Citation Nr: 1625218 Decision Date: 06/22/16 Archive Date: 07/11/16 DOCKET NO. 03-18 527A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. The propriety of a reduction in evaluation from 20 percent to 0 percent under Diagnostic Code (Code) 5202 2. Entitlement to a rating in excess of 30 percent for service-connected right shoulder disability prior to July 23, 2003. 3. Entitlement to a rating in excess of 30 percent for service-connected right shoulder disability from September 1, 2003 to July 19, 2007. 4. Entitlement to a rating in excess of 30 percent for service-connected right shoulder disability from November 1, 2007 to March 23, 2008. 5. Entitlement to a rating in excess of 30 percent for service-connected right shoulder disability from July 1, 2008 to September 8, 2009. 6. Entitlement to a rating in excess of 30 percent for service-connected right shoulder disability from December 1, 2009. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Yuan, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from February 1985 to April 1994. Service department correspondence of record dated in April 2012 shows that he was ordered to active duty in active guard/reserve status effective in June 2012 for a three year period. This matter comes before the Board of Veterans' Appeals (Board) by order of the United States Court of Appeals for Veterans Claims in April 2014, which vacated a June 2012 Board decision and remanded the issue for additional development. The appeal arose from a February 2002 rating decision by the Indianapolis, Indiana, Regional Office (RO) of the Department of Veterans Affairs (VA). That decision assigned a temporary total rating for a period of post-surgical convalescence from July 9, 2001, to September 30, 2001, and a 20 percent rating, effective October 1, 2001. An August 2002 decision extended the temporary total rating to November 30, 2001. Subsequent rating decisions in December 2003, August 2007, and May 2008 assigned temporary total ratings from July 24, 2003, to September 1, 2003, July 20, 2007, to October 31, 2007, and March 24, 2008 to June 30, 2008. A June 2004 rating decision granted increased 30 percent ratings for the periods between surgical convalescence, effective December 1, 2001. A December 2009 rating decision also assigned a temporary total rating for a period of post-surgical convalescence from September 9, 2009, to November 30, 2009, and reassigned a 30 percent rating, effective December 1, 2009. As the Veteran has been assigned temporary total ratings for several periods throughout the appeal period, only those "stages" where he has not been awarded a temporary total rating are for consideration. The Court also raised the matter of the propriety of an April 2000 reduction in the schedular rating for the Veteran's right shoulder disability under Code 5202 as part and parcel of this appeal. The issues have been characterized to reflect the above. The case has been remanded for additional development, most recently in February 2015. FINDINGS OF FACT 1. At the time of the April 2000 reduction of the schedular rating for the Veteran's right shoulder disability under Code 5202, a disability rating of 20 percent had been in effect for a period of six years; the AOJ failed to comply with the due process requirements in implementing a reduction. 2. Prior to July 23, 2003, the Veteran's right shoulder disability did not produce frequent episodes of dislocation of the humerus head and guarding of all arm movements; right arm motion limited to 25 degrees from his side; neurological manifestations; or symptomatic scars (i.e., painful, unstable, or occupying a total area greater than 29 square centimeters).. 3. From September 1, 2003 to July 19, 2007, the Veteran's right shoulder disability did not produce frequent episodes of dislocation of the humerus head and guarding of all arm movements; right arm motion limited to 25 degrees from his side; neurological manifestations; or symptomatic scars. 4. From November 1, 2007 to March 23, 2008, the Veteran's right shoulder disability did not produce frequent episodes of dislocation of the humerus head and guarding of all arm movements; right arm motion limited to 25 degrees from his side; neurological manifestations; or symptomatic scars. 5. From July 1, 2008 to September 8, 2009, the Veteran's right shoulder disability did not produce frequent episodes of dislocation of the humerus head and guarding of all arm movements; right arm motion limited to 25 degrees from his side; neurological manifestations; or symptomatic scars. 6. From December 1, 2009, the Veteran's right shoulder disability was productive of orthopedic pathology functionally limiting motion to 25 degrees from the side and a right shoulder surgical scar that was painful; but did not produce frequent episodes of dislocation of the humerus head and guarding of all arm movements or neurological manifestations. CONCLUSIONS OF LAW 1. The April 2000 rating decision reducing the disability rating for the Veteran's lumbosacral spine disability from 20 to 0 percent without compliance with the regulatory requirements renders the reduction void ab initio. 38 U.S.C.A. §§ 1155, 5112 (West 2014); 38 C.F.R. §§ 3.105 (e), 3.344, 3.655 (2015). 2. Higher (or separate) ratings are not warranted (based on either impairment of the humerus, limitation of motion, neurological manifestations, or scars) for the service-connected right shoulder disability prior to July 23, 2003. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.71a, Codes 5201-04, 4.118, Codes 7800-04(2015). 3. Higher (or separate) ratings are not warranted (based on impairment of the humerus, limitation of motion, neurological manifestations, or scars) for the service-connected right shoulder disability from September 1, 2003 to July 19, 2007. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.71a, Codes 5201-04, 4.118, Codes 7800-04(2015). 4. Higher (or separate) ratings are not warranted (based on impairment of the humerus, limitation of motion, neurological manifestations, or scars) for the service-connected right shoulder disability from November 1, 2007 to March 23, 2008. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.71a, Codes 5201-04, 4.118, Codes 7800-04(2015). 5. Higher (or separate) ratings are not warranted (based on impairment of the humerus, limitation of motion, neurological manifestations, or scars) for the service-connected right shoulder disability from July 1, 2008 to September 8, 2009. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.71a, Codes 5201-04, 4.118, Codes 7800-04(2015). 6. A 40 percent (but not higher) rating is warranted for the service-connected right shoulder disability based on limitation of motion during the period beginning December 1, 2001; higher (or separate) ratings are not warranted (based on impairment of the humerus or neurological manifestations) during that period. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.71a, Codes 5201-04, 4.118 (2015). 7. A separate 10 percent rating (but not higher) is warranted for a painful right shoulder surgical scar associated with his service-connected right shoulder disability. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.118, Code 7804 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) At the outset, the Board notes that, insofar as it finds the AOJ's April 2000 reduction of the evaluation for the Veteran's right shoulder disability from 20 to 0 percent under Code 5202 was improper, there is no need to discuss the requirements of the VCAA. With respect to the Veteran's increased rating claims, VA's duty to notify was satisfied by letters dated in October 2003, March 2006, December 2006, May 2008, February 2010, and June 2010. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Veteran has had ample opportunity to respond and has not alleged that notice was less than adequate. In addition, the Veteran's service treatment records (STRs) and pertinent postservice treatment records have been secured. VA examinations in conjunction with this claim were conducted in April 1999, May 2000, August 2003, April 2004, March 2007, September 2008, January 2010, November 2010, March 2012, August 2015, and December 2015. Together, the reports of these examinations describe the Veteran's right shoulder disability in sufficient detail to allow for application of the relevant rating criteria. In April 2014, the Court remanded this matter to the Board for readjudication with appropriate consideration of functional loss due to subjective factors, the propriety of a April 2000 reduction of the schedular rating for the right shoulder disability under Code 5202, and consideration of the Veteran's right shoulder surgical scars. In February 2015, the Board remanded this matter to secure updated VA treatment records, updated STRs, and new VA examinations evaluating the Veteran's right shoulder and associated scars to comply with the Court's remand directives; the AOJ has substantially complied with that request. The evidence in the record is adequate to support a decision on the merits in these matters. Notably, the Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Propriety of Reduction In the Court's April 2014 remand, it specifically noted that an April 2000 rating decision had inexplicably changed the diagnostic code under which the Veteran's right shoulder disability was rated from 5202 to 5201. It also noted that the Veteran had been granted service connection for his right shoulder disability, rated 20 percent under Code 5202 for six years. However, there was no explanation by the AOJ regarding the change. Under the circumstances, the Court found it could not determine whether VA had impermissibly reduced the Veteran's disability rating by changing the diagnostic code under which it was originally evaluated. See Murray v. Shinseki 24 Vet. App. 420, 428 (2011) (holding that a change in diagnostic codes amounts to a reduction of the disability rating to 0 percent before the assignment of a new disability rating under a different diagnostic code). As such, the Court indicated that the issues on appeal implicitly involve a discussion of the propriety of the AOJ's April 2000 reduction. Under 38 C.F.R. § 3.105(e), "[w]here the reduction in evaluation of a service-connected disability or employability status is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. The beneficiary will be notified at his or her latest address of record of the contemplated action and furnished detailed reasons therefor, and will be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at their present level. Unless otherwise provided in paragraph (i) of this section, if additional evidence is not received within that period, final rating action will be taken and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires." Under 38 C.F.R. § 3.344, the Veteran's 20 percent rating under Code 5202 was no longer "likely to improve" given it had been in effect for six years. See 38 C.F.R. § 3.344(c). In such circumstances, the evidence upon which a reduction is based must be strictly scrutinized. In particular, ratings for diseases subject to temporary or periodic improvement required multiple examinations to confirm sustained improvement warranting a reduction in the rating. Here, as noted in the Court's April 2014 remand, the AOJ did not initiate a line of inquiry or development to evaluate the Veteran's right shoulder disability prior to reducing the rating from 20 to 0 percent under Code 5202. No examinations were ordered to determine whether the disability experienced sustained improvement. Most importantly, however, there was no notice provided to the Veteran of a proposal to reduce that rating, and the Veteran was not given time to present additional evidence to refute discontinuation or reduction of that rating. As the procedural requirements under 38 C.F.R. § 3.105(e) for reduction of a schedular disability rating were not properly carried out, that reduction was improper, and must be considered void ab initio. As such rating compensated the Veteran for recurrent dislocation, which is distinct from the limitation of motion considered under Code 5201 for which there is an entirely separate diagnostic code, it should be reinstated in addition to his current rating under Code 5201. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Increased Ratings Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from a disability. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In a claim for increase the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating the level of disability of an increased rating claim begins one year before the claim was filed. As the instant claim for increase was received on March 13, 2000, the period for consideration is from March 13, 1999 to the present. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban, 6 Vet. App. at 262. The Veteran's right shoulder disability is ratable under Diagnostic Codes 5200 through 5203. However, at the outset, the Board notes that Codes 5200 (for ankylosis) and 5203 (for impairment of the clavicle, including dislocation, nonunion, or malunion) are not applicable to the present case because there is simply no evidence of the requisite pathology. In so finding, the Board acknowledges that the Veteran does have a documented history of a distal clavicle resection, but notes that there is absolutely no evidence (or allegation) to suggest such resulted in dislocation, nonunion, malunion, or other notable impairment of the clavicle. In addition, while the evidence also shows the Veteran has right shoulder arthritis, such disability is rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved, unless there is noncompensable limitation of motion. 38 C.F.R. § 4.71a, Code 5003. Here, the Veteran has limitation of motion that is compensable. Thus, the only applicable criteria in this case are in Codes 5201 and 5202 (for impairment of the humerus). For rating purposes, the Veteran's dominant side is his right side. The Veteran is currently rated 30 percent under Code 5201 for all periods under consideration. In order to warrant a 40 percent (maximum) rating based on limitation of motion, the evidence must show that he has right shoulder motion limited to 25 degrees from the side. 38 C.F.R. § 4.71a, Code 5201. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. The Veteran's right shoulder disability may also be rated on the basis of impairment of the humerus. Specifically, under Code 5202, a 20 percent rating is warranted for malunion of the humerus with moderate deformity and a 30 percent rating is warranted for malunion of the humerus with marked deformity. In addition, a 20 percent rating is also warranted for recurrent dislocation of the humerus at the scapulohumeral joint with infrequent episodes, and guarding of movement only at the shoulder level, and a 30 percent rating is warranted for frequent episodes of dislocation and guarding of all arm movements. A higher 50 percent rating is warranted for fibrous union of the humerus; a 60 percent rating is warranted for nonunion of the humerus (false flail joint); and a maximum 80 percent rating is warranted for loss of the humeral head (flail shoulder). 38 C.F.R. § 4.71a, Code 5202. In addition, postoperative or other residual scars associated with a service-connected right shoulder disability may warrant a separate rating under Codes 7801-04. Under Code 7801, scars not of the head, face, or neck that are deep and nonlinear warrant a 10 percent rating if they occupy a total area or areas of at least 6 square inches (39 square centimeters) but less than 12 square inches (77 square centimeters). A 20 percent rating is warranted if the affected area(s) are at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.); a 30 percent rating if the affected area(s) are at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.); and a maximum 40 percent rating is warranted if they occupy a total area(s) of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118 at Code 7801. Code 7802 provides for a sole 10 percent rating for scars not of the head, face, or neck that are superficial and nonlinear and occupy an area or areas of 144 square inches (929 sq. cm.) or greater. Id. at Code 7802. Under Code 7804, scars that are unstable or painful warrant a 10 percent rating if there are one or two such scars; a 20 percent rating for three or four such scars; and a maximum 30 percent rating for five or more such scars. An unstable scar is one where, for any reason, there is frequent loss of covering of the skin over the scar, and if one or more scars are both unstable and painful, 10 percent is added to the evaluation. Id. at Code 7804. As a final introductory note, the Board acknowledges that the evidence includes a March 2012 VA examiner's opinions that indicate certain right shoulder pathology is independent of and unlikely to be related to his service connected right shoulder disability. However, the examiner does not indicate that the resultant functional impairment (i.e., effect on the use, motion, or function in the joint) can be clearly apportioned between service connected or non-service connected sources, nor is there any other clear evidence which indicates such delineation is possible. Under Mittleider v. West, 11 Vet. App. 181, 182 (1998), the Board is precluded from differentiating between pathology attributable to service-connected disorders and those associated with nonservice-connected disorders absent clear evidence of such distinction. Moreover, VA has already granted the Veteran several temporary total ratings, and the underlying 30 percent rating, based in large part on consideration of all the Veteran's right shoulder symptoms (specifically including certain symptoms the March 2012 examiner felt were not related to the original service-connected disability). In light of the above, and in the interest of affording the Veteran a broad and sympathetic scope of review, the Board will consider the entire right shoulder disability picture in assessing the Veteran's claim. The Board will discuss each period under consideration individually. As the Board has already found the April 2000 removal of a 20 percent rating for recurrent dislocations under Code 5202 was improper and void, it will also discuss such pathology to determine whether a higher 30 percent rating is warranted for such pathology during the periods under consideration. Prior to July 23, 2003 On June 1994 VA examination, the Veteran said he had multiple dislocations of his right shoulder after an initial injury during the Persian Gulf War. He said he had a right shoulder rotator cuff tear repaired in June 1991, but continued to have problems with dislocations and increased pain, and required a second surgery (arthroscopically) in July 1992. He complained of increased pain in his bilateral shoulders at night while trying to sleep because he rolls onto his shoulders. He said he was unable to lift anything about his head due to decreased range of motion with stiffness and pain. He denied any further dislocation of either shoulder recently, and reported he only took Motrin for pain at the time. On examination, the examiner noted a well-healed surgical scar of the right shoulder. There was also severe stiffness of both shoulders with crepitus, greater on the right than left. Range of motion tests should right shoulder flexion at approximately 90 degrees and abduction to approximately 90 degrees. X-rays found right shoulder soft tissue calcification adjacent to the medial border of the neck of the humerus and a pattern of focal hyperplasia of the cortex at the posteromedial aspect of the surgical neck of the right humerus. The diagnosis was "chronic right shoulder pain secondary to multiple dislocations and a torn rotator cuff with status post repair of the rotator cuff per the Veteran's history, with positive clinical, post-operative, and radiographic findings on examination." Based on that examination, an October 1994 rating decision granted service connection for residuals of a right shoulder injury under Code 5202 (which was either on the basis of malunion of the humerus with moderate deformity, or recurrent dislocation of the humerus at the scapulohumeral joint with infrequent episodes and guarding of movement only at the shoulder level). On August 1996 VA examination, the Veteran had a 4-inch scar over the right anterior shoulder that was well-healed. He had very well defined musculature in the upper extremity and the arms, as well as the shoulder area. On examination of the shoulders, there was no muscle spasm, hypertrophy, or atrophy. Sensory, circulation, and strength in the upper extremities were normal and symmetrical. Right shoulder flexion was to 180 degrees, extension was to 50 degrees, abduction was to 80 degrees, and adduction was to 50 degrees. X-rays showed focal cortical thickening of the right humeral neck and some adjoining small soft tissue calcifications. On April 1999 VA examination, the Veteran reported sharp pain that shot from his shoulder into his hand when he slept, waking him and preventing him from laying on the painful side. He was apprehensive anytime he went to lift his right shoulder over his head, and felt like "his shoulder [was] going to come out" when he externally rotated his arm. On physical examination, right shoulder flexion was to 165 degrees. There was a large scar over the right shoulder and point tenderness over the acromioclavicular joints bilaterally. He had good supraspinatus strength bilaterally and laxity in both shoulders. The examiner could "feel the humeral head sliding up onto the glenoid rim bilaterally." X-rays were not reviewed. On May 2000 VA examination, the Veteran reported continued episodes of shoulder partial dislocation (with as many as five in the preceding year) when he accidentally flexes or abducts his left arm in a forceful manner. However, he had learned to reduce the intraarticular displacement on his own. On physical examination, the examiner found a long, semi-circular surgical scar on the right anteriorly. There was point tenderness over the acromioclavicular joint area on the right and left. No evidence of laxity was found at the time, and an apprehension test was negative. The upper extremities were neurologically intact. Range of motion testing showed right shoulder flexion to 105 degrees, abduction to 170 degrees. There was no objective evidence of significant pain during range of motion measurements. The examiner diagnosed a right shoulder status post operations with recurrent right shoulder dislocation. An October 2000 private record notes right shoulder active flexion to 130 degrees and passive flexion was to 165 degrees. A January 2001 VA record notes bilateral shoulder pain with no history of trauma. The Veteran reported motor pain and weakness when lifting his arms above his head. The record notes bilateral shoulder impingement, with active flexion to 135 degrees and passive flexion to 170 degrees. It also notes passive external and internal rotation to 90 degrees each. In April 2001, the Veteran reported dislocating his right shoulder in 1991 with a rotator cuff tear later that year. Range of motion testing showed right shoulder active and passive flexion to 170 degrees. He reported some pain with extreme range of motion with positive impingement signs. There was a well-healed deltopectoral incision with no tenderness over the acromioclavicular joint. X-rays showed right os acromiale with some spurring but indicated no evidence of degenerative changes. The examiner noted that the right shoulder showed some signs of impingement consistent with his os acromiale and that he would likely need surgery for that in the future. A motor nerve conduction study was normal with no evidence of focal neuropathy. In July 2001, the Veteran underwent a Neer-Mumford acromioplasty with open reduction and internal fixation of os acromiale in the right shoulder. The record notes a history of right rotator cuff repair nine years prior with right acromioclavicular degenerative joint disease and os acromiale on the right shoulder. Private records document a July 2003 hardware removal in the right shoulder. Discharge records indicated the Veteran was not to return to work for at least two weeks. August 2003 VA X-rays showed an interval hardware removal in the right shoulder with postsurgical changes but not evidence of acute abnormality. On August 2003 VA examination, the Veteran reported a right shoulder surgery with hardware removal in 2003. He said he was presenting just two weeks after the most recent hardware removal, and complained of bilateral shoulder pain worse in the right, and said he was limited in activity and unable to participate in weight conditioning. However, he did continue to jog with minimal symptoms. On examination, the examiner noted a well healed scar on the right shoulder. There was significant tenderness over the area, and the Veteran had significant decreased range of motion in the bilateral shoulder with forward flexion at approximately 70 degrees bilaterally with abduction to approximately 75 degrees bilaterally. He had positive impingement signs bilaterally with tenderness over both acromioclavicular joints. Motor and neurovascular examination was noted to be intact on both sides. The examiner noted some improvement in symptoms postoperatively but still had some significant pain. The symptoms appeared to limit his activity while at work with regard to lifting and overhead motions. The examiner felt his shoulder symptoms would improve. First, the Board notes that, prior to July 23, 2003, there is no evidence which indicates that the Veteran's right shoulder disability manifested as loss of the humeral head (flail shoulder), nonunion of the humerus (false flail joint), fibrous union of the humerus, or malunion of the humerus. Thus, a higher rating based on such pathology is not warranted. Furthermore, notwithstanding the Board's finding that the inexplicable removal of the Veteran's 20 percent rating for his right shoulder disability (based on dislocation) was improper, there is no evidence suggesting that the Veteran met the criteria for a higher still 30 percent rating based on such impairment. In so finding, the Board has considered that dislocations were alleged on April 1999 and May 2000 examination. However, a higher 30 percent rating based on dislocation of the humerus requires frequent episodes with guarding of all arm movements. Here, notwithstanding the fact that he reported five dislocations between 1999 and 2000, he was consistently able to perform range of motion testing with flexion and abduction reaching 100 or more degrees without notation of significant guarding of movement. Furthermore, on May 2000 examination (when he reported five dislocations in the prior year), an apprehension test (which specifically tests for laxity, instability, subluxation, or dislocation) was negative. Consequently, the Board finds no evidence to suggest the Veteran's history of dislocation also produced guarding of all arm movements. A higher rating is not warranted under Code 5202 based on recurrent dislocation of the humerus with frequent episodes and guarding of all arm movements prior to July 23, 2003. Turning to limitation of motion, a review of the evidence from this period shows the Veteran, at the very most, was limited to 105 degrees of flexion (which involved no objective evidence of pain). The only evidence which addresses abduction during this period indicates he could abduct to 170 degrees (also without objective evidence of pain). The Board has considered the notations of painful motion, tenderness on palpation, and weakness in the record. However, at the time of the greatest documented limitation of motion (flexion to 105 degrees) during the period under consideration, there was no objective evidence of pain, indicating that the recorded data reflects active motion to well above the shoulder level. Moreover, while other records did note pain and weakness on motion, they also indicated significantly broader ranges of motion. Notably, for subjective factors such as pain, weakness, and tenderness on palpation to warrant a higher rating based on limitation of motion under Deluca, they would have to produce enough additional limitation to approximate the criteria for a higher rating. Here, that would require severe additional functional loss given the relatively high ranges of motion noted. Unfortunately, there is simply no evidence suggesting such impairment. The Board notes that the only evidence of greater limitations on motion either falls before or after the evidentiary period under consideration (and even considering that data, the greatest limitations of motion shown are 50 degrees of adduction following 80 degrees of abduction in August 1996, and 70 degrees of flexion with 75 degrees of abduction in August 2003). Even that data does not approximate the degree of limitation contemplated by a higher rating under Code 5201 (i.e., limitation of right arm motion to 25 degrees from the side). The Board has also considered whether the Veteran had any right shoulder scars (including surgical scars) warranting a separate rating. However, while the evidence does note right shoulder scars, there is no evidence or allegation indicating that such scars were symptomatic or occupied an area large enough (greater than 39 square centimeters) to warrant a separate rating under the applicable rating criteria; all indications are that his right shoulder scars were well-healed and exhibited no compensable pathology. September 1, 2003 to July 19, 2007 A February 2004 VA record notes the Veteran complained of continued bilateral shoulder pain post-surgery. Range of motion in the right shoulder was painful, with active flexion to 130 degrees and passive flexion to 150 degrees. There was global weakness due to pain, pain to palpation in the supraspinatus bilaterally and in the left biceps tendon. The doctor recommended he not lift more than 30 pounds and not engage in overhead work. At the March 2004 hearing before a Decision Review Officer (DRO), the Veteran said he had "mastered" his shoulder movement (i.e., was very familiar with it) because it was his dominant side. He endorsed occasional episodes of constant pain while at rest that shot down through his shoulder, and could induce sharp pain by turning his elbow around. However, pain was primarily described as periodic. He denied any swelling in the right shoulder but said his doctor recently told him he had a bone spur that developed after his most recent surgery. He indicated he had limited range of motion, and his representative estimated he could "lift" his arm about 30 degrees before he experienced pain. The pain was not unbearable but was "annoying," increasing as he continued to lift his arm. At a certain point, he indicates the pain stops him from moving further, and his shoulder locks up. He said he avoided sleeping on his right side. On April 2004 VA examination, the Veteran said he had not worked since 2000 (when he was a mechanic) and was unable to do "things above his head." However, he was in school at the time. On examination, the Veteran had a negative lift-off test bilaterally, and was tender about the right rotator cuff. There were well-healed surgical incisions bilaterally. There was a right anterior shoulder incision which was well-healed. The Veteran had negative apprehension tests bilaterally with positive impingement signs. He had give-way weakness of both shoulders. Active forward flexion was to 80 degrees bilaterally, with passive flexion to 90 or 100 degrees. Abduction was to 80 degrees on the right. The examiner felt the Veteran had significant residual pain, weakness, and loss of motion in both shoulders after attempts at osteo acromial fixation, as well as Neer-Mumford acromioplasty in the right anterior shoulder. These were all related to injuries he sustained in service and has left him with a significant functional defect that would not allow him to perform any activities above his head or a job with any pushing, pulling, or lifting. As a result, he was attempting to go to school and find a career in child psychology. The examiner believed his symptoms and believed he was in an extreme amount of pain. A February 2005 X-ray showed irregularity of the right clavicular head that was stable. There was also a bony outgrowth of the right humeral head that was probably degenerative in nature. An April 2005 VA CT scan of the right shoulder showed evidence of prior pinning of the acromion after removal with normal trabecular bridging across the fixation site, bony fragmentation at the anterior tip of the acromion, a remote injury of the subscapularis with secondary enthesopathic change at the lesser tuberosity, and degenerative changes of the glenohumeral joint. August 2005 VA records note right shoulder flexion was to 150 degrees and abduction was to 130 degrees. He was tender to palpation over the lateral acromion, with positive impingement signs and positive empty can sign. A CT scan confirmed a bony fragmentation at the anterior tip of the acromion. The diagnosis was pseudoarthrosis at the right os acromiale. June 2006 VA records note a neurological evaluation found normal motor strength in the right upper extremity with normal sensory and reflex evaluations bilaterally. In February 2007, the Veteran reported some increased and intermittent right and left hand numbness. On March 2007 VA examination, the Veteran reported constant shoulder pain and described a popping and clicking sensation. He reported pain with any kind of reaching or lifting, and found he could not lift weight unless he was in a certain position. On examination, he had 130 degrees of flexion. Strength was slightly reduced, and he had no crossover. There was a negative acromioclavicular compression test and no pain on palpation of his acromioclavicular joint. He had a transverse, well-healed incision over the acromioclavicular joint. The examiner noted some pain with general range of motion in the glenohumeral articulation as well, and a negative apprehension sign. In addition, the examiner found a longitudinal incision that was well healed at the deltopectoral interval as well. The diagnosis was right shoulder degenerative joint disease and residuals from a distal clavicle resection. In March 2007, the Veteran reported worsening pain over the past few years, and said he had pain with overhead activities and at night. On examination, he could flex his right shoulder to 130 degrees and abduct to 95 degrees. The shoulder was tender to palpation at the distal acromion, and he was positive for impingement. X-rays showed evidence of os acromiale with fragmentation and questionable evidence of post-glenoid injury. CT scans showed acromiale. The following month, VA records note strength, sensation, and reflexes were normal in both upper extremities. Neurological studies were normal bilaterally, and the provider noted no evidence of right ulnar, cervical, or median neurological impairment. A June 2007 VA records notes right shoulder flexion to 130 degrees and abduction to 90 degrees. MRIs revealed a small articular surface tear of the distal supraspinatus tendon, a posterior labral tear, mild biceps and subscapularis tendinopathy, and degenerative changes of the acromioclavicular joint with an incidentally noted os acromiale. EMGs were negative for neuropathy or radiculopathy. June 2007 private records note the Veteran had 150 degrees of active elevation on the right. He had a normal belly press test and minimal tenderness over the acromioclavicular joint and acromion. He had some discomfort with anterior and posterior drawer tests but no significant laxity. X-rays showed an inferior spur off his humeral head consistent with some early osteoarthritis. MRI revealed a very small area of undersurface tearing of the supraspinatus with a degenerative tear of his posterior labrum. A July 2007 private record notes the Veteran underwent a right shoulder arthroscopy with labral debridement with an expected recovery time of 8-12 weeks, after which the AOJ granted a temporary total rating based on convalescence following surgery. Here, again, the Board notes that there is nothing in the evidence suggesting loss of the head, nonunion, fibrous union, or malunion of the humerus head. Therefore, any rating based on such pathology is not warranted. In addition, the evidence does not suggest that there is pathology consistent with frequent episodes of dislocation and guarding of all arm movements. Notably, with the exception of a March 2007 report on VA examination, the Veteran did not endorse a pattern of continued recurrent dislocations, and apprehension tests throughout this period were negative. Moreover, just as the Board mentioned above, the Veteran was again consistently able to undergo range of motion testing throughout the period under consideration with relative success (as most results showing motion above the shoulder, as discussed further below) and no notations of significant guarding of movement. Therefore, the evidence does not suggest that a higher 30 percent rating based on recurrent dislocation with frequent episodes and guarding of all arm movement under Code 5202 is warranted during this period. Consequently, the only remaining question for consideration is whether the Veteran suffered from limitation of motion and associated functional impairment warranting a rating in excess of 30 percent during this period. Range of motion data during this period shows the Veteran was able to consistently flex and abduct his right arm to at least shoulder level (which is consistent with a 20 percent rating under the schedular criteria). Notably, the lowest range of motion test results were in April 2004 (80 degrees of active flexion and abduction). Thus, even at his worst, the Veteran was very nearly able to flex and abduct his arm to shoulder level. At the time, he did report significant pain and weakness, which the examiner believed was "extreme." However, the range of motion figures here reflected active motion, which already contemplates the limitations imposed by subjective factors such as pain or weakness. Furthermore, limitation to 80 degrees of active flexion and abduction is nonetheless significant and consistent with the doctor's notations of "extreme pain." While the Board acknowledges that other evidence of record during this period does note additional factors such as pain on palpation, painful motion, and weakness, it again notes that those records also indicate significantly broader ranges of flexion and/or abduction (over 100 degrees). As noted above, given these relatively high range of motion figures, the evidence would have to show these subjective factors were incredibly severe, and likely to the point of being near-debilitating for the Board to consider the Veteran to operate with the functional equivalent of limitation to 25 degrees of motion from his side under Deluca. The Board also acknowledges that the Veteran's representative estimated at the DRO hearing that the Veteran could only lift his right arm 30 degrees before pain began. However, there is nothing indicating that representative is a medical professional competent to make such assessments. Furthermore, by his own admission, the Veteran indicated that the pain that began at that point was merely "annoying," suggesting it was not the type that would preclude further movement. Thus, that estimation is not, in the face of clinical medical evidence that overwhelmingly suggests much larger ranges of motion, probative evidence in this matter. Consequently, while the Board does not doubt the Veteran has significant pain and is sympathetic of that fact, there is no evidence or allegation of functional impairment so dire that it could reasonably be seen as causing an additional 100 or more degrees of lost motion. Thus, a higher rating based on limitation of motion is not warranted. The Board has also considered whether a separate rating is warranted during this period for scars associated with the service-connected right shoulder disability. However, as above, there is no evidence indicating that any right shoulder scars were manifested during this period that were symptomatic or otherwise occupying a total area warranting a separate rating (i.e., greater than 39 square centimeters). All scars identified were noted to be well-healed; thus, they appear to have been asymptomatic at the time. Consequently, a separate rating for right shoulder scars is not warranted between September 1, 2003 and July 19, 2007. November 1, 2007 to March 23, 2008 February 2008 VA records note active right shoulder flexion was to 80 degrees (and beyond with pain), and abduction was to 70 degrees. X-rays showed no scapular abnormalities. In March 2008, MRIs revealed supraspinatus and subscapularis tendinopathy, a tiny articular surface tear of the distal infraspinatus tendon, degenerative changes at the glenohumeral joint, likely associated with a posterior labral tear, postsurgical or degenerative changes of the acromion process, and mild superior subluxation of the humeral head relative to the bony glenoid. VA records later that month note right shoulder flexion to 110 degrees. In late March 2008, the Veteran underwent a right shoulder Mumford acromioplasty to treat his right shoulder acromioclavicular joint degeneration and impingement (after which he was granted a temporary total rating based on convalescence following surgery). Again, the Board notes that there is no evidence of loss, nonunion, malunion, or fibrous union of the humerus during this period. Moreover, there is nothing to suggest frequent episodes of dislocation with guarding of all arm movements. The only notation which suggests any dislocation is a March 2008 notation indicating MRI findings may be consistent with "mild superior subluxation of the humeral head relative to the bony glenoid." However, even this only notes a possibility of mild subluxation, and does not bear on the frequency of such episodes (if they existed for certain). In addition, just as before, the Veteran was able to perform range of motion testing during this period and providers did not note apprehension or efforts to resist motion. Therefore, the Board finds no evidence which suggests guarding of all arm movements as required by the relevant criteria. Consequently, there is no basis for awarding a higher rating under Code 5202. Turning to limitation of motion, the Board notes that, during this relatively brief period under consideration range of motion tests showed, at the worst, active flexion limited to 80 degrees and abduction to 70 degrees. Pain was noted, but as explained above, accounted for in the results (as the examiner specifically notes the Veteran could go beyond 80 degrees with pain). There is no notation of additional subjective factors such as weakness, instability, incoordination, fatigability, lack of endurance, or other such factors which might cause functional loss of motion without being reflected on physical evaluation. Rather, it would appear that, even at its worst, the Veteran's right arm could elevate to at least 20 degrees shy of shoulder level. Therefore, there is no basis upon which the Board may reasonably conclude that the Veteran's range of motion during this period approximated that required for a higher 30 percent rating (i.e., limited to 25 degrees from the side). Moreover, there is no evidence which suggests any scars associated with the Veteran's right shoulder disability became or were found to be symptomatic or occupying areas (i.e., greater than 39 square centimeters) such that a separate rating under Codes 7801 through 7804 would be warranted. July 1, 2008 to September 8, 2009 On September 2008 VA examination, the Veteran reported pain, weakness, fatigability, and lack of endurance, but denied swelling, heat, redness, instability, giving way, or locking. He also reported pain was worse with any lifting, particularly overhead lifting, and internal rotation. In addition, he endorsed a three-year history of intermittent paresthesias in the right fourth and fifth fingers at night. He denied flare-ups. He reported one additional episode of dislocation and subluxation after the initial injury in 1993. The examiner noted that no reduction was needed at the time. The condition was felt to affect his usual occupation and recreational activities, but did not interfere with mobility, activities of daily living, or driving. The examiner noted that the Veteran had been unable to work his former job as a welder since 2000 and was a full time student at the time. The examiner noted a history of a March 2008 distal clavicle resection and acromioplasty, with no reported improvement afterwards. On examination, flexion was to 90 degrees and abduction was to 90 degrees. There was pain throughout the arc of motion with severe pain at the limits of motion. Repetitive motion yielded pain throughout the arc of motion with every repetition, but did not cause fatigue, weakness, lack of endurance, or incoordination. There was objective evidence of painful motion and tenderness over the acromioclavicular joint. There was no ankylosis or inflammatory arthritis. The examiner noted a positive Tinel's sign at the elbow with paresthesia in the fourth and fifth finger, a positive Phalen test, and a subluxatable ulnar nerve at the medial epicondyle. X-rays showed a right shoulder status post resection of the distal clavicle with no acute fracture. The Veteran reported having an EMG to evaluate ulnar neuropathy but this study was not available at the time of examination. The diagnoses were early glenohumeral degenerative joint disease, adhesive capsulitis, and cubital tunnel syndrome. The examiner opined that cubital tunnel syndrome is a condition that is independent of any shoulder pathology, and was not caused or a result of his right shoulder disability. In November 2008, the Veteran said he had a long history of right shoulder pain that had become unbearable in the last five years. He indicated that sometimes he has to take his left hand and move his right arm into a sling position to ease the pain at night, and often sleeps in a 45 degree angle while sitting up. He reported two surgeries in the preceding year and multiple trips to the emergency room due to constant pain. He did not think there was anything that could be done to ameliorate his nighttime pain, or that would help him hold a physical job. He said he was in college working on a bachelor's degree in business leadership because he knew that going back to his skilled trade as a welder was out of the question. He suggested that his range of motion results on examination overstated his functionality because he was assisted by doctors during such examinations. January 2009 VA records show the Veteran said he fell while jogging and presented complaining of right shoulder pain. X-rays showed postoperative changes with no evidence of acute injury. Records later that month show he complained that his right shoulder was painful "all the time," at a 7/10 on the pain scale. He reported difficulty raising his arm. A February 2009 record notes an EMG conducted in 2007 showed normal right ulnar and median motor and sensory nerves. Physical examination showed tenderness to palpation, and flexion to 100 degrees and abduction to 60 degrees. The examiner noted right shoulder tendonitis. March 2009 private records indicate the Veteran presented for initial evaluation and treatment of his right shoulder pain. He said he had fallen in January 2009 and experienced acute onset of increased right shoulder pain. On examination, he held his arm in a normal position and used it without severe pain. There was no atrophy, ecchymosis, effusion, erythema, increased skin temperature, scar, swelling, or warmth. Strength was normal. The examiner noted passive right external rotation at the side to 70 degrees. An apprehension and relocation test was negative. Later that month, he held his arm in a "protected position" on examination, and used it with moderate pain. There was a well-healed scar noted. Strength was normal (except in the subscapularis region, where it was slightly reduced), and distal neurovascular status was intact with normal sensation and pulses. In April 2009, the Veteran reported only short-term relief from a cortisone injection provided on the last appointment. On examination, distal neurovascular status was intact with normal sensation and pulses. Strength was normal, but he used the arm with moderate pain. Apprehension and relocation tests were positive, but a posterior drawer test was negative. A motor and sensory examination was grossly normal and nonfocal. X-rays showed no dislocation, fracture, or subluxation. It appeared that one to two centimeters of his clavicle had been excised in the past, with increased ossification near the lesser tuberosity. There was also significant exostosis on the anterior aspect of the proximal humerus near the lesser tuberosity. August 2009 VA records show the Veteran reported "really bad pain in the shoulder, neck, back of neck, going on for five months." August 2009 private records note distal neurovascular status was intact with normal distal sensation and pulses. Strength was normal, but the Veteran used his arm with moderate pain. Apprehension and relocations tests were positive, but a posterior drawer test was negative. On September 9, 2009 the Veteran underwent an examination under anesthesia with diagnostic right shoulder arthroscopy and right shoulder type II a superior labral, from anterior to posterior (SLAP) repair (after which he was granted a temporary total rating based on convalescence following surgery). There is, again, no evidence of loss, nonunion, malunion, or fibrous union of the humerus during this period. Therefore, a higher rating based on such criteria under Code 5202 is not warranted. Moreover, while the Board does note that positive apprehension and relocation tests in April and August 2009 suggest laxity or instability in the right shoulder, there is no clinical evidence confirming either dislocation or subluxation of that joint during the time under consideration. In fact, both the April and August 2009 evaluations also noted that posterior drawer tests were negative, and X-rays reviewed in April 2009 showed no clinical evidence of dislocation, fracture, or subluxation. Notably, there are no documented complaints of dislocation or subluxation during this period (which would reasonably be expected, particularly if the Veteran was having frequent episodes of such symptoms). Furthermore, while the Board acknowledges that the Veteran was noted as keeping his arm in a "protected position" during March 2009 evaluation, this alone does not suggest "guarding of all arm movements" as required for a higher 30 percent rating under Code 5202. Significantly, that is the only such notation in the record for this period, and all other evaluations during this time either did not note abnormal positioning of the right arm or explicitly noted normal positioning. Consequently, the Veteran is not shown to have impairment approximating the criteria for a rating in excess of 30 percent under Code 5202. Turning to limitation of motion, the Board notes that the greatest degree of limitation was in January 2009, when the Veteran could only abduct to 60 degrees (albeit flexing to 100 degrees). At the time, the provider also noted tenderness on palpation, and based on the consistent complaints in the record, the Board may reasonably concede that the Veteran experiences painful motion of the right shoulder. Nonetheless, such evidence plainly shows the Veteran's right shoulder was, at worst, limited to movement between his side and shoulder-level. In so finding, the Board has also considered his allegation that official range of motion studies overstate his functionality because they are physician-assisted. However, even assuming arguendo that his painful motion (and other subjective factors) likely caused additional functional loss, there is nothing to suggest that such loss was so severe as to cause an additional 35 degrees of lost motion during this period (which is what would be required to meet the criteria for a rating in excess of 30 percent under Code 5201). Notably, the evidence during this period shows the Veteran went jogging (that does not appear to have been impeded by his right shoulder disability, as he reported pain following a fall while jogging), an activity that involves at least a fair amount of arm movement. Consequently, the preponderance of the evidence is against finding the Veteran's right shoulder disability is productive of impairment approximating the criteria for a higher rating based on limitation of motion under Code 5201 for the period under consideration. The Board has considered whether a separate rating is warranted based on right shoulder surgical scars during this period. However, there is nothing in the evidence suggesting that any such scars were painful, unstable, occupying a total area larger than 39 square centimeters, or otherwise symptomatic. Therefore, a separate rating for scars associated with his service-connected right shoulder disability is not warranted. From December 1, 2009 A December 2009 VA records notes the Veteran had an eleven month history of right shoulder and neck pain that began behind the right scapula as a sharp "catch," but progressed to involve the muscles of his shoulder and right neck. The pain occasionally extended into the face or down the left arm. It was frequently a burning type of pain and was worse when muscles were tight or in spasm. An EMG was noted to show borderline signs of myopathy with mildly small motor unit fibers, but otherwise was negative. On examination, motor strength was normal bilaterally. Reflexes, sensation, and gait were also normal. However, there was minimal give-away weakness of the right proximal muscles. EMG results revealed a mild myopathic process without fiber splitting, necrosis, or membrane instability. There was no evidence of left cervical radiculopathy. The neurologist concluded that the symptoms described appeared to be a musculoskeletal spasm (though she would not expect such to persist for nearly a year with little resolution). However, the Veteran did not have abnormal strength, bulk, tone, or other expected neurological deficits that would be consistent with dystrophic disease. Radiculopathy was not found. On January 2010 VA examination, the Veteran reported right shoulder pain, with no weakness, stiffness, swelling, heat, redness, instability, giving way, "locking," fatigability, or lack of endurance. He also reported flare-ups of right shoulder pain (to an 8/10 on the pain scale) when it rains that prevent him from attending school. He denied any episodes of dislocation but said his shoulder pops when it moves it. On examination, there was no ankylosis of the right shoulder. Right shoulder flexion was to 94 degrees and abduction was to 110 degrees. On a second test, flexion was to 86 degrees and abduction was to 82 degrees. The examiner noted pain, fatigue, and weakness with these initial tests. He also noted objective evidence of painful motion, instability, weakness, tenderness, and guarding of movement. On a final test, flexion was to 80 degrees and abduction was to 78 degrees with pain, fatigue, weakness, and lack of endurance. Surgical scars were noted on the right shoulder. The Veteran appeared "moderately affected by his right shoulder condition." The residuals of his surgeries included degenerative joint disease, weakness, pain, and lost motion in the right shoulder, pain with sleeping on his right shoulder, a distal clavicle resection, and a large keloid over the right shoulder. The examiner noted multiple right shoulder scars. The first was on the right anterior shoulder, measuring 10 centimeters by 1 centimeter (10 square centimeters). The skin was atrophic, with no tenderness, adherence, frequent loss of covering, elevation or depression of the surface contour, or areas of induration and inflexibility. It was superficial and dark, but did not cause any additional limitation. The second scar was on the right superior shoulder, and measured 7 centimeters by 2 centimeters (14 square centimeters). The texture was "keloidal," and it was tender on examination. There was elevation or depression of the surface contour on palpation, but the scar was not deep. There was no area of induration and inflexibility of skin, no breakdown, and no adherence to the underlying tissue. It did not cause any limitation. The final scars were multiple arthroscopy scar sites on the posterior shoulder, measuring 2 centimeters by 0.2 centimeters in total (0.4 square centimeters). The texture of the skin was normal, and there was no tenderness on examination. The scars did not break down, adhere to the underlying skin, result in frequent loss of the covering, elevate or depress on palpation, or include areas of induration and inflexibility. They were all superficial, and the examiner felt they caused no limitations. Together, the scars occupied an area of (24.4 square centimeters). October 2010 STRs show the Veteran reported severe right shoulder pain (7/10 on the pain scale). He said he had injured his right shoulder on the prior day lifting weights, and had limited range of motion with pain and stiffness. On examination, the shoulder was tender to palpation, and pain was elicited on motion. There was no swelling, erythema, warmth, or misalignment. In July 2010, he injured his right shoulder lifting weights. The shoulder was tender on palpation with pain on motion. There was no swelling, erythema, warmth, or misalignment, and motion was normal. The following month, he endorsed painful range of motion, but denied paresthesia. The provider noted multiple right shoulder scars, painful range of motion, good strength, normal grip, and tenderness to palpation anteriorly. A September 2010 temporary physical profile was issued prohibiting climbing, crawling, pushing, pulling, lifting or carrying more than 15 pounds, reaching above the shoulder, swimming, diving, or wearing load-bearing equipment. In a September 2010 statement, he reported a total of eight surgeries on his right shoulder, with six in the last nine years. He indicated that he had recently graduated from college and was looking for employment. He said he had not worked in ten years because there were not many jobs he could perform with his right shoulder problems. He said he performs strength and stretch exercises every morning before he starts his day, and works out with five pound barbells to maintain his muscles. He reported pain and swelling, with bone spurs from his surgeries that must be shaved down periodically. He also said he wakes up in the night often because he rolls over into positions that agitate his shoulders. On October 2010 VA evaluation, the Veteran presented with right shoulder pain and immobility since August 2010 after he injured himself lifting weights. He reported constant pain. On examination, MRIs showed stable postsurgical changes and degenerative disease. Range of motion tests showed flexion to 110 degrees (with passive motion to 155) and abduction to 110 degrees. On November 2010 VA examination, the Veteran reported his right shoulder disability had improved since its onset. The examiner noted a history of eight surgeries. The Veteran also endorsed pain, stiffness, weakness, incoordination, and flare-ups of joint disease. He denied deformity, instability, dislocation or subluxation, locking episodes, or effusions. He reported swelling, and said his reported flare-ups are moderate and occur when weather is cold and rainy. He denied any limitations on standing or walking. On examination, the examiner noted that there was no recurrent shoulder dislocation or loss of a bone or part of a bone. There was tenderness, abnormal motion, and guarding of movement in all arcs of motion. Range of motion testing showed flexion to 90 degrees and abduction to 85 degrees. There was objective evidence of pain with active motion, and repetitive testing did not cause additional limitation. The examiner also noted a superior scar measuring 2.5 inches on the right shoulder and an anterior scar measuring 4.5 inches. Furthermore, the examiner noted he was unable to accurately determine the right shoulder arcs of motion due to guarding. The Veteran was going to school at the time. The examiner opined that his disability would cause moderate problems with chores, mild problems with shopping, exercise, recreation, bathing, and dressing, prevent sports, and have no effect on traveling, feeding, toileting, grooming, or driving. He also opined that the Veteran's shoulder pain could impair function during flare-ups or with repeated use over time, but could not determine whether this actually occurs or express such a possible effect in terms of range of motion without resorting to mere speculation. Moreover, while additional loss of motion was not exhibited during the actual evaluation, the examiner indicated that the testing was not "under more rigorous conditions, such as the weight lifting described in the record," and therefore was unable to offer an opinion as to whether or not subjective factors might result in additional loss of motion at the time. A December 2010 physical profile indicates the Veteran could not climb, crawl, push, pull, or lift and carry over 15 pounds. He also could not reach above his shoulder, swim, or dive. The profile noted right shoulder pain due to an August 2010 surgery. The profile was temporary as he was undergoing evaluation and treatment. A January 2012 STR notes reports of right shoulder pain since 1990 with numerous surgeries. He sought a profile to exclude him from push-ups and heavy lifting with the right shoulder. He also reported numbness in both hands and arms, particularly when waking in the morning. The symptoms depend on which shoulder he slept on at night, and had been worsening over the past seven years. On March 2012 in-service evaluation, the Veteran reported intermittent bilateral forearm and hand tingling for the past seven years that was worse in the morning, which was felt to be consistent with cubital tunnel syndrome. In October 2013, he reported right shoulder pain for 20 years, off and on, but progressively worse in the last week. The pain was sharp and stiff, and occurred daily. On average, the pain was rated a 6/10. At worst, it was rated 8/10, and at the least, it was rated 5/10. It was exacerbated by any kind of movement, and at the time, the Veteran rated it an 8/10 on the pain scale at the time. On examination, there was tenderness to palpation of the acromioclavicular joint. Shoulders showed a normal appearance, but palpation revealed right shoulder abnormalities. Motion was also abnormal (though there was no indication of how), and pain was elicited on motion. In November 2013, the Veteran was referred to a private provider for evaluation of his right shoulder. He had pain of some degree over the past 20 to 25 years. Pain increased two months prior in association with getting ready for a physical therapy test and doing pushups. His pain was generally reported in the right shoulder region, more anterolaterally than elsewhere, though he also complained of pain at the superior trapezius and right paracervical regions. He complained of decreased range of motion and strength, and had difficulty reaching overhead or behind his back. He was able to use his right arm to feed and dress himself, but pain symptoms regularly interrupt his sleep at night. There was no major numbness or tingling. On examination, the doctor found no swelling, atrophy, or deformity about the shoulder girdles or upper extremities. He had hypertrophic scars at the superior lateral aspect of both shoulders and over the anterior axillary region of the right shoulder. Right shoulder elevation was to 100 degrees. The doctor could not tell whether passive motion was better than active motion because of pain with range of motion testing. There was pain and weakness with subscapularis strength testing, and pain with external rotation strength testing (but good external rotation strength). Clinically, the right shoulder was stable and the skin was in good condition. Distal joint range of motion was good, and distal sensation to light touch was intact. Distal capillary refill was also good, but bicep, tricep, and brachioradialis deep tendon reflexes were unobtainable. X-rays showed distal clavicle incision in the right shoulder with moderately large prominent at the lesser tuberosity level consistent with a healed avulsion fracture and/or some type of bone transfer surgery in the region. The glenohumeral joint space was well maintained. The examiner could not make a definite diagnosis with respect to the right shoulder. However, he indicated that the Veteran's reported pain running from the shoulder to the neck was associated with cervical degenerative changes (rather than his right shoulder disability). December 2013 private MRIs showed severe degenerative changes of the glenohumeral joint, a SLAP tear involving the entire posterior labrum as well, and signs of a resection of the distal clavicle. Later that month, his muscle bulk about the right shoulder was good, but he had pain with range of motion testing and to a lesser extent with strength testing. There was slight intermittent glenohumeral crepitus with motion, and good rotator cuff strength in all directions. Active right shoulder elevation was to 100 degrees. MRIs showed postoperative changes at the glenoid and subacromial level. There was a suggestion of an os acromiale of the meta-acromion type. There was also severe glenohumeral cartilage loss and associated posterior subluxation of the glenohumeral joint associated with a prior distal clavicle resection. There was also a one centimeter diameter posterior glenoid cyst. However, the rotator cuff appeared intact. Tentatively, the Veteran decided to proceed with an arthroscopic joint debridement under general anesthesia as an outpatient. A March 2014 private record indicates the Veteran reported cubital tunnel syndrome of the right hand causing pain and numbness that radiates to the elbow and decreases grip strength. Later that month, he presented to schedule surgery for his right shoulder, complaining of pain, decreased range of motion, and decreased strength, and had been working. On examination, he had moderately decreased right shoulder range of motion with mild acromioclavicular crepitus and mild subacromial crepitus. There was moderate tenderness over the acromioclavicular interval and anterolateral portion of the rotator cuff. He had pain and weakness with subscapularis strength testing. He had pain with external rotation strength testing, but external rotation strength was good. The biceps tendon, longitudinally, was intact, and the doctor did not feel a defect in the rotator cuff. The shoulder was stable, and there was slight glenohumeral crepitus. The diagnosis was posttraumatic arthritis of the right shoulder. A May 2014 STR notes a rotator cuff tear in the right shoulder, and that the Veteran was scheduled for surgery the following day. A May 2014 record notes that the Veteran tolerated his arthroscopic debridement of the right shoulder well and returned to the recovery room in good condition with minimal blood loss. On postsurgical follow-up evaluation, the Veteran's right shoulder distal joint range of motion was good and distal neurovascular status was intact. The doctor felt he was not yet ready to return to work for another four weeks. In July 2014, the Veteran presented for follow-up treatment after the May 2014 right shoulder arthroscopic debridement and capsular release. He complained of pain, decreased range of motion, and decreased strength. He was able to use his right upper extremity to help feed and dress himself, and had been working. He was usually able to sleep, and not regularly taking any medications for pain. He was able to job without major difficulty. However, anything more than light use of the upper extremity was associated with increased pain. On examination, distal joint range of motion was good and distal neurovascular status was intact. Active right shoulder elevation was to 95 degrees. There was slight, intermittent glenohumeral crepitus with motion, no subacromial crepitus, and very mild generalized tenderness about the right shoulder. He had pain with range of motion testing and with strength testing. Passive motion was approximately the same as active motion. The diagnosis was posttraumatic arthritis of the right shoulder that was "unresponsive to arthroscopic debridement surgery." Work restrictions were "no repetitive or overhead lifting and no lifting over 1-3 pounds." The doctor also "recommended against doing push-ups or sit ups" because he was "unable to position his hands behind his head per the usual sit-up position." A September 2014 physical profile indicates the Veteran was status post an arthroscopic debridement for the right shoulder and had temporary limitation while being treated for chronic shoulder pain. He had residual pain despite the debridement, and could not perform repetitive lifting, overhead lifting, or lifting greater than one to three pounds with his right arm. He also could not perform push-ups or sit-ups. However, he was expected to be fully mission capable by December 2014. An October 2014 private record notes the Veteran had significant pain and weakness while testing his right rotator cuff. He reported increased pain and stiffness in the shoulder since his last surgery in May 2014. On examination, his neurovascular status was "intact," and he had 80 degrees of active elevation in the right shoulder. He had significant when the doctor tested the supraspinatus, and less in this infraspinatus. He also had pain on a belly press test. An October 2014 private MRI showed no evidence of a full-thickness rotator cuff tear, but there was a small amount of intrasubstance high signal within the supraspinatus that could reflect postoperative change or minimal intrasubstance partial tearing extending less than 35 percent of the tendon thickness. There was also abnormal thickening of the rotator cuff involving predominantly the subscapularis and supraspinatus suggesting tendinopathy or postoperative change. The MRI also showed severe glenohumeral joint degeneration, postoperative changes along the anterior acromion and lateral clavicle, a longitudinal split tear within the long head of the biceps, and at least degenerative signal within the posterior superior labrum with a possible small amount of tearing as well. In December 2014, the Veteran had 80 degrees of active elevation in the right shoulder. He had significant pain when the doctor tested his supraspinatus and less so his infraspinatus. There was also pain with a belly press test. MRIs were reviewed and showed severe glenohumeral osteoarthritis with mild rotator cuff tendinitis (without significant tearing). The doctor indicated that he would have to have a shoulder arthroplasty in the future. He also opined the Veteran had permanent restrictions including "no push-ups, sit ups, or lifting any more than 5 [pounds] with his right arm." A December 2014 physical profile was issued for posttraumatic osteoarthritis of the shoulder and rotator cuff tendonitis that precluded him from performing push-ups, sit-ups, or lifting greater than five pounds with the right arm, per his private physician's note (which also confirmed the "permanent nature of [the] condition." However, the profile was temporary. In April 2015, the Veteran reported continued shoulder pain and limitation of motion. His orthopedic surgeon had placed him on a permanent restriction including no push-ups, sit-ups, or lifting more than five pounds with the right arm. Examination showed he had trouble even removing his outer blouse and could barely lift his arms above his head. He could not place his right arm in parade rest. The record also noted a protrusion on the distal clavicle at the acromioclavicular joint that appeared to be a postoperative bone shift. Later that month, he was referred for a fitness for duty evaluation secondary to bilateral shoulder pain. He was noted to have had at least eight surgeries on his shoulders, to include arthroscopic cleanouts, bilateral Mumford's procedure, hardware removal, and rotator cuff tear on the right side. His last surgery was "the last fairly minor surgery that was attempted." His shoulders continued to have significant pain. He was given a significant diagnosis of "severe glenohumeral osteoarthritis of his right shoulder" and his orthopedic surgeon was noted to have placed him on permanent restrictions including no push-ups, no sit-ups, and no lifting more than five pounds with the right arm. On examination, he had trouble even removing his outer blouse, could barely lift his arms over his head, could not place his right arm in parade rest, and reported tenderness to palpation along the entire acromioclavicular joint, acromion process, bursa, and supraspinatus. He also had a protrusion on the distal clavicle at the acromioclavicular joint that appeared to be a bone shift after his Mumford's procedure. On April 2015 private evaluation, the Veteran reported continued right shoulder pain and irritation. On examination, neurovascular status was intact, and compartments were soft and nontender. There was persistent right shoulder pain with both active and passive motion of the right shoulder joint. A neurological examination was nonfocal. In June 2015, the Veteran's private doctor indicated he had cancelled an August 2015 shoulder surgery and intended to reschedule it in the following year. The following month, he reported pain and numbness in the right elbow. On August 2015 VA neurological examination, the Veteran was diagnosed with right and left cubital tunnel syndrome, with a history of left ulnar decompression. There was mild, intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness in the right upper extremity. Muscle strength, sensation, and reflexes were normal in the upper extremities. There were no trophic changes noted, and gait was normal. The examiner also found mild, incomplete paralysis of the right ulnar nerve. A February 2014 EMG was noted as showing a normal right upper extremity. His cubital tunnel syndrome was not felt to impact his ability to work. On August 2015 scars examination, the Veteran was found to have multiple right shoulder surgical scars, including a horizontal scar (measuring 7 by 1.5 centimeters), a vertical scar (measuring 11 by 1.7 centimeters), an anterolateral scar (measuring 3.5 by 0.2 centimeters), a lateral scar (measuring 1.5 by 1 centimeters), and a medial, painful scar (measuring 1 by 0.4 centimeters). In total, the combined area of these scars (as reported) was 31.8 square centimeters. There were no superficial, non-linear scars or deep, non-linear scars. None of the scars were productive of any other pertinent physical findings, or impacted his ability to work On August 2015 VA orthopedic examination, the Veteran said he was having recurrent bilateral shoulder pain in the early 2000s with symptoms of impingement and rotator cuff tendonitis, and an October 2000 MRI of the right shoulder showed degenerative changes in the acromioclavicular joints and tendinopathy of the supraspinatus and infraspinatus tendons. He underwent a Neer-Mumford procedure in 2001, with acromial screws removed in July 2003. The examiner noted an April 2005 CT scan revealed remote injury of the subscapularis with secondary spurring at the lesser tubercle and degenerative change in the glenohumeral joint. Bony fragmentation of the anterior tip of the acromion was also noted. In 2007, he underwent a right shoulder arthroscopy and labral debridement, and in 2009 he "experienced a fall with increased right shoulder pain." A March 2009 MRI revealed tendinopathy of the distal infraspinatus, supraspinatus, and subscapularis. Extension labral tear and SLAP tear along the entirety of the posterior labrum was also noted. In 2010, the Veteran apparently reinjured his right shoulder lifting weights, and underwent arthroscopic debridement in 2014 with only temporary relief. More recent reevaluation showed severe degenerative arthritis, and the Veteran discussed a possible shoulder replacement. Range of motion testing showed flexion and abduction to 40 degrees. Loss of motion, independently of pain that was also present during passive motion, was felt to contribute to his functional loss. Pain was noted across all planes of motion, but there was no evidence of pain with weight-bearing. There was pain to palpation anterolaterally along the rotator cuff, but no objective evidence of crepitus. On repetitive use, the Veteran had additional functional loss that was medically consistent with his statements describing functional loss with repetitive use over time, despite not examining him immediately after such use. While the examiner felt pain also caused additional functional limitations, he could not find an empirical or conceptual basis for estimating the additional degree of impairment caused. There was no sign of ankylosis. However, the examiner suspected right shoulder instability because the Veteran could not perform a crank apprehension and relocation test. The examiner noted no loss of the humeral head (flail shoulder), nonunion (false flail shoulder), of fibrous union of the humerus. There was no malunion of the humerus with moderate or marked deformity. There was a history of right shoulder arthroscopic surgeries in 2001, 2007, 2009, and 2014 with residual glenohumeral joint osteoarthritis that was severe. It was not felt that the Veteran's right shoulder was so disabled that amputation with prosthesis would equally serve him. Imaging confirmed osteoarthritis. The examiner felt that the Veteran was unable to perform any Army training or wear body armor due to severe shoulder pain. He reported constant discomfort of the right shoulder and was unable to do any repetitive manual labor. The Veteran also reported intermittent bilateral numbness and tingling radiating from the elbows to the fourth and fifth digits, but denied any actual difficulty in the joints themselves. He had been diagnosed as having cubital tunnel syndrome for many years that had recently been confirmed, leading to a left ulnar release. However, he opted to not have a right ulnar release because his symptoms were minimal on that side. No neurological findings were noted. A September 2015 medical evaluation board report notes right shoulder osteoarthritis since 1990, diagnosed as right shoulder glenohumeral and acromioclavicular osteoarthritis status post rotator cuff repair, Mumford acromioplasty for tendinitis and impingement, anterior-superior SLAP repairs and arthroscopic debridement, rotator cuff tendinitis, labral tear including SLAP, glenohumeral osteoarthritis, and shoulder impingement syndrome. He reported bilateral shoulder pain since 2000. The medical evaluation board found the "preponderance of disability comes from shoulder concerns" and mild difficulties completing tasks and duties to standard, doing well at the administration level but unable to do physical activities due to lack of range of motion (without citing specific test results) in shoulders. On December 2015 VA examination, the examiner diagnosed right shoulder glenohumeral and acromioclavicular osteoarthritis status post rotator cuff repair, Mumford acromioplasty for tendinitis and impingement, anterior-superior SLAP repairs, and arthroscopic debridement. The Veteran reported a history of eight right shoulder surgeries, and said he is meant to have a total right shoulder replacement when he gets out of the military. He reported pain that was constant, rated 4/10 on the pain scale, with sharp pain up to an 8/10 with certain motions. He said his marked limitation of motion in his right shoulder feels "froze" and that he is unable to move it much. He said it is difficult to be active with his son and carry or lift much. Range of motion tests showed flexion to 65 degrees and abduction to 45 degrees. The examiner noted that loss of motion and painful motion (in all ranges of motion) results in significant functional losses. There was also evidence of pain on weight-bearing and tenderness with palpation. On repetitive testing, there was additional functional loss or range of motion due to pain, fatigue, and lack of endurance. There was an additional loss of five degrees of flexion and abduction, but no change in rotation. Muscle strength was reduced (4/5) on flexion and abduction, and was due entirely to his service-connected right shoulder disability. There was no sign of muscle atrophy or ankylosis. However, he did have evidence of a right shoulder rotator cuff condition. There was no evidence of instability, clavicle, scapula, acromioclavicular joint, or sternoclavicular joint conditions, or impairment of the humerus (including loss of head (flail shoulder), nonunion (false flail shoulder), fibrous union, or malunion of the humerus. The examiner noted a history of right shoulder surgery (eight in total) in 2001, 2007, 2009, and 2014. The residual symptoms include pain and very limited range of motion. The examiner did not feel that the Veteran would be equally served by amputation of the right shoulder with prosthesis. The examiner also felt that the Veteran's right shoulder problems would limit his ability to lift, carry, reach, or pick up things, and would cause "severe impairment to working in any job that required arm/hand manipulation and carrying/lifting objects." On December 2015 scars examination, the examiner found four right shoulder surgical scars. The first was an anterior 1 by 0.6 centimeter scar (0.6 square centimeters) that was slightly hypertrophic, hyperpigmented, and painful. The second was an anterior linear hypertrophic and hyperpigmented scar was 11 by 1.2 centimeters (9.1 square centimeters), non-painful, but described as "numb." The third scar was linear, hypertrophic, hyperpigmented, non-painful, "numb" and measured 7 by 1.5 centimeters (17.5 square centimeters). The final scar was a posterior right shoulder scar that was superficial, hyperpigmented, painful, and measured 5 by 1 centimeters (5 square centimeters). All three scars were linear, and occupied a total area of approximately 32.3 square centimeters. There were no superficial, non-linear, or deep, non-linear scars. None of the scars resulted in limitation of function or caused other pertinent physical findings. The examiner felt they did not impact his ability to work. There is, again, no evidence of loss, nonunion, malunion, or fibrous union of the humerus during this period. Therefore, a higher rating based on such criteria under Code 5202 is not warranted. Furthermore, while the Board notes that during the course of this period, the November 2010 examiner noted "guarding of all arcs of motion," there was no sign of instability, dislocation, or subluxation at the time. Similarly, while December 2013 private records explicitly note evidence of posterior subluxation at the glenohumeral joint, there is no indication that such was accompanied by guarding of all arm motions. There are also other notations of his shoulder "popping" with movement and a suggestion of instability on August 2015 VA examination. However, considering the totality of the evidence (which is largely silent for complaints, treatment, or diagnoses related to dislocation or subluxation), the Board concludes that these scattered notations do not rise to the level of showing frequent episodes of dislocation that are also productive of guarding of all arm motion. Notably, the independent notations reference above were three years apart. Consequently, there is no basis for awarding a rating in excess of 20 percent under Code 5202. Turning to limitation of motion, the Board notes that the most recent VA examinations in August and December 2015 document the lowest range of motion results in the record as 40 degrees of flexion and abduction. Moreover, the August 2015 VA examiner felt that there was additional loss of motion on repetitive testing due to subjective factors (though he could not estimate the precise amount in degrees). To that end, the Veteran reported his pain ranges from a 4/10 on the pain scale to an 8/10 (which is rather severe). STRs from this period note that he could not even place his arms in parade rest (just behind his back) because of severe pain, and VA examination reports note his glenohumeral arthritis is "severe" and note objective evidence of reduced motor strength in the right arm. In addition, the Veteran did report that during flare-ups, his pain doubles (going from a 4/10 to an 8/10 on the pain scale). In light of the above, and particularly the clinical acknowledgment of additional loss of motion due to subjective factors, the ruling in Deluca, and the fact that the most recent range of motion results were only fifteen degrees away from those required for a higher rating under Code 5201, the Board resolves reasonable doubt in the Veteran's favor as required by 38 C.F.R. § 3.102, and finds the evidence is at least in relative equipoise as to whether his right shoulder disability is shown to cause overall impairment which functionally limits his motion to the degree contemplated by a higher 40 percent rating (the maximum under Code 5201). See 38 C.F.R. § 4.71a, Code 5201. Consequently, a higher rating based on limitation of motion is warranted during the period under consideration. Furthermore, the Board has considered whether a separate rating is warranted for surgical scars associated with the Veteran's right shoulder disability. To that end, both the August 2015 and December 2015 examination reports noted a 1 centimeter by 0.6 (or 0.4) centimeter scar that was painful. Under Code 7804, one or two scars that are unstable or painful warrant a 10 percent rating. Therefore, a separate rating for the painful is warranted. However, there is nothing in the record suggesting that any of the other scars noted during this period were productive of symptoms (i.e., pain, instability, or occupying a total area greater than 39 square centimeters) warranting a separate, compensable rating. Neurological Considerations The Board has also considered whether the Veteran's right shoulder orthopedic disability is productive of neurological manifestations that may warrant a separate rating. To that end, it notes that there are notations of neurological complaints throughout the entire record. Such complaints primarily describe feelings of numbness or tingling in the right elbow and right hand, which has been diagnosed as cubital tunnel syndrome. However, a September 2008 VA examination report specifically addresses his cubital tunnel syndrome and explained that such is a disability which is completely independent of any shoulder pathology, and therefore could not have been caused by his right shoulder disability. A review of Dorland's Illustrated Medical Dictionary shows the cubital pertains "to the elbow...[or] the ulna or to the forearm." Dorland's Illustrated Medical Dictionary 448 (31st ed., 2007). A review of medical literature shows that cubital tunnel syndrome is the result of entrapment or compression of the ulnar nerve, which runs through the "cubital tunnel" in the elbow and does not suggest involvement of any processes outside that region. See Bradley A. Palmer & Thomas B. Hughes, Cubital Tunnel Syndrome, 35A J. Hand. Surg. 153, 153-54 (2010); Steven Curtis, Cubital Tunnel Syndrome, 83 Postgrad. Med. J. 28, 28-29 (2006). Thus, the evidence shows the Veteran's cubital tunnel syndrome is an independent disability that is not a manifestation of his service-connected right shoulder disability. The record also includes notations of shooting pain in his neck and right shoulder. However, much like his cubital tunnel syndrome, an April 2007 VA record specifically notes normal neurological studies bilaterally and a December 2009 VA neurologist specifically found, after conducting an EMG, that such symptoms were caused by a muscle spasm because there were no objective signs of neurological deficit consistent with dystrophic disease, neuropathy, or radiculopathy. A private physician later noted in November 2013 that similar complaints reported at that time were associated with cervical degenerative changes noted on examination (rather than his right shoulder disability). The evidence otherwise largely shows normal neurological evaluations, with good sensation, reflexes, and pulses in the right upper extremity throughout all periods on appeal. Therefore, the Board finds no evidence which suggests that the Veteran's service-connected right shoulder disability is productive of neurological manifestations warranting separate ratings. Extraschedular Considerations The Board has also considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis for the above disabilities. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is, thus, found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto 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 to determine whether the Veteran's disability picture requires the assignment of an extraschedular rating. In this case, the Veteran's right shoulder disability manifests as limited motion and associated subjective factors (i.e., pain, weakness, stiffness, etc.) that cause additional functional loss, with several surgical scars. There is no allegation that the Veteran's symptoms present a unique or exceptional disability picture that is not captured by the criteria laid out in the rating schedule. Therefore, the Board finds that the associated symptomatology and degree of disabilities shown are entirely contemplated, and are adequate to evaluate his disability. Therefore, referral for extraschedular consideration is not warranted. The Board has also considered whether the evidence has reasonably raised the matter of entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability. In so doing, it recognizes that the Veteran previously suggested he was unable to work as a welder and mechanic due to his right shoulder problems and does not question that assertion. However, at the time, he also indicated he was a full-time student pursuing (and eventually completing) a degree in business management. Thereafter, June 2012 records show he was to serve on another period of active duty for three years. Although a September 2015 medical evaluation board report indicated he could no longer perform his duties as a soldier, it specifically noted that he performed well at an administrative level, but could not keep up with the physical requirements of service. There has been no allegation or evidence that indicates, either explicitly or implicitly, that he has been unable to work in any capacity since being found unfit to continue his active service. Finally, the Board notes that, although the medical evidence in the record does indicate that the Veteran would be impaired in performing any work that is physically demanding or otherwise required manipulation of his arms, there is no indication that he would also be precluded from all types of sedentary work (which is, notably, quite consistent with his education and training in business management). Consequently, the matter of entitlement to a TDIU rating has not been reasonably raised by the record. Accordingly, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran's right shoulder disability warrants a higher (and maximum) 40 percent rating based on limitation of motion during the period beginning December 1, 2009, and whether it warrants a separate 10 percent rating for a painful scar during that period. To that extent, it resolves all remaining doubt in the Veteran's favor, and those appeals must be granted. However, the preponderance of the evidence is against finding his right shoulder disability produces symptoms or pathology warranting ratings in excess of 20 percent under Code 5202 (for impairment of the humerus) or neurological manifestations warranting a separate rating during any period on appeal, or limitation of motion warranting a rating in excess of 30 percent (or scars warranting separate ratings) for any period on appeal prior to December 1, 2009. To that extent, the benefit of the doubt rule does not apply, and the appeals in those matters must be denied. ORDER Restoration of a separate 20 percent rating for the right shoulder disability based on dislocation of the humerus is granted, subject to the regulations governing payment of monetary awards. The appeals seeking higher ratings for the right shoulder disability prior to July 23, 2003 and from September 1, 2003 to July 19, 2007, November 1, 2007 to March 23, 2008, and July 1, 2008 to September 8, 2009 are denied. For the period beginning December 1, 2009, a 40 percent rating for the Veteran's right shoulder disability (based on limitation of motion) is warranted; to that extent, the appeal is granted subject to the regulations governing payment of monetary awards. For the period beginning December 1, 2009, a separate 10 percent rating is warranted for a painful scar; to that extent, the appeal is granted subject to the regulations governing payment of monetary awards. ____________________________________________ VICTORIA MOSHIASHWILI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs