinitis have not been met during the appeal period. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.97 Diagnostic Code 6522 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was provided appropriate notice in letters dated in May 2006, November 2008, and March 2009. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notices provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls on party attacking agency decision); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and her representative suggest actual knowledge of the elements necessary to substantiate the claims. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Thus, VA has satisfied its duty to notify the appellant. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, including VA and private records, Social Security records, lay statements, and VA examination reports. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to the claims on appeal and the examinations are adequate and sufficient upon which to decide the claims and rate the disabilities at issue. Stefl v. Nicholson, 21 Vet. App. 120 (2007); Barr v. Nicholson, 21 Vet. App. 303 (2007) (When VA provides an examination, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate). Consequently, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Increased Initial Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2013). The Schedule is primarily a guide in the rating of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). Consideration of the whole recorded history is necessary so that a rating may accurately compensate the elements of disability present. 38 C.F.R. § 4.2 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, consideration must be given as to whether staged ratings should be assigned to compensate entitlement to a higher rating at any point during the pendency of the claim. When the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is warranted. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two ratings is to be applied, 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 (2013). When rating disabilities using Diagnostic Codes which provide a rating on the basis of loss of range of motion, VA must consider, to the extent possible, the degree of additional range of motion loss due to pain, weakened movement, excess fatigability, or incoordination. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45 (2013). After careful consideration of the evidence, any reasonable doubt remaining should be resolved in favor of the veteran. 38 C.F.R. §§ 3.102, 4.3 (2013). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Left and Right Knee Disabilities The Veteran's left and right knee disabilities have been rated 10 percent, respectively, under Diagnostic Code 5010 for arthritis with painful range of motion that is otherwise noncompensable (other than a temporary 100 percent rating for the left knee for the period from March 9, 2006, to April 30, 2006 based on a period of convalescence). Degenerative or traumatic arthritis, established by X-ray findings, is rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. When, however, the limitation of motion of the 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 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. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (degenerative arthritis) and Diagnostic Code 5010 (traumatic arthritis) (2013). Under Diagnostic Code 5260, covering limitation of flexion of the knee, flexion limited to 45 degrees warrants a 10 percent rating, and when limited to 30 degrees, a 20 percent rating is assigned. Flexion limited to 15 degrees warrants a 30 percent rating. Diagnostic Code 5261, covering limitation of extension of the knee, states that a 10 percent rating is assigned for extension limited to 10 degrees, and a 20 percent rating is warranted for extension limited to 15 degrees. Extension limited to 20 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2013). For the purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45 (2013). Normal range of motion of the knee is to zero degrees extension and zero to 140 degrees flexion. 38 C.F.R. § 4.71a, Plate II (2013). The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2013). Disabilities involving cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2013). A maximum 20 percent rating is assigned for any such disability. Under 38 C.F.R. § 4.71a, Diagnostic Code 5257, a 10 percent rating is assigned for slight recurrent subluxation or lateral instability and a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is assigned for severe recurrent subluxation or lateral instability. VA's General Counsel has held that knee arthritis and instability may be rated separately under Diagnostic Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). Further, the General Counsel has held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004; 69 Fed. Reg. 59990 (2004). Initially, the Board observes that it is neither contended nor shown that the Veteran's service-connected left and right knee disabilities involve ankylosis (Diagnostic Code 5256). Hence, a higher rating under that diagnostic code may not be assigned for either knee at any time during the rating period. Knee disability involving cartilage, dislocations and with frequent episodes of "locking," pain, and effusion into the joint has also not been clinically shown for either knee. Hence, a higher rating under 38 C.F.R. § 4.71a, Diagnostic Code 5258 is also not warranted during the appeal period. The Board finds that the preponderance of the evidence is against an increased evaluation for either the left or right knee disability at any time during the appeal period because the medical evidence of record does not show that the Veteran has a compensable limitation of motion (flexion or extension) to warrant a higher rating under Diagnostic Code 5010, 5260 or 5261. For example, upon VA examination in May 2005, both knees exhibited extension to 0 degrees and flexion to 105 degrees. Upon VA examination in December 2008 range of motion of the left knee was from 0 degrees to 100 degrees and 0 degrees to 140 degrees on the right. There was pain at the extremes but no additional limitations. Stability was within normal limits. Upon VA examination in March 2010, range of motion of the left knee was from 10 degrees in extension to 100 degrees in flexion. Right knee motion was from 0 degrees to 120 degrees. There was grinding and crepitus throughout left knee range of motion as well as tenderness on both knees. Upon VA examination in November 2011, range of motion of the left knee was from 0 degrees to 65 degrees and the right knee from 0 degrees to 60 degrees. There was no objective evidence of pain during range of motion although the Veteran complained of pain. Based on the Veteran's complaints of pain, the Veteran has been awarded a 10 percent rating for each knee pursuant to the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and DeLuca, supra. Hence, additional consideration of these factors to award the next higher 20 percent rating would essentially amount to pyramiding in violation of 38 C.F.R. § 4.14 (2013). Moreover, even if the Board conceded that the Veteran's pain equated to an additional limitation of flexion and/or extension of several degrees, she would still need a significant loss of motion to warrant higher evaluations under either Diagnostic Code 5260 or 5261. Despite the Veteran's assertions, clinical evaluation has not shown such a loss of motion to be present in this case in either knee. For example, although a December 2008 VA examination indicated that the Veteran wore braces on both knees and ambulated with a cane, the clinician was unable to determine which doctor made these recommendations, or why the equipment was necessary. Significantly, moreover, neither knee has had flexion limited to 30 degrees to warrant a higher 20 percent rating or extension limited to 15 degrees, to warrant a higher 20 percent rating. In fact, the Veteran's actual limitation of flexion and extension does not warrant a compensable rating under either Diagnostic Code 5260 or 5261; hence the 10 percent rating for each knee is provided under the criteria for rating arthritis pursuant to Diagnostic Code 5010. Therefore, the Board finds that neither the Veteran's left nor right knee symptomatology equated to the criteria for a higher evaluation under Diagnostic Codes 5260 and/or 5261. This is true throughout the period of time that his claim has been pending. The Board also finds that the medical evidence does not show that the Veteran experiences recurrent subluxation or lateral instability in either knee to warrant the assignment of a separate 10 percent rating under Diagnostic Code 5257. Although the Veteran has reported her knees "giving out," the VA examination reports revealed no signs of instability, or medial or collateral ligament laxity of the knees; and anterior drawer sign, Lachman's, McMurray's were consistently negative. In an addendum statement in December 2010, the examiner specifically noted that there was no instability in the Veteran's knees. Consequently, the Board finds that the clinical evidence is against finding that there is even slight recurrent subluxation or lateral instability to warrant a separate 10 percent rating under Diagnostic Code 5257. In reaching its decision, the Board has considered the Veteran's statements. The Board finds that the Veteran is competent to report that she has pain. Charles v. Principi, 16 Vet. App. 370 (2002); see also, e.g., Layno v. Brown, 6 Vet. App. 465, 469 (1994) (a veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses). However, she is not competent to provide an opinion requiring medical knowledge, such as attributing those symptoms to specific disability rating criteria. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). As a result, her assertions cannot constitute competent medical evidence that her disability has increased in severity so as to warrant a higher evaluation. Here, the clinical evidence pertaining to the Veteran's left and right knee disabilities is more probative for the purposes of assigning ratings in conjunction with the relevant rating criteria - and the Board finds that the pain and functional impairment reported has been appropriately considered in assigning the 10 percent ratings in effect during the appeal period. Finally, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claims, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, the Veteran's claims for higher ratings for left and right knee disabilities are denied. Low Back Disability The Veteran's low back disability encompasses degenerative joint disease and degenerative disc disease. It is rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2013). Degenerative or traumatic arthritis, established by X-ray findings, is rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. When, however, the limitation of motion of the 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 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. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (degenerative arthritis) and Diagnostic Code 5010 (traumatic arthritis) (2013). Under the General Rating Formula for Diseases and Injuries of the Spine (for diagnostic codes 5235 to 5243 unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes), there is a schedule of ratings for spine disabilities with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Unfavorable ankylosis of the entire spine warrants a 100 percent rating. Unfavorable ankylosis of the entire thoracolumbar spine warrants a 50 percent rating. Unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine warrants a 40 percent rating. Forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine warrants a 30 percent rating. Forward flexion of the thoracolumbar spine greater than 20 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or the combined range of motion of the cervical spine not greater than 170 degrees; 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 warrants a 20 percent rating. Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, the combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or, vertebral body fracture with loss of 50 percent or more of the height warrants a 10 percent rating. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (2013). The rater is instructed to evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (2013). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71, 4.71a, Plate V, General Rating Formula for Diseases and Injuries of the Spine, Note (2) (2013). Each range of motion measurement is rounded to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (4) (2013). In exceptional cases, an examiner may state that because of age, body habitus, neurologic 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 Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (3) (2013). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (0 degrees) always represents favorable ankylosis. Each range of motion measurement is rounded to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5) (2013). Upon VA examination in May 2005, the Veteran reported localized back pain for the past two years. Clinical evaluation showed no complaints of radiating pain upon movement. There was no muscle spasm or tenderness. Straight leg raising was negative, bilaterally. Range of motion was flexion to 90 degrees; extension to 30 degrees; right and left lateral flexion to 30 degrees; and right and left rotation to 30 degrees. There were no additional limitations due to pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. There were no signs of intervertebral disc syndrome. X-rays showed degenerative joint disease and degenerative disc disease. Upon VA examination in December 2008, the Veteran reported that she "can't bend [her] back" but she could not provide a specific activity she could not perform. She has had lumbar epidural injections. Clinical evaluation revealed flexion to 65 degrees; extension to 30 degrees; left lateral flexion to 15 degrees; right lateral flexion to 30 degrees; right and left rotation to 30 degrees. There was pain at the extreme of extension, but no pain in other planes of motion. There was no additional limitation of motion upon use. Reflexes were normal, there were no sensory deficits. Motor strength was also normal. The assessment was chronic lumbar strain. Upon VA examination in March 2010, the Veteran reported constant pain in her low back at level 8. She considered the condition incapacitating on a frequent basis with stiffness, fatigue, spasms, weakness, etc. Clinical evaluation showed no ankylosis. There was tenderness and the lumbar was mildly spastic. Flexion was to 50 degrees with pain; extension to 10 degrees with pain; left lateral flexion to 15 degrees with pain; right lateral flexion to 20 degrees with pain; left lateral rotation to 20 degrees with pain; and right lateral rotation to 15 degrees with pain. Straight leg raising was positive bilaterally. In a December 2010 addendum, the examiner stated that the Veteran did not have lumbar radiculopathy and electrodiagnostic testing was not necessary. Upon VA examination in November 2011, forward flexion was to 45 degrees and extension was to 20 degrees with objective evidence of painful motion. Right lateral flexion was to 20 degrees; and left lateral flexion was to 25 degrees with evidence of painful motion. Right and left lateral rotation was to 30 degrees with no objective evidence of pain. There was no functional loss or functional impairment and no muscle spasm. There was also no localized tenderness to palpation. There was no muscle atrophy and motor strength was normal. Sensory examination was also normal, and straight leg raising was negative. There were no signs or symptoms of radiculopathy. In considering the evidence of record, including the Veteran's assertions, the Board finds that the Veteran's increased rating claim must be denied. Prior to November 9, 2007, the clinical evidence shows that the Veteran's low back disability was manifest by virtually full range of motion of the thoracolumbar spine with some painful motion, including on repetitive testing. Consequently, the Veteran met the criteria for a 10 percent rating for rating arthritis for the period from June 24, 2005 through November 8, 2007. From November 9, 2007, the objective clinical evidence demonstrated more restrictive limitation of motion of the thoracolumbar spine, as detailed in the discussion of the examination reports above, and with pain on motion. Based on that objective clinical evidence, a 20 percent rating was assigned from that date. There were no additional factors demonstrated to warrant the assignment of a higher rating, such as persistent muscle spasms, abnormal gait, or more significant loss of range of motion demonstrated on the clinical evaluations as required for the next higher evaluation. Furthermore, these clinical evaluations indicate that the Veteran does not have neurological symptomatology, including radiculopathy, as a result of her low back disability. Hence, a separate rating based on neurological impairment is not warranted during the appeal period. In reaching its decision, the Board has considered the Veteran's statements. The Board finds that the Veteran is competent to report that she has pain. Charles v. Principi, 16 Vet. App. 370 (2002); see also, e.g., Layno v. Brown, 6 Vet. App. 465, 469 (1994) (a veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses). However, she is not competent to provide an opinion requiring medical knowledge, such as attributing those symptoms to specific disability rating criteria. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). As a result, her assertions cannot constitute competent medical evidence that her disability has increased in severity so as to warrant a higher evaluation. Here, the clinical evidence pertaining to the Veteran's low back disability is more probative for the purposes of assigning ratings in conjunction with the relevant rating criteria - and the Board finds that the pain and functional impairment reported has been appropriately considered in assigning the 10 and 20 percent ratings in effect during the appeal period. Finally, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, the Veteran's claim for higher ratings for a low back disability is denied. Left Shoulder Disability The Veteran is right-hand dominant; hence, her left upper extremity is her minor extremity. Her left shoulder disability has been rated 10 percent disabling from June 24, 2005 through November 13, 2011 and 20 percent disabling from November 14, 2011, pursuant to Diagnostic Code 5010. Degenerative or traumatic arthritis, established by X-ray findings, is rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. When, however, the limitation of motion of the 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 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. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (degenerative arthritis) and Diagnostic Code 5010 (traumatic arthritis) (2013). The Veteran's shoulder disabilities may be variously rated under the provisions of 38 C.F.R. § 4.71a, Diagnostic Codes 5003/5010, 5200, 5201, 5202, or 5203 (2013). Under Diagnostic Code 5203, malunion of a clavicle or scapula, or nonunion without loose movement, warrants a 10 percent rating. A 20 percent rating requires nonunion with loose movement or dislocation. These disabilities may also be rated on the basis of impairment of function of the contiguous joint. The 20 percent rating is the maximum rating available under Diagnostic Code 5203. 38 C.F.R. § 4.71a (2013). Under Diagnostic Code 5202, a 20 percent rating is warranted for malunion of the humerus of either upper extremity with moderate deformity, or with marked deformity of the minor upper extremity, or for infrequent episodes of recurrent dislocation of the scapulohumeral joint of either upper extremity with guarding of movement only at the shoulder level, or with frequent episodes of recurrent dislocation of the minor upper extremity with guarding of all arm movements. A 30 percent rating requires malunion of the major humerus with marked deformity or frequent episodes of recurrent dislocation with guarding of all arm movements. A 40 percent rating requires fibrous union of the minor humerus. A 50 percent rating requires fibrous union of the major humerus, or nonunion (a false, flail joint) of the minor humerus. A 60 percent rating requires nonunion (a false, flail joint) of the major humerus. A 70 percent rating requires loss of the head of the minor humerus (flail shoulder). An 80 percent rating requires loss of the head of the major humerus (flail shoulder). 38 C.F.R. § 4.71a (2013). Under Diagnostic Code 5201, a 20 percent rating is assigned for limitation of motion of either arm where motion is possible to the shoulder level, or where minor arm motion is possible to mid-way between the side and shoulder level. A 30 percent rating requires that major arm motion be limited to mid-way between the side and shoulder level, or that minor arm motion be limited to 25 degrees from the side. A 40 percent rating requires that major arm motion be limited to 25 degrees from the side. 38 C.F.R. § 4.71a (2013). Under Diagnostic Code 5200, a 20 percent rating is warranted for favorable ankylosis of the minor scapulohumeral articulation, with abduction possible to 60 degrees and the ability to reach the mouth and head. A 30 percent rating requires favorable ankylosis of the major scapulohumeral articulation, with abduction possible to 60 degrees and the ability to reach the mouth and head, or ankylosis of the minor scapulohumeral articulation which is intermediate between favorable and unfavorable. A 40 percent rating requires ankylosis of the major scapulohumeral articulation which is intermediate between favorable and unfavorable, or unfavorable ankylosis of the minor scapulohumeral articulation, with abduction limited to 25 degrees from the side. A 50 percent rating requires unfavorable ankylosis of the major scapulohumeral articulation, with abduction limited to 25 degrees from the side. 38 C.F.R. § 4.71a (2013). Standard ranges of shoulder flexion and abduction are from 0 to 180 degrees each, and external and internal rotation are from 0 to 90 degrees each. See 38 C.F.R. § 4.71, Plate I (2013). In determining whether the appellant has limitation of motion to shoulder level, it is necessary to consider forward flexion and abduction. See Mariano v. Principi, 17 Vet. App. 305, 314-316 (2003). Initially, the Board observes that it is neither contended nor shown that the Veteran's service-connected left shoulder disability involves ankylosis (Diagnostic Code 5200), malunion of a clavicle or scapula (Diagnostic Code 5203), or malunion of the humerus (Diagnostic Code 5202). Hence, a higher rating under any of those diagnostic codes may not be assigned for the left shoulder at any time during the rating period. In considering the evidence of record, including the Veteran's assertions, the Board finds that the Veteran's increased rating claim must be denied. Prior to November 14, 2011, the clinical evidence shows that the Veteran's left shoulder disability was manifest by range of motion greater than shoulder level, sometimes with complaints of pain. For example, upon VA examination in May 2005, flexion was to 180 degrees; abduction was to 180 degrees; external rotation was to 90 degrees; and internal rotation was to 90 degrees. There was no objective observance of pain on motion and no additional factors. Upon VA examination in December 2008, flexion was to 140 degrees; abduction was to 140 degrees; and external rotation was to 80 degrees. The Veteran declined testing of internal rotation. Upon VA examination in March 2010, flexion was to 105 degrees; abduction was to 95 degrees; external rotation was to 60 degrees; and internal rotation was to 45 degrees. Consequently, the Veteran met the criteria for a 10 percent rating for the period from June 24, 2005 through November 13, 2011 under Diagnostic Codes 5010-5201, and consideration of 38 C.F.R. §§ 4.40, 4.45 and DeLuca v. Brown, 8 Vet. App. 202 (1995). From the date of the Veteran's most recent VA examination, November 14, 2011, her left shoulder range of motion was clinically demonstrated to be more restricted. For example, her flexion was limited to 75 degrees with objective evidence of pain on motion. Based on that objective clinical evidence, a 20 percent rating was assigned from that date. There were no additional factors demonstrated to warrant the assignment of a higher rating. To require the next higher 30 percent rating, range of motion of a minor upper extremity must be limited to 25 degrees from the side. The clinical evidence in the file simply does not comport with such a finding, even with consideration of the Veteran's complaints of pain. In reaching its decision, the Board has considered the Veteran's statements. The Board finds that the Veteran is competent to report that she has pain. Charles v. Principi, 16 Vet. App. 370 (2002); see also, e.g., Layno v. Brown, 6 Vet. App. 465, 469 (1994) (a veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses). However, she is not competent to provide an opinion requiring medical knowledge, such as attributing those symptoms to specific disability rating criteria. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). As a result, her assertions cannot constitute competent medical evidence that her disability has increased in severity so as to warrant a higher evaluation. Here, the clinical evidence pertaining to the Veteran's left shoulder disability is more probative for the purposes of assigning ratings in conjunction with the relevant rating criteria - and the Board finds that the pain and functional impairment reported has been appropriately considered in assigning the 10 and 20 percent ratings in effect during the appeal period. Finally, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, the Veteran's claim for higher ratings for a left shoulder disability is denied. Rhinitis The Veteran's rhinitis is rated as noncompensable under Diagnostic Code 6522. Under Diagnostic Code 6522, a 10 percent rating is assigned for allergic or vasomotor rhinitis without polyps but with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side; a 30 percent rating is assigned if there are polyps. 38 C.F.R. § 4.97 (2013). VA treatment records consistently reflect findings of no nasal polyps. Although the Veteran uses medication consistently, the clinical findings, including on the most recent VA examination in November 2011, indicate that there is no permanent hypertrophy of the nasal turbinates, and there is not greater than 50 percent obstruction of the nasal passages on both sides or complete obstruction on one side. As such, the evidence of record does not support the assignment of a compensable rating for allergic rhinitis at any time during the appeal period: there is no evidence of polyps or any obstruction of a nasal passage, let alone greater than 50-percent obstruction of the nasal passage on both sides or complete obstruction on one side. The Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, the claim is denied. Extraschedular Consideration The Board has considered whether extraschedular consideration is warranted for any of the Veteran's disabilities during the appeal period. 38 C.F.R. § 3.321(b) (2012); Barringer v. Peake, 22 Vet. App. 242 (2008). The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disabilities are inadequate. There must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, and the assigned schedular rating is adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). Here, the record does not establish that the rating criteria are inadequate for rating the Veteran's service-connected knees, low back, left shoulder, and rhinitis disabilities. The competent medical evidence of record shows that her musculoskeletal disabilities primarily manifested by pain and limited motion, which are specifically contemplated by the rating criteria. Her rhinitis requires continuous medication but does not result in nasal blockage or functional impairment. Therefore, the Board finds that the effects of the Veteran's disabilities have been fully considered under the appropriate schedular rating criteria, which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology for each of the disabilities decided herein. Thus, referral for extraschedular ratings are unnecessary at this time. Furthermore, the evidence does not show marked interference with employment or frequent hospitalization due to the disabilities at issue. Therefore, the Board finds that referral for consideration of an extraschedular rating is not warranted. 38 C.F.R. § 3.321(b) (2013). ORDER An initial rating in excess 10 percent disabling for a left knee disability from June 24, 2005 to March 8, 2006 and from May 1, 2006 is denied. An initial rating in excess of 10 percent for a right knee disorder is denied. An initial rating in excess of 10 percent for low back disorder from June 24, 2005, to November 8, 2007; and in excess of 20 percent from November 9, 2007 is denied. An initial rating in excess of 10 percent for a left shoulder disability from June 24, 2005 to November13, 2011, and in excess of 20 percent from November 14, 2011 is denied. An initial compensable rating for rhinitis is denied. REMAND In the October 2011 remand, the Board directed that the Veteran be afforded a VA examination complete with pulmonary function tests in order to ascertain the current severity of her service-connected asthma. She was afforded an examination in November 2011; however, pulmonary function tests were specifically not performed, and an explanation for the non-performance was not made. Therefore, a remand is necessary. A remand by the Board confers on a claimant the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268 (1998) (). The issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities is inextricably intertwined with the issue of entitlement to a higher rating for asthma. Harris v. Derwinski, 1 Vet. App. 180 (1990) (issues are inextricably intertwined when they are so closely tied together that a final Board decision cannot be rendered unless all are adjudicated). Therefore, a decision on that claim must be deferred pending the development needed as discussed below. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case is REMANDED for the following actions: 1. Obtain the names and addresses of all medical care providers who treated the Veteran for asthma since November 2011. After securing the necessary release, obtain those records. 2. Schedule the Veteran for a VA pulmonary examination to assess the severity of asthma. The examiner must review the claims folder and that review must be noted in the report. All indicated tests and studies should be performed, to include pulmonary function tests, and all findings should be set forth in detail as required by the rating criteria. The examiner should also describe all symptoms and manifestations attributable to the asthma. 3. Then readjudicate the claims. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the claim to the Board. 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. 2013). ______________________________________________ Lesley A. Rein Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs