Citation Nr: 1639703 Decision Date: 09/30/16 Archive Date: 10/13/16 DOCKET NO. 10-27 929 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a cervical spine disability. 2. Entitlement to service connection for a left shoulder disability. 3. Entitlement to an initial rating higher than 10 percent for a right shoulder disability. 4. Entitlement to an increased initial rating for temporomandibular joint dysfunction (TMD), rated as 10 percent disabling prior to November 2, 2009, and as 20 percent disabling thereafter. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Erdheim, Counsel INTRODUCTION The Veteran served on active duty from January 1997 to June 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2008 and a June 2010 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection for a right shoulder disability and TMD and denied service connection for an upper back disability and a left shoulder disability. In January 2013, the RO increased the ratings for a right shoulder disability and TMD as reflected on the title page. In January 2015, the Veteran testified before the Board via videoconference. The Board remanded the claims in March 2015 for additional development. FINDINGS OF FACT 1. Resolving the benefit of the doubt in favor of the Veteran, the Veteran's cervical spine disability was caused or aggravated by his service-connected TMD. 2. The competent, credible, and probative evidence of record is against a finding that a left shoulder disability first manifested during active service or is otherwise related to active service, or was proximately caused or aggravated by service-connected TMD or right shoulder disability. 3. Prior to October 29, 2013, the Veteran's right shoulder disability was manifested by popping of the joint and pain on lifting. Range of motion of the arm was higher than shoulder level. 4. Since October 29, 2013, the Veteran's right shoulder disability has been manifested by popping of the joint and pain on lifting. Range of motion of the arm has been no higher than shoulder level. 5. Prior to November 2, 2009, the Veteran's inter-incisal range of the jaw was greater than 31 millimeters. 6. Since November 2, 2009, the Veteran's inter-incisal range of the jaw has been 21 millimeters or greater. CONCLUSIONS OF LAW 1. The requirements for service connection for a cervical spine disability have been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2015). 2. A left shoulder disability was not incurred in or aggravated by active military service and was not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2015). 3. Prior to October 29, 2013, the criteria for a rating in excess of 10 percent for a right shoulder disability were not met. 38 U.S.C.A. §§ 1155, 5103, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.71a, Diagnostic Codes (DCs) 5019, 5201 (2015). 4. Since October 29, 2013, the criteria for a higher 20 percent rating for a right shoulder disability have been met. 38 U.S.C.A. §§ 1155, 5103, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.71a, DCs 5019, 5201 (2015). 5. Prior to November 2, 2009, the criteria for a rating in excess of 10 percent for TMD were not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.150, DC 9905 (2015). 6. Since November 2, 2009, the criteria for a rating in excess of 20 percent for TMD have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.150, DC 9905 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Board finds the June 2008 and August 2015 VA examinations are sufficient to adjudicate the functional loss and pain that result from the Veteran's right shoulder disability, to include during the staged portions of the appeal period, giving particular weight to the 2015 VA examination which was based upon the use of a standard post-May 2013 VA Disability Benefits Questionnaire. Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet.App. 289 (2013). For chronic diseases listed in 38 C.F.R. § 3.309 (a), service connection may also be established by showing continuity of symptoms or the existence of a chronic disease during an applicable presumption period. 38 C.F.R. § 3.303 (b); 38 C.F.R. § 3.309(a); see Walker v. Shinseki, 708 F.3d 1331 (Fed.Cir.2013). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). When resolving the benefit of the doubt in favor of the Veteran, the Board finds that service connection for a cervical spine disability is warranted. The Board takes note of the two VA examinations, dated in June 2010 and August 2015, that found no cervical spine diagnosis. However, at other times during the appeal period the Veteran was diagnosed with cervical spine disabilities related to his TMD. An August 2010 VA treatment record demonstrates a diagnosis of "cervical strain with TMJ." At the time, the Veteran reported experiencing neck and upper back pain for two days. His neck would lock up on him and would cause him to have trouble turning his head. Physical examination showed tenderness at the base of the cervical spine. Then, an undated letter by the Veteran's chiropractor submitted in 2009 reflects a diagnosis of cervical segmental dysfunction. The chiropractor stated there was a relationship between the Veteran's TMD and the muscle pain that he experienced in the cervical region. The Veteran's jaw demonstrated a right lateral deviation when opening which correlated with the right-sided neck pain that he experienced. Significantly, the August 2010 and undated 2009 positive medical evidence was not discussed on either VA examination. Because these records must be taken into consideration, the Board finds that the VA examinations are of lower probative value in this case. Moreover, despite finding no diagnosis of a cervical spine disability, the August 2015 VA examiner went on to state that the Veteran's TMD was causing neck tension and pain radiation to the anterior neck. It was noted on examination that the Veteran treated this neck pain with a prescription muscle relaxer. This inconsistency leads the Board to conclude that the Veteran does suffer from a cervical spine condition manifested by muscle tenderness and pain as found in the private medical evidence. Thus, the Board places greater probative weight on the private medical evidence demonstrating a cervical spine disability proximately caused by the Veteran's service-connected TMD. Based upon the above, when weighing the competent medical and lay evidence, the Board finds in the Veteran's favor, and service connection for a cervical spine disability is warranted. With regard to the Veteran's claim for service connection for a left shoulder disability, however, the Board finds that the preponderance of the evidence is against the claim. Both the June 2010 and August 2015 VA examiners' conducted physical examination of the Veteran's shoulders and reviewed the claims file, but found that there was no association between the Veteran's right shoulder disability and left shoulder disability or between his left shoulder disability and his TMD. The examiners also found no indication of service incurrence of a left shoulder disability, or other link to service. Specifically, there was no indication in the service treatment records of an injury or condition of the left shoulder and the post-service treatment records did not demonstrate a relationship to service or to a service-connected disability. When analyzing the claim on a direct basis, the VA examination opinions are consistent with the record and are thus afforded significant probative weight. A review of the service records is negative for any indication of a left shoulder injury, rather, the Veteran sought ongoing treatment for the right shoulder only. Consistently during service the Veteran would report pain in the right shoulder, but did not report any symptoms related to the left shoulder. The post-service records reflect that in 2009, the Veteran was diagnosed with mild rotator cuff tendinopathy, bilaterally. It was documented at that time that he had had shoulder pain for over five years. The Board must construe that documented statement as related to the right shoulder, rather than the left shoulder, because any other interpretation would be entirely inconsistent with the record and with the Veteran's statements to the VA during the appeal period. At his hearing, and in documents of record, to include in July 2008, the Veteran reported that his right shoulder, only, exhibited pain and problems in service. At a June 2008 VA shoulder examination, he did not report any left shoulder symptomatology. Again, prior to 2009, there was no indication of left shoulder pain or problems, in the records or as stated by the Veteran. For these reasons, absent an indication of service incurrence, a continuity following service separation, or positive medical nexus, service connection for a left shoulder disability is not warranted on a direct basis. On a secondary basis, the Board also finds no competent or probative evidence to support the Veteran's claim. The Veteran contends that he has left shoulder pain related to his TMD or to his right shoulder disability. However, his left shoulder disability has not been linked to either of these service-connected disabilities. The VA examiners found no indication of an association between the left and right shoulder disabilities based upon a review of the shoulder history and pathology. The Veteran has not put forth any specific statement, other than a generalized conclusion, in support of that theory. Additionally, the medical evidence reflects tendinopathy of the left shoulder, but does not correlate that diagnosis with the Veteran's TMD or symptoms thereof, on any basis. The Veteran's TMD pain that radiates from his jaw has been determined to cause a cervical strain and be related to his cervical spine disability, but has not been medically related to his left rotator cuff tendinopathy, or possible bursitis, either through causation or aggravation. There is no suggestion in the record that the Veteran's TMD has either caused or aggravated his left shoulder disability. For these reasons, service connection for a left shoulder disability is not warranted on a secondary basis. The Board notes that lay persons are competent to provide opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). The specific issues in this case, however, fall outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran is competent to testify as to observable symptoms, however, the medical evidence does not support the Veteran's claims, and his contentions lack credibility in contrast to the medical evidence. Increased Rating Ratings for service-connected disabilities are determined by comparing the veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant 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. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Raters must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare-ups. 38 C.F.R. § 4.14. The guidance provided by the Court in DeLuca must be followed in adjudicating claims where a rating under the diagnostic codes governing limitation of motion should be considered. However, the Board notes that the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45. For the purpose of rating disability from arthritis, the shoulder and cervical spine are each considered a major joint. 38 C.F.R. § 4.45. Right Shoulder Disability The Veteran's right shoulder disability is rated under Diagnostic Code 5201-5019. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. DC 5201 pertains to limitation of motion of the arm. DC 5019 refers to bursitis and is rated pursuant to limitation of motion of the parts, as arthritis. The rating criteria provide different ratings for the minor arm and the major arm. The Veteran has indicated (in various treatment records and on VA examination) that he is left-handed; therefore, the Board will apply the ratings and criteria for the minor arm. 38 C.F.R. § 4.69. In considering the applicability of other diagnostic codes, the Board finds that DCs 5200, 5202, and 5203, which pertain to ankylosis of the shoulder, impairment of the clavicle and scapula, and recurrent dislocations of the scapulohumeral joint, do not apply. Specifically, VA examinations and the treatment records do not show the presence of any of these conditions. While the Veteran has reported popping of the shoulder, and there was an isolated finding of right shoulder instability in 2009, actual shoulder dislocation has not been diagnosed or reported. Accordingly, the criteria pertaining to those conditions are not applicable. 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202, 5203. Under DC 5201, for the minor arm, a 20 percent rating is warranted for limitation of arm motion to shoulder level. A 20 percent rating is warranted for limitation midway between the side and shoulder level. A maximum 30 percent rating is warranted for limitation of arm motion to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Under DC 5019, rated pursuant to DC5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, the disability shall be rated pursuant to X-ray evidence of arthritis. A 20 percent rating will be assigned when there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations . A 10 percent rating will be assigned with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Normal forward flexion of the shoulder is 0 to 180 degrees; abduction is 0 to 180 degrees; and internal and external rotation are from 0 to 90 degrees. 38 C.F.R. § 4.71a, Plate I. Forward flexion and abduction to 90 degrees amounts to shoulder level. Turning to the evidence of record, on June 2008 VA examination, the Veteran reported constant aching and occasional sharp pains in his shoulder. He had lots of popping during exercises. Physical examination showed positive impingement sign. There was tenderness at the AC joint as well as in the bicipital groove. Muscle strength was normal. Range of motion showed forward extension from 0 to 175 degrees with active passive resistance. Abduction was 0 to 180 degrees. Internal and external rotation were from 0 to 85 degrees out of 90 degrees. There was no additional pain, fatigue, or incoordination on repetitive testing. X-rays from 2006 showed a normal right shoulder. The diagnosis was impingement syndrome, right shoulder, mild. The June 2008 VA examination comports with a May 2008 treatment record showing normal range of motion of the shoulder joint, with pain on end point examination. However, a VA treatment record shows that on October 29, 2013, the Veteran reported increased pain in the right shoulder. Physical examination showed active forward flexion limited to 90 degrees, and active abduction of the shoulder limited to 90 degrees. Pain was noted to begin at 35 degrees. Passive range of motion was to 180 degrees and 120 degrees, respectively. On August 2015 VA examination, it was noted that the Veteran had a rotator cuff tear and a labral tear of the right shoulder. He had not had surgery. He had chronic aching pain in the shoulder and had a reduced ability to exercise. He had trouble driving. Typing irritated his shoulder. He had difficulty sleeping and had some loss of motion. Range of motion testing showing flexion to 90 degrees, abduction to 90 degrees, and external and internal rotation to 90 degrees. There was no pain noted on examination. There was no evidence with pain on weightbearing. There was no additional functional loss on repetitive testing. Muscle strength testing was 4/5. There was no dislocation present. In this case, the Board finds that prior to the October 29, 2013, treatment record, there was no objective medical evidence to demonstrate limitation of motion of the shoulder such that the Veteran could not reach shoulder level or above. While he did report ongoing shoulder pain and problems, the medical records showed greater forward flexion and abduction. Therefore, when applying the applicable rating criteria, a rating in excess of 10 percent is not warranted for that period of time. Beginning on October 29, 2013, and as shown on August 2015 VA examination, there was a consistent showing of forward flexion and abduction of the right shoulder that was limited to shoulder level, as contemplated by the higher 20 percent rating under DC 5201. Accordingly, an increased 20 percent rating is warranted since October 29, 2013, the first objective indication of this sort of limitation of motion. A higher rating is not warranted under this code or any other rating criteria contemplating a disability of the shoulder because the Veteran's symptoms do not meet such criteria. A higher rating is not warranted pursuant to DC 5019, as the Veteran's shoulder disability does not affect two major joints. TMD The Veteran's TMD has been rated as 10 percent disabling prior to November 2, 2009, and as 20 percent thereafter pursuant to DC 9905. DC 9905, for limited motion of temporomandibular articulation, is rated 10 percent where the Veteran's range of lateral excursion of the jaw is 0 to 4 millimeters, or where his inter-incisal range of motion of the jaw is 31 to 40 millimeters. Ratings for limited inter-incisal movement shall not be combined with ratings for limited lateral excursion. A 20 percent evaluation applies where the Veteran's inter-incisal range of motion is 21 to 30 millimeters. A 30 percent rating applies where the Veteran's inter-incisal range of motion is 11 to 20 millimeters. A 40 percent rating applies where the Veteran's inter-incisal range of motion is 0 to 10 millimeters. In this case, prior to November 2, 2009, the Veteran's inter-incisal range of motion of the jaw was greater than 31 millimeters. Specifically, on June 2008 VA examination, he was able to open his jaw to 48 millimeters inter-incisally. His right and left excursions were 100 percent with mild pain. There are no other records from this time period to show a lesser ability to open the jaw. Then, on December 2, 2009, the Veteran was treated at the VA for his TMD, at which time the range of motion of the jaw was at maximum 28 millimeters with pain. This treatment record, demonstrating objective evidence to meet the higher rating, was used by the RO to increase the Veteran's rating from 10 to 20 percent under DC 9905, effective November 2, 2009. Since November 2, 2009, a rating higher than 20 percent has not been warranted. The September 2015 VA examination demonstrated inter-incisal distance of 28 millimeters. The Veteran was experiencing pain and could not complete repetitive movements. The examiner determined that due to this pain, weakness, fatigability, or incoordination, the Veteran was limited to an inter-incisal distance of 21 millimeters. It was noted that the Veteran was guarding very strongly during the examination. The examiner noted that the Veteran had a diagnosis of PTSD, anxiety, and headaches, and that these diagnoses were confounding his symptoms. The examiner felt that the Veteran's difficulty on examination could be related to these disorders than to his TMD, though such would require speculation. The examiner noted that the Veteran also complained of neck and shoulder pain, with vague reports of cervical dystonia. Posturing from cervical complaints could contribute to the Veteran's TMD symptoms, but such would be speculative at that time. The remainder of the treatment records document ongoing treatment for TMD, but do not indicate criteria that would meet the higher 30 percent rating. Accordingly, a rating in excess of 20 percent is not warranted in this instance since November 2, 2009. In so finding, the Board has taken into account the Veteran's functional loss as shown on 2015 VA examination. At that time, the examiner quantified the loss of movement to an inter-incisal distance of 21 millimeters, and such limitation is accounted for by the 20 percent rating. Other Considerations Consideration has been given to the provisions of 38 C.F.R. §§ 4.40 and 4.4 and DeLuca v. Brown, 8 Vet. App. 202 (1995). In that regard, the Board has considered the Veteran's complaints of pain, stiffness, limitation of motion, and other reported symptoms related to his right shoulder disability and TMD, as well as all evidence of record related to limitation of motion, weakened motion, excess motion, incoordination, fatigability, and pain on motion, in determining that ratings in excess of those assigned are not warranted. Specifically, there is no indication, even on repetitive testing, that the next higher ratings would be available to the Veteran under the applicable criteria. An extraschedular disability rating is warranted if 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 application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321 (b)(1). The discussion above reflects that the rating criteria reasonably describes and contemplates the severity and symptomatology of the Veteran's service-connected disabilities. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected right shoulder disability with the established criteria found in the rating schedule. The discussion above reflects that the symptoms of the Veteran's disability, to include limitation of motion of the shoulder with accompanying pain and tenderness of the joint, are contemplated by the applicable rating criteria. With regard to the Veteran's TMD, the Board notes the Veteran's contentions that he suffers from radiating pain to the upper and lower neck/shoulder area. The Veteran has been awarded service connection for a cervical spine disability and a right shoulder disability. The pain that he suffers in the upper neck and left side of the neck, and right shoulder, are compensated under a separate diagnostic criteria that takes into account these symptoms of pain and resulting limited motion. When reviewing the immediate issue on appeal, a greater deficit in terms of the Veteran's ability to open his jaw has not been shown. Thus, the full effects of the Veteran's disabilities have been considered and are contemplated in the rating schedule, to include the notations and findings of functional loss by the respective VA examiners, and by his other disability ratings. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). A claim for TDIU has not been raised by the record, as the Veteran is currently employed in more than marginal employment, and has not made a claim for a TDIU either expressly or as raised by the record. The Board has considered whether higher ratings might be warranted for any period of time during the pendency of this appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). ORDER Service connection for a cervical spine disability is granted. Service connection for a left shoulder disability is denied. Prior to October 29, 2013, a rating in excess of 10 percent for a right shoulder disability is denied. Since October 29, 2013, an increased 20 percent rating for a right shoulder disability is granted, subject to the laws and regulations governing the award of monetary benefits. Prior to November 2, 2009, a rating in excess of 10 percent for TMD is denied. Since November 2, 2009, a rating in excess of 20 percent for TMD is denied. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs