Citation Nr: 1752656 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 11-22 698 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for a disorder of the feet, to include bilateral plantar fasciitis. 2. Entitlement to a rating in excess of 10 percent for residuals of dislocation of the left shoulder. 3. Entitlement to a rating in excess of 10 percent for a mechanical low back disorder. 4. Entitlement to an increased rating for patellofemoral syndrome of the left knee, rated as 10 percent disabling prior to April 7, 2015, and 20 percent thereafter. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU rating). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A.Z., Counsel INTRODUCTION The Veteran had active service from June 1973 to June 1995. This matter came before the Board of Veterans' Appeals (Board) from a January 2009 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA) which denied increased ratings for all of the Veteran's service-connected disorders and denied service connection for bilateral plantar fasciitis. The Veteran's December 2009 notice of disagreement (NOD) was received as to the denials of service connection for bilateral plantar fasciitis and ratings in excess of 10 percent for disabilities of the left shoulder, low back, and left knee, and after a July 2011 Statement of the Case (SOC) addressed those matters, the appeal was perfected by filing VA Form 9 in August 2011. The Board notes that an August 2011 rating decision denied service connection for sleep apnea. The Veteran initiated an appeal by filing an NOD in October 2011. That matter was addressed in an August 2012 SOC. However, the Veteran did not perfect that appeal by filing a Substantive Appeal, VA Form 9 or equivalent. See 38 C.F.R. §§ 19.32, 20.302(b) (2017). A November 2013 rating decision granted service connection for a right shoulder strain with arthritis which was assigned an initial 10 percent rating. The Veteran applied to reopen his claim for service connection for sleep apnea in June 2014. The Veteran testified at an April 2014 videoconference before the undersigned. At the videoconference, testimony was additionally taken as to sleep apnea. At the videoconference the Veteran submitted additional evidence, together with a waiver of initial RO consideration of such evidence. Subsequently, an October 2014 rating decision denied reopening of the claim for service connection for sleep apnea. The Veteran has not yet submitted a NOD with this decision. Therefore, this issue is not before the Board for appellate consideration at this time. In December 2014, the Board remanded the appeal for further development. With respect to the claims decided herein, the instructions have been substantially complied with. See Stegall v. West, 11 Vet. App. 268 (1998). Furthermore, the Veteran was provided with all appropriate laws and regulations in the July 2011 Statement of the Case and September 2016 Supplemental Statement of the Case. In a July 2015 Rating Decision, the Agency of Original Jurisdiction (AOJ) granted a 20 percent rating for the Veteran's left knee disorder, effective April 7, 2015. The Veteran has not expressed satisfaction with the ratings assigned for either of the periods on appeal; therefore, the issue has been characterized to reflect that "staged" ratings are assigned, and that each stage remains on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). The issues of entitlement to service connection for a foot disorder and TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's left shoulder disorder was manifested by pain; range of motion was not limited to shoulder level. 2. Throughout the appeal period, the Veteran's low back disorder was not manifested by forward flexion of the thoracolumbar spine greater than 30 degrees but less than 60 degrees, combined range of motion of the thoracolumbar spine was less 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; or favorable or unfavorable ankylosis of the entire thoracolumbar spine. 3. Prior to April 7, 2015, the Veteran's left knee disorder did not result in flexion limited to 30 degrees; extension limited to 15 degrees; or dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint. 4. From April 7, 2015, the Veteran's left knee disorder has resulted in dislocated semilunar cartilage, but has not resulted in flexion limited to 15 degrees or extension limited to 20 degrees. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for a left shoulder disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5203 (2017). 2. The criteria for a rating in excess of 10 percent for a low back disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2017). 3. The criteria for a rating in excess of 10 percent for a left knee disorder, prior to April 7, 2015, and 20 percent, thereafter, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257, 5258 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A. Left Shoulder Disorder The Veteran contends that his left shoulder disability should be rated higher than the currently-assigned disability rating of 10 percent under Diagnostic Code 5203. Turing to the facts of the case, the Veteran underwent a VA examination in November 2008 for his left shoulder. At such time, he described minimal pain when engaged in extreme stretching activities. History was negative for weakness, stiffness, swelling, redness, locking, easy fatigability or endurance. He reported a history of giving way of the left shoulder joint. He described his pain as an unsevere grinding, usually brought on by lifting weights and with sudden twisting and stretching movements. The Veteran reported no occupational impairment form his left shoulder disability or limitation of his activities of daily living. Upon physical examination, the Veteran had forward flexion to 180 degrees, with minimal crepitus in the last 10 degrees of motion. Abduction was to 170 degrees, with mild pain and grinding at 145 degrees. He had extension to 30 degrees, external ration to 90 degrees, with no pain, internal rotation to 70 degrees, with pain starting at 65 degrees. There was worsening with repetitive movement. He was diagnosed with moderately advanced osteoarthritis. He reported his last episode of shoulder dislocation was about two years ago. Private medical evidence shows that the Veteran underwent physical therapy for his left shoulder. Range of motion testing performed in November 2014 showed flexion to 155 degrees and abduction to 111 degrees, external rotation to 61 degrees and external rotation in adduction to 34 degrees. Range of motion testing performed in December 2014 showed flexion to 155 degrees and abduction to 134 degrees, external rotation to 70 degrees and external rotation in adduction to 38 degrees. The Veteran underwent another VA examination in April 2015. Such report states that the Veteran is right-hand dominant. He reported flare-ups resulting in difficulty sleeping or lifting. He reported functional loss due to pain. Range of motion testing was normal in all directions. The examiner noted pain upon flexion, abduction and external rotation, but that such does not result in functional loss. There was no evidence of pain with weight bearing, tenderness or pain on palpation of the joint or associated soft tissue, or crepitus. The Veteran was able to perform repetitive use testing , which resulted in functional loss manifested by pain, fatigue and weakness. There was no decreased range of motion upon repetitive use testing, and the examiner found that pain, weakness, fatigability or incoordination did not significantly limit his functional ability with repeated use over a period of time or with flare-ups. Muscle strength testing was 5/5. Findings were negative for a rotator cuff condition and shoulder instability, dislocation or labral pathology. The Veteran was noted to have arthritis and a cuff tear (impairment of the clavicle or scapula). Cross-body adduction testing was negative. There was no loss of head (flail shoulder), nonunion (false flair shoulder) or fibrous union of the humerus. There was also no malunion of the humerus with moderate or marked deformity. In addition, there are VA treatment records documenting symptomatology which are consistent with the findings in the VA examinations, including, particularly, that the primary symptom is pain. Turning now to an evaluation of the most appropriate rating for the Veteran's left shoulder disability, Diagnostic Codes 5200 through 5203 address impairment of the shoulder and arm. 38 C.F.R. § 4.71a (2017). Diagnostic Code 5200, applicable to ankylosis of the scapulohumeral articulation, does not apply because the Veteran has not demonstrated ankylosis of the left shoulder at any time. Under Diagnostic Code 5201, which is applicable to a limitation of motion of the arm, a 20 percent disability rating applies to arm motion limited to the shoulder level in the minor extremity. A 20 percent disability rating also applies to motion limited midway between the side and shoulder level for the minor extremity. A maximum 30 percent disability rating applies to limitation of motion of the arm to 25 percent from the side for the minor extremity. 38 C.F.R. § 4.71a (2017). A Veteran is only entitled to a single disability rating under this Diagnostic Code for each arm that suffers from limited motion at the shoulder joint. The Diagnostic Code does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to "limitation of motion of" the arm. Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). In this case, the Veteran's left shoulder, even taking pain into consideration, has not resulted in a limitation of motion. In other words, the Veteran has not shown a limitation of motion to shoulder level (or 90 degrees) that is associated with a rating of 20 percent or greater. A rating in excess of the Veteran's currently-assigned 10 percent rating is unavailable under Diagnostic Code 5201. In reviewing the evidence, the Board considered functional loss due to pain and weakness that causes additional disability beyond that which is reflected on range of motion measurements. 38 C.F.R. § 4.40 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board has considered the effects of weakened movement, excess fatigability, and incoordination. 38 C.F.R. § 4.45 (2017). The Board accepts the Veteran's competent and credible assertions that his left shoulder disability causes him to experience pain, and the Veteran has been awarded with his current 10 percent rating based in part on those assertions. The rating schedule does not require a separate rating for pain itself. Spurgeon v. Brown, 10 Vet. App. 194 (1997). Diagnostic Code 5202, applicable to impairment of the humerus, does not apply because the Veteran has not shown symptoms such as malunion, recurrent dislocation, fibrous union, nonunion, or loss of head of the humerus. As mentioned, the Veteran's left shoulder disability is currently rated as 10 percent disabling under Diagnostic Code 5203, which is applicable to impairment of the clavicle or scapula. A greater rating under this Diagnostic Code requires nonunion or dislocation of the clavicle or scapula. Symptoms approaching nonunion or dislocation of clavicle or scapula have not been shown in this case, and a rating in excess of 10 percent under this Diagnostic Code is unavailable. In sum, the Board concludes that the overall manifestations of the Veteran's left shoulder disability demonstrate a degree of functional loss most nearly approximating the criteria for the currently-assigned 10 percent rating, and a greater rating is denied. B. Low Back Disorder The Veteran contends that his low back disability should be rated higher than the currently-assigned disability rating of 10 percent under Diagnostic Code 5237. All spinal disabilities are evaluated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Chronic lumbar sprain is to be evaluated either under the General Rating Formula or under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes (38 C.F.R. § 4.71a, DC 5243 (2017)), whichever method results in the higher rating. Under the General Rating Formula, a 10 percent rating is warranted when the forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine is 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 when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted when the forward flexion of the thoracolumbar spine is 30 degrees or less; or, favorable ankyloses of the entire thoracolumbar spin. A 50 percent rating is assigned for unfavorable ankylosis of entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The General Rating Formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate Diagnostic Code. Id. at Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. at Note (2). In August 2008, the Veteran underwent a VA examination for his low back disorder. He stated that his last incapacitating episode had occurred two years prior. He reported a negative history of fatigue, decreased motion, weakness and flare-ups, and a positive history of stiffness, spasms and pain. He described a dull aching pain of constant and moderate severity, occurring daily when he gets out of bed in the morning. Physical examination was negative for spasm, atrophy, guarding, pain with motion, tenderness and weakness. Gait and posture were normal, however there was lumbar flattening. There was no evidence of impaired sensation or reflexes. Ankylosis was absent. Range of motion testing for the lumbar spine showed flexion to 90 degrees, extension to 30 degrees, lateral flexion to 25 degrees and lateral rotation to 20 degrees. There was pain upon repetitive use on flexion and extension, but no additional loss of motion on repetitive use in any direction. X-rays showed a normal spine, and the Veteran was diagnosed with chronic lumbar strain. Such was noted to have no significant effects on his occupation. The Veteran again underwent a VA examination in April 2015. He reported back pain most of the time, which was then a level 4, and that such contributed to him not being able to perform his job as a security guard any more. The examiner noted a 2015 X-ray showing mild degenerative disc disease of the lumbar spine, with no evidence of fracture or subluxation. The Veteran reported flare-ups of low back pain which interfere with his activity level, and that such pain causes him functional loss. Range of motion testing revealed full range of motion in all directions. The examiner found that there was pain on forward flexion and extension, but that such did not result in functional loss. There was no pain with weight-bearing, and no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion after three repetitions. Pain, weakness, fatigability or incoordination were not found to significantly limit functional ability with repeated use over a period of time. Guarding or muscle spasms were absent, as was muscle atrophy. Sensory testing was normal and straight-leg raising test was negative. Findings were negative for radiculopathy, anklyosis, other neurologic abnormalities, and intervertebral disc syndrome. The evidence indicates that throughout the appeal period, the Veteran's lumbar spine disability manifested with pain and limitation of motion, however, forward flexion of the thoracolumbar spine was not greater than 30 degrees but less than 60 degrees, the combined range of motion of the thoracolumbar spine was not less than 120 degrees, and muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis and favorable or unfavorable ankylosis of the entire thoracolumbar spine has not been shown. Indeed, the Veteran had full range of motion in the forward flexion during both VA examination. At worst, the combined range of motion of the thoracolumbar spine was 165 during the August 2008 VA examination. Accordingly, a disability rating in excess of 10 percent for a lumbar spine disability at any point in the appeal period is not warranted. The Board has considered whether higher ratings should be assigned pursuant to 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca v. Brown, 8 Vet. App. 202 (1995), and Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011) criteria but a higher rating is not warranted for the Veteran's disability picture. The range of motion testing conducted during the medical evaluations considered the thresholds at which pain limited motion. The August 2008 VA examination report indicates that the Veteran had pain following repetitive motion but there was no additional limitation following 3 repetitions of range of motion testing, and the Veteran denied flare-ups. In the April 2015 VA examination report, the examiner noted that the Veteran did reported flare-ups, but was able to perform repetitive use testing with no additional loss of function or range of motion after three repetitions. Pain, weakness, fatigability or incoordination were not found to significantly limit functional ability with repeated use over a period of time. After considering the effects of pain and functional loss, forward flexion was not greater than 30 degrees but less than 60 degrees for the thoracolumbar spine and the combined range of motion of the thoracolumbar spine was not less than 165 degrees, and muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis, and favorable or unfavorable ankylosis of the entire thoracolumbar spine has not been present. Thus, a higher rating under 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, and Mitchell criteria is not approximated in the Veteran's disability picture for the entire appellate period. Separate ratings for neurological abnormalities associated with the Veteran's thoracolumbar spine disability were also considered but are not warranted. The April 2015 VA examination report indicates that the Veteran did not have these neurological abnormalities related to the thoracolumbar spine disability; to include bowel or bladder problems. Accordingly, a separate rating for neurological symptoms is not applicable. In sum, the evidence does not show that a disability rating in excess of 10 percent for a low back disorder is warranted. C. Left Knee Disorder The Veteran contends that his left knee disability should be rated higher than the currently-assigned disability ratings of 10 percent, prior to April 7, 2015, and 20 percent thereafter. Disabilities of the knee joint, generally, are rated under Diagnostic Codes 5256 through 5263. See 38 C.F.R. § 4.71a. In addition, arthritis due to trauma is rated as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5010. Degenerative arthritis of the knee may be evaluated under Diagnostic Code 5003. When there is painful motion of a major joint caused by degenerative arthritis (rated under Diagnostic Code 5003) that is detected on X-ray, such painful motion, pursuant to § 4.59, will be considered limited motion and entitled to a minimum 10 percent rating, per joint, combined under Diagnostic Code 5003, even though there was no actual limitation of motion. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). Ankylosis (i.e. immobility) is rated under DC 5256. DC 5257 provides for 10, 20, or 30 percent ratings for recurrent subluxation or lateral instability that is, respectively, slight, moderate, or severe. Under DC 5258, a 20 percent evaluation is assigned for semilunar, dislocated cartilage with frequent episodes of "locking," pain, and effusion into the joint. Under DC 5259, a 10 percent evaluation is assigned for symptomatic removal of semilunar cartilage. Under DC 5260, a noncompensable evaluation is assigned for flexion limited to 60 degrees. A 10 percent rating is assigned for flexion limited to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is assigned for flexion limited to 15 degrees. Under DC 5261, a noncompensable evaluation is assigned for extension limited to 5 degrees. A 10 percent rating is assigned for extension limited to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. Impairment of the tibia and fibula is rated under DC 5262 and genu recurvatum is rated under DC 5263. Here, the relevant evidence includes an August 2008 VA examination for his left knee. During the examination, findings were negative for constitutional symptoms or incapacitating episodes of arthritis. Functional limitations included only being able to stand for 15-30 minutes, and only being able to walk less than a mile. Findings were negative for deformity, giving way, instability, weakness, episodes of dislocation, subluxation or locking, effusion, flare-ups of joint disease, and inflammation. Pain and stiffness was present. Gait was normal, with no evidence of abnormal weight bearing. Range of motion testing showed flexion from 0 to 125 degrees, extension from 90 to 0 degrees, with no evidence of pain or loss of range of motion on repetitive use. The examiner noted that the Veteran's range of motion was limited by his body habitus and not by pain or functional limitations. Clicks/snaps and grinding was present. Ankylosis, Osgood-Schlatters disease, crepitation, patellar/meniscus abnormality, or tendon/bursa was not found. Patello-femoral pain syndrome and degenerative joint disease was diagnosed. The examiner found that such had a significant effect of the Veteran's occupation due to decreased mobility and pain. The Veteran' reported difficulty with stairs and pain with most weight-bearing activities. In April 2015, the Veteran underwent another VA examination for his left knee. The Veteran reported a pain level of 6, and that he experiences flare-ups after walking extending periods, resulting in swelling of the knee. He described his functional loss as manifesting in pain after a long period of repetitive use. Upon examination, he had flexion to 130 to 0 degrees and extension from 0 to 130 degrees; the examiner noted that such did not contribute to functional loss. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, and no objective evidence of crepitus. Repetitive use testing yielded functional loss manifested by pain and fatigue, but not a decreased range of motion. The examiner found that pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time, but that his functional ability was significantly limited during flare-ups due to pain and fatigue. Muscle strength testing for the left knee was 5/5 for flexion and extension, with no atrophy. Ankylosis was absent. Findings were negative for a history of recurrent subluxation or effusion. Testing revealed no joint instability. In particular, anterior, posterior, medial and lateral instability tests were all normal. Findings were negative for recurrent patellar dislocation, medial tibial stress syndrome, stress fractures, chronic exertional compartment syndrome or any other tibial and /or fibular impairment. A history of a left side meniscal tear (semilunar cartilage) with frequent episodes of joint pain and effusion was noted. A May 2014 X-ray, cited in the report, found degenerative joint disease of the left knee. In addition, there are VA treatment records documenting symptomatology which are consistent with the findings in the VA examinations, including, particularly, that the primary symptom is pain. The Board notes that the Veteran's left knee disability has been rated as 10 percent disabling prior to April 7, 2015, and 20 percent thereafter. For efficiency, the Board will discuss the appeal period as a whole, to the extent possible. The Veteran has not alleged, nor does the medical evidence suggest, that he has ankylosis of the left knee, impairment of the tibia and fibula, or genu recurvatum, so DCs 5256, 5262, and 5263 are not applicable. DC 5257 provides ratings for recurrent subluxation or lateral instability. Although the Veteran alleges that he has instability, the medical evidence is against finding that the Veteran experiences subluxation or instability of the knee warranting a rating under this diagnostic code. See April 2015 VA examination (noting normal joint stability tests) and August 2008 VA examination (noting absence of a history or recurrent patellar subluxation/dislocation). Accordingly, the Veteran does not meet the criteria for a rating under DC 5257. The Veteran has degenerative arthritis verified by x-rays, so DC 5003 is applicable. DC 5003, as already noted, provides that "[w]hen...the limitation of motion of the specific joint...is noncompensable under the appropriate diagnostic codes, a rating of 10 [percent] is for application." 38 C.F.R. § 4.71a, DC 5003. The diagnostic codes relating to limitation of motion of the knee must be considered. The Board has already recounted a number of the range of motion findings above. None of the VA examiners have found flexion of the left knee to be limited to less than 125 degrees, including due to pain on repetitive motion. To be entitled to any compensable rating for limitation of flexion, flexion would have to be functionally limited to 45 degrees or less. The medical evidence establishes that the Veteran's limitation of flexion does not meet the criteria for any compensable rating based on limitation of flexion. While the Veteran does have functional loss consisting of pain on movement, no examiners (or other medical professionals) have found that his pain limits the range of motion to 45 degrees or less or that it is present prior to 125 degrees. Therefore, a minimum rating of 10 percent under Diagnostic Code 5260, as currently assigned, prior to April 7, 2015, is warranted, and the 20 percent rating, assigned from such date, is more than adequate in this regard. See 38 C.F.R. § 4.71a, DCs 5003 and 5260. In assigning these ratings, the Board has considered painful motion, swelling (which results in pain and limitations of motion), and weakness. See DeLuca, supra; 38 C.F.R. §§ 4.40, 4.45, 4.59. The Board notes that, as the Veteran has extension of the knee to 0 degrees, he does not meet the criteria for a compensable rating under Diagnostic Code 5261; therefore the Veteran would not benefit from assigning a rating under such diagnostic code. See 38 C.F.R. § 4.71a, DC 5261. As the Veteran has not had removal of the semilunar cartilage, Diagnostic Code 5259 (symptomatic removal of the semilunar cartilage) is not for application. Given the above, the Board finds that, prior to April 7, 2015, the Veteran is not entitled to a rating in excess of 10 percent. Such rating is appropriate under Diagnostic Code 5003 based on his arthritis with painful motion (interpreted from the Veteran's lay statements of difficulty ascending and descending stairs). The Board notes that dislocation of the semilunar cartilage was found during the April 2015 VA examination. Accordingly, from such point, Diagnostic Code 5258 is applicable. Such warrants a 20 percent evaluation, which is already assigned from April 7, 2015, forward. Accordingly, entitlement to a 10 percent rating prior to April 7, 2015, and 20 percent thereafter, for a left knee disability, is denied. D. Other Considerations The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his left shoulder, left knee and low back disability. The Board also acknowledges that the Veteran, in advancing this appeal, believes that the disabilities on appeal have been more severe than the assigned disability ratings reflect. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disabilities on appeal. As the preponderance of the evidence is against the claims for higher ratings, the benefit of the doubt doctrine is not for application, and the Veteran's claims must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. ORDER A rating in excess of 10 percent for residuals of dislocation of the left shoulder is denied. A rating in excess of 10 percent for a mechanical low back disorder is denied. An increased rating for patellofemoral syndrome of the left knee, rated as 10 percent disabling prior to April 7, 2015, and 20 percent thereafter, is denied. REMAND Additional development is required regarding the remaining claims, as described in the directives. Accordingly, the case is REMANDED for the following action: 1. Obtain any recent, outstanding VA treatment record. 2. After any outstanding records have been associated with the claims file, forward the claims file to a podiatrist for an addendum opinion on the etiology of the Veteran's foot disorder. The need for another examination is left up to the discretion of the clinician authoring the addendum opinion. The claims file, to include a copy of this Remand and the Veteran's April 2015 VA examination must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. The examiner must identify all foot disorders found to be present. If pes planus is diagnosed: (A) The examiner should state whether such condition(s) constitutes a congenital or developmental defect or a disease (per VAOPGCPREC 82-90, in general, a congenital abnormality that is subject to improvement or deterioration is considered a disease). (i) If the Veteran's diagnosed pes planus is considered a defect, was there additional disability due to disease or injury superimposed upon such defect during service? If so, please identify the additional disability. (ii) If the examiner finds that the Veteran's diagnosed pes planus is a disease, was it aggravated beyond the natural progression during his military service? Aggravation indicates a permanent worsening of the underlying condition as compared to a temporary increase in symptoms. (B) If pes planus is not a congenital or developmental defect or disease, is such at least as likely as not related to the Veteran's military service, to include as due to his work in maintenance in the Air Force, which he stated required a lot of walking and time on his feet while maintaining the equipment? For all other diagnosed foot disorders: (A) With respect to each foot disorder diagnosed (other than pes planus), the examiner should offer an opinion as to whether it is at least as likely as not related to the Veteran's military service, to include as due to his work in maintenance in the Air Force, which he stated required a lot of walking and time on his feet while maintaining the equipment. The examiner must consider the full record, to include the Veteran's testimony that he experience foot pain in service. The examiner should provide the supporting rationale for any opinion expressed. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims, to include his intertwined TDIU claim, should be readjudicated based on the entirety of the evidence. If any claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ L. M. BARNARD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs