Citation Nr: 1715329 Decision Date: 05/08/17 Archive Date: 05/22/17 DOCKET NO. 12-11 609 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for sleep apnea. 2. Entitlement to an increased rating for left knee, anterior cruciate insufficiency, postoperative, currently rated as 20 percent disabling. 3. Entitlement to an increased rating for postoperative fracture dislocation of the right shoulder with degenerative joint disease, currently rated as 20 percent disabling. 4. Entitlement to an increased rating for degenerative disc disease of the lumbar spine with narrowing at L4-L5, L5-S1 disc spaces, currently rated as 10 percent disabling. 5. Entitlement to an increased rating for bilateral hearing loss, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD Mary E. Rude, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1975 to January 1976, and from December 1976 to February 1984. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2010 rating decision of the St. Louis, Missouri, Regional Office (RO) of the Department of Veterans Affairs (VA). The case was subsequently transferred to the Wichita, Kansas RO. The claims file is now entirely in VA's secure electronic processing systems, Virtual VA and the Veterans Benefits Management System (VBMS). In August 2013, the Veteran and his spouse testified at a Travel Board hearing before the undersigned. In April 2015, the Board granted the issue of entitlement to service connection for a right knee disability and remanded the remaining issues for further development. In a September 2015 rating decision, the Veteran was granted entitlement to service connection for bilateral hearing loss, with a continued evaluation of 10 percent, effective February 1, 2010, and to an increased rating of 20 percent for postoperative fracture dislocation of the right shoulder with degenerative joint disease, effective February 8, 2010. As this does not constitute full grants of the benefits sought, the claims remain on appeal. See A.B. v. Brown, 6 Vet. App. 35 (1993). In January 2017, the Veteran submitted a Form 9 substantive appeal for the issue of entitlement to service connection for a right wrist disability and requested a Board video conference hearing on this issue. This hearing request is still pending, and therefore this issue will be addressed by the Board at a later date. FINDINGS OF FACT 1. Sleep apnea was not demonstrated while on active duty, and there is no competent evidence linking the disorder to service. 2. The Veteran's left knee, anterior cruciate insufficiency, postoperative is manifested by slight recurrent subluxation or lateral instability and dislocated cartilage with frequent episodes of locking, pain, and effusion. It has not manifested by extension limited to 10 degrees or flexion limited to 45 degrees, and the preponderance of the evidence does not show that he has moderate recurrent subluxation or lateral instability. 3. The Veteran's postoperative fracture dislocation of the right shoulder with degenerative joint disease is not manifested by intermediate ankylosis between favorable and unfavorable, range of motion limited to 25 degrees from the side, or nonunion, malunion, or other deformity of the humerus. 4. The Veteran's degenerative disc disease of the lumbar spine has not manifested by forward flexion limited to 60 degrees, a combined range of motion limited to 120 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, favorable or unfavorable ankylosis, or any incapacitating episodes. 5. The Veteran's bilateral hearing loss has manifested by no worse than Level XI hearing in the right ear and Level I hearing in the left ear. CONCLUSIONS OF LAW 1. Sleep apnea was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2016). 2. The criteria for a rating higher than 20 percent for left knee, anterior cruciate insufficiency, postoperative, due to symptoms associated with dislocated cartilage have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5258 (2016). 3. The criteria for a separate 10 percent rating, but no higher, for left knee, anterior cruciate insufficiency, postoperative, due to symptoms associated with recurrent subluxation or lateral instability have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (2016). 4. The criteria for a rating higher than 20 percent for postoperative fracture dislocation of the right shoulder with degenerative joint disease have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5200-5202 (2016). 5. The criteria for a rating higher than 10 percent for degenerative disc disease of the lumbar spine have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5235-5243 (2016). 6. The criteria for a rating higher than 10 percent for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.385, 4.1, 4.2, 4.3, 4.7, 4.10, 4.85, 4.86, Diagnostic Code 6100 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. The notification obligation in this case was accomplished by way of letters from the RO to the Veteran dated in December 2009, February 2010, and May 2010. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notices. See Shinseki v. Sander, 129 U.S. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); see also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). In April 2015, the case was remanded for further development. New VA examinations were held and additional VA and additional VA treatment records were associated with the record. All new evidence was considered prior to the issuance of the February 2016 supplemental statement of the case. The Board therefore finds that there has been substantial compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Board also finds that the VA examination reports of record are adequate to decide the issues herein. See 38 C.F.R. § 3.159(c). These VA examinations included notations that there was pain on weight bearing, and thus this is taken into account, and testing was completed for the opposite joints for the shoulder and the knee. Although the VA examinations have not included testing of both active and passive ranges of motion, there is no evidence indicating that the Veteran's passive range of motion would reveal any more restricted range of motion of the left knee, right shoulder, or lumbar spine which would allow for the assignment of higher ratings, nor has the Veteran alleged any difference in his passive range of motion from the recorded active range of motion. See 38 C.F.R. § 4.59 (2016), Correia v. McDonald, 28 Vet. App. 158 (2016). The Veteran's VA treatment records also include evaluation of his range of motion in the knee in both the active and passive, and they were found to be the same. The Board therefore finds that remanding either issue for further examination would not result in any further benefit to the Veteran and would cause an unnecessary delay in the adjudication of the case. Sabonis v. Brown, 6 Vet. App. 426 (1994); Soyini v. Derwinski, 1 Vet. App. 540 (1991) (remand not required when it would impose unnecessary burdens on VA adjudication system with no benefit flowing to the Veteran); cf. Shade v. Shinseki, 24 Vet. App. 110, 123-24 (2010) (Lance, J., concurring) ("reopening [a] claim only to deny it without providing assistance would be a hollow, technical decision. There is no reason to expend agency resources on a semantic determination that is not tied to a meaningful procedural duty.") The AOJ has provided adequate assistance to the appellant as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The appellant and his representative have not made the AOJ or the Board aware of any additional evidence that needs to be obtained in order to fairly decide the issues decided herein, and have not argued that any error or deficiency in the accomplishment of the duty to assist has prejudiced him in the adjudication of his appeal. Id. Therefore, the Board has decided upon the merits of the claims addressed below. Sleep Apnea The Veteran contends that he has sleep apnea, which had its onset during his active duty service. At the August 2013 Board hearing, he testified that in the 1970s he kept half his barracks awake with his movement and snoring at night. He stated that he did not know to seek treatment for sleep apnea until 2009 when it was recommended by his doctor. The Veteran's colleague J.R. submitted a letter in May 2012 which stated that he witnessed the Veteran having loud snoring, jerking around, gasping, and getting up and down all night while he was sleeping during service. He wrote that when in the field, the Veteran was placed in a tent by himself, and that his sleep habits were known as a nuisance to everyone. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). The Veteran has a current diagnosis of sleep apnea. In October and December 2009, the Veteran underwent sleep studies, and was diagnosed with mild obstructive sleep apnea The preponderance of the evidence does not show, however, that the Veteran's sleep apnea was incurred in or is otherwise related to his military service. The Veteran attended a VA examination in August 2015. The examining physician assistant reviewed the Veteran's medical records and performed an in-person examination of the Veteran. The Veteran reported that he had irregular sleep since he was in service in 1980 and that his sergeant had him sleep away from the platoon because of his loud snoring. The Veteran's wife stated that she remembered him snoring since they got together in 1991. The examiner stated that it was less likely than not that sleep apnea was incurred in service, stating that the Veteran admitted to snoring prior to service and that this condition more likely than not existed prior to service. A December 2015 addendum opinion was then obtained, because the Veteran's December 1974 entrance examination did not indicate any sleep apnea or snoring, and the presumption of soundness had not been rebutted by clear and unmistakable evidence. The examiner wrote that although the Veteran admitted to snoring prior to service, this did not constitute clear and unmistakable evidence that sleep apnea preexisted service. The examiner revised his medical opinion, stating that it was less likely than not that the Veteran's sleep apnea was directly related to his military service. He explained that sleep apnea cannot be clinically diagnosed without a sleep study, and that the Veteran was not diagnosed with sleep apnea until 2009, which was approximately 15 years after separation from service. The Veteran's service treatment records did not show any sleep complaints, and there was no nexus of care from the time of separation from service until the diagnosis in 2009. He discussed the lay statements from the Veteran's colleague and wife, which suggested that the Veteran's problems with sleeping may have been present for a prolonged period of time, but that there were a variety of other common conditions that could cause similar symptoms to sleep apnea, such as obesity, nasal congestion, craniofacial abnormalities, hypothyroidism, and alcohol abuse. He noted that the Veteran had been diagnosed with morbid obesity, alcohol dependency, and allergic rhinitis. He wrote that it was unclear whether snoring progresses to obstructive sleep apnea, but that the evidence did seem to suggest that it was likely associated with weight gain. He discussed the Veteran's weight gain of over 100 pounds between 1998 and 2015 as a likely risk factor for sleep apnea. The weight of the most probative medical evidence of record therefore indicates that the Veteran's sleep apnea did not have its onset during service, and competent medical evidence has not connected sleep apnea to any event or injury in service. The December 2015 addendum medical opinion is the only medical opinion of record from a qualified medical professional, and the Board finds the opinion to be highly probative evidence, as it was written after a competent examiner reviewed the Veteran's complete medical records and claims file and performed an in-person examination. The examiner provided an adequate rationale, and the facts discussed by the examiner accurately reflect the medical evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (noting that most of the probative value of a medical opinion comes from its reasoning); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). The examiner acknowledged the Veteran's contentions and the lay statements indicating that the Veteran snored and had disruptive sleep during his service and in the early years of his marriage, but explained that this was not necessarily an indication that the Veteran had sleep apnea at that time, and provided an alternate etiology for the Veteran's later diagnosis of sleep apnea. There are no contradictory opinions from any medical provider. The Board acknowledges the lay statements that the Veteran tossed and turned in his sleep and snored during service and in the early 1990s. The Veteran, his wife, and his colleague are competent to report such symptoms, and the Board accepts that he snored at that time. The medical evidence of record, which is more probative, does not indicate however that the Veteran was diagnosed with sleep apnea until 2009, and these lay statements are not adequate to establish a diagnosis of sleep apnea in service or in the 1990s. While the Veteran may sincerely believe that he incurred sleep apnea in service or that his sleep apnea is related to his sleep problems in service, this lay testimony on the etiology of the condition or its diagnosis is less probative than the findings of the VA examiner. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, the Veteran's belief that he incurred sleep apnea in service is outweighed by the December 2015 medical opinion, which is the most probative evidence on the question of the etiology of the Veteran's sleep apnea. The evidence therefore preponderates against entitlement to service connection for sleep apnea. The preponderance of the competent and probative medical evidence indicates that the Veteran's sleep apnea was not was incurred in service and is not related to any event or injury in service, and the claim must be denied. In reaching this determination, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left Knee Disability The Veteran filed a claim for an increased rating for his left knee disability in December 2009. The Veteran has submitted written statements describing having daily pain and decreased mobility. He wrote that in May 2008, his knee gave out, causing him to fall, and that he had increased problems from that time. He has also written that knee pain prevents him from carrying anything or working in the garden, and it has caused him to fall. At the August 2013 VA examination, the Veteran stated that his knees give out and that he has to use a walker for mobility. A statement from the Veteran's wife indicated that he had fallen many times because of his knee giving out and that he was gaining weight because of his knee pain. She wrote that he was unable to do chores at home, such as pushing a lawn mower, carrying heavy sacks, or climbing a ladder. She wrote that he also has increased difficulty getting out of bed, the shower, or the car. A statement from a colleague described the mobility problems the Veteran has at work, including difficulty with stairs and walking. A letter from the Veteran's supervisor stated that the Veteran suffered a fall in May 2008, and that from that point on his mobility deteriorated. Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of the two evaluations shall be applied, the higher evaluation 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. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 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 may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45. In DeLuca, it was held that when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be "'portray[ed]' (38 C.F.R. § 4.40) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." Id. at 206. The Veteran's left knee disability is currently rated under Diagnostic Code 5257-5010, for traumatic arthritis and impairment of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5257. Under Diagnostic Code 5257, recurrent subluxation or lateral instability can be rated as slight (10 percent), moderate (20 percent), or severe (30 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5257. Separate ratings for knee disabilities may be assigned for disability of the same joint, if none of the symptomatology on which each rating is based is duplicative or overlapping. See VAOPGCPREC 9-04 (2004); 69 Fed. Reg. 59,990 (2004); 38 C.F.R. § 4.14. Diagnostic Codes 5260 and 5261 pertain to limitation of knee motion. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. In this regard, a normal range of knee motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. A limitation of leg flexion allows for a 10 percent evaluation when it is limited to 45 degrees, a 20 percent evaluation when it is limited to 30 degrees, and a 30 percent evaluation when it is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. A limitation of leg extension is assigned a 10 percent evaluation when it is limited to 10 degrees, a 20 percent evaluation when it is limited to 15 degrees, and a 30 percent evaluation when it is limited to 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Under Diagnostic Code 5259, a 10 percent rating can be assigned for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a. Under Diagnostic Code 5258, a 20 percent evaluation can be assigned for cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. Id. Evaluations for knee impairment can also be assigned due to ankylosis or genu recurvatum, but as the Veteran has not at any time been found to have ankylosis or genu recurvatum, these diagnostic codes are not applicable and will not be further discussed. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5263 (2016). The Veteran's VA treatment records show frequent complaints of knee pain with walking, and they note a past left knee meniscus repair. In May 2008, the Veteran fell, injuring his left knee. In August 2009, physical examination found an antalgic gait and active and passive range of motion of 0 degrees of extension to 100 degrees of flexion. Stability tests were negative, and there was moderate bilateral crepitus. X-rays showed bilateral genu varum, slight lateral subluxation of the tibia, degenerative arthritis, and joint effusion. In September 2009, the Veteran reported that his knee would "constantly pop-out" and that he had pain from prolonged ambulation since 1981, with aggravation following a 2008 reinjury. Physical examination found positive McMurray's test, patellar crepitus, effusion, and antalgic gait. The Veteran received an injection of hyaluronate in his left knee. In July 2009, it was noted that the Veteran was able to have partial weight bearing on his left knee. The Veteran again reported painful knees in December 2009 and was provided with a rollator walker. It was noted that the Veteran worse bilateral knee braces, but that they did not help much. He was noted to be fully independent with activities of daily living and to use a shower chair. Examination found that he favored his left leg with a shortened right leg stride. In March 2011, the Veteran stated that he had fallen a couple months earlier when his knees "had given out." The Veteran had pain with range of motion. In May 2011, the Veteran reported knee pain that made him "unable to do anything." He had knee tenderness and pain with range of motion. The Veteran reported continued knee pain in February 2013, and evaluation found active and passive range of motion of 0 degrees of extension and 100 degrees of flexion. Stability testing was negative, and there was no tenderness or atrophy. In June 2012, the Veteran reported that his knees had recently given out and caused him to fall. The Veteran again fell in the bathroom in March 2015. The Veteran reported having difficulty getting around his house due to his knee problems in April 2014. It was noted that the Veteran had some increased pain with passive motion and tenderness. At a March 2015 examination, the Veteran had full range of motion in his knees with no pain. At a February 2010 VA examination, the Veteran reported that his knee was unstable and caused him to fall in 2008, leading to right knee and arm injuries. He reported marked weakness, stiffness, some deformity, and frequent giving way. There was marked lack of endurance and some swelling, but no episodes of dislocation or subluxation. He reported periods of flare ups, which cause the symptoms to be worse. The Veteran had difficulty with activities of daily living, including getting in and out of bed and the shower, and with grooming. He reported that he did not get out very much except to go to work as a supply technician. He reported difficulty driving and inability to do any vigorous recreational activities. Range of motion testing found flexion to 110 degrees, somewhat restricted, with some diffuse swelling. The Veteran had marked crepitation with repetitive action. The examiner noted that additional limitation of the function of the joint was caused by pain, lack of endurance, weakness, and repetitive use. At a July 2010 VA examination follow up to the February 2010 examination, the Veteran's left knee was stable, with no laxity of ligaments or instability. The examiner also found no subluxation. The Veteran also attended a VA examination in August 2015. The examiner noted that the Veteran had left knee cartilage restoration surgery in 1980 to repair dislocated semilunar meniscal cartilage. The Veteran reported daily knee pain, locking, and instability, as well as his knees giving out and difficulty walking more than 25 feet. He denied any subluxations or flare ups. Range of motion testing found flexion and extension of 0 to 140 degrees. Range of motion testing was also performed on the right knee. There was pain with weight-bearing and evidence of localized tenderness or pain with palpation. Pain and weakness did significantly limit functional ability with repeated use over time, but the examiner was unable to describe in terms of range of motion. Swelling, instability of station, and interference with standing also contributed to the Veteran's disability. There was no instability or subluxation. The examiner did not perform instability testing because the Veteran said it was too painful. The Veteran had meniscal tear with frequent episodes of joint locking, pain, and effusion. After reviewing all of the evidence of record, the Board finds that the preponderance of the evidence indicates that the Veteran is entitled to both a 20 percent rating for dislocated cartilage under Diagnostic Code 5258, as well as a separate rating of 10 percent for slight lateral instability under Diagnostic Code 5257. 38 C.F.R. § 4.71a, Diagnostic Codes 5257-5258. The evidence indicates that the Veteran has undergone surgery due to dislocated cartilage, and he has complained of continued symptomatology since that surgery, including locking, pain, and effusion. Such symptoms warrant a 20 percent rating under Diagnostic Code 5258, and this is the highest evaluation available under that diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Codes 5258. Because separate ratings for knee disabilities may be assigned if none of the symptomatology on which each rating is based is duplicative or overlapping, the Board finds that affording the Veteran the benefit of the doubt, he also has additional symptomatology of mild lateral instability or recurrent subluxation which allows for a separate 10 percent rating. See VAOPGCPREC 9-04 (2004); 38 C.F.R. § 4.14, 4.71a, Diagnostic Code 5257. The Veteran was found to have slight lateral subluxation, and the Veteran has repeatedly asserted that he feels instability in his knees and that his knees have "given out." Although the VA examiners did not find any clinical evidence of subluxation or instability, the August 2015 VA examiner was unable to test for instability due to the Veteran's complaints of pain. After looking at the totality of the evidence, the Board affords the Veteran the benefit of the doubt and assigns a separate 10 percent rating under Diagnostic Code 5257. The Board does not find, however, that a higher rating of 20 percent can be assigned, as there is no clinical evidence of any kind of symptoms approximating moderate subluxation or instability. The Veteran's assertions that he has frequent and serious instability are outweighed by the medical findings that the Veteran may not, in fact, have clinically diagnosed instability. While the Veteran has asserted having significant problems with ambulation and falling, the Board notes that at a November 2015 VA examination pertaining to an injury to the wrist caused by a fall, the examiner found that the Veteran's falls were not related to his left knee but were instead due to his morbid obesity, massive ankle edema, and decreased ability to adequately lift his feet in device-free ambulation. He noted that there was no credible medical documentation of interval laxity in either knee and that the Veteran's ankles were massively swollen with edema and required ambulation with a rollator walker. The Board therefore does not find the Veteran's reports of falling to be indicative of a more severe level of impairment due to subluxation or instability in his left knee. The Board is not able to assign separate ratings under the Diagnostic Codes 5260 and 5261, the criteria for ratings based on limitation of flexion and extension. The Veteran has not at any time been found to have a limitation of extension greater than 0 degrees or a limitation of flexion greater than 100 degrees. At the August 2015 VA examination, he was actually found to have full range of motion in his knee. At no time has the Veteran ever been found to have limitation of extension of 10 degrees or more or limitation of flexion of 45 degrees or less, even when considering the Veteran's reports of pain. The Veteran reported having some flare ups in 2010, but in August 2015 denied any flare ups, and there is no clinical evidence of any increased restriction in range of motion during periods of flare ups. Therefore, even considering the Veteran's assertions of frequent or constant knee pain, in the absence of a finding of a limitation of motion, including due to factors such as weakness, fatigability and pain, to an extent of 45 degrees of flexion and 10 degrees of extension, a compensable rating under 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261 cannot be assigned. In sum, the preponderance of the competent medical and other evidence of record allows for separate 10 and 20 percent ratings under Diagnostic Codes 5257 and 5258 for the Veteran's left knee disability, but no higher. The preponderance of the evidence is against finding for any higher ratings than those now assigned, and the benefit of the doubt doctrine is not for further application. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. 49. Right Shoulder Disability The Veteran requested an increase in the evaluation for his right shoulder disability in February 2010. In a September 2015 rating decision, the Veteran was granted an increased rating from 10 percent to 20 percent, effective February 8, 2010. In a February 2010 statement, the Veteran wrote that his right shoulder was a "mess" and was very painful. He has also written that it makes some activities more challenging and prevents him from sleeping on his right side. The Veteran testified in August 2013 that he could not carry things or comb his hair with his right arm. A letter from the Veteran's wife stated that the Veteran struggled to put deodorant on his right underarm and that his shoulder hurts when he lies down. There are several diagnostic codes which pertain to limitation of motion or disabilities of the shoulder. The Veteran is left handed, and therefore his right shoulder is his minor extremity. 38 C.F.R. § 4.69 (2016). The Veteran's right shoulder disability has been rated under Diagnostic Codes 5010-5200, for traumatic arthritis and ankylosis of the scapulohumeral articulation. Under Diagnostic Code 5200, a 20 percent rating is warranted when there is favorable ankylosis with abduction to 60 degrees, and the Veteran can reach the mouth and head. A 30 percent rating is assigned when there is intermediate ankylosis between favorable and unfavorable. 38 C.F.R. § 4.71a, Diagnostic Code 5200. Under Diagnostic Code 5201, a 20 percent rating is warranted when there is limitation of motion at shoulder level or midway between the side and shoulder level. A 30 percent rating is assigned when there is limitation of motion to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Higher evaluations are available under Diagnostic Code 5202, which pertains to impairment of the humerus. The Veteran has not at any time been found to have malunion, fibrous union, nonunion, loss of head, or recurrent dislocation of the humerus, and therefore this diagnostic code is not applicable and will not be further discussed. 38 C.F.R. § 4.71a, Diagnostic Code 5202. No higher rating is available under Diagnostic Code 5203, and therefore these criteria will not be discussed. 38 C.F.R. § 4.71a, Diagnostic Code 5203 (2016). The Veteran's VA treatment records show regular notations of right shoulder degenerative joint disease, which was better with injections or pain medication. In May 2008, the Veteran fell, injuring his right shoulder. In March 2011, he was noted to have decreased range of motion. In April 2011, the Veteran reported shooting pain in his shoulder. Range of motion was more than 90 degrees of abduction. In May 2011, the Veteran reported that he was independent in his activities of daily living, but his wife helped him with his socks and coat. He had shoulder pain with limited motion and strength. Range of motion testing of the right shoulder revealed flexion to 100 degrees, abduction to 100 degrees, extension to 20 degrees, internal rotation to around 40 degrees, and external rotation to around 25 degrees. In March 2015, the Veteran had chronic limitation of movement of the right shoulder. The Veteran attended a VA examination in February 2010, and reported pain on a daily basis. He reported that the right shoulder was weak and stiff, but denied swelling, heat, redness, or instability, although it did "give way" on occasion. He had not had any locking, dislocation, or subluxation. He reported that he was left-handed. He complained of flare ups of increased pain caused by sleeping on it or lifting heavy things. He reported that he still worked and that he had never been incapacitated due to his shoulder. The Veteran was able to move his extremities without difficulty, but the right shoulder was limited in upward movement. Physical examination found no redness, swelling, heat, effusion, muscle atrophy, instability, or deformity. There was mild crepitus with motion, and mild pain with motion. There was mild pain with external rotation with the arm abducted 90 degrees or with adduction, crossing over to each opposing shoulder. Integrity of the rotator cuff appeared intact with no weakness. Range of motion testing found flexion of 0 to 100 degrees, abduction of 0 to 100 degrees, and external and internal rotation of 0 to 40 degrees. The examiner could not express, without resort to speculation, what the additional limitation would be due to pain, fatigue, weakness, or lack of endurance due to repetitive use or during a flare up. The examination findings were based on a minimum of three repetitions of motion. X-rays showed advanced degeneration of the right shoulder joint and humerus. At an August 2015 VA examination, the Veteran reported that he had pain everyday and limited use of his shoulder because of pain and loss of motion. He reported being left handed, and did not report any flare ups. Range of motion testing found flexion of 0 to 60 degrees, abduction of 0 to 60 degrees, and external and internal rotation of 0 to 90 degrees. Pain prohibited movement starting and ending at 60 degrees. There was pain with flexion and abduction and localized tenderness or pain on palpation, but no pain with weight-bearing or crepitus. Left shoulder range of motion was also tested. Pain did limit functional ability with repeated use over time, but the predicted range of motion was unchanged. The examiner stated that there was less movement than normal due to ankylosis and adhesions. He also indicated that the Veteran had ankylosis in abduction up to 60 degrees and could reach the mouth and head. The examiner diagnosed the Veteran with glenohumeral joint osteoarthritis, acromioclavicular joint osteoarthritis, and ankylosis of the glenohumeral articulations. He also found that a rotator cuff condition was suspected, but was unable to perform testing for it. The examiner found no instability, dislocation, or labral pathology. There was no loss of head, malunion, nonunion, or fibrous union of the humerus. The Veteran reported that his shoulder disability affected his ability to get dressed, do housework, prepare meals, or carry with his right arm. After reviewing all the evidence, the Board finds that a rating higher than 20 percent is not warranted. The preponderance of the evidence shows that the Veteran's right shoulder, although stiff and painful, has been shown to have flexion varying from 60 degrees to 100 degrees. As the full range of motion of the shoulder is 180 degrees, this indicates that the Veteran's shoulder range of motion is limited to either midway between the side and shoulder level or to shoulder level. Both of these criteria allow for a rating of 20 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5201. There is no evidence that the Veteran has had limitation of motion less than 60 degrees at any time, even when the Veteran's limitations due to pain are taken into account. The August 2015 VA examiner clearly indicated that pain began at 60 degrees. The Board therefore cannot assign a higher rating based on limitation of motion, even taking into account the Veteran's pain and its impact on his functional mobility when assigning evaluations. See DeLuca, 8 Vet. App. 202. The evidence also does not show that the Veteran has had ankylosis between favorable and unfavorable which would allow for a higher rating under Diagnostic Code 5200. While the August 2015 VA examiner found that the Veteran had favorable ankylosis with abduction to 60 degrees, which would also allow for only a 20 percent rating, the majority of the medical evidence indicates that the Veteran does not have in fact have ankylosis of the shoulder joint. Generally, 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 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)). An ankylosed joint is more commonly referred to as "frozen." See, e.g., Dorland's Illustrated Medical Dictionary 286 (32d ed.2012). Although the August 2015 VA examiner stated that the Veteran had ankylosis in the scapulohumeral articulation, this finding is contradictory with the other findings of that examination, including that the Veteran was able to perform range of motion testing to 60 degrees, indicating that the Veteran did not, in fact, have a fully "frozen" shoulder. Furthermore, even if the Board were to accept this finding as accurate, ankylosis with abduction to 60 degrees would only allow for a 20 percent rating, and therefore would not allow for a higher rating. 38 C.F.R. § 4.71a, Diagnostic Code 5270. The Board also notes that no effective date earlier than February 8, 2010 can be assigned for the increase to a 20 percent rating. Except when otherwise provided, the effective date of a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C.A. § 5110; 38 C.F.R. § 3.400 (2016). Claims for increased benefits may be awarded at the earliest date in which it is factually ascertainable that an increase in disability had occurred, if the claim is received within 1 year of the date such an increase occurred. Otherwise, the increase is effective the date of receipt of claim. 38 C.F.R. § 3.400(o)(2). In this case, there is no medical evidence indicating that the Veteran underwent an increase in the severity of his right shoulder disability during the 1 year prior to receipt of his claim in February 2010. The evidence clearly shows, in fact, that the Veteran likely underwent a worsening in his right shoulder disability in May 2008, when he fell and injured his right shoulder. This injury occurred prior to the 1 year period before February 2010, and therefore an effective date earlier than the February 8, 2010 submission of the claim for an increased rating cannot be assigned. In sum, the Board finds that the preponderance of the evidence is against the claim, and a rating in excess of 20 percent for a right shoulder disability since February 8, 2010 is denied. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. 49. Lumbar Spine Disability The Veteran filed a claim for an increased rating for his lumbar spine disability in December 2009. The Veteran has submitted statements describing his increased pain and difficulty with mobility. The Veteran's wife submitted a February 2010 statement indicating that the Veteran has back pain when he sits too long. The applicable criteria for evaluating disability of the spine provide a single set of criteria for rating conditions of the spine, the General Rating Formula for Disease and Injuries of the Spine (General Rating Formula). See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Disabilities of the spine are to be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25 (2016). 38 C.F.R. § 4.71a, Note (6) (2016). Under the General Rating Formula, a 10 percent evaluation is assigned when there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for thoracolumbar spine forward flexion greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. The Veteran's VA treatment records do not include any treatment or diagnoses for the lumbar spine. At a March 2015 examination, the Veteran had no spine tenderness or deformity. At a February 2010 VA examination, the Veteran reported having difficulty standing and pain and numbness in the mid lumbar area which radiated somewhat to the left buttock. He did not have any sciatica or distal numbness or weakness. He reported some flare ups, particularly with bending and lying down. He denied stiffness, but had easy fatigue and some spasms. He did not report any paresthesias. While he reported some bladder difficulty, there was no evidence that the Veteran had neurogenic bladder or bowel problems. The Veteran was unable to walk great distances and had difficulty with stairs. The Veteran had a wide stance and moved slowly. Physical examination found mid tenderness but no scoliosis. Range of motion found bending to 60 or 70 degrees, where there were complaints of pain, and the Veteran preferred not to repeat the motion due to increasing discomfort. Extension was from 0 to 10 degrees. Right and left lateral flexion was from 0 to 15 degrees, and left and right rotation was from 0 to 15 degrees. The examiner noted that additional limitation of the function of the spine was caused by pain, lack of endurance, weakness, and repetitive use. At a July 2010 VA examination follow up to the February 2010 examination, the Veteran's spine was straight with no scoliosis. His posture was normal and gait was antalgic due to his bilateral knee pain, and not due to his spine/back condition. The curvature of the spine was normal. Range of motion testing found forward flexion of 0 to 80 degrees, extension of 0 to 10 degrees, left and right lateral flexion of 0 to 15 degrees, and left and right lateral rotation of 0 to 15 degrees. There was evidence of painful motion, mild spasm on the right, and tenderness, but no guarding. There was no muscle spasm or guarding severe enough to result in an abnormal gait, abnormal spinal contour, or abnormal kyphosis. There was no deformity or abnormality of musculature other than spasm. The Veteran also attended a VA examination in August 2015. He reported having daily pain in his lower back, without radiation or bowel/bladder issues. He stated that he could not ride or push a mower, carry groceries, or lift things. He did not report any flare ups. Range of motion testing found normal range of motion, with no pain noted on examination. There was no pain with weight-bearing or localized tenderness. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion. The examiner found that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. There was no guarding or muscle spasm. There was no ankylosis or neurologic abnormalities, and the Veteran did not have intervertebral disc syndrome. After reviewing all of the evidence of record, the Board finds that the assignment of a rating higher than 10 percent is not warranted at any time during the period on appeal. At no time has the Veteran been found to have forward flexion of the thoracolumbar spine that was limited to 60 degrees or less or a combined range of motion of 120 degrees or less. While the February 2010 VA examination found that the Veteran could "bend to about 60 to 70 degrees," with pain that increased from 60 to 70 degrees, this indicates that the Veteran could forward flex to just over 60 degrees, which allows for only a 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Furthermore, the Veteran's subsequent VA examinations, including one held just 5 months after the February 2010 VA examination, found much greater forward flexion ability. The February 2010 VA examination found flexion to 80 degrees, and the most recent examination in August 2015 found that range of motion testing was normal. The Board is therefore unable to assign a rating higher than 10 percent, even after consideration of pain, weakness, and other symptoms described in DeLuca; 38 C.F.R. § 4.71a. The Veteran has not been shown to have pain, weakness, or other symptoms which actually limit his range of motion to 60 degrees or less of flexion or 120 degrees or less of combined range of motion at any time during the period on appeal. The Veteran reported some flare ups in February 2010, but did not indicate whether they caused increased limitation of motion, and in August 2015 he denied any flare ups. The Veteran has also been found to have muscle spasms at the July 2010 VA examination, but the examiner clarified that the muscle spasm was not severe enough to result in an abnormal gait. The August 2015 VA examiner found no guarding or muscle spasm, and he stated that there was no pain with weight-bearing and that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. There is therefore no indication, even when taking the Veteran's painful motion into consideration, that a rating higher than 10 percent is warranted. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. The Veteran has also not been found to have ankylosis of the lumbar spine at any time during the period on appeal. The Board notes that ratings can also be assigned under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. A 20 percent evaluation is assigned for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. For purposes of evaluations under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Note (1) (2016). In this case, however, the Veteran was found by the August 2015 VA examiner to not have a current diagnosis of intervertebral disc syndrome, at no time has he ever reported having an incapacitating episode, and his medical records do not show that he was prescribed bed rest due to his low back disability at any time. A higher rating therefore cannot be assigned under these criteria. The Board also notes that any associated objective neurologic abnormalities, including, but not limited to bowel or bladder impairment, are evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, Note (1) (2016). In this case, the Veteran has denied having any associated bowel or bladder impairment or other neurological symptoms related to his lower back. In February 2010, the Veteran had some radiating pain and bladder difficulty, but the examiner did not find any neurogenic bladder problems and the Veteran was not diagnosed with any neurological disorders such as radiculopathy or neuropathy. The August 2015 VA examiner specifically noted that there were no neurological abnormalities. There is no medical evidence of any further neurological symptoms associated with his low back disorder. Neurological manifestations of the Veteran's low back disorder will therefore not be further discussed. In sum, the preponderance of the evidence establishes that the Veteran's service-connected degenerative disc disease of the lumbar spine with narrowing at L4-L5, L5-S1 disc spaces warrants no higher than a 10 percent rating at any time during the period on appeal, and the reasonable doubt doctrine is not for application. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. 49. Bilateral Hearing Loss The Veteran filed a claim for an increased rating for hearing loss in December 2009. The Veteran had previously been service connected for only right ear hearing loss, because hearing acuity in the left ear had tested as normal. In a September 2015 rating decision, the issue was recharacterized as service connection for bilateral hearing loss, because the Veteran's left ear hearing ability was now shown to be severe enough to be considered a disability under 38 C.F.R. § 3.385. The Veteran wrote in February 2010 that his hearing had diminished and that he was deaf in the right ear. He has also written that he has to ask people to repeat themselves, especially when on the telephone. He testified in August 2013 that he has trouble hearing people when there is background noise. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by puretone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85. To evaluate the degree of disability from defective hearing, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. §§ 4.85, Tables VI and VII, Diagnostic Code 6100. Disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). An exceptional pattern of hearing impairment occurs when the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Further, when the average puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). The Veteran attended a VA examination in February 2010. The Veteran reported having decreased hearing ability in his left ear. The examiner noted that the Veteran had profound loss in the right ear since his service. Puretone threshold testing showed the following results, in decibels: HERTZ 1000 2000 3000 4000 AVERAGE RIGHT 105+ 105+ 105+ 105+ 105 LEFT 10 20 20 25 18.75 Speech discrimination scores were 93 percent in the left ear, and the right ear could not be tested. Applying the findings from the February 2010 examination to Table VI or VIA in 38 C.F.R. § 4.85 yields a finding of Level XI hearing loss in the right ear and Level I in the left ear. Where hearing loss is at Level XI and Level I, a 10 percent rating is assigned. 38 C.F.R. § 4.85. The Veteran next attended a VA examination in August 2015. The Veteran reported having difficulty hearing in meetings or situations with background noise, as well as difficulty hearing fast speech or his wife's voice, and he often needed statements to be repeated. He stated that if he sleeps on the left, he is unable to hear his alarm clock. Puretone threshold testing showed the following results, in decibels: HERTZ 1000 2000 3000 4000 AVERAGE RIGHT 105 105 105 105 105 LEFT 30 40 35 50 38.75 Speech discrimination scores were 0 percent in the right ear and 96 percent in the left ear. Applying the findings from the August 2015 examination to Table VI or VIA in 38 C.F.R. § 4.85 yields a finding of Level XI hearing loss in the right ear and Level I in the left ear, and a 10 percent rating is again assigned. 38 C.F.R. § 4.85. After reviewing all of the evidence, the Board finds that no rating higher than 10 percent can be assigned. The medical evidence does show that the Veteran's left ear hearing loss underwent a slight worsening by 2010 and then again in 2015, but it did not worsen to a severity that would allow for a rating higher than 10 percent. The Veteran has not submitted any private evaluations or other evidence that shows that higher ratings have been warranted at any time during the appeal, and there is no evidence in his VA treatment records pertaining to complaints or treatment for hearing loss. There is no evidence that the Veteran's speech discrimination abilities or puretone thresholds have ever been recorded to be at any greater severity that those shown at the examinations and medical treatment discussed above. The Board has taken into consideration the Veteran's complaints regarding the impact of hearing loss on his daily life, but as noted above, the assignment of disability ratings for hearing impairment is primarily derived from a mechanical formula based on levels of puretone threshold average and speech discrimination. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The functional effects of hearing loss on his daily life activities and occupational functioning have been discussed by the Veteran at his August 2015 VA examination and at the August 2013 Board hearing. See 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447, 455-56 (2007). The Veteran reported having difficulty hearing conversation and needing to ask people to repeat themselves, which is reflective of the types of functional difficulty that would be expected to be caused by his recorded levels of hearing loss. See Doucette v. Shulkin, No. 15-2818, 2017 U.S. App. Vet. Claims LEXIS 319 (Vet. App. March 17, 2017) (Manifestations such as difficulty hearing speech are the types of difficulties contemplated by the schedular criteria for hearing loss.). Accordingly, the Board finds these examinations to be sufficiently in compliance with the provisions of VA regulations, and they are afforded great probative value in determining the Veteran's level of hearing impairment. The most probative medical evidence as to the nature of the appellant's hearing loss are the audiometric findings, and those discussed above reveal that the Veteran's hearing loss does not warrant a rating higher than 10 percent at any time during the current appeal. In reaching this conclusion, the Board has again considered the applicability of the benefit of the doubt doctrine; the preponderance of the evidence is against the Veteran's claim, and the doctrine is not applicable. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. 49. Other Considerations The Board acknowledges the Veteran's reports of having pain on motion with regard to his lumbar spine, right shoulder, and left knee disabilities, but there is no indication that this pain results in any further functional loss which would allow for a rating higher than those now assigned. See DeLuca, 8 Vet. App. 202. VA regulations do allow for consideration of a Veteran's pain and its impact on his functional mobility when assigning evaluations. Actually painful joints are entitled to at least the minimum compensable rating. 38 C.F.R. § 4.59; Petitti v. McDonald, 27 Vet. App. 415 (2015). The Veteran has already been assigned at least the minimum compensable rating for the lumbar spine, right shoulder, and left knee, and there is no indication that a higher rating based on functional impairment due to pain is warranted. The Board has also considered the Veteran's lay statements regarding the functional impact of the service-connected right shoulder, left knee, and lumbar spine disabilities. The Veteran is competent to report his own observations with regard to the severity of his orthopedic disabilities, including reports of pain and decreased mobility. Jandreau, 492 F.3d 1372. He has described the limitations they cause him with performing physical activities, including carrying heavy objects, walking for long distances, or performing chores around the house or in the garden. The Board finds his statements to be credible and consistent with the rating assigned. To the extent that the Veteran argues his symptomatology is more severe than shown on evaluation, his statements must be weighed against the other evidence of record. Here, the specific examination findings of trained health care professionals are of greater probative weight than the Veteran's more general lay assertions. Those objective findings did not find symptomatology that would warrant any higher rating. The Veteran has been diagnosed with osteoarthritis in his left knee, right shoulder, and lumbar spine. Diagnostic Code 5003 states 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. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When, however, the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Because the Veteran has already been assigned at least a 10 percent evaluation for the entire period on appeal for each of the orthopedic disabilities currently addressed, no higher ratings can be assigned based on Diagnostic Code 5003 alone or in addition to the ratings now assigned. The Board also notes that while the Veteran and his wife have indicated that his physical disabilities make work more difficult, he has not at any time indicated that he was unable to obtain or maintain gainful employment because of his service-connected disabilities. He has consistently indicated that he remains employed full-time, and therefore the issue of entitlement to a total disability based on individual unemployability is not raised at this time. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Lastly, the question of entitlement to referral for consideration of an extraschedular rating is neither an issue argued by the claimant nor reasonably raised by the record through evidence of the collective impact of the claimant's service-connected disabilities. Yancy v. McDonald, 27 Vet. App. 484, 494 (2016). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, No. 15-2818, 2017 U.S. App. Vet. Claims LEXIS 319 (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER Entitlement to service connection for sleep apnea is denied. Entitlement to a rating higher than 20 percent for left knee, anterior cruciate insufficiency, postoperative, for symptoms associated with dislocated cartilage is denied. Entitlement to a separate 10 percent rating, but no higher, for left knee, anterior cruciate insufficiency, postoperative, for symptoms associated with recurrent subluxation or lateral instability is granted, subject to the laws and regulations governing the payment of VA compensation. Entitlement to a rating higher than 20 percent for postoperative fracture dislocation of the right shoulder with degenerative joint disease is denied. Entitlement to a rating higher than 10 percent for degenerative disc disease of the lumbar spine with narrowing at L4-L5, L5-S1 disc spaces, is denied. Entitlement to a rating higher than 10 percent for bilateral hearing loss is denied. ____________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs