Citation Nr: 1339525 Decision Date: 12/02/13 Archive Date: 12/13/13 DOCKET NO. 07-39 598 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a right shoulder disability, claimed as secondary to a service-connected left knee disability. 2. Entitlement to a compensable rating for shortening of the left leg as secondary to a service-connected left knee disability. REPRESENTATION Appellant represented by: James G. Fausone, Attorney at Law WITNESSES AT HEARING ON APPEAL Veteran and his wife ATTORNEY FOR THE BOARD M. Young, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from February 1964 to February 1967. These matters are before the Board of Veterans' Appeals (Board) on appeal from May 2007 and March 2010 rating decisions by the Roanoke, Virginia Department of Veterans Affairs (VA) Regional Office (RO). The May 2007 rating decision, in pertinent part, denied service connection for right shoulder disability. In July 2009, a Travel Board hearing was held before the undersigned; a transcript of the hearing is associated with the claims file. In October 2009 and December 2011, the Board remanded the matter of service connection for a bilateral shoulder disability for additional development. A March 2010 rating decision granted service connection for shortening of the left leg, rated 0 percent, effective July 28, 2009. On his May 2010 VA Form 9 (Substantive Appeal), the Veteran requested a Board videoconference hearing regarding that matter. By August 2012 letter, the Veteran's attorney withdrew the request. A July 2012 rating decision granted service connection for left shoulder rotator cuff tear, rated 0 percent, effective June 28, 2007 and 10 percent effective June 25, 2012. Such decision represents a full grant of the benefit sought on appeal as to t the issue of service connection for a left shoulder disability, that matter is no longer before the Board. FINDINGS OF FACT 1. A right shoulder disability was not manifested in, and is not shown to be directly related to, the Veteran's active duty service, or to have been caused or aggravated by his use of crutches for his service-connected left knee disability. 2. At no time under consideration is shortening of left lower extremity bones due to knee disability shown to have been to (or approximating) 1 1/4 inches. CONCLUSIONS OF LAW 1. Service connection for a right shoulder disability, to include as secondary to a service-connected left knee disability is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2013). 2. A compensable rating for left leg shortening secondary to a left knee disability is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code (Code) 5275 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Letters in October and November 2006 (and regarding disability rating, and effective date criteria in April 2008) provided the Veteran VCAA-mandated notice. Any notice timing defect was cured by readjudication (in August 2008, October 2008, May 2009, and July 2012 supplemental statements of the case (SSOCs)) after notice was provided. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (A timing error is cured by adequate VCAA notice and subsequent readjudication.). The Veteran has had ample opportunity to respond/supplement the record, and has not alleged that notice was less than adequate. The appeal as to the rating for left leg shortening is from the rating decision that granted service connection for such disability and assigned a disability rating and effective date for the award; hence, statutory notice had served its purpose, and its application was no longer required. See Dingess/Hartman, 19 Vet. App. 473, aff'd, Hartman, 483 F.3d 1311. A June 2010 SOC provided notice on the "downstream" issue of entitlement to an increased initial rating and readjudicated the matter. See 38 U.S.C.A. § 7105. The Veteran has had opportunity to respond/supplement the record. He has not alleged that notice in this case was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) ("where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream issues"); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (discussing the rule of prejudicial error). The Veteran's service treatment records (STRs), pertinent postservice treatment records and Social Security Administration records are associated with his claims file. He has not identified any pertinent evidence that is outstanding. He was afforded VA examinations in October 2008, November 2009, and January 2012 (with June 2012 addendum). The Board finds the 2009 and 2012 VA examinations (with2012 addendum) cumulatively to be adequate for rating purposes; the examiners expressed familiarity with the record/pertinent medical history, and conducted thorough examinations, noting all findings necessary for consideration of the Veteran's claims. See Barr v. Nicholson, 21 Vet. App. 303 (2007). In July 2009 a Travel Board hearing was held before the undersigned to address, in pertinent part, the issue of service connection for a right shoulder disability, claimed as secondary to a service-connected left knee disability. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing must (1) explain the issues and (2) suggest the submission of evidence that may have been overlooked. At the hearing, the undersigned explained what is needed to substantiate the claim, and explained the action the Board would take to resolve conflicting medical opinions. [The issue pertaining to left leg shortening arose subsequent to the hearing.] It is not alleged that the Veteran is prejudiced by a Bryant notice defect. He has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background and Analysis Service Connection Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection also may be granted for any disease initially 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). To establish service connection for a claimed disability, there must be evidence of: (1) a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Briefly, the legal requirements for a successful secondary service connection claim are: (1) evidence of a current disability for which secondary service connection is sought; (2) a disability which is service connected; and (3) competent evidence of a nexus between the two. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board notes that all of the evidence in the Veteran's claims file and in Virtual VA with an emphasis on the evidence relevant to this appeal, has been reviewed. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. A right shoulder disability was not manifested in service (and it is not alleged that such disability is directly related to his service/was incurred therein). The Veteran's theory of entitlement to service connection for a right shoulder disability is primarily one of secondary service connection. He claims that his prolonged use of crutches following left knee replacement (in 1982) caused his shoulder problems. He alleges that following a left total knee replacement he has had weakness and has been unable to fully use his left knee, resulting in a need to use crutches for about thirty years. [He also alleged that he had multiple falls due to his left knee giving out, resulting in shoulder injuries that contributed to the current shoulder disability.] A June 2003 VA Medical Center (VAMC) outpatient report notes the Veteran complained of bilateral shoulder pain, (right greater than left). He reported that he regularly used crutches for stability (for 27 years), which impacted on his shoulders. The assessment was bilateral shoulder impingement. A later June 2003 VA physical therapy consult report notes that the Veteran was referred to the clinic because of bilateral shoulder impingement. On examination he was unable to stand without support. There was positive impingement bilaterally. He was encouraged to consider other assistive devices for ambulation because the crutches were contributing to shoulder impingements. The assessment was bilateral shoulder impingement likely from years of crutch use. In June 2005 the Veteran was seen at a VA outpatient clinic for a routine annual follow-up. He inquired about injections in the shoulders. The impression was degenerative joint disease of the bilateral shoulders. He received an injection in each shoulder. In October 2005 he was seen at for right shoulder pain (of 3 to 4 weeks duration). The assessment was right shoulder impingement. He received injections in the right shoulder. A June 2006 MRI [magnetic resonance imaging] showed mild degenerative change at the glenohumeral joint and the acromioclavicular joint. There was a full thickness tear of the supraspinatus tendon in the anterior one third with fluid in the subacromial and subdeltoid bursa. There was evidence of tendonopathy involving the supraspinatus tendon and mild atrophy of the supraspinatus muscle. There was subluxation of the long head of the biceps from the bicipital grove. In July 2006 the Veteran presented at a VA orthopedic clinic with a longstanding history of right shoulder pain (bilateral shoulder impingement, degenerative joint disease) that had been treated with multiple injections in the past. He reported having a slip/fall on April 27, 2006 and threw his shoulder back; consequently, he developed an acute onset of right shoulder pain, which had been steadily worsening. He could hardly move his shoulder to comb his hair, shave or eat. It was noted that he had been crutch-dependent for the past 30 years due to a left leg injury; and over the past two years, began using a walker. He had an electric wheelchair, but it was too large to use in his home. The examiner noted there was difficulty examining the Veteran's right shoulder due to extreme discomfort. The impressions were right rotator cuff tear, right biceps dislocation, and walker/wheelchair dependent. On March 2007 VA outpatient orthopedic clinic notes the Veteran complained of bilateral shoulder pain. It was noted that he had a right rotator cuff tear that was documented and a displaced biceps tendon. He was wheelchair-dependent and used his arms to get in and out of the wheelchair. The impressions were right rotator cuff tear with biceps tendon dislocation, and walker/wheelchair-dependent. In a September 2008 statement the Veteran's private physician, Dr. Clary, noted that the Veteran had chronic shoulder problems secondary to use of crutches for his left knee problem, and had developed chronic bilateral rotator cuff syndrome from the use of crutches for the left knee problem. On October 2008 VA joints examination, the Veteran reported that his right shoulder became painful over a period of time. He attributed his rotator cuff condition to using crutches. He admitted to having several falls in the past that injured his right shoulder. He used crutches because his left knee would not lock straight. He also had spastic paraparesis, but denied the use of crutches for that condition. He had used crutches prior to the a diagnosis of spastic paraparesis in 1995. He had a total left knee replacement in 1982. He reported using crutches prior to 1982. He had a motorcycle accident in 1975 and fractured his left hip for which he had a pin inserted. That following year he had a partial hip replacement and a total revision of that in 1980. VA treated his right shoulder with steroid injections, oral medication and physical therapy. He had not had surgery. The diagnosis was radiographic evidence of a full thickness tear of the supraspinatus tendon of the right shoulder. The Veteran was not employed. He had retired in 1975/76 due to a left hip disability. The examiner noted the claims file, including service treatment records, various statements from providers who discussed the diagnosis, procedures and use of crutches, the arthrotomy procedure while in service, administration records, MRI and orthopedic documentation, and University of Michigan clinic notes and orthopedic evaluations after the motorcycle accident, was reviewed. He opined that the Veteran's right shoulder disability was not caused by or a result of use of crutches for his left knee. He explained that the Veteran had a familial spastic paraparesis (a progressive disability that results in lower extremity weakness) diagnosed sometime in 1995. He was able to maintain employment after service despite his knee injury in service. He did not have to use a crutch(es) on 1969 and 1971 VA compensation examinations. He was seen in 1976 (when there was no mention of crutch-use). The Veteran told the examiner that his crutch use, usually one crutch, began after his motorcycle accident in 1975. He injured his left femur and hip in the 1975 motorcycle accident and had hip surgery in 1980 and a knee replacement in 1982. The evidence shows the use of crutches in 1981 (the examiner noted that it was more likely than not that the Veteran had symptoms of ensuing familial spastic paraparesis around that time, considering the nature of the condition). The examiner opined that the Veteran's bilateral shoulder disability is unrelated to his service-connected knee disability, but rather, resulted from his chronic, progress familial spastic paraparesis (and falls he had over the years related to his familial spastic paraparesis. He did not have falls due to his knee disability. His record did not show crutch use after military service, but did show crutch use after a postservice 1975 motorcycle accident. He was not on active duty at the time of the accident. In a June 2009 statement, Dr. Clary noted that the Veteran had chronic shoulder problems secondary to use of crutches for his previous left knee problem. He had developed chronic rotator cuff syndrome, more likely than not, related to his knee injury. At the July 2009 Travel Board hearing, the Veteran testified that he began using crutches shortly after his knee surgery, and had he used them about thirty years. He stopped using crutches "a little over a year" ago (in 2008), when he "went into the wheelchair." He stated that he used crutches prior to being diagnosed with familial spastic paraparesis in 1995. He related he had fallen many times because his knee was weak and would give out, and had injured his shoulders in the falls. He stated that his motorcycle accident occurred before the knee replacement. His wife testified that he did not use crutches after the hip injury in 1975/1976; he did not use crutches until 1981 (when his knee was treated prior to the actual knee replacement). He used crutches at that time because the knee kept giving out. On November 2009 VA joints examination, the Veteran reported that after his initial knee injury in 1964 he was non-weight bearing and had to use crutches for a month. He was able to complete his service. He was employed until his 1975 motorcycle accident that resulted in a comminuted left hip fracture, and had multiple surgeries over the next few years; he was on crutches most of that time. After his hip and knee replacement surgeries he had to use crutches and a cane intermittently. He had complications of left leg shortening and progressive weakness in the lower extremities. In 1995 familial spastic paraparesis was diagnosed, causing more difficulty walking and he had had to use crutches for stability continuously then. He also developed right shoulder pain during that time. A 1997 MRI showed arthritis of the right acromioclavicular joint. The Veteran reported several falls that injured the shoulders. His shoulder problems progressed until he was unable to use crutches, and began using a rolling walker and/or an electric scooter chair for mobility. X-rays of the shoulders showed high riding humeral heads that indicated rotator cuff tears. The diagnosis was bilateral shoulder arthritis and tendonopathy. The examiner opined that the Veteran's bilateral shoulder arthritis and tendonopathy were not permanently aggravated by crutch use for the service-connected left knee disability. The examiner explained that the Veteran used crutches for only a short time after his 1964 left knee injury. He used crutches more after his motorcycle injury in 1975 and multiple hip surgeries. Many notes documented that the left knee was stable, even after surgery and total knee replacement. He had symptoms of left knee flexion contracture and hyperactive reflexes due to early manifestations of his familial spastic paraplegia. His use of crutches increased with chronic progression of the familial spastic paraplegia. A 1997 bone scan showed early signs of arthritis in many joints, including both shoulders, which would also be a progressive condition with ageing. The evidence did not support extensive use of crutches over the years required by his service-connected left knee disability alone. Regarding his bilateral shoulder arthritis and tendonopathy, although arthritis is a chronic condition increasing with age, the tendonopathy was probably aggravated by extensive use of crutches due to multiple hip surgeries and familial spastic paraparesis. On January 2012 VA examination, the Veteran reported that he had been using crutches on and off since his knee surgery in 1976. He was in a motorcycle accident in 1976 and a second knee surgery in 1982. He started having shoulder pain four to five years ago, and had a torn rotator cuff diagnosed. He stated that his shoulder problems began with the right shoulder and were always worse on the right. The diagnosis was rotator cuff tear; the examiner opined that the bilateral shoulder disability was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran's testimony that he began using crutches after his left knee surgery was not supported by the medical records. The medical history given by Dr. Sutton in December 1975 notes that "he has had no difficulty until after a recent accident in which he received a fracture of the left proximal femur." In December 2007 the Veteran stated that he used a cane in 1975 and after the total knee replacement in 1980 was on crutches. This was after the motorcycle accident. In May 1977 a VA examiner observed the Veteran walked with one crutch, and on the ball of the left foot. He noted that that the majority of the Veteran's shoulder complaints were on the right, it would be physiologically impossible for left crutch use to be the cause of right shoulder pain. Crutch use has not been documented to be the cause of rotator cuff tears. Crutch use may cause axillary nerve damage if used repeatedly and incorrectly, however, the Veteran had no sign of such condition. He had multiple other orthopedic and neurologic reasons to have had falls and injuries to the shoulders, the primary cause of rotator cuff tears. The examiner opined that the shoulder disability was less likely than not (less than 50 percent probability) caused by crutch use necessary for the Veteran's service-connected left knee disability. Regarding whether the Veteran's right shoulder disability was aggravated by his service-connected left knee disability, the VA examiner reviewed the entire record and opined that the Veteran's shoulder disability was at least as likely as not aggravated beyond its natural progression by the service-connected left knee disability. His rationale was that multiple other orthopedic issues including his hip surgery and femur fracture, motorcycle accident and neuromuscular disorder were the primary cause of multiple falls over the years that caused the Veteran's rotator cuff tears. He further opined that crutch use would be a minor cause of aggravation of the Veteran's shoulder disability to a degree, within reasonable medical certainty, of no more than 20 percent of his increased shoulder disability over that caused by his other causes. In a June 2012 addendum to the January 2012 VA examination report, the examiner opined that the Veteran's right shoulder disability was less likely as not caused or aggravated by crutch use for his service-connected left knee disability. The cause of the right shoulder disability was specifically noted to be a fall; a situation which would have been prevented by proper crutch use. This would logically argue that the cause of the Veteran's fall was his neuromuscular condition. There was no evidence in the record to support the contention of aggravation of the right shoulder condition from crutch use. He noted that the association between rotator cuff tears and chronic crutch use is widely available in medical literature and beyond the scope of a medical opinion but readily available. He noted that the complexity of the Veteran's orthopedic and neuromuscular conditions made differentiating the various specific causes of the shoulder condition (with the exception of the right shoulder rotator cuff which occurred after a specific event in 2006) speculative. A right shoulder disability was not manifested in service (and arthritis of the right shoulder is not shown to have been manifested in the first postservice year). Consequently, service connection for a right shoulder disability on the basis that such disability became manifest in service and has persisted (or on a chronic disease presumptive basis under 38 U.S.C.A. §§ 1112, 1137) is not warranted. Notably, it is not alleged, that a right shoulder disability is directly related to the Veteran's active service. The instant claim is based strictly on a secondary service connection theory of entitlement. The Veteran contends that his claimed right shoulder disability is secondary to crutch use necessitated by his service-connected left knee disability. VA examinations (in October 2008, November 2009, and January 2012 (with June 2012 addendum), which the Board finds adequate and probative, produced opinions weighing against the Veteran's claim. The January 2012 (June 2012 addendum) VA examiner specifically addressed whether the right shoulder disability was aggravated by crutch use for the left knee, and ultimately (see addendum opinion) found it was not. The examiner observed that the right rotator cuff tear was specifically noted to be due to an April 2006 fall, and indicated that medical literature did not implicate crutch use as an etiological factor for rotator cuff injuries (although it could cause nerve pathology, which was not shown). Notably, the examiner (by citing to contradictory clinical data) implicitly rejected the Veteran's accounts that his crutch use was primarily for his service-connected left knee disability not credible. He identified degenerative changes (the aging process) as the most likely etiology for the arthritis found.. The Board acknowledges the June 2003 VAMC report (by a physical therapist) that notes an assessment of bilateral shoulder impingement likely from years of crutch use, and Dr. Clary's medical opinion that the Veteran had chronic shoulder problems secondary to use of crutches for his left knee disability. The probative value of a medical opinion is determined based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusions reached. The credibility and weight to be attached to such opinions are within the providence of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Greater weight may be placed on one physician's opinion over another depending on factors such as reasoning employed by the physicians and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). The Board finds that the June 2003 VAMC assessment/opinion that the Veteran had bilateral shoulder impingement likely from years of crutch use, lacks probative value. The assessment is unaccompanied by rationale, and the physical therapist who made the assessment appears to have relied strictly on the Veteran's account of his medical history. Although she noted that the Veteran has a history of familial spastic paraparesis, knee surgery and involvement in a motor vehicle accident, the Veteran's account does not reflect his complete disability picture. The opinion of Dr. Clary, the Veteran's private physician, who states the Veteran's chronic shoulder problems are secondary to use of crutches for his left knee disability, is conclusory, unaccompanied by adequate explanation of rationale. He does not account for the nonservice-connected disabilities to which the Veteran's crutch use might be related. Therefore, his opinions are lacking in probative value. Regarding the Veteran's expressions of his belief that his right shoulder arthritis disability is due to use of crutches for his service-connected left knee disability, the Board finds his accounts (and those of his wife in hearing testimony) that his crutch use has been primarily for his left knee to be contradicted by clinical notations (which show crutch use began after his motorcycle accident, and increased with the appearance and progression of familial spastic paraparesis) in the record, and self-serving. Therefore they are lacking in probative value. On the other hand, to the extent that he offers opinion that his rotator cuff tear shoulder disability is due to crutch use (and not the documented injury), the etiology of such insidious process is a medical question, requiring medical expertise. His opinion in the matter is not probative evidence. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board notes that a private provider (Dr. Clary) appears to relate the rotator cuff disability to crutch use. However, he does not explain the rationale for the opinion and does not cite to supporting factual data/medical literature for this proposition. The December 2012 VA examiner has indicated there is none. In light of the foregoing, the Board finds that the preponderance of the evidence is against a finding that the Veteran's right shoulder disability was caused or aggravated by his left knee disability (including as due to use of crutches for such disability). Accordingly, the appeal in the matter must be denied. Increased Rating Claim Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. A zero percent rating is assigned when the requirements for a compensable evaluation are not met and the schedule does not provide a zero percent evaluation. 38 C.F.R. § 4.31. In a claim for a higher initial rating assigned with an award of service connection, all of the evidence submitted in support of the Veteran's claim for the entire time period involved is to be considered, and "staged" ratings may be assigned for specific periods of time, as warranted. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's STRs are silent for any mention of shortening of the left leg. In a October 1980 postservice medical report (for SSA disability benefits) by Dr. Townley, it was noted that the Veteran fractured his left hip in a motorcycle accident five years earlier and had hip pinning. Two months later, because of failure of the procedure he had an arthroplasty (Gilberty type). It was noted that he had been getting progressively worse the past year and reported that he could not walk without a cane. On examination he walked with a gluteal limp and up on his toe. When he stood flat he had 4 to 5 degrees of shortening. The physician noted that it was "true shortening" because the Veteran's pelvis was level when he was up on his toe. An October 1991 private treatment report notes that over the past two years the Veteran had developed some increased shortening and now had a lift in the left shoe of about 31/2 inches. A June 1992 private treatment report notes that he had a severe overall disabling problem with perhaps 4 inches or so shortening of the left lower extremity which required an extensive shoe lift. In an August 1992 private medical report, it was noted that the Veteran had approximately 3 to 4 inches shortening of the left lower extremity. On June 2008 VA joints examination, it was noted that the Veteran's left leg was shorter than the right leg; he wore a 6-inch built-up shoe. His leg measurement from the anterior superior iliac spine to the medial malleolus was 97 cm on the left and 106 cm on the right. He was unable to stand without support. In an undated written statement the Veteran notes that due to knee complications (1982 knee replacement surgery) his left leg is 31/2 to 4 inches shorter. At the July 2009 Travel Board hearing, when asked by the representative "What caused the shortening?" the Veteran's wife responded "They say that the shortening is from his hip surgery." On November 2009 VA joints examination, left leg length from the umbilicus to the proximal patella was 20 inches; from the proximal patella to the medial malleolus was 16 inches. The total length from the umbilicus to the medial malleolus was 37.5 inches. Right leg length from the umbilicus to the proximal patella was 22.25 inches; from the proximal patella to the medial malleolus was 16.5 inches. Total length from the umbilicus to the medial malleolus was 42.25 inches. Approximately 2 inches of the increased length is due to the other knee having contracture. The length difference from umbilicus to the knee shows 2.25 inches longer than left and from the knee to the ankle the length difference is 0.5 inches longer than left. The diagnosis was shortening of the left leg by 2.4 inches by x-ray bone measurement. The Veteran report that the effects of the shortened left leg on daily activities were mild for chores, shopping and traveling, and severe for exercise. There was no effect of daily activities for recreation, feeding, bathing, dressing, toileting, grooming, or driving. The examiner opined that the Veteran's left leg shortening was not caused by or a result of his service-connected left knee disability. It is more a result of his multiple surgeries on the left hip than it is due to his left knee. The bone length x-rays show a left leg shorter than right by 6 cm which is equivalent to 2.4 inches. The examiner measured both legs from the umbilicus to the knee and then from the knee to the ankle. He noted that the length difference from the umbilicus to the right knee shows 2.25 inches longer than the left and from the right knee to the ankle the length difference is 0.5 inches longer than the left. The Veteran had multiple surgeries on the left hip including pinning, ORIF [open reduction internal fixation], partial hip replacement, total hip replacement, and revision of the left THR [total hip replacement] with osteotomy of the femur. The left knee had arthroscopic surgery, wedge osteotomy distal femur with minimal bone loss and then total knee replacement with later replacement of only the tibial part of the prosthesis. The Veteran's left knee contracture deformity (due to spastic paraplegia) contributes to the overall appearance of a shorter left leg requiring more elevation in his shoe lifts. The Veteran's left leg shortening (by bone measurement) is approximately 1/2 inch due to his service-connected left knee disability and approximately 1.75 inches due to other factors described above. Shortening of the lower extremity is rated under 38 C.F.R. § 4.71a, Code 5275 (shortening of the bones of the lower extremity). Shortening of 1 1/4 to 2 inches (3.2 cms. to 5.1 cms.) warrants a 10 percent rating; of 2 to 2 1/2 inches (5.1 cms. to 6.4 cms.) a 20 percent rating; of 2 1/2 to 3 inches (6.4 cms. to 7.6 cms.) a 30 percent rating; of 3 to 3 1/2 inches (7.6 cms. to 8.9 cms.) a 40 percent rating; of 3 1/2 to 4 inches (8.9 cms. to 10.2 cms.) a 50 percent rating; and over 4 inches (10.2 cms.) a 60 percent rating. These ratings are not to be combined with other ratings for fracture or faulty union in the same extremity. The March 2010 rating decision assigned a 0 percent rating for the left leg shortening was assigned based on the November 2009 VA examiner's opinion that approximately 0.5 inches of the left leg shortening was due to the service-connected left knee disability. The remainder of the left leg shortening was due to other [non-service connected] factors, including multiple left hip surgeries. On November 2009 VA examination, the examiner measured both legs from the umbilicus to the knee and then from the knee to the ankle and the length difference from the umbilicus to the right knee shows 2.25 inches longer than the left and from the right knee to the ankle the length difference was 0.5 inches longer than the left. The examiner attributed 1/2 inch discrepancy in left leg length to the Veteran's service-connected left knee disability and approximately 1.75 inches due to other (non-service connected) factors. The evidence does not show a left leg shortening, due to the service-connected left knee disability of (or approximating, see 38 C.F.R. § 4.7) 1 1/4 to 2 inches (3.2 cms to 5.1 cms) or more as required for a compensable rating. Accordingly, a 0 percent rating must be assigned. 38 C.F.R. § 4.31. The Veteran's own lay opinion (essentially that his left leg shortening is [all] the result of his left knee disability) is not probative evidence. He is a layperson, and lacks the training to offer an opinion regarding the actual cause of his left leg shortening. That is a complex medical question that requires medical expertise. See Jandreau v. Nicholson, 492 F3d. 1372, 1377 (Fed. Cir. 2007). He does not cite to supporting medical opinion or literature. Notably, his wife has testified that they were told by a treating surgeon that the shortening was due to a [nonservice -connected] hip disability. As the preponderance of the evidence is against a compensable rating for shortening of the left leg as secondary to the service-connected left knee disability, the benefit of the doubt doctrine does not apply; the appeal in this matter must be denied. The increased rating sought is for a specific symptom of a left knee disability (and other symptoms and their associated impairment are not for consideration in this matter. The schedular criteria for the rating assigned specifically encompass the extent of the symptoms shown. Therefore they are not inadequate, and referral of this matter for consideration of an extraschedular rating is not warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Finally, the evidence of record shows the Veteran has not worked since 1975. The November 2009 VA examiner noted that he worked in a shop doing high speed threading and retired in 1975 due to a motorcycle accident with comminuted fracture of the left hip and surgery. Thus, the record does not show, nor has the Veteran alleged, that he is rendered unemployable by virtue of his left leg shortening due to left knee disability. Accordingly, the matter of entitlement to a total rating based on individual unemployability is not raised by the record in this instance. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER Service connection for a right shoulder disability, claimed as secondary to a service-connected left knee disability is denied. The appeal seeking a compensable rating for shortening of the left leg secondary to a service-connected left knee disability is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs