Citation Nr: 1622176 Decision Date: 06/02/16 Archive Date: 06/13/16 DOCKET NO. 09-24 628 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE 1. Entitlement to an increased rating for status post left shoulder surgery, currently evaluated as 10 percent disabling. 2. Entitlement to an increased rating for gastritis and hiatal hernia with reflux esophagitis, currently evaluated as 10 percent disabling. 3. Entitlement to an increased rating for degenerative joint disease (DJD) of the right shoulder, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran's representative ATTORNEY FOR THE BOARD S. Keyvan, Counsel INTRODUCTION The Veteran served on active duty from January 2000 to May 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the June 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. This matter was before the Board in August 2014 and August 2015, at which times it was remanded for additional development. It is now returned to the Board. Although the Veteran was scheduled to testify before a Veterans Law Judge (VLJ) in June 2014 at the Cleveland RO, he was unable to appear at the hearing. However, the Veteran's representative did appear before the VLJ and informed the VLJ that the Veteran is more disabled than currently evaluated. A transcript of the hearing has been associated with the Veteran's VA claims folder. In a February 10, 2016 letter, the Board informed the Veteran that the VLJ who conducted his June 2014 hearing was currently unavailable. Under the applicable regulation of 38 C.F.R. § 20.707, the VLJ who conducts a hearing shall participate in making the final determination of the claim. 38 C.F.R. § 20.707 (2015). The February 10, 2016 letter offered the Veteran the opportunity to testify at another hearing. See 38 C.F.R. §20.717 (2015). The Veteran was also informed that if he did not respond within 30 days of the letter, the Board would assume he did not want another hearing and proceed accordingly. The Veteran did not respond to the letter. As such, the Board will proceed with adjudicating the Veteran's claim based on the evidence of record. FINDINGS OF FACT 1. The Veteran's gastritis and hiatal hernia with reflux esophagitis has been manifested by adverse symptomatology, to include persistently recurrent epigastric distress with pyrosis and reflux. His gastritis and hiatal hernia with reflux esophagitis has not been manifested by chronic gastritis with multiple small eroded or ulcerated areas, dysphagia, regurgitation, or recurring symptoms productive of considerable or severe impairment of health. 2. The Veteran is right-hand dominant. 3. The Veteran's status post left shoulder surgery has not been manifested by dislocation or nonunion of the clavicle or scapula with loose movement, nor has it been manifested by recurrent dislocation of the humerus at the scapulohumeral joint with infrequent episodes and guarding of movement only at shoulder level, nor has it been productive of limitation of motion of the arm at shoulder level. 4. The Veteran's service-connected DJD of the right shoulder is manifested by limitation of abduction to no worse than 140 degrees, forward elevation to no worse than 180 degrees, internal rotation to 45 degrees, external rotation to 90 degrees, and no complaints of pain on movement. No additional impairment resulting from excess fatigability, pain, weakness, of lack of endurance of his right shoulder has been shown. The DJD of the right shoulder was not manifested by pain on motion or limitation of function; malunion and nonunion of the clavicle or scapula and limitation of motion of the arm to shoulder level have not been shown. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for gastritis and hiatal hernia with reflux esophagitis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.113, 4.114, Diagnostic Code 7307, 7346 (2015). 2. The criteria for an evaluation in excess of 10 percent for status post left shoulder surgery have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40-4.46, 4.71a, Diagnostic Codes 5200-5203 (2015). 3. The criteria for a compensable evaluation for service-connected DJD of the right shoulder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40-4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5200-5203 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See eg. 38 U.S.C.A. §§ 5103, 5103A (West 2014) and 38 C.F.R. § 3.159 (2015). In the instant case, VA provided adequate notice in a letter sent to the Veteran in June 2006. VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of relevant treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service, VA, and private treatment records are associated with the claims file. Pursuant to the August 2015 Board remand, the Veteran's updated VA treatment records issued from the Cleveland VA Medical Center have been retrieved and associated with the claims file. VA afforded the Veteran examinations in connection to his gastrointestinal disorder, as well as his bilateral shoulder disability in December 2006, March 2009, May 2012 and, pursuant to the August 2014 Board remand, in March 2015. The Board finds that the VA examinations obtained in this case are adequate, as they were predicated on physical examinations of the Veteran, as well as the Veteran's reported history and symptomatology. The examiners considered all of the pertinent evidence of record, to include statements given by the Veteran at the time of the VA examinations, and provided the findings necessary to apply pertinent rating criteria. The Board finds that the medical examination reports and opinions, along with his VA treatment records, are adequate for purposes of rendering a decision in the instant appeal. 38 C.F.R. §4.2 (2015). Indeed, there is no objective evidence indicating that there has been a material change in the severity of his service-connected gastrointestinal and bilateral shoulder disorders since the Veteran was last examined. See 38 C.F.R. § 3.327(a) (2015). The duty to assist does not require that a claim be remanded solely because of the passage of time since otherwise adequate VA examinations were conducted. See VAOPGCPREC 11-95. As such, the Board finds that VA's duty to assist with respect to obtaining a VA examination with respect to the issues decided herein have been met. 38 C.F.R. § 3.159(c)(4). Under these circumstances, the Board finds that VA has complied with all duties to notify and assist required by 38 U.S.C.A. §§ 5103(a), 5103A and 38 C.F.R. § 3.159. Analysis Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). Increased Rating for Gastritis and Hiatal Hernia with Reflux Esophagitis In a June 2004 rating decision, the AOJ granted service connection for gastritis and evaluated it as 10 percent disabling, effective from May 31, 2004. In a December 2005 rating decision, the AOJ also granted service connection for hiatal hernia with reflux esophagitis, and combined it with the already service-connected gastritis, evaluating it as 10 percent disabling pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7307-7346 (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned, the additional code is shown after the hyphen). In June 2006, the Veteran filed a claim seeking a higher disability rating for his gastrointestinal disability. In the June 2007 rating decision, the AOJ continued the 10 percent rating assigned for the Veteran's gastritis and hiatal hernia with reflux esophagitis. The Veteran filed a notice of disagreement with this decision in September 2007. For the reasons that follow, the Board concludes that a rating in excess of 10 percent rating is not warranted. Under Diagnostic Code 7307, a 10 percent rating is assigned for chronic gastritis with small nodular lesions, and symptoms. A 30 percent rating is assigned for chronic gastritis with multiple small eroded or ulcerated areas, and symptoms. A 60 percent rating is assigned for chronic gastritis with severe hemorrhages, or large ulcerated or eroded areas. 38 C.F.R. § 4.114. Under Diagnostic Code 7346, a 10 percent rating is warranted when there are two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent disability evaluation is contemplated for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain and productive of considerable impairment of health. A 60 percent evaluation is warranted where there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptoms combinations productive of severe impairment of health. 38 C.F.R. § 4.114. Dysphagia is defined as difficulty in swallowing. Dorland's Illustrated Medical Dictionary, 587 (31st ed. 2007). Pyrosis is defined as heartburn. Id. at 1587. Hematemesis is defined as the vomiting of blood. Dorland's Illustrated Medical Dictionary, 842 (31st ed. 2007). Melena is defined as the passage of dark-colored feces stained with blood pigments or with altered blood. Id. at 1142. At the December 2006 VA examination, the Veteran provided his medical and military history and explained that prior to his discharge from service, he started to experience pain in the left anterior chest, predominantly at night, while stationed in Korea, and he was clinically started on the medication omeprazole. Because of this history, while awaiting his Medical Evaluation Board at Walter Reed Hospital, he underwent an endoscopy, the results of which reflected signs of a hiatal hernia. Currently, the Veteran states that he experiences pain in his left anterior chest several days out of the month, for which he takes omeprazole. Specifically, the Veteran stated that he was taking 20 milligrams of omeprazole on a daily basis to treatment any flare-ups of stomach disease, and he typically uses this medication approximately five days of the month. He denied any symptoms of dysphasia with either solids or liquids, and he also denied pyrosis proper, but he did describe sharp pain in the left anterior chest region. The Veteran also denied any symptoms of hematemesis, melena, reflux or regurgitation, but did comment that he belches frequently. He also denied any nausea or vomiting and added that he has never required dilation or surgical intervention for his hiatal hernia. Physical examination of the abdomen revealed a soft and nontender abdomen with no rebound, rigidity, or guarding. The examination was also negative for any masses or signs of hepatosplenomegaly, and his bowel sounds were normal active, with no epigastric tenderness on palpation. However, the Veteran did have tenderness over the left anterior chest overlying the costochondral margin of the seventh rib, and the pain was similar to pain he had experienced due to his hiatal hernia. Based on his discussion with, as well as his evaluation of the Veteran, the VA examiner diagnosed the Veteran with having a hiatal hernia. At the March 2009 VA examination, the Veteran stated that although he rarely takes 20 milligrams of omeprazole for his stomach condition, the medication is helpful when he does take it. The Veteran reported that his condition affects his activities of daily living; specifically his eating and toileting. The Veteran stated that he is always aware of what is going on, and is worried at times that his gastrointestinal symptoms could be a heart attack. The Veteran denies any dysphagia for solids or liquids. Although he denied any pyrosis, he did complain of substernal epigastric pain without associated left arm pain that occurs every few months and will last up to two weeks. The Veteran denied any history of hematemesis and had one episode of melena at the onset of his symptoms while in service. He (the Veteran) also denied any history of nausea and vomiting, and further denied any history of hospitalizations or surgery for this condition. He underwent an endoscopy for this problem. However, there was no history of esophageal trauma or neoplasm. On physical examination, the examiner described the Veteran's abdomen as nontender and nondistended. There was no hepatosplenomegaly and the bowel sounds were present in all four quadrants. The abdomen was clear to percussion, and there was no organ enlargement, ventral hernia, mass, or tenderness. There was also no clinical sign of anemia. Based on her review of the medical records and diagnostic test results, as well as her discussion with, and evaluation of, the Veteran, the VA examiner diagnosed the Veteran with having a hiatal hernia and gastroesophageal reflux disease (GERD). At the May 2012 VA examination, the Veteran provided his medical history and noted that his gastrointestinal symptoms began in 2003 during his military service when he developed a slow onset of chest pain after eating. After visiting the military physician on base, and undergoing an upper endoscopy, he was diagnosed with having GERD, gastritis, and hiatal hernia. He received periodic treatment for his condition during the remainder of his tenure in active military service, which ended in 2004. The Veteran reported that he had not undergone any medical visits for this condition after leaving the military, but he self-medicates by not eating late, limiting his processed meat intake, and taking occasional over-the-counter Prevacid an average of once a month. The Veteran denied taking continuous medication for the diagnosed condition. He also reported to experience infrequent episodes of epigastric distress and pyrosis as a result of his esophageal condition, and he denied experiencing any type of esophageal stricture, spasm of esophagus, or an acquired diverticulum of the esophagus. Report of the 2004 upper endoscopy reflected signs of gastritis, hiatal hernia and mild esophagitis. The examiner noted that the Veteran currently works on a full-time basis as a mail handler for the U.S. Postal service, and there were no work restrictions in this job as a result of his service-connected gastrointestinal disability. Based on his discussion with, as well as his evaluation of the Veteran, the VA examiner diagnosed the Veteran with having GERD, hiatal hernia, and gastritis. At the March 2015 VA examination, the VA examiner reviewed the Veteran's claims file in full. During the evaluation, the Veteran reported symptoms of reflux and chest discomfort at night and when straining with a bowel movement. He also reported to have reflux of small particles in his throat and mouth upon awakening in the morning. The Veteran treats his hiatal hernia and reflux with dietary restrictions, avoids meats, spicy or greasy foods, and takes over-the-counter omeprazole for his reflux on an as needed basis. According to the Veteran, he had experienced three episodes of reflux in the last month. It was noted that the Veteran currently takes over-the-counter omeprazole for his gastrointestinal condition. With respect to his current symptoms, the Veteran reported to experience infrequent episodes of epigastric distress and reflux as a result of his esophageal condition, and he denied experiencing any incapacitating episodes due to signs or symptoms of any stomach or duodenum condition. The Veteran further denied any other pertinent physical findings, complications, conditions, signs and/or symptoms associated with his gastrointestinal condition. The examiner noted that results of the May 2004 upper endoscopy reflected signs of a hiatal hernia of the lower third of the esophagus with normal stomach and duodenum, and results of the upper gastrointestinal studies revealed a normal stomach, esophagus and duodenum. Based on his discussion with, as well as his evaluation of the Veteran, the VA examiner diagnosed the Veteran with having gastritis. According to the examiner, the Veteran's stomach or duodenum condition does not impact his ability to work. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an evaluation greater than 10 percent for his service-connected gastrointestinal disability. With respect to Diagnostic Code 7307, although the Veteran was seen for complaints of abdominal pain in service, and was diagnosed with having gastritis in February 2004, the more recent VA treatment records and VA examination reports are predominantly clear for symptoms associated with his gastritis. Indeed, although his VA examiners took into consideration the prior diagnostic test results reflecting a diagnosis of gastritis, he was not assessed with an active diagnosis of gastritis during these examinations. Moreover, the Veteran does not claim, and neither the treatment records nor the VA examination reports show that the Veteran has multiple small eroded or ulcerated areas along with his symptoms. With respect to his hiatal hernia, which is rated under Diagnostic Code 7346, the Board acknowledges the Veteran's reported history of pyrosis, epigastric distress, and reflux. However, the Veteran has consistently denied symptoms of dysphagia, and he has never reported to experience regurgitation as a result of his gastrointestinal condition. Although the Veteran reported to experience substernal epigastric pain during the March 2009 VA examination, it was noted that these symptoms were not accompanied by left arm pain, dysphagia or regurgitation. Indeed, the criteria for a 30 percent rating under Code 7346 are stated in the conjunctive and must all be met to warrant such rating. Furthermore, the Veteran has also consistently denied any symptoms of nausea, vomiting and hematemesis, and reported just one episode of melena in service at the onset of his symptoms, but none since. As such, lacking any other evidentiary basis in the record, the Board does not find that the Veteran's gastritis and hiatal hernia with reflux esophagitis has resulted in considerable or severe impairment of health. In this regard, the March 2009, May 2012 and March 2015 VA examiners commented that the Veteran had no functional limitations as a result of his service-connected gastrointestinal disability, and that said disability had no significant effect on his ability to perform his occupational duties. As such, the Board concludes that a rating in excess of 10 percent for the Veteran's service-connected gastrointestinal disability is not warranted. The Board has also considered whether a higher evaluation would be in order under other relevant diagnostic codes pertaining to the digestive system. See e.g., 38 C.F.R. § 4.114, Diagnostic Code 7203 to 7306; however, a higher rating is not warranted under another diagnostic code. In this regard, the Veteran does not claim, and the record does not show that his gastritis caused or causes stricture, spasm, and/or diverticulum of the esophagus. In fact, both the May 2012 and March 2015 VA examiners determined that he did not have esophageal stricture, spasms or diverticula of the esophagus. Also, Diagnostic Codes 7304-7306 are not for application as the Veteran does not have any type of ulcer (gastric, duodenal or marginal). In the absence of such adverse symptomatology, the Board will not rate the Veteran's gastritis and hiatal hernia with reflux esophagitis under another Diagnostic Code for rating digestive system disorders. See 38 C.F.R. § 4.114; see also Butts v. Brown, 5 Vet. App. 532, 538 (1993). Increased Rating for the Right and Left Shoulder Disabilities In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. Where the question of functional loss due to pain upon motion is raised, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). In the June 2004 rating decision, the AOJ granted service connection for the Veteran's status post left shoulder surgery, and evaluated it as 10 percent disabling, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5203. This disability rating was continued in the December 2005 rating decision. The Veteran sought a higher rating for his left shoulder disability in June 2006, and in the June 2007 rating decision, the AOJ denied the claim for a rating in excess of 10 percent for the Veteran's status post left shoulder surgery. The Veteran filed a NOD with this decision in September 2007. Under DC 5201, a 20 percent disability rating is contemplated for limitation of motion of the major or minor arm at shoulder level or for limitation of the minor arm to midway between side and shoulder level. A 30 percent disability rating is warranted for limitation of the major arm to midway between side and shoulder level or when motion of the minor arm is limited to 25 degrees from the side. A 40 disability rating is warranted when motion of the major arm is limited to 25 degrees from the side. 38 C.F.R. § 4.71a. Under DC 5202, pertaining to other impairment of the humerus, malunion with moderate deformity (major and minor shoulder) warrants a 20 percent disability rating; malunion with marked deformity is evaluated as 30 percent disabling for the major shoulder and as 20 percent disabling for the minor shoulder. 38 C.F.R. § 4.71a. Recurrent dislocations of the humerus at the scapulohumeral joint, with infrequent episodes, and guarding of movement only at the shoulder level, is evaluated as 20 percent disabling (major and minor shoulder); recurrent dislocations of the humerus at the scapulohumeral joint, with frequent episodes and guarding of all arm movements, is evaluated as 30 percent disabling for the major shoulder and as 20 percent disabling for the minor shoulder. Id. A fibrous union of the humerus is evaluated as 50 disabling for the major shoulder and as 40 percent disabling for the minor shoulder; a nonunion of the humerus is evaluated as 60 disabling for the major shoulder and as 50 percent disabling for the minor shoulder; and a flail shoulder (loss of head of humerus) is evaluated as 80 disabling for the major shoulder and as 70 percent disabling for the minor shoulder. Id. Under Diagnostic Code 5203, a 10 percent disability evaluation is contemplated for impairment of the clavicle or scapula manifested by malunion. 38 C.F.R. § 4.71a. A 10 percent disability evaluation is also contemplated for impairment of the clavicle or scapula manifested by nonunion without loose movement. Id. A 20 percent disability evaluation is contemplated for impairment of the clavicle or scapula, manifested by nonunion with loose movement. Id. A 20 percent disability evaluation may also be assigned for dislocation of the clavicle or scapula. Id. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The Veteran is right hand dominant. When evaluating the left shoulder disability, minor, as opposed to major, extremity disability ratings will be applicable. When evaluating the right shoulder disability, major, as opposed to minor, extremity disability ratings will be applicable. 38 C.F.R. § 4.69. The standard ranges of motion of the shoulder are 180 degrees for forward elevation (flexion) and 180 degrees for abduction. The standard range of motion for internal and external rotation is 90 degrees. 38 C.F.R. § 4.71, Plate I. During a July 2006 VA treatment visit, the Veteran reported a history of left shoulder pain since August 2000 when he dislocated his shoulder while participating in physical training exercises during his period of active duty in the Army. He eventually underwent an open Bankart repair procedure in February 2001, and did very well until July 2002 when he sustained a full thickness rotator cuff tear while playing softball for the Army softball team. He underwent another surgery for a rotator cuff repair in September 2002, and although he received physical therapy for rehabilitation, he continued to experience pain in the left shoulder and was eventually discharged from service for medical reasons in May 2004. The Veteran currently works at the post office which requires repetitive heavy lifting and reaching which has exacerbated his pain. On physical examination, the examiner observed mild tenderness-to-palpation over the left greater tuberosity, and the Veteran's range of motion was shown to be full, with external rotation to 90 degrees at 90 degree abduction. The Veteran's motor strength was 5/5 and results from the Hawkins/Neer impingement test were modestly positive while results from the Drop arm test were negative. The Veteran was assessed with having chronic left shoulder pain with mild impingement signs and a history of open Bankart and rotator cuff repairs. The treatment provider noted that the Veteran worked in a job that involved repetitive motion and lifting which appeared to be directly exacerbating his symptoms. At the December 2006 VA examination, the Veteran reported near constant pain in the left shoulder, the extent of which he minimized, and he described the pain as a feeling of fatigue or burn, akin to the sensation he has after exercising. The Veteran described his left shoulder as somewhat stiff in the morning when he awakens, but added that it quickly loosens up and then he has an onset in the progression of shoulder pain throughout the workday until, on a scale from one to ten (with one being the least level of pain and ten being the highest), it reaches a 5 by the end of the work day. He reported that the pain is reduced to a two to three with rest, but he does have pain in the left shoulder when he rolls onto his left side while sleeping, which forces him to roll onto his right side. The Veteran also reported to have degenerative joint disease affecting the right shoulder, and commented that he experiences pain in this shoulder when sleeping on it. He reported that the pain level in his right shoulder reaches a 2 by the end of the day and resolves more quickly than his left shoulder symptoms. The Veteran explained that his current job involves the processing of parcels which are too large or bulky to be handled by machine and frequently involve lifting items that are 30 pounds or heavier in weight. The Veteran stated that he is able to perform this task, but reports significant discomfort and an increasing rapid onset of fatigue of the left arm as compared to the right arm. During periods of increased pain, the Veteran denies decreased range of motion or strength, but he does have increased fatigability. The Veteran also denied episodes of dislocation or subluxation subsequent to his second shoulder surgery, and further denied any constitutional symptoms suggestive of inflammatory arthritis. According to the Veteran, his shoulder condition affects his usual occupation and daily activities in that he is fatigued and sore at the end of the work day. He is hoping to seek vocational training so that he can qualify for a job that is less physically demanding. The Veteran also contends that he no longer exercises, or participates in sports, and he is not involved in any upper extremity weight training program. The Veteran indicated that he is right hand dominant and reports that he eats, writes and performs other activities requiring manual dexterity with his right hand. The Veteran denied symptoms of weakness, stiffness, swelling, heat or redness of the shoulder, and he also denied any current locking or fatigability. On physical examination, the examiner observed that the Veteran had surgical scars over the lateral aspect of the shoulder as well as in the deltopectoral groove anteriorly that measured 6 centimeters (cm) in length and 7 millimeters (mm) in width. The scars were described as well-healed, nonadherent, nontender, and asymptomatic. Physical examination of the shoulder revealed minimal tenderness in the anterior aspect of the deltoid and overlying the bicipital tendon. Active and passive range of motion was symmetric and pain-free unless otherwise noted. The Veteran was shown to have abduction to 180 degrees in the left shoulder, and an audible click was noted at 160 degrees with attendant pain. However, between 160 and 180 degrees, the Veteran observed decreasing pain as he progressed to the actual endpoint of 180 degrees abduction. The Veteran also had forward flexion to 180 degrees, external rotation to 80 degrees with pain and apprehension at the terminus of external rotation, and internal rotation to 45 degrees. Physical examination of the right shoulder reflects that the Veteran had abduction to 180 degrees that was pain-free and not attendant with a click. The Veteran also had forward flexion to 180 degrees, external rotation to 110 degrees, and internal rotation to 45 degrees. The Veteran reported to have positive apprehension sign with the left shoulder, which is absent on the right, as well as tenderness over the anterior aspect of his shoulder. There was no swelling or joint effusion noted. Following repetitive use, the Veteran did have decreased endurance and pain with no loss of strength or range of motion noted. Report of the December 2006 x-rays of the shoulders revealed stable mild suspected tendinopathy involving left supraspinatus tenderness, and were otherwise unremarkable. A June 2006 magnetic resonance imaging (MRI) of the left shoulder revealed "postsurgical changes with probable supraspinatus and mild subscapularis tendinopathy" as well as [g]lenohumeral chondromalacia...with very small glenohumeral joint effusion." Based on his discussion with, as well as his evaluation of the Veteran, the examiner diagnosed the Veteran with having left shoulder dislocation and rotator cuff tear, status post surgical repair with persistent tendinopathy; right shoulder degenerative joint disease by history with a normal examination of the right shoulder; and left anterior costochondritis unrelated to other diagnoses. At the March 2009 VA examination, the Veteran complained of constant bilateral shoulder pain that is worse on the left than right. He denied any weakness, heat, redness, or locking in the affected joints but did report stiffness, swelling, instability or giving way, as well as a feeling of impingement and fatigability with a lack of endurance in both shoulders. He did not take any prescription medication for his shoulder condition and noted that he experiences flare-ups of increased pain that he rates as an 8-9/10 and which awakens him at night. These flare-ups occur every night and are precipitated by sleeping in the wrong position, and alleviated by moving around in bed. During a flare-up, or following repetitive use, the Veteran will be additionally limited by pain but not by weakened movement, excess fatigability, endurance, incoordination, or functional loss. He noted that he had undergone surgery on the left shoulder in March 2001 and October 2002, and on the right shoulder in November 2006 or 2007. He denied any symptoms of recurrent subluxation in the affected joint and there was no history of inflammatory arthritis or any indication of constitutional symptoms. The Veteran reported that his shoulder disability affects his mobility, to include walking and transfers, and it affects his activities of daily living, to include eating, grooming, bathing, toileting, dressing, recreational activities, driving, and his ability to perform his occupational duties. He reported that he has to think about everything that he does in terms of reaching and weight bearing, and his shoulder disability affects the way he holds his children. On physical examination, the Veteran was shown to have forward flexion to 180 degrees in the right shoulder, and flexion to 165 degrees in the left. In addition, he was shown to have abduction to 140 degrees, and internal rotation to 50 degrees in both shoulders. Also, the Veteran had external rotation to 90 degrees in the right shoulder, and 20 degrees in the left. The examiner observed no painful motion at any point. It was noted that during a flare-up or following repetitive use, the Veteran was additionally limited by pain, but not by weakened movement, excess fatigability, endurance, incoordination, or functional loss. There was no objective evidence of painful motion, edema, effusion, instability, weakness, tenderness, redness, heat, abnormal movement, or guarding of movement. Based on her review of the medical records and diagnostic test results, as well as her discussion with, and evaluation of, the Veteran, the VA examiner diagnosed the Veteran with having impingement syndrome of the right shoulder and supraspinatus and mild subscapularis tendinopathy of the left shoulder. At the May 2012 VA examination, the Veteran provided his military history, and noted that he had experienced pain and discomfort in his left shoulder since injuring, and undergoing treatment for it, in service. Specifically, the Veteran reported to experience an aching sensation in the interior and surrounding the deltoid region adding that increased use serves to increase the pain. The Veteran also reported to experience right shoulder pain since 2003 when he first observed a clicking sensation in the shoulder. He sought medical treatment for both shoulders in 2006, and he was prescribed with physical therapy that did not help. The Veteran denied experiencing any flare-ups that impact the function of the shoulder and/or arms. On physical examination, he was shown to have flexion and abduction to 180 degrees in both shoulders with no evidence of painful motion. The examiner noted that the Veteran could perform repetitive-use testing with three repetitions, and he had flexion to 180 and abduction to 180 post testing bilaterally. The Veteran did not have additional limitation in his range of motion, or any functional loss and/or functional impairment in the shoulder and arm following repetitive use testing. Also, the Veteran did not report any localized tenderness, pain on palpation of the joints/soft tissue/biceps tendon in either shoulder, or guarding in either shoulder. All the specific tests for rotator cuff conditions, to include the Hawkins' Impingement, Empty-can, external rotation/infraspinatus strength, and lift-off subscapularis tests were shown to be negative for abnormalities. The Veteran did report a history of mechanical symptoms, to include clicking and catching, in the right arm. The Veteran also reported to experience infrequent episodes of subluxation in the glenohumeral joint in the left shoulder. Results of the crank apprehension and relocation test were shown to be positive in the left shoulder. When asked whether the Veteran had an AC joint condition or any other impairment of the clavicle or scapula, the examiner indicated that he did not. There was no tenderness on palpation of the AC joint, and the cross-body adduction test was also shown to be negative. The Veteran did not undergo a total shoulder joint replacement procedure, but he did undergo two anterior reconstruction surgeries on the left shoulder in 2001 and 2002 from which he still experiences residual symptoms. Although the Veteran has scars as a result of this procedure, the scars are neither painful nor unstable, and the total area of the related scars is not greater than 39 square centimeters. According to the examiner, the Veteran's shoulder condition does not impact his ability to work. However, it was noted that the Veteran's job at the post office did include constantly grabbing sacks that were up to 60 pounds in weight with his extended left arm and throwing them forward for two hours at a time. The Veteran reported ongoing problems with his left shoulder since his in-service injuries and the surgeries he had undergone for these injuries. He also reported some pain in the right shoulder but nothing similar to the pain in his left shoulder. Based on his evaluation of the Veteran, the VA examiner diagnosed the Veteran with mild arthritic changes at the glenohumeral joint which is seen on the MRI, as well as some extra fluid in the glenohumeral joint. The Veteran also had full thickness rotator cuff repair in the past which left some scar tissue, and while the VA examiner did not observe any evidence of a re-tear, he did note that the Veteran's job places an extra amount of stress on things. Although there was no impingement signs on examination, the examiner suspected that after the Veteran performs his job for half-an-hour or hour, he produces some impingement that is very mild in severity. At the March 2015 VA examination, the Veteran provided his military and medical history, and described how his left shoulder injury occurred, as well as how his right shoulder pain began. He reported that his current symptoms include left shoulder pain, which consists of an aching and locking sensation, as well as a sensation of numbness that travels throughout the left arm. He also reported to experience right shoulder pain which consisted of an occasional sharp pain in the posterior region of the right shoulder similar to a pinching sensation. The Veteran states his bilateral shoulder pain is worse with heavy lifting, or whenever he climbs a ladder, or sleeps on either shoulder. He treats his bilateral shoulder pain with ice/heat therapy, stretching, and over-the-counter Tylenol. The Veteran reported to experience flare-ups of right shoulder pain that occur two to three times a week, and are precipitated by certain shoulder movements or heavy lifting, and are alleviated with rest and medication. He reported that he has daily flare-ups of the left shoulder that are precipitated by daily activities, and alleviated with rest and medication. The Veteran denied experiencing any functional loss or impairment of the joint or extremity regardless of repetitive use. On physical examination, the Veteran's range of motion in the right shoulder was shown to be normal, with flexion and abduction to 180 degrees, and internal and external rotation to 90 degrees. The Veteran denied any pain during the range of motion exercises, and the examiner observed no objective evidence of crepitus, nor any evidence of pain with weight bearing. The examiner did observe tenderness to palpation over the posterior right shoulder. The Veteran was able to perform repetitive use testing with at least three repetitions, and there was no additional functional loss or additional loss of motion after repetitive movement. When asked whether the Veteran was being examined immediately after repetitive use over time or during a flare-up, the examiner marked that he was not, and further noted that the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time and during flare-up. When asked whether pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time and with flare-ups, the examiner marked that he was unable to make this determination without mere speculation, noting that the Veteran was not being examined following repetitive use of the right shoulder or during flare-up of the right shoulder. As for the left shoulder, the Veteran was shown to have flexion to 175 degrees, and abduction to 170 degrees, with pain during both exercises. He was also shown to have external and internal rotation to 90 degrees. Although the range of motion was described as abnormal, it did not contribute to any functional loss. In this regard, the examiner wrote that pain was noted on examination, but it did not result in/cause functional loss. The examiner did not observe evidence of pain with weight bearing, crepitus, nor evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran could perform repetitive use testing with at least three repetitions, and there was no additional functional loss or additional limitation of motion following repetitive movement. When asked whether the Veteran was being examined immediately after repetitive use over time or during a flare-up, the examiner marked that he was not, and further noted that the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time and during flare-up. When asked whether pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time and with flare-ups, the examiner marked that he was unable to make this determination without mere speculation, noting that the Veteran was not being examined after repetitive use of or during flare-up of the left shoulder. The muscle strength tests reflect that the Veteran displayed normal strength during forward flexion and abduction of both shoulders. The Veteran did not exhibit any signs of muscle atrophy and the examiner noted that the Veteran did not have ankylosis in either shoulder. The examiner noted that the Veteran did not have a rotator cuff condition in the right shoulder, but he did have one in the left shoulder. However, results of the Hawkins' Impingement, Empty-can, External Rotation/Infraspinatus strength, and Lift-off Subscapularis tests were shown to be negative. The examiner observed no sign of shoulder instability, dislocation or labral pathology, but did note that a clavicle, scapula, acromioclavicular joint or sternoclavicular joint condition was suspected. However, the examiner did not observe an AC joint condition or any other impairment of the clavicle or scapula, and there was no evidence of tenderness on palpation of the AC joint. In addition, results of the cross-body adduction tests were shown to be negative. The Veteran did not have loss of head, nonunion, or fibrous union of the humerus, and he was not shown to have malunion of the humerus with moderate or marked deformity. According to the examiner, the Veteran underwent a rotator cuff and Bankart repair procedure in 2001, and an open left shoulder reconstruction procedure with inferior capsular shift in 2002. Report of the right shoulder x-ray revealed mild AC joint arthrosis, with no fracture or dislocation, and no abnormal soft tissue calcifications. Report of the left shoulder x-ray revealed mild AC joint arthrosis, a tiny ossific density adjacent to the humeral head on the internal rotation view, and no fracture or dislocation. Based on his discussion with, and evaluation of the Veteran, the VA examiner diagnosed the Veteran with degenerative arthritis in both shoulders, and status post left shoulder surgeries. When asked whether the Veteran's shoulder disabilities impact his ability to perform any type of occupational task, the examiner indicated that they did not, and commented that the Veteran had no functional limitations as a result of his service-connected conditions. Status Post Left Shoulder Surgery In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an evaluation in excess of 10 percent for his status post left shoulder surgery for any period on appeal. The Board acknowledges that the Veteran sustained a traumatic dislocation of his left shoulder in September 2000, which required an arthroscopic procedure revealing a Bankart lesion. However, he successfully rehabilitated his shoulder the following year, and although he sustained a resubluxation of the left shoulder in 2002 during a game of softball, a subsequent physical examination of the left shoulder, which was conducted prior to his undergoing an open shoulder reconstruction Bankart and inferior capsular shift procedure, revealed a well-healed left shoulder with full range of motion. Moreover, following this procedure, and subsequent rehabilitation, an August 2003 clinical visit reflects that other than signs of mild anterior rim arthrosis and deficiency, x-rays of the left shoulder were otherwise within normal limits. Indeed, the more recent diagnostic test results are clear for any bone deformity, dislocation, or nonunion of the left shoulder. As noted above, while the December 2006 x-ray report revealed stable mild suspected tendinopathy involving left supraspinatus tenderness, the remainder of the diagnostic test findings were otherwise unremarkable. Also, results of the June 2006 MRI of the left shoulder revealed postsurgical changes with probable supraspinatus and mild subscapularis tendinopathy, and glenohumeral chondromalacia with glenohumeral joint effusion. Report of the March 2015 left shoulder x-ray revealed normal mineralization, mild acromioclavicular (AC) joint arthrosis, and was otherwise negative for any fracture or dislocation. Moreover, both the May 2012 and March 2015 VA examiners found that the Veteran did not have an AC joint condition or any other impairment of the clavicle or scapula. Furthermore, at both the May 2012 and March 2015 VA examinations, the Hawkins' Impingement, Empty-can, External rotation/Infraspinatus strength, Lift-off subscapularis, and Cross-body adduction tests were negative for any abnormalities. As such, the competent medical evidence of record fails to show dislocation of the clavicle or scapula, or nonunion of the clavicle or scapula with loose movement at any time during the appeal period. Therefore, the Veteran is not entitlement to a rating in excess of 10 percent under Diagnostic Code 5203. In addition, the medical evidence of record does not reflect limitation of motion of the arm at shoulder level, midway between the side and shoulder level, or major arm motion to 25 degrees from the side. As noted above, the December 2006 VA examination report reflected forward flexion and abduction to 180 degrees; the March 2009 VA examination report reflected forward flexion to 165 degrees and abduction to 140 degrees; the May 2012 VA examination report reflected forward flexion and abduction to 180 degrees; and the March 2015 VA examination report reflected flexion to 175 degrees and abduction to 170 degrees. While the Veteran expressed some complaints of pain on movement during some of the range of motion exercises, these measurements still far exceed the criteria for an evaluation greater than 10 percent under Diagnostic Code 5201. The Board also observes that the rating schedule contains additional diagnostic codes pertaining to the shoulder and arm. See 38 C.F.R. § 4.71a, Diagnostic Codes 5200 and 5202. While the Board has considered whether an increased evaluation would be in order under other relevant diagnostic codes, the Board finds that the criteria for a rating in excess of 10 percent for the Veteran's left shoulder disability are simply not met. In this regard, the medical evidence of record does not show the Veteran to have ankylosis of the scapulohumeral articulation or other impairment of the humerus. As demonstrated by the range of motion findings of record, the Veteran's arm and shoulder do not appear to be fixed or immobile. The Board notes that ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)); Dinsay v. Brown, 9 Vet. App. 79, 81 (1996), (Ankylosis is "stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint", citing Stedman's Medical Dictionary 87 (25th ed. 1990). Although the diagnostic test results revealed arthritic findings in the glenohumeral joints, and the May 2012 VA examiner noted a history of recurrent dislocation of the glenohumeral joint, it was noted that the dislocations were infrequent in nature, and not associated with or accompanied by guarding of movement. Indeed, the objective evidence of record has been negative for, and the Veteran has never reported or exhibited guarding of movement in the left shoulder. In this regard, the criteria for a rating of 20 percent or higher under Code 5202 are stated in the conjunctive and must all be met to warrant such rating. Furthermore, while the March 2015 VA examiner suspected there to be a clavicle, scapula, AC joint or sternoclavicular joint condition, the examiner observed no AC joint condition or any other impairment of the clavicle or scapula, no tenderness on palpation of the AC joint, and no loss of head, nonunion, or fibrous union of the humerus. In addition, the Veteran was not shown to have any malunion of the humerus with moderate or marked deformity. Therefore, the Board finds that the Veteran is not entitled to a higher or separate evaluation under Diagnostic Codes 5200 and 5202. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca and Mitchell. However, an increased evaluation for the Veteran's left shoulder disability is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are supported by pathology consistent with the assigned 10 percent rating, and no higher. In this regard, the Board observes that the Veteran has complained of pain, stiffness, an aching sensation, and apprehension in his left shoulder during some of the range of motion exercises, and with increased use of the left arm. However, the Board notes that the effect of the left shoulder pain is contemplated in the currently assigned 10 percent disability evaluation under Diagnostic Code 5203. The Board acknowledges that the Veteran's job as a postal worker requires a great deal of lifting, and increased use of the left arms serves to increase his pain. However, the Board finds that the Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant a higher evaluation. In this regard, the March 2009 VA examiner did not observe objective evidence of pain during the range of motion exercises, and while the Veteran reported additional limitation of motion in his shoulders following repetitive use and during flare-ups due to pain, the examiner commented that any additional limitation of motion would not be attributed to weakened movement, excess fatigability, incoordination, or functional loss. In addition, the May 2012 VA examination observed no additional limitation of motion or functional loss in the shoulders and arms following repetitive-use testing, and the March 2015 VA examiner observed that the Veteran was able to perform repetitive use testing, and that he did not exhibit additional functional loss or additional limitation of motion following repetitive use. The March 2015 VA examiner further noted that the Veteran's left shoulder disability did not impact his ability to perform his occupational duties. Therefore, the Board finds that the preponderance of the evidence is against an increased evaluation for the Veteran's left shoulder disability. The Board acknowledges the Veteran's reports of numbness that radiates throughout the left arm. However, at the December 2006 VA examination, the left shoulder was shown to be stable with a negative sulcus sign, and although positive impingement signs were noted upon evaluation of the left shoulder, the Veteran's muscle strength was shown to be 5/5 and symmetric, and he was described as well-developed with good musculature which appeared symmetric and balanced. In addition, the drop arm test was negative for signs weakness. Also, at both the May 2012 and March 2015 VA examinations, the Veteran's muscle strength tests were shown to be normal during forward flexion and abduction of both shoulders, and the March 2015 VA examiner observed no reduction in muscle strength or signs of muscle atrophy during these exercises. Thus, while the Veteran has reported to experience pain and numbness in his left upper extremity, the medical findings produced by these evaluations are clear for any underlying neurological abnormalities associated with the left shoulder disability. As such, the Board finds that a separate rating for neurological manifestations of the left shoulder disability, is not warranted. The Board acknowledges that the Veteran was granted service connection for surgical scars, status post left shoulder surgery, which was evaluated as noncompensably disabling by way of the June 2012 rating decision. Indeed, the December 2006, May 2012 and March 2015 VA examiners all noted that the Veteran had several scars attributed to the surgical procedures he had undergone for his left shoulder disability. The December 2006 VA examiner observed one scar on the lateral aspect of the shoulder, and another scar in the deltopectoral groove anterior, both of which were 6 cm in length with a maximum width of 7 mm. The examiner described these scars as well-healed, nonadherent, nontender, and asymptomatic. The May 2012 VA examiner observed scars on the Veteran's left shoulder that were neither painful nor unstable, and marked that the total area of all scars was not greater than 39 cm. The March 2015 VA examiner observed one scar on the anterior level of the left shoulder that is 7 cm in length and 0.2 cm in width, and a second scar is on the posterior region of the left shoulder that is 0.5 cm in length and 0.1 cm in width. This examiner described the scars as linear, non-adherent, non-tender and superficial. In light of the descriptions provided, the Board finds that any impairment associated with the Veteran's left shoulder scars do not warrant a compensable rating pursuant to Diagnostic Codes 7801-7805. In this regard, the total area of the aforementioned scars measures less than 6 square inches, and less 144 square inches. As such, the Veteran is not entitled to a compensable rating for his scars under 38 C.F.R. § 4.118, Diagnostic Code 7801-7802. In addition, the scars have been described as neither unstable nor painful, and there is no indication that the Veteran's scars have resulted in limited movement in his left shoulder. As such, a compensable rating for the Veteran's residual scars on his left shoulder, is not warranted under 38 C.F.R. § 4.118, Diagnostic Codes 7804-7805. DJD of the Right Shoulder The AOJ granted service connection for the Veteran's DJD of the right shoulder and assigned it a noncompensable evaluation pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5003. See June 2004 rating decision. In the December 2005 rating decision, the AOJ continued the noncompensable evaluation assigned for the Veteran's right shoulder disability. In June 2006, the Veteran filed another claim seeking a higher rating for his right shoulder disability, and in the June 2007 rating decision, the AOJ continued the noncompensable evaluation for the right shoulder disability. In September 2007, the Veteran filed a notice of disagreement (NOD) in connection to this decision. Diagnostic Code 5003 provides that 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, which in this case would be Diagnostic Code 5201 (limitation of motion of arm). 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, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For rating disability based on arthritis, the shoulder is considered a major joint. 38 C.F.R. § 4.45(f). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to a compensable evaluation for his DJD of the right shoulder. As noted above, the radiographic evidence of record does not demonstrate the involvement of two or more major joints or two or more minor joint groups. Therefore, an evaluation of 10 percent or higher is not warranted under Diagnostic Code 5003. Furthermore, the competent medical evidence of record does not reflect limitation of motion of the arm at shoulder level, midway between the side and shoulder level or major arm motion to 25 degrees from the side. Specifically, the December 2006 VA examination report reflects forward flexion and abduction to 180 degrees, and the March 2009 VA examination report reflects forward flexion to 180 degrees and abduction to 140 degrees. The May 2012 and March 2015 VA examination reports reflect forward flexion and abduction to 180 degrees, with no complaints of pain on movement. These measurements far exceed the criteria for a compensable rating under Diagnostic Code 5201. The Board also observes that the rating schedule contains additional diagnostic codes pertaining to the shoulder and arm. See 38 C.F.R. § 4.71a, Diagnostic Codes 5200 and 5202-5203. In addition, the objective medical findings show that the Veteran does not have ankylosis of the scapulohumeral articulation. Further, the objective medical evidence is negative for any findings or signs of impairment of the right humerus, clavicle or scapula. As noted above, report of the December 2006 right shoulder x-ray was unremarkable. Also, the May 2012 VA examiner noted no evidence of right shoulder pathology on examination, nor any evidence of right shoulder DJD on the diagnostic test findings. Although the Veteran reported a history of mechanical symptoms, such as clicking, in the right shoulder, the May 2012 examiner determined that the Veteran did not have any type of AC joint condition, or any other impairment of the clavicle or scapula. Also, although the March 2015 VA examiner noted there to be signs of a clavicle, scapula, acromioclavicular joint or sternoclavicular joint condition, it was noted that the Veteran did not have an AC joint condition, or any other impairment of the clavicle or scapula, that there was no tenderness on palpation of the AC joint, and that the cross-body adduction test was negative for abnormalities. In addition, the March 2015 VA examiner noted that the Veteran did not exhibit loss of head, nonunion, or fibrous union of the humerus, nor was he shown to have malunion of the humerus with moderate or marked deformity. As such, the Veteran is not entitled to higher ratings under Diagnostic Code 5200, 5202, and 5203. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca and Mitchell. However, a compensable evaluation for the Veteran's right shoulder DJD is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are supported by pathology consistent with the assigned noncompensable rating, and no higher. In this regard, the Board acknowledges the Veteran's reports of pain in his right shoulder. However, the Board notes that the effect of any pain in the Veteran's right shoulder is contemplated in the currently assigned noncompensable disability evaluation under Diagnostic Code 5003. Moreover, the Veteran did not report any pain on movement during the range of motion exercises at the December 2006, March 2009, May 2012 and March 2015 VA examinations. In addition, the VA examiners did not observe objective evidence of pain on motion, and further noted that the Veteran did not exhibit additional limitation of motion or functional loss in the right arm following repetitive movement. The Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant a higher evaluation. Therefore, the Board finds that the preponderance of the evidence is against a compensable evaluation for the Veteran's DJD of the right shoulder. As discussed above, while the Veteran has reported to experience pain and discomfort in the right shoulder, the medical findings produced by these evaluations are clear for any underlying neurological abnormalities associated with the right shoulder disability. As such, the Board finds that a separate rating for neurological manifestations of the right shoulder disability is not warranted. Extraschedular Consideration Consideration has also been given to whether the schedular evaluations are inadequate, thus requiring that the AOJ refer a claim to the Under Secretary for Benefits or the Director, Compensation Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The schedular evaluations in this case are not inadequate. An evaluation in excess of the assigned ratings is provided for certain manifestations of the service-connected gastrointestinal and bilateral shoulder disability, but the evidence reflects that those manifestations are not present in this case. As noted above, the Veteran primarily complains that his right shoulder disorder is manifested by pain, and his left shoulder disorder is manifested by pain on increased use, tenderness, stiffness, limited range of motion, occasional swelling and instability. The Veteran also reports that his gastrointestinal disability is manifested reflux, pyrosis, and epigastric distress. His symptoms and the type of resulting functional impairment described by him are contemplated in the rating criteria. As the Board finds that the Veteran's disability picture is contemplated by the rating schedule, the inquiry ends and the Board need not consider whether the disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Accordingly, referral for consideration of an extra-schedular rating is not warranted. Further, there are no additional symptoms that have not been attributed to a specific service-connected condition. The Veteran's service-connected conditions are those addressed in this decision, to include his scars. The Board notes that under Johnson v. McDonald, 362 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual condition fails to capture all the service-connected disabilities experienced. However, in this case, there are no additional service-connected symptoms that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. A total disability rating based on individual unemployability (TDIU) is part of an increased disability rating claim when such claim is raised by the record; and that when evidence of unemployability is submitted at the same time that the Veteran is appealing the rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. See e.g., Rice v. Shinseki, 22 Vet. App. at 447. The Veteran did not specifically raise a claim of a TDIU due to his service-connected disabilities. Although the May 2012 VA examiner noted that increased use of the left shoulder places an additional strain on the Veteran's ability to perform his duties as a postal worker, he observed no additional limitation of motion, functional loss, or functional impairment of the shoulder and arm as a result of this disability. He also found that the Veteran's shoulder condition did not impact his ability to work. The March 2015 VA examiner also found that the Veteran's shoulder condition did not impact his ability to perform his occupational duties. In light of the Veteran's continued employment, and given that the examiners found that he was able to perform his occupational duties despite any problems associated his disability, the Board finds that a TDIU claim was not raised and there is no basis for granting a TDIU. ORDER An evaluation in excess of 10 percent for gastritis and hiatal hernia with reflux esophagitis is denied. An evaluation in excess of 10 percent for status post left shoulder surgery is denied. A compensable evaluation for DJD of the right shoulder is denied. ____________________________________________ JAMES G. REINHART Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs