Citation Nr: 1339181 Decision Date: 11/27/13 Archive Date: 12/13/13 DOCKET NO. 07-35 181 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a left carpal tunnel syndrome disorder with degenerative changes in the first metacarpophalangeal joint (thumb), to include as secondary to service-connected recurrent dislocation of the left shoulder, postoperative, with degenerative arthritis. 2. Entitlement to service connection for a left elbow disorder with a bone spur, to include as secondary to service-connected recurrent dislocation of the left shoulder, postoperative, with degenerative arthritis. 3. Entitlement to an increased rating for a recurrent dislocation of the left shoulder, postoperative, with degenerative arthritis, currently evaluated as 20 percent disabling. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran served on active duty from February 1975 to February 1979. This appeal comes to the Board of Veterans' Appeals (Board) on an appeal from an October 2006 rating determination of the Department of Veterans Affairs (VA) Regional Office (RO) located in Denver, Colorado. In April 2011, the Veteran was afforded a Travel Board hearing at the RO before the undersigned Acting VLJ (AVLJ). A transcript of the hearing is currently of record in the claims file. In February 2012, the Board remanded this matter for further development. The requested development has been completed insofar as possible and the matter is now ready for appellate review. FINDINGS OF FACT 1. The weight of the evidence is against a finding that left carpal tunnel syndrome disorder with degenerative changes in the first metacarpophalangeal joint (thumb) either began during or was otherwise caused by the Veteran's military service, or is secondary to or aggravated by his service-connected left shoulder disorder. 2. The weight of the evidence is against a finding that a left elbow disorder with a bone spur either began during or was otherwise caused by the Veteran's military service, or is secondary to or aggravated by his service-connected left shoulder disorder. 3. For the entire increased rating period on appeal, and having considered the impact of functional limitations such as pain, the Veteran's service-connected left shoulder disability was not shown to have restricted the range of motion of the shoulder to 25 degrees from the side. 4. The left shoulder disability has not been shown to cause fibrous union of the arm, nonunion (false flail joint), flail shoulder, or ankylosis of the left shoulder. CONCLUSIONS OF LAW 1. Left carpal tunnel syndrome disorder with degenerative changes in the first metacarpophalangeal joint (thumb) was not incurred in or aggravated by service nor may it be presumed to have been incurred in service nor is it proximately due to or the result of a service-connected disability. 38 U.S.C.A. §1101, 1110, 1112 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2013). 2. A left elbow disorder with a bone spur was not incurred in or aggravated by service nor may it be presumed to have been incurred in service nor is it proximately due to or the result of a service-connected disability. 38 U.S.C.A. § 1101, 1110, 1112 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2013). 3. For the entire increased rating period, the criteria for a disability rating in excess of 20 percent for recurrent dislocation of the left shoulder, postoperative, with degenerative arthritis have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5200-5203 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a). 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; (3) and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). As it relates to all issues, a VCAA notice letter sent in August 2006 satisfied the provisions of 38 U.S.C.A. § 5103(a). In this letter, VA informed the Veteran about the information and evidence not of record that was necessary to substantiate the claim; the information and evidence that VA would seek to provide; the information and evidence the Veteran was expected to provide; and the information on disability ratings and effective dates required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Furthermore, neither the Veteran, nor his representative, has either alleged, or demonstrated, any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders, 129 U.S. 1696 (2009) (clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). Thus, adjudication of his claim at this time is warranted. The Board finds that there has been substantial compliance with the assistance provisions set forth in the law and regulations. The record in this case includes VA and private treatment records, VA examination reports, and lay evidence. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c). No additional pertinent evidence has been identified by the claimant as it relates to the claimed disorders. As it relates to the left shoulder, the Veteran was afforded VA examinations in September 2006 and May 2012. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Given that the examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the Board finds the examinations to be adequate for rating purposes. Moreover, neither the Veteran, nor his representative, has asserted that the recent examination was inadequate. In the representative's brief, it was noted that the Veteran had stated that his left shoulder disability was progressively worsening, and that his disability picture was worse than currently rated, but there has been no allegation that his disability had materially worsened since the 2012 shoulder examination. As it relates to the left elbow, left carpal tunnel syndrome, and left thumb claims, the Board notes that the Veteran was afforded VA examinations in September 2006 and May 2012, and an addendum to the May 2012 examination report was provided in August 2012. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Given that the examination reports set forth detailed examination findings in a manner which allows for informed appellate review and provide the necessary opinions to properly address the Veteran's claims, as well as comply with the Board remand directives, Board finds the examinations to be adequate for rating purposes. Here too, neither the Veteran, nor his representative, has either alleged, or demonstrated, that the VA examinations taken in their totality are inadequate for rating purposes. The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claim, including by submission of statements and by appearing at the April 2011 Travel Board hearing. For these reasons, it is not prejudicial to the Veteran for the Board to proceed to finally decide the appeal. In the Board's February 2012 decision and remand, it was acknowledged that the Veteran was currently receiving disability benefits from the Social Security Administration (SSA) for disabilities unrelated to this current appeal. He was specifically asked at his hearing if his SSA claim involved any evidence that might possibly involve his shoulder, elbow or wrist claims, but the Veteran assured the Board that they did not. As a general matter, VA is required to obtain pertinent federal government records, including medical records held by SSA. 38 C.F.R. § 3.159(c)(2). In Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010), however, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that SSA records must only be sought when potentially relevant to the claim. The Board finds that the Veteran's SSA records are not relevant to the claims currently on appeal, and thus a remand to obtain these records is not necessary. It is noted that neither the Veteran nor his representative objected to this conclusion in the 2012 decision, and the representative did not suggest in the September 2013 brief that SSA records should be obtained here. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating this claim. Service Connection-General Criteria Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Arthritis has been determined a policy matter by VA to be a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303(b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as arthritis become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, at 448 (1995) (holding that service connection on a secondary basis requires evidence sufficient to show that the current disability was caused or aggravated by a service-connected disability). To establish secondary service connection, the law states that there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between a service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); see also Jandreau, 492 F.3d 1372, and Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Left Carpal Tunnel Syndrome Disorder with degenerative thumb In January 2006, the Veteran filed a claim indicating that he was applying for a higher disability percentage, and when asked why he felt it was warranted, he indicated that he had swelling in his left hand and thumb. In February 2006, he wrote that he was concerned about the arthritis problems in his left elbow and hand. In his substantive appeal in October 2008, the Veteran suggested that because of the impact of the injury in service, he was experiencing other problems later in life. These statements were taken as a claim for left carpal tunnel syndrome with degenerative changes in the thumb. This claim will be considered on both direct and secondary bases. It is noted that service connection is currently in effect for a recurrent dislocation of the left shoulder, postoperative, with degenerative arthritis. A review of the Veteran's service treatment records reveals that there were no complaints or findings related to either the left wrist or hand in service. The Veteran was seen and treated for his left shoulder on numerous occasions during service but there were no complaints or findings related to the left hand and/or wrist. There were also no complaints or findings of left wrist or left hand problems during the years immediately following service. At March and May 1979 VA examinations, just months after separating from service, the Veteran did not report having any complaints relating to his left wrist or hand. The first diagnosis of carpal tunnel syndrome was not until 1997, nearly 20 years after service, when the Veteran was actually diagnosed with bilateral carpal tunnel syndrome. At the time of a June 2001 VA examination, the Veteran reported that his carpal tunnel syndrome problems started in 1996. He indicated that while working at a grocery warehouse, he had the feeling that both of his arms were on fire and he filed for and reportedly received worker's compensation based on this bilateral wrist condition. In conjunction with his claim, the Veteran was afforded a VA examination in September 2006. Following examination, diagnoses of left ulnar extremity neuropathy and carpal tunnel syndrome with degenerative changes on x-ray of the thumb were rendered. The examiner stated that it was not at least as likely as not that the Veteran's current left hand conditions and ulnar and median neuropathies were caused by or residuals from his left shoulder injury which occurred in service. He noted that there was no evidence of treatment in the service medical records for the hand or forearm while in the military. The examiner indicated that the Veteran had extensive work-ups for on-the-job injury related symptoms occurring in the 1990s. The examiner stated that the Veteran's hand condition was unlikely related to an injury to the shoulder occurring decades earlier. At his April 2011 hearing, the Veteran testified that his left carpal tunnel syndrome problems first began in the early 1990s. He acknowledged that no physician had ever indicated that his carpal tunnel syndrome was related to his period of service, and he denied having received any treatment for his left wrist or hand in service. In conjunction with the Board remand, the Veteran was afforded a VA examination in May 2012. Following examination, the examiner opined that the Veteran's left carpal tunnel syndrome was not aggravated by his service-connected left shoulder disorder. The examiner indicated that it was the natural history of carpal tunnel syndrome to worsen over time for most individuals. She noted that while it was possible for carpal tunnel syndrome to worsen beyond its natural progression, such aggravation was typically due to repetitive wrist and hand activities and to relative overuse. She observed that the Veteran reported that because of the progressively worsening left shoulder symptoms, he has been using the left upper limb much less than the right side for years. Hence, the left carpal tunnel syndrome could not be due to relative overuse, and underuse did not cause progression/aggravation of carpal tunnel syndrome. She further noted the fact that the Veteran had developed bilateral carpal tunnel syndrome argued against the claim that his left carpal tunnel syndrome had been aggravated by his service-connected left shoulder condition. The examiner also indicated that the Veteran's left carpal tunnel syndrome did not begin or was otherwise caused by his military service. She noted that the service treatment records did not demonstrate complaints of left wrist problems in service and there was no documentation of any nerve-related problems in service. The examiner noted that the Veteran was followed for his left shoulder on numerous occasions during service and had multiple opportunities to bring up any concerns related to the left upper limb, including the peripheral nerves, be he did not report the onset of his carpal tunnel syndrome until the mid 1990s. She indicated that this span of time made it difficult to attribute the carpal tunnel syndrome to his period of service. At the time of an August 2012 VA examination, the Veteran was diagnosed as having degenerative joint disease of the thumb. Following examination, the examiner indicated that it was not as likely as not that the Veteran's left thumb condition was aggravated by his service-connected left shoulder disorder. She noted that degenerative joint disease typically occurred with aging and overuse. In this case, the Veteran was 58 years old at the time of the examination, which the examiner explained was old enough for the effects of aging on the joints to have become manifest. Hence, age was likely the key explanatory factor. The examiner also observed that the Veteran had reported less use of his left limb over the years on account of his left shoulder disorder. Hence, the left thumb could not be due to overuse. She explained that underuse did not cause degenerative joint disease. The examiner indicated that there was no causal relationship between the Veteran's service-connected left shoulder condition and his claimed left thumb condition. The examiner also opined that the Veteran's left thumb condition did not begin in service and was not caused by his military service. She indicated that per the service treatment records, there was no documentation of any complaints regarding, diagnoses given, or treatment for the left thumb. She further observed that during military service the Veteran was regularly followed for the left shoulder and had multiple opportunities to bring up the left thumb, but no such concerns or complaints were noted in the treatment records. The examiner observed that the Veteran reported to her that he first noted thumb problems six years earlier, which would place the onset decades after service. She also observed that x-rays taken of the hands in 2001 were normal and that x-rays taken in 2006 revealed severe degenerative changes in the first joint of the left hand. She stated that it was important to note that the Veteran was discharged from the military in 1979. Hence, a number years passed between the end of his military service and the onset of his left thumb symptoms, and this span of time made it difficult to attribute his claimed left thumb degenerative joint disease to any event that occurred in service. Service connection for a left carpal tunnel syndrome and degenerative joint disease of the thumb is not warranted. Based on the evidence of record, lay and medical, the Board finds that the weight of the evidence does not demonstrate that the Veteran had chronic symptoms related to the left carpal tunnel syndrome or degenerative joint disease of the thumb in service or continuous symptoms since service. The service treatment records do not show complaints, findings, or a diagnosis of a left wrist/carpal tunnel or left thumb problems during service. There were no diagnoses of a left wrist/carpal tunnel syndrome or left thumb disorders in service or within the one year following service. The first post service complaints of elbow problems did not occur for nearly two decades after service. For example, in a May 1998 VA treatment records, it was noted that the Veteran had experienced numbness and tingling in his left hand for approximately two years (and had begun experiencing the same symptoms in his right hand six months earlier). Moreover, contemporaneous evidence, such as the 2001 VA examination, noted that the onset of carpal tunnel syndrome was in approximately 1997 in conjunction with a job at that time. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (noting that contemporaneous evidence has greater probative value than history as reported by a veteran). Additionally, x-rays of the thumb in 2001 did not show degenerative changes, whereas x-rays in 2006 did. While the Veteran's statements and testimony have generally attempted to link his carpal tunnel syndrome and left thumb problems to the same injury which caused his left shoulder disorder, the contemporaneous evidence in the service treatment records do not show complaints of, or a diagnosis of, a left wrist/carpal tunnel or left thumb disorders in service. In addition, the evidence includes the May and November 2012 VA examination reports in which the VA examiner thoroughly reviewed the record but concluded that the Veteran did not have symptoms/signs of left wrist/carpal tunnel problems or left thumb problems in service, with the examiner providing specific detail as to why the Veteran did not have left wrist/carpal tunnel or left thumb manifestations in service or within the one year period following service. Therefore, the weight of the evidence does not demonstrate chronic symptoms of a left thumb or left wrist/carpal tunnel disorders during service. The Board finds that the Veteran did not have continuous symptoms of left thumb or left wrist/carpal tunnel disabilities since service. The first post-service medical evidence of carpal tunnel syndrome was not shown until 1997 and the first notation of left thumb degenerative joint disease was not shown until 2006. The Board finds that the Veteran's non-reporting of left thumb or left wrist/carpal tunnel problems at numerous VA examinations performed in close proximity to service and the lack of any treatment for symptoms possibly related to a left wrist/carpal tunnel syndrome or left thumb problems until decades after service, is also highly probative. The Veteran has through the course of his appeal voiced some assertions that his wrist and thumb problems may be related to his service connected shoulder disability or to the fall, but he has not described experiencing left thumb or wrist symptoms during service, or for a number of years after service. As such, the evidence simply does not show chronic wrist or thumb symptoms in service or within a year of service, and it does not show a continuity of symptoms since service regarding the claimed left thumb or left wrist/carpal tunnel syndrome. Thus, presumptive service connection is not warranted. Service connection may also be proven by establishing a nexus between a current disability and either service or a service connected disability. As to the Veteran's belief that his current left thumb and left carpal tunnel syndrome are related to his period of service, including his traumatic fall, or his left shoulder disability, the Board acknowledges the holding of the U.S. Court of Appeals for the Federal Circuit in Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Here, the question of causation extends beyond an immediately observable cause-and-effect relationship. For example, the diagnosis of degenerative joint disease in the thumb was based on the interpretation of x-ray images. With carpal tunnel syndrome, the Veteran is considered competent to observe the symptoms of carpal tunnel syndrome, such as burning, but determining a diagnosis for, or cause of, the symptoms requires medical training and expertise. Likewise, the determination of the etiology of both conditions is a medically complex determination that requires advanced knowledge of the mechanical systems of the body. Here, the Veteran has not been shown to have the requisite medical qualifications and/or training to address etiology of either his thumb or wrist disabilities. Nevertheless, service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. When evaluating the weight of medical evidence, the Board is guided by the principle that the probative value of a medical opinion largely rests upon the extent to which such opinion is based upon a thorough evaluation of the Veteran's medical history, including but not limited to the medical evidence contained in the claims file. See, e.g. Miller v. West, 11 Vet. App. 345, 348. The Board may examine the factual foundation of a medical opinion, including whether the physician had access to relevant information of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). In the current case, the Veteran has not submitted any medical evidence specifically indicating that his current left thumb disorder or left carpal tunnel syndrome is related to his period of service. Nevertheless, in an effort to assist the Veteran in establishing service connection, the Board did obtain VA opinions to investigate the nature of the Veteran's current left thumb and left carpal tunnel syndrome and their relationship, if any, to his period of service. The VA examiner's opinions specifically found that the Veteran's current left thumb and left carpal tunnel syndrome are unrelated to his period of service. The examiner provided specific detail in support of the opinions, including citing to service treatment records and post-service treatment records. The VA examiner was fully aware of the Veteran's past medical history. Moreover, her opinion has not been questioned or undermined by any other medical opinion. Thus, the Board finds this opinion to be highly probative and entitled to great weight. In sum, the evidence weighs against a finding that the Veteran's left thumb degenerative joint disease developed in service or in the one year period following service, or that it has been continuous since service. Moreover, the evidence is against a finding that the degenerative joint disease in the thumb and/or the left carpal tunnel syndrome is related to either service on a direct basis or as secondary to his service connected left shoulder disability. As it relates to the statements from the Veteran asserting a nexus between his left carpal tunnel syndrome and left thumb and his service-connected left shoulder disorder, the Board again acknowledges Jandreau; here, however, the question of causation extends beyond an immediately observable cause-and-effect relationship and, as such, the Veteran is not competent to address etiology in the present case. The May and August 2012 VA examiner, following a review of the claims folder, which included the Veteran's statements and testimony, and a comprehensive examination of the Veteran, indicated that it was less likely as not that his current left carpal tunnel syndrome and left thumb degenerative joint disease were related to his service-connected left shoulder disorder, either on a secondary basis or on the basis of aggravation. The examiner provided detailed rationale for her opinions, and her opinion has not been questioned by any medical evidence of record. It is therefore found to be highly probative and entitled to great weight. In sum, the preponderance of the evidence weighs against a finding that the Veteran's left carpal tunnel syndrome and left thumb degenerative joint disease were caused or aggravated by his service-connected left shoulder disorder. As the preponderance of the evidence is against the claims, the benefit of the doubt rule is not applicable. Accordingly, the Veteran's claim is denied. Left Elbow Disorder with a Bone Spur As with the left wrist and thumb, the Veteran similarly has provided vague statements that his left elbow disability is the result of either his period of service, having been injured at the same time that he injured his left shoulder, or that it was either caused or aggravated by his service-connected left shoulder disorder. A review of the Veteran's service treatment records reveals that there were no complaints or findings related to the left elbow in service. The Veteran was seen and treated for his left shoulder on numerous occasions during service but there were no complaints or findings related to the left elbow. There were also no complaints or findings of left elbow problems during the years immediately following service. At the time of March and May 1979 VA examinations, the Veteran did not report having any complaints relating to his left elbow. The first diagnosis of a left elbow disorder was not until 1997. In a January 1999 VA treatment record, it was noted that the Veteran had experienced left elbow pain for two years. In conjunction with his claim, the Veteran was afforded a VA examination in September 2006. Following examination, a diagnosis of left ulnar extremity neuropathy was rendered. The examiner stated that it was not at least as likely as not that the Veteran's current left elbow condition was caused by or residuals from the left shoulder injury which occurred in service. He noted that there was no evidence of treatment in the service medical records for the left elbow while in the military. The examiner stated that the Veteran had extensive work-ups for on-the-job injury related symptoms occurring in the 1990s. He indicated that Veteran reported that his elbow symptoms started about 1.5 years earlier. The examiner stated that the Veteran's elbow condition was unlikely related to an injury to the shoulder occurring decades earlier. At his April 2011 hearing, the Veteran testified that his left elbow problems first began in the 1980s, probably 1986 (although such a contention is questionable given the treatment records from 1999 showing elbow problems for only two years). He denied that any physician had ever indicated that his left elbow disorder was related to his period of service. The Veteran also denied receiving any treatment for his left elbow in service. At the May 2012 VA examination, the examiner opined that the Veteran's left elbow disorder was not aggravated by his service-connected left shoulder disorder. The examiner stated that the Veteran had early degenerative joint disease and chronic lateral epicondylitis (referred to as tennis elbow or tendonitis in the record). She indicated that while it was possible for degenerative joint disease and lateral epicondylitis to worsen beyond their natural progression, such aggravation was typically due trauma, including microtrauma due to relative overuse. She noted that the Veteran reported that because of the progressively worsening left shoulder symptoms, he had been using the left upper limb much less than the right side for years. Hence, the left elbow disorder could not be due to the relative overuse, and underuse did not cause progression/aggravation of degenerative joint disease or chronic epicondylitis. She further noted the fact that the Veteran had developed bilateral epicondylitis argued against the claim that his left elbow condition had been aggravated by his service-connected left shoulder condition. The examiner also indicated that the Veteran's left elbow did not begin or was otherwise caused by his military service. She noted that the service treatment records did not contain any complaints of left elbow problems in service and there was no documentation of any nerve-related problems of the left upper limb in service. The examiner noted that the Veteran was followed for his left shoulder on numerous occasions during service and had multiple opportunities to bring up any concerns related to the left upper limb, including the peripheral nerves. The Veteran did not report the onset of his left elbow problems until the mid 1980s. She stated that this span of time made it difficult to attribute the left elbow problems to his period of service. Service connection for a left elbow disorder is not warranted. Based on the evidence of record, lay and medical, the Board finds that the weight of the evidence is against a finding that the Veteran had chronic left elbow symptoms in service or continuously since service. The service treatment records do not show complaints, findings or a diagnosis of a left elbow problem; and the Veteran specifically denied having any elbow problems in service. There were no diagnoses of a left elbow disorder in service or within the one year following service. The earliest indication of any left elbow problems was not until the mid 1980s, as reported by the Veteran at his hearing. As noted, the onset appears to be later than that, but even if 1986 were accepted as the onset of elbow problems, it would still place the onset years after service. To the extent that the Veteran now contends that his left elbow problems resulted from the same injury which caused his left shoulder disorder, he testified that he did not actually specifically remember any elbow component to the in-service fall that caused the left shoulder disability; and the evidence generated contemporaneously with service does not show complaints or a diagnosis of a left elbow problem during service. Likewise, no left elbow problems were noted at a VA examination in 1979, several months after separation. In addition, the evidence includes the May 2012 VA examination report. The VA examiner thoroughly reviewed the record and stated that the Veteran did not have symptoms/signs of left elbow problems in service, with the examiner providing specific detail as to why the Veteran did not have left elbow manifestations in service or within the one year period following service. Therefore, the weight of the evidence does not demonstrate chronic symptoms of a left elbow disorder during service or within a year of service. The Board finds that the Veteran did not have continuous symptoms of a left elbow disability. The first post-service evidence of left elbow problems did not appear for many years following service. As such, the weight of the credible and probative evidence does not demonstrate chronic left elbow symptoms in service or continuity of symptoms since service. As noted above, even when a condition has not been continuous since service, service connection may still be awarded by nexus evidence. To the extent that the Veteran believes that his current left elbow problem, which he acknowledges began years after separation, resulted from the traumatic fall in service, or as a secondary result of his left shoulder disability, such determinations extend beyond an immediately observable cause-and-effect relationship and, as such, the Veteran is not shown to possess the required expertise to render such an opinion as etiology in the present case. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. In the current case, the Veteran has not submitted any medical evidence specifically indicating that his current left elbow disorders are related to his period of service. In contrast, the Board obtained a VA opinion as to the nature of the Veteran's current left elbow disorders and their relationship, if any, to his period of service. The VA examiner's opinion specifically found that his current left elbow disorders are unrelated to his period of service. The examiner provided specific detail in support of the opinions, to include her citing to service treatment records and post-service treatment records. There was no indication that the VA examiner was not fully aware of the Veteran's past medical history or that she misstated any relevant fact. Thus, the Board finds this opinion to be the most probative evidence of record and it is entitled to great weight. Next, service connection may be granted when the evidence establishes a medical nexus between a service-connected disability and current complaints. The May 2012 VA examiner, following a review of the claims folder, which included the Veteran's statements and testimony, and a comprehensive examination of the Veteran, indicated that it was less likely as not that his current left elbow disorders were related to his service-connected left shoulder disorder. The examiner provided detailed rationale for her opinions, and her opinions have not been questioned by any other medical evidence of record. Based upon the above, the Board finds the examiner's opinion to be highly probative and entitled to great weight. In sum, the weight of the evidence conclusively shows that it is less likely than not that the Veteran's left elbow degenerative joint disease or left epicondylitis were either caused or aggravated by either his time in service or his service-connected left shoulder disorder. As noted by the examiner, the Veteran developed bilateral elbow problems, not just elbow problems in the arm with a service connected shoulder problem. Additionally, the examiner explained that the Veteran's left shoulder disability was unlikely to have aggravated his left elbow disability, because the elbow problem he experiences is caused by over use, and the Veteran has indicated that he does not use his left arm much on account of the shoulder disability. As described, the evidence of record shows that the Veteran's left elbow disability onset years after separation, was not caused by the incident in service in which he injured his left shoulder, and was not secondary to or aggravated by his left shoulder disability. Therefore, the criteria for service connection have not been met, and the Veteran's claim is denied. Left Shoulder Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. As is the case here, where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is the inability to perform normal working movement with normal excursion, strength, speed, coordination, and endurance. Weakness is as important as limitation of motion, and a part which becomes disabled on use must be regarded as seriously disabled. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is to be considered in evaluating the degree of disability, but a little-used part of the musculoskeletal system may be expected to show evidence of disuse, through atrophy, the condition of the skin, absence of normal callosity, or the like. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. § 4.45 contemplate inquiry into whether there is crepitation, limitation of motion, weakness, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing are also related considerations. It is the intention of the rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as at least minimally compensable. See also DeLuca v. Brown, 8 Vet. App. 202 (1995) (indicates that pursuant to 38 C.F.R. §§ 4.40 and 4.45, pain may be the basis for a rating for a disability rated based on limitation of motion, regardless of whether or not the limitation of motion specified in the Diagnostic Code criteria is shown). With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to the affected joints. The intent of the rating 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. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. 38 C.F.R. § 4.59. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). As it relates to the left shoulder, the codes overlap in that some form of movement is contemplated with regard to each applicable code. Thus, the Veteran will be rated under the most appropriate code to determine if an increased disability evaluation is warranted. The Veteran is in receipt of a 20 percent rating for his service-connected left shoulder disability under the provisions of 38 C.F.R. § 4.71a , DC 5201. Under DC 5201 (arm, limitation of motion of), a 20 percent rating is available where limitation is at shoulder level or midway between side and shoulder level. A 30 percent rating for the minor shoulder is available where limitation is to 25 degrees from the side. The Federal Circuit has established that the plain language of section 4.71a confirms that a veteran is only entitled to a single disability rating under diagnostic code 5201 for each arm that suffers from limited motion at the shoulder joint. The diagnostic code does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to "limitation of motion of" the arm. Yonek v. Shinseki, 722 F.3d 1355 (Fed. Cir. 2013). Under Diagnostic Code 5202, for impairment of the humerus in the minor arm, a 20 percent rating is granted when there is malunion, with moderate deformity or marked deformity. Also under Diagnostic Code 5202, for recurrent dislocations at the scapulohumeral joint, a 20 percent rating is granted with infrequent episodes, and guarding of movement only at shoulder level; or for frequent episodes and guarding of all arm movements. A 40 percent rating is warranted for fibrous union of the arm and a 50 percent rating is granted for nonunion (false flail joint) of the minor arm; a 70 percent rating is granted for loss of head of (flail shoulder) for the minor arm. Under Diagnostic Code 5203, for impairment of the clavicle or scapula in the major or minor arm, a 10 percent rating is granted for malunion or nonunion without loose movement; a 20 percent rating is granted for nonunion with loose movement or for dislocation. Plate I under 38 C.F.R. § 4.71a reveals that shoulder level is equivalent to 90 degrees of shoulder forward flexion or abduction. The Veteran's dominant arm is his right arm. Therefore, his service-connected left shoulder is the minor appendage. In conjunction with his claim, the Veteran was afforded a VA examination in September 2006. Examination of the left shoulder revealed symmetrical musculature when compared to the right. There was no tenderness of spasm. The Veteran had onset of pain at 47 degrees of abduction, with full adduction to 88 degrees. Onset of pain was observed at 70 degrees of flexion with full forward flexion to 98 degrees. The Veteran had 28 degrees of external motion and 18 degrees of internal motion. After repetitive motion, the Veteran's abduction remained the same and his forward flexion decreased to 87 degrees. His external motion decreased to 23 degrees and his internal motion increased to 40 degrees. At the time of an August 2009 outpatient visit, the Veteran was noted to have full range of motion for both shoulders. He was able to abduct to 120 degrees and able to maintain the strength of the joint against resistance. Point tenderness was noted at the subacromion and posterior. The Veteran testified in 2006 that his left arm had changed considerably since his examination in 2006. He stated that he could not raise his hand above his head. He indicated that he was taking medication for his left shoulder pain. It was noted at the hearing that the Veteran's flexion was limited, and the abduction was slightly less limited. In conjunction with the February 2012 Board remand, the Veteran was afforded a VA examination in May 2012 to assess the current nature of the Veteran's left shoulder disability. A diagnosis of left shoulder recurrent dislocation status post-surgical repair, with residuals scar, pain, and decreased range of motion was rendered. The Veteran reported a progressive worsening of left shoulder pain and stiffness. He stated that he was unable to reach overhead or lift anything overhead with the left side. He noted experiencing pain reaching forward and as a result tended to drive with one hand. The Veteran stated that he did not have any catching, locking, or clicking. The Veteran indicated that he had not had any shoulder dislocations since undergoing surgery in 1977. He stated that he did not have any flare-ups. Left shoulder flexion was to 90 degrees, with pain beginning at 50 degrees. Left shoulder abduction was to 90 degrees with pain beginning at 60 degrees. Range of motion for flexion and abduction did not change with repetitive motion. The Veteran's function limits were noted as less movement than normal, weakened movement, and pain on movement. Muscle strength was 4/5 with abduction and forward flexion. There was no ankylosis present. The Veteran did not have an AC joint condition or other impairment of the clavicle or scapula. The scar was noted to be asymptomatic and measured 8 cm x .2 cm. The scar was completely intact and nontender. The scar was not disfiguring and did not affect shoulder range of motion. The examiner again indicated that the Veteran had not suffered any shoulder dislocations or subluxations since service. As to DC 5201, as demonstrated above, there has been no demonstration of limitation of motion of the left arm to 25 degrees from side. The Board has reviewed the Veteran's multiple statements to the effect that the examiners have not fully appreciated the limitations caused by his left shoulder disability. However, at follow-up VA examinations, the Veteran demonstrated range of motion in his left arm which greatly exceeded 25 degrees from the side. The Board has considered whether a higher disability rating is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. 202. Here, the Board notes the Veteran's reported impairment of function and has considered additional limitations of motion due to pain or other orthopedic factors as limiting motion where the pain begins or where the evidence shows such factors limit functional use. See VAOPGCPREC 9-98 (painful motion is considered limited motion at the point that the pain actually sets in). While the Board notes that pain was reported on examination, there was no demonstration that pain or other functional limitations effectively caused the range of motion in his left arm to be limited to 25 degrees or fewer from the side at any time. In fact, at his most recent VA examination, pain did not begin with abduction until 60 degrees and did not begin with flexion until 50 degrees. Thus, he demonstrated pain-free motion that greatly exceeded 25 degrees from his side. Moreover, limitation of motion did not increase following repetitive motion. The specific clinical measures of ranges of motion, including examiners' findings and opinions regarding additional limitations of motion due to such factors, have been weighed and considered by the Board. Such specific measures and findings are of more probative value in determining specific ranges of motion than are general histories or general descriptions of symptoms of pain. As to DC 5202, as noted above, there has been no demonstration of fibrous union of the arm, nonunion (false flail joint), or flail shoulder. As such, an evaluation in excess of 20 percent would not be warranted. The maximum rating under DC 5203 for impairment of the clavicle or scapula is 20 percent; therefore, DC 5203 would not provide an increased rating. For these reasons, the Board finds the schedular criteria for a rating in excess of 20 percent for left shoulder disability have not been met or more nearly approximated for any distinct period of the increased rating claim. Because the weight of the evidence shows that the Veteran's service-connected left shoulder disability did not manifest limitation of motion of the left arm 25 degrees from the side; and did not manifest fibrous union, nonunion, or ankylosis of the left shoulder at any time during the increased rating period, an increased rating in excess of 20 percent is not warranted for any period. 38 C.F.R. § 4.71a, DCs 5200-5203. For these reasons, the Board finds that the weight of the evidence is against a finding of an increased rating in excess of 20 percent for left shoulder disability. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has considered whether an extraschedular evaluation would have been warranted for the Veteran's left shoulder disability. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. However, in this case, the evidence fails to show anything unique or unusual about the Veteran's left shoulder disability. There is no dispute that the condition is symptomatic. However, the main symptoms are pain and the resulting limitation of motion, which have both specifically been contemplated in this case. Comparing the Veteran's disability level and symptomatology to the rating schedule, the degree of disability throughout the appeal period under consideration is contemplated by the rating schedule. The Veteran's left shoulder disability corresponds to the schedular criteria for the assigned disability evaluations, which also incorporates various orthopedic factors that limit motion or function. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. The schedular rating criteria also provide a higher rating for greater limitation of motion. For this reason, the Board finds that the assigned schedular rating is adequate to rate the Veteran's left shoulder residuals and no referral for an extraschedular rating is required. ORDER Service connection for a left carpal tunnel syndrome disorder with degenerative changes in the first metacarpophalangeal joint (thumb), to include as secondary to service-connected recurrent dislocation of the left shoulder, postoperative, with degenerative arthritis, is denied. Service connection for a left elbow disorder with a bone spur, to include as secondary to service-connected recurrent dislocation of the left shoulder, postoperative, with degenerative arthritis, is denied. An evaluation in excess of 20 percent for recurrent dislocation of the left shoulder, postoperative, with degenerative arthritis is denied. ____________________________________________ MATTHEW W. BLACKWELDER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs