Citation Nr: 1453005 Decision Date: 12/02/14 Archive Date: 12/10/14 DOCKET NO. 10-24 600 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to a disability rating in excess of 20 percent for post-traumatic anterior wedging of the twelfth thoracic vertebra beginning on October 21, 2009. 2. Entitlement to a disability rating in excess of 20 percent for synovitis of the acromicolavicular (AC) joint, status post fracture of the left shoulder beginning on December 29, 2009. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. R. Harrigan Smith, Counsel INTRODUCTION The Veteran had active service from April 2003 to October 2007. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. A February 2009 rating decision denied service connection for asthma, a November 2009 rating decision assigned a 20 percent rating for the Veteran's post traumatic wedging at the twelfth thoracic vertebra effective, and a March 2010 rating decision denied an increased rating for his left shoulder disability and entitlement to a TDIU. The Veteran perfected an appeal as to these actions. In March 2011, the Veteran testified during a hearing at the RO before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In February 2012, the Board granted entitlement to service connection for asthma and continued the assigned 20 percent disability ratings for post-traumatic anterior wedging of the twelfth thoracic vertebra for the period prior to October 21, 2009, and for synovitis of the AC joint, status post fracture of the left shoulder, for the period prior to December 29, 2009. In addition, the Board remanded the issues of entitlement to a disability rating in excess of 20 percent for post-traumatic anterior wedging of the twelfth thoracic vertebra for the period from October 21, 2009, entitlement to a disability rating in excess of 20 percent for synovitis of the AC joint, status post fracture of the left shoulder, from December 29, 2009, and entitlement to TDIU. In a February 2012 rating decision, the Appeals Management Center (AMC) awarded a 10 percent rating for asthma effective December 7, 2008, and in a February 2013 rating decision, the RO granted entitlement to TDIU effective July 17, 2008. As such, these issues are no longer on appeal. The Veteran's Virtual VA and VBMS files were reviewed in connection with this decision. Accordingly, any future consideration of this appellant's case should take into consideration the existence of these electronic records. FINDINGS OF FACT 1. Beginning on October 21, 2009, post-traumatic anterior wedging of the twelfth thoracic vertebra has been manifested by pain and limited motion, but was not characterized forward flexion of the thoracolumbar spine of 30 degrees or less, favorable ankylosis of the lumbar spine, or incapacitating episodes having a duration of four weeks but less than six weeks. 2. Beginning on December 29, 2009, synovitis of the AC joint, status post fracture of the left shoulder (minor extremity) has been manifested by pain and limited motion, however, the evidence did not establish that motion of the left arm was limited to 25 degrees from the side. CONCLUSIONS OF LAW 1. Beginning on October 21, 2009, the criteria for a rating higher than 20 percent for post-traumatic anterior wedging of the twelfth thoracic vertebra have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5299-5237 (2014). 2. Beginning on December 29, 2009, the criteria for the assignment of an initial rating in excess of 20 percent for synovitis of the AC joint, status post fracture of the left (minor) shoulder have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5020- 5201 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2014). Proper notice from VA must inform the claimant of any information and 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. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield, 444 F.3d 1328; see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's claim arises from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). The appellant testified at a hearing before the undersigned Veterans Law Judge in March 2011. In Bryant v. Shinseki, 23 Vet. App. 488, the Court held that 38 C.F.R. 3.103(c)(2) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. At the hearing, the undersigned identified the issues on appeal and sought information as to treatment to determine whether all relevant records had been obtained. Ultimately the claim was remanded to obtain additional records and to provide the Veteran with an examination. The Board thereby met the duties imposed by 38 C.F.R. § 3.103(c)(2) as interpreted in Bryant. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with its duties; they have not identified any prejudice in the conduct of the Board hearing. Neither the Veteran nor his representative have asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. The Board finds that the Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) extant at the time of the hearing. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board remanded this case in February 2012 in order to obtain VA medical records and to provide the Veteran with a VA examination to determine the current nature and severity of his service-connected back and left shoulder disabilities. VA medical records have been added to the record. In addition, the Veteran was provided with a VA examination in February 2013. The Board finds that the VA examination was adequate because, as shown below, it was based upon consideration of the Veteran's pertinent medical history, and because the report describes the disability in detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Post-service VA medical records and examination reports have been associated with the claims file. The Board has reviewed these records to establish if any other medical evidence relevant to the Veteran's claim exists and has determined that all relevant medical evidence has been associated with the record. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The appeal is thus ready to be considered on the merits. Laws and regulations - evaluation of disability ratings Disability evaluations 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 his 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. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. 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. 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 entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be 'staged.' Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. See Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the 'authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence'); Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). VA regulations instruct that evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Notably, the Court has held that pain alone does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Painful motion with joint or periarticular pathology and unstable joints due to healed injury are recognized as productive of disability entitled to at least a minimal compensable rating for the joint. 38 C.F.R. § 4.59. The application of 38 C.F.R. § 4.59 is not limited to arthritis-related claims. Burton v. Shinseki, 25 Vet. App. 1 (2011). Evaluation of lumbar spine disability beginning on October 21, 2009 Post-traumatic anterior wedging of the twelfth thoracic vertebra is service-connected at a 20 percent disability rating under Diagnostic Codes 5299-5237. Diagnostic Code 5237 pertains to lumbosacral or cervical strain. 38 C.F.R. § 4.71a, Diagnostic Code 5237. VA regulations provide that conditions not listed in the rating schedule will be rated by analogy and coded with the first two numbers of the schedule provisions for the most closely related body part and '99.' Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27 (2014). Under the General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain, whether or not it radiates, stiffness, or aching in the area of the spine affected by the residuals of injury or disease, a 10 percent evaluation is warranted for disability of the thoracolumbar spine when there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted for disability of the thoracolumbar spine when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted for disability of the thoracolumbar spine when there is forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the entire thoracolumbar spine is evaluated as 50 percent disabling, and unfavorable ankylosis of the entire spine is evaluated as 100 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5237 (2014). The following notes accompany the General Rating Formula: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphasia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Id. Additionally, intervertebral disc syndrome is to be evaluated either under the general rating formula for diseases and injuries of the spine or under the formula for rating intervertebral disc syndrome based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. For intervertebral disc syndrome manifested by incapacitating episodes having a total duration of at least six weeks during the past 12 months, a 60 percent evaluation is warranted; with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, a 40 percent evaluation is warranted; and with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months, a 20 percent evaluation is warranted. Note one states that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. Background In a July 2010 statement, the Veteran contended that he had difficulty standing up after bending over, and that he had ongoing pain in his back, even with medication. He could not life his young children due to his back disability. At his hearing, the Veteran testified that his forward flexion was limited, and that he could not bend backwards. He also contended that he could not lift anything. A January 2010 VA emergency room medical record includes the Veteran's complaints of lower back muscle spasms after sneezing at work. Objectively, his back was tender to palpation mostly in the paraspinal muscles. The Veteran was advised to use rest and heat and progress activity as tolerated. In March 2010, he was seen for a flare up of pain without any identified precipitating event. He ambulated steadily without difficulty or need for an assistive device and was given pain medication. When seen in the VA outpatient clinic in April 2010 for his annual physical examination, the Veteran reported that his back pain returned to baseline level but was worse in the mornings. He said he frequently changed positions throughout the day to control pain and used rest, heat, and medication for pain control at home. Objectively, the examiner said the Veteran's back had very poor range of motion with forward flexion 10 to 15 degrees, poor extension, side bending, and rotation. There were significantly spasmed muscles in the bilateral paraspinals with negative straight leg raise. Deep tendon reflexes were symmetrical at the ankle and knee. The assessment was chronic back pain with poor range of motion, essentially no therapy, and 'activity limiting.' In a July 2010 written statement, the Veteran said he experienced daily back pain and had difficulty standing up after bending over. He was unable to pick up or bathe his children, and had difficulty sleeping, sitting or standing for long periods, and walking more than a short distance. He used Tylenol and Ibuprofen for pain. The Veteran was afforded a VA examination in March 2012. The VA examiner noted that the Veteran reported that he had infrequent flare-ups that lasted about an hour, during which time the Veteran could not move around. Forward flexion was to 70 degrees, with pain at 60 degrees. The Veteran's forward flexion was not additionally limited after three repetitions. The Veteran's functional loss was manifested by less movement than normal and pain. The examiner noted that the Veteran did not have IVDS and therefore did not address whether the Veteran had incapacitating episodes due to IVDS. Neurological examination reflected normal results, with the exception of limitation in left knee extension, which was associated with a left knee disability and not his lumbar spine disability. The examiner found that there were no neurological abnormalities associated with the Veteran's lumbar spine disability. The Board finds that the Veteran's service-connected back disability does not warrant a higher disability rating. There is no evidence that the Veteran had favorable ankylosis of the entire thoracolumbar spine. The VA examiner did not report any fixation of the thoracolumbar spine. In fact, the Veteran was able to achieve forward flexion of the thoracolumbar spine throughout the appeals period. The Board notes that the April 2010 VA medical record reflected limitation of forward flexion to 10 to 15 degrees; however, at his March 2012 VA examiner which included repetitive movements, the Veteran was able to flex to 70 degrees. Even if the Veteran stopped movement at the onset of pain at 60 degrees, he would not meet the criteria for a 40 percent disability rating. The Board finds that, while the evidence reflects that he has limitation of flexion, the results of the March 2012 examination are more probative than the April 2010 VA medical record, as the examiner measured the Veteran's range of motion with a goniometer, and accounted for limitation of motion after three repetitive movements. The Board notes that the Veteran reported flare-ups; however, these were admittedly infrequent and lasted only an hour. Overall, the Board finds that the Veteran's service-connected back disability does not meet the criteria for a higher disability rating under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. The March 2012 VA examiner did not make a determination as to the occurrence or frequency of incapacitating episodes due to the Veteran's service-connected back disability, as he found that the Veteran did not have IVDS. However, the Board notes that, even if the Veteran had IVDS and it was appropriate to rate him on the basis of incapacitating episodes, the Board finds that there is no evidence that the Veteran had more than four weeks of incapacitating episodes over any twelve week period since October 21, 2009. The Board has considered whether separate evaluations are warranted for any neurological abnormalities associated with the Veteran's service-connected spine disability. However, the evidence fails to show that the Veteran has any neurological abnormalities associated with this back disability. In fact, the March 2012 examiner specifically noted such a finding. Therefore, disability ratings for any associated neurological disorders are not appropriate. As such, the evidence is against a finding that the Veteran's service-connected back disability meets the criteria for a higher disability rating. Therefore, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107. Evaluation of left shoulder disability beginning on December 29, 2009 The Veteran's service-connected synovitis of the AC joint, status post fracture of the left shoulder is rated at a 20 percent disability rating under Diagnostic Codes 5020-5201. Generally, hyphenated diagnostic codes are used when an unlisted disability is at issue. See 38 C.F.R. § 4.27 (2014). Use of the second diagnostic code helps provide further detail regarding the origins of the unlisted disability, the bodily functions affected, the symptomatology, and anatomical location. Id.; see Tropf v. Nicholson, 20 Vet. App. 317, 321 (2006). Additionally, the diagnostic code following the hyphen is the diagnostic code by which the disability is evaluated. Id. Diagnostic Code 5020 states that the condition will be rated on limitation of motion of affected parts as degenerative arthritis under Diagnostic Code 5003, which in turn, states that the severity of degenerative arthritis, established by x-ray findings, is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5020 (2014). When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. Diagnostic Code 5201 specifies ratings for limitation of motion of the arm. The record shows that the Veteran is right handed and therefore the ratings for the minor arm, as opposed to the major arm, are considered. See 38 C.F.R. § 4.69 (2014). A 20 percent evaluation is warranted for limitation of motion of the minor arm to shoulder level. 38 C.F.R. § 4.71a, Diagnostic Code 5201. For limitation of motion of the minor arm to midway between the side and the shoulder, a 20 percent rating is also assigned. Id. For limitation of motion of the minor arm to 25 degrees from the side, a 30 percent rating is assigned. Id. For VA purposes, the normal range of shoulder motion is: forward flexion 0 to 180 degrees; abduction 0 to 180 degrees; external rotation 0 to 90 degrees; and internal rotation 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I (2014). In evaluating the examination reports, forward flexion to means forward elevation, with shoulder abduction indicating motion from the side. Id. Background The Veteran testified at his hearing that range of motion of his should was limited due to pain. According to an April 2010 VA outpatient record, the Veteran complained of left shoulder pain with essentially no range of motion. Objectively, the left shoulder with distal clavicle deformity and tenderness to palpation at the AC joint and entire anterior shoulder had very poor active range of motion with 10 to 15 degrees of abduction, forward flexion, passive range of motion was improved but with significant pain. There was significant tenderness by the superomedial border of the scapula and a trigger point. The examiner said the Veteran's left shoulder was 'essentially frozen' and was 'very activity limiting.' But, results of x-rays of the left shoulder taken by VA in April 2010 were considered unchanged since those taken in January 2009. In July 2010, the Veteran underwent an arthrogram at the VA outpatient clinic due to his painful left shoulder joint. The impression was mild bursal sided fraying of the distal 2.1 centimeters of the supraspinatus without full thickness tear. Prior labral tear and scarring of the anterior/inferior labrum and superior labral fraying without full thickness tear and mild subacromial-subdeltoid bursitis were also noted. An August 2010 VA outpatient orthopedic clinic record indicates that the Veteran felt better after his 2008 shoulder surgery but, over the last several months his range of motion decreased and the shoulder hurt more. When seen later that month, the orthopedist reviewed the results of the Veteran's recent arthrogram and reported a clinical impression of pasta cuff tears of the left shoulder, supraspinatous, questionable pasta versus thinning of subscapularis tendon, superior portion (possible coracoids impingement) and labral pathology. An April 2011 VA medical record shows that the Veteran's left shoulder had flexion to 70 to 80 degrees. The Veteran was provided with a VA examination in March 2012. The examiner confirmed that the Veteran's dominant hand was his right. The Veteran reported that he had flare-ups during which time he could not move his arm above his head. Range of motion was forward flexion to 70 degrees with pain beginning at 60 degrees, abduction to 80 degrees with pain beginning at 70 degrees. The Veteran did not lose any range of motion with repetitive movement. The examiner noted that his functional loss was less movement than normal and pain on movement. The examiner noted that the Veteran did not have ankylosis of his scapulohumeral (glenohumeral) articulation shoulder and that there was no evidence of recurrent dislocation of this joint. VA medical records in December 2012 and February 2014 reflect that the Veteran could not lift his arm above his shoulder. Based on the evidence of record, the Board finds that the Veteran's left shoulder disability does not warrant a higher disability rating under Diagnostic Code 5201. A higher disability rating would be warranted if the Veteran's left shoulder was limited to 25 degrees from his side. The April 2010 VA outpatient record shows that he had very poor active range of motion with 10 to 15 degrees abduction, forward flexion; however, the Board finds that the results of the March 2012 VA examination are more probative, as the examiner used a goniometer to measure the Veteran's range of motion, and measured his range of motion after repetition of movement three times. Here, even after repeated movement, the Veteran was able to move his left shoulder with forward flexion to 60 degrees and abduction to 80 degrees. Even if the Veteran's movement stopped at the point where pain began and, he would not meet the criteria for a higher rating. The preponderance of the evidence fails to show that the movement of the Veteran's left shoulder was limited to 25 degrees. The Board has considered rating the Veteran's left shoulder disability under other Diagnostic Codes pertaining to disabilities of the shoulder, in order to provide him with the most beneficial disability rating; however, the evidence does not reflect that he has ankylosis of the shoulder joint or other impairment of the humerus, including fibrous union, nonunion or loss of head of the humerus. 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202 (2014). The Board has considered the benefit of the doubt doctrine but, as the preponderance of the evidence is against the claim, that doctrine is not for application in this case. 38 U.S.C.A. § 5107. Extraschedular Considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2014). The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 3.321. The Board finds that neither the first nor second Thun element is satisfied here. The Veteran's service-connected back and left shoulder disabilities are manifested by signs and symptoms such as pain and limited range of motion. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule. The diagnostic codes in the rating schedule corresponding to disabilities of the back and shoulder provide disability ratings on the basis of limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Codes 5201, 5237. For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet.App. 32, 37 (2011). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet.App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture. In short, there is nothing exceptional or unusual about the Veteran's back and left shoulder disabilities because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet.App. at 115. With respect to the second Thun element, the evidence does not suggest that any of the "related factors" are present. In particular, the Veteran does not contend, and the evidence of record does not suggest, that his back or right knee disabilities have resulted in marked interference with employment or frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1). Thus, even if his disability picture was exceptional or unusual, referral would not be warranted. ORDER A disability rating in excess of 20 percent for post-traumatic anterior wedging of the twelfth thoracic vertebra beginning on October 21, 2009 is denied. A disability rating in excess of 20 percent for synovitis of the acromicolavicular (AC) joint, status post fracture of the left shoulder beginning on December 29, 2009 is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs