Citation Nr: 1753871 Decision Date: 11/24/17 Archive Date: 12/01/17 DOCKET NO. 07-07 064 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial evaluation in excess of 20 percent for degenerative disc disease (DDD) of the cervical spine. 2. Entitlement to an initial evaluation in excess of 20 percent for degenerative arthritis of the right shoulder. 3. Entitlement to an initial evaluation in excess of 10 percent for right knee osteoarthropathy. 4. Entitlement to an initial evaluation in excess of 10 percent for left knee osteoarthropathy. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD R. Casadei, Counsel INTRODUCTION The Veteran had service from July 1984 to November 1984 and from July 1985 to March 2005. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran was scheduled to appear before a Hearing Officer in April 2007 at the RO. He was informed of the scheduled hearing through a letter mailed in March 2007. The Veteran withdrew his hearing request. By way of procedural background, these claims, along with others, were previously denied by way of the January 2013 Board decision. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans' Claims (Court). A Joint Motion Remand (JMR) was filed by the parties and subsequently granted by the Court. The Court remanded these four issues to the Board for further development pursuant to 38 U.S.C.A. § 7252 (a). The appeal as to the remaining issues has been dismissed. These issues were subsequently remanded in July 2014, November 2015, and May 2017 for further development. The issues were subsequently readjudicated in a September 2017 Supplemental Statement of the Case and are properly before the Board for consideration. The Board also notes that after the November 2015 Board remand, the Appeals Management Center, in a January 2017 rating decision, granted TDIU effective the day following the Veteran's last day of employment. That award constitutes a full grant of the benefit sought, and the issue is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997) (holding that where an appealed claim of service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of the claim concerning "downstream" issues, such as the compensation level assigned for the disability and the effective date). FINDINGS OF FACT 1. The Veteran's cervical spine disability has not been manifested by forward flexion of the cervical spine functionally limited to 15 degrees or less, favorable ankylosis of the entire cervical spine, or incapacitating episodes of intervertebral disc syndrome having a total duration of at least 4 weeks but less than 6 weeks during the course of his appeal. 2. The Veteran's degenerative arthritis of the right shoulder is characterized by motion of the arm limited to 90 degrees with pain and flare-ups with activity. 3. The Veteran's right knee disability has been manifested by normal extension, with flexion, at worst, to 85 degrees, without lateral instability or recurrent subluxation. 4. The Veteran's left knee disability has been manifested by normal extension, with flexion, at worst, to 90 degrees, without lateral instability or recurrent subluxation. CONCLUSIONS OF LAW 1. The criteria for a disability evaluation in excess of 20 percent for a cervical spine disability have not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.14, 4.71a, Diagnostic Code 5242 (2017). 2. The criteria for a disability evaluation in excess of 20 percent for degenerative arthritis of the right shoulder have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2017). 3. The criteria for a disability evaluation in excess of 10 percent for right knee osteoarthropathy have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5010-5260 (2017). 4. The criteria for a disability evaluation in excess of 10 percent for left knee osteoarthropathy have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5010-5260 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability Rating Criteria Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2017). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. 38 C.F.R. § 4.1. This appeal originates from a rating decision that granted service connection and assigned the initial rating. Accordingly, "staged" ratings may be assigned, if warranted. Fenderson v. West, 12 Vet. App. 119 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology; or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. When evaluating disability of a joint, VA must consider evidence of less movement than normal, more movement than normal, weakened movement, excess fatigueability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse, as well as instability, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. 38 C.F.R. § 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 207 (1995). VA must also consider further limitation of functional ability during flare-ups or when a joint is used repeatedly over a period of time. See DeLuca, 8 Vet. App. at 206; see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability, and to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Burton v. Shinseki, 25 Vet. App. 1, 1-2 (2011); 38 C.F.R. § 4.59. However, while pain may cause functional loss, pain, by itself, does not constitute further compensable functional loss unless there is evidence of pain of such severity that it affects the normal working movements of the body. Mitchell, 25 Vet. App. at 36. Where the diagnostic code is not predicated on the loss of range of motion, the provisions regarding pain in 38 C.F.R. §§ 4.40 and 4.45 do not apply. Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Rating Analysis for Cervical Spine Disability The Veteran's cervical spine disability has been assigned a 20 percent rating throughout the period on appeal under DC 5242 for degenerative arthritis of the spine based on limitation of motion. Under DC 5242, the cervical spine disability can either be rated under the General Rating Formula for Disease and Injuries of the Spine (General Formula) or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula), whichever results in a higher evaluation. 38 C.F.R. § 4.71a, DC 5242. Under VA regulations, normal range of motion of the cervical spine, or neck, is flexion and extension to 45 degrees each, lateral flexion to 45 degrees in both directions, and rotation to 80 degrees bilaterally. 38 C.F.R. § 4.71a, Plate V. Under the General Formula, a 20 percent rating is warranted for forward flexion of the cervical spine between 15 and 30 degrees; combined range of motion of the cervical spine less than 170 degrees; or, muscle spasm or guarding severe enough to result in abnormal gait or spinal contour. A 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. The evidence includes an October 2004 VA examination. During the evaluation, the Veteran reported a grinding sensation when he turned his neck. It did not interfere with his ordinary lifting or carrying. Upon physical examination, the curvature was within normal limits. There was no muscle atrophy. Sensory perception and deep tendon reflexes were within normal limits. Range of motion was within normal limits and without restriction or pain, with flexion, extension, and lateral flexion to 45 degrees and rotation to 80 degrees. Pain, weakness, lack of endurance, fatigue, or incoordination did not impact further on the range of motion. An x-ray revealed moderate degenerative disc space disease. The diagnosis was that no pathology was identified on physical examination to render a diagnosis. In May 2007, the Veteran underwent a VA examination. He described neck pain that radiated to the shoulders. He also complained of stiffness and muscle spasms of the neck. He had flare-ups of neck pain on turning suddenly. Upon physical examination, range of motion of the cervical spine was to 30 degrees in flexion, without further flexion due to pain and some muscle spasm. Repetitive use showed no additional loss of motion by pain, fatigue, weakness, or lack of endurance. On neurological examination related to the cervical spine, sensation of the upper extremities was normal, motor examination showed no muscle atrophy or weakness. Reflexes were normal, and there was no evidence of cervical radiculopathy. The diagnosis was DDD of the cervical spine with residual pain and limitation of motion with no cervical radiculopathy. The Veteran was afforded another VA examination in May 2011. At that time, the Veteran complained of constant pain in his cervical spine with occasional numbness in the bilateral arms that lasted for up to fifteen minutes. There was a history of fatigue, decreased motion, stiffness, weakness, and pain. There were no incapacitating episodes of spine disease. On examination, there was no abnormal spinal curvature or ankylosis. Range of motion of the cervical spine is flexion to 20 degrees. There was objective evidence of pain following repetitive motion, but no additional limitations after three repetitions of range of motion. In a December 2016 VA cervical spine examination, the Veteran reported that his cervical spine disability had progressively worsened over time. It was noted that the Veteran underwent cervical fusion in August 2016 and the Veteran indicated that while his pain persisted, it was less than before. Range of motion of the cervical spine was limited to 40 degrees in flexion. There was no pain on weight bearing and mild tenderness to palpation was noted. There was objective evidence of pain following repetitive motion, but no additional limitations after three repetitions of range of motion. There was no ankylosis of the cervical spine. The Veteran also did not have any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. Most recently, the Veteran underwent a cervical spine Disability Benefits Questionnaire in July 2017. The Veteran reported a burning sensation in the neck area and indicated difficulty driving, reading, using the computer, and looking upward. Range of motion of the cervical spine was limited to 40 degrees in flexion. Functional impairment was noted to involve tasks that required frequent head and neck motions such as typing, working overhead, and driving. There was no additional limitation after three repetitions of range of motion. There was no ankylosis of the cervical spine. Upon review of all the evidence of record, the Board finds that a rating in excess of 20 percent for the Veteran's cervical spine disability is not warranted. First, there is no lay or medical evidence of any ankylosis of the lumbar or cervical spine. Further, although the Veteran reported having some difficulty typing, working overhead, and driving, the Veteran has always been able to flex his cervical spine in excess of 15 degrees, to include with repetitive use testing. Therefore, the functional impairment of the Veteran's cervical spine disability never approximated forward flexion limited to 15 degrees or less. DeLuca v. Brown, 8 Vet. App. 202 (1995). As such, a disability rating in excess of 20 percent for degenerative disc disease of the cervical spine is not warranted under the General Rating Formula for Diseases and Injuries of the Spine. Furthermore, a higher rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes is not warranted. The April 2015 examiner noted that the Veteran did not have incapacitating episodes due to cervical spine IVDS. There is no lay or medical evidence that the Veteran experienced incapacitating episodes of the DDD of the cervical spine. The Veteran has not reported that he experienced such episodes involving bed rest prescribed by a physician, and there is no other evidence in the record suggesting that such episodes occurred. The December 2016 VA examination report specifically noted that there was no history of incapacitating episodes of spine disease. As such a higher evaluation for the cervical spine disability is not warranted under these criteria. VA regulations also provide that any neurologic impairment (to the extent one is found to exist) associated with a cervical disability should be rated separately and then combined with the orthopedic rating. 38 C.F.R. § 4.71a, Note 1. In a January 2017 rating decision, the RO granted separate disability ratings of 40 percent for right upper extremity radiculopathy and a 30 percent rating for left upper extremity radiculopathy, both effective December 8, 2016. The Veteran has not disagreed with the ratings or effective dates assigned for these neurological impairments. The Board finds that no additional higher or alternative ratings under different Diagnostic Codes can be applied. For complete paralysis of the upper radicular group (fifth and sixth cervical), a 70 percent rating is to be assigned for complete paralysis of the major extremity and a 60 percent rating for the minor extremity. For severe incomplete paralysis, a 50 percent rating is warranted for the major extremity and a 40 percent rating for the minor extremity. A 40 percent rating is warranted for moderate incomplete paralysis of the major extremity, with a 30 percent rating for the minor extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8510. During the October 2004 VA examination, the Veteran denied any history of radiating pain associated with his cervical spine disability. The May 2007 VA examiner noted that there was "no evidence of cervical radiculopathy condition." During the May 2011 VA examination, the Veteran reported that if he moved his head a certain way, he would experience numbness in his arms for 5-15 minutes. A diagnosis of radiculopathy of the upper extremities was not provided. The first evidence of diagnosed bilateral upper extremity radiculopathy was noted in a December 8, 2016 VA peripheral nerves examination. The examiner noted that the Veteran was right hand dominant. Upon examination, the examiner indicated that the Veteran had bilateral upper extremity radiculopathy of the C5-C7 nerve roots of "moderate" severity. See also July 2017 DBQ (showing "moderate" impairment of the C5-C7 nerve roots). Upon review of the evidence of record, the Veteran was first diagnosed with radiculopathy of the upper extremities in the December 2016 VA examination. Accordingly, separate ratings for radiculopathy prior to December 8, 2016 are not warranted. Moreover, his impairment has been manifested by, at worst, moderate incomplete paralysis. As such, higher ratings for the right and left upper extremities are not warranted. 38 C.F.R. § 4.124a, Diagnostic Code 8510. Rating Analysis for Right Shoulder Disability The Veteran maintains that his right shoulder disability is more severe than what is contemplated by the currently assigned 20 percent rating. The Veteran's degenerative arthritis of the right shoulder has been rated as 20 percent disabling for entire initial rating period on appeal under Diagnostic Code 5003. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. Under 38 C.F.R. § 4.71a, Diagnostic Code 5201, a 20 percent rating is assigned for limitation of the major arm to shoulder level. A 30 percent rating is assigned for limitation to midway between the side and shoulder level, and a 40 percent rating is warranted for motion limited to 25 degrees from the side. On his October 2004 claim, the Veteran indicated that he had pain and weakness associated with overhead or repetitive movement. The shoulder continually popped and grinded with movement. In October 2004, the Veteran underwent VA examination. He complained of pain at times, especially when he was exposed to strenuous activity. It did not interfere with his ordinary activities. Presently, the shoulder was normal in outline and symmetric in form and function with no muscle atrophy. There was no heat, redness, effusion, or swelling. Sensory perception was within normal limits. Range of motion occurred without restriction or pain. Flexion and abduction were to 180 degrees, and external and internal rotation was to 90 degrees. Pain, weakness, lack of endurance, fatigue, or incoordination did not impact further on the range of motion. An x-ray of the right shoulder revealed moderate degenerative arthritic changes in the AC joint of the right shoulder with a normal glenohumeral joint. Degenerative arthritis of the right shoulder was the diagnosis. In May 2007, the Veteran underwent VA examination. He complained of pain in the acromial area. He experienced stiffness of the right shoulder, but there was no swelling, erythematous changes, or giving way. There was occasional popping noted. The Veteran had flare-ups of right shoulder pain on heavy lifting or raising his arm over his head. There were no episodes of dislocation or history of inflammatory arthritis. It limited his daily and occupational activities because he was not able to do heavy lifting or raise his arm over his head. On examination, forward flexion was to 180 degrees, abduction was to 110 degrees, external rotation was to 80 degrees, and internal rotation was to 45 degrees. Further movement was not possible due to pain or muscle spasm. There was no instability. The diagnosis was degenerative arthritis of the AC joint of the right shoulder with residual pain and limitation of motion of the right shoulder with no instability. In May 2011, the Veteran underwent another VA examination. During the evaluation, the Veteran complained of constant pain and grinding. On examination, the right shoulder demonstrated tenderness and pain at rest. Flexion was to 110 degrees, abduction was to 90 degrees, internal rotation was to 80 degrees, and external rotation was to 90 degrees. There was objective evidence of pain with active motion of the right shoulder, but there was no additional limitation after three repetitions. The diagnosis was osteoarthritis of the right shoulder. In a December 2016 VA examination, the Veteran reported increased pain with use of the shoulder above the head. Flexion was to 135 degrees, abduction was to 120 degrees, internal rotation was to 35 degrees, and external rotation was to 65 degrees. There was objective evidence of pain with active motion of the right shoulder, but there was no additional limitation after three repetitions. During flare-ups, the examiner indicated that the Veteran range of motion would be decreased in flexion to 130 degrees, abduction was to 115 degrees, internal rotation was to 30 degrees, and external rotation was to 55 degrees. There was no ankylosis of the shoulder joint. The Veteran was afforded another VA examination in July 2017. During the evaluation, the Veteran reported that, when using the arm overhead, he had increased pain and a feeling of instability. Flare-ups were noted to involve difficulty with above shoulder activities. Flexion was to 135 degrees, abduction was to 120 degrees, internal rotation was to 30 degrees, and external rotation was to 65 degrees. The examiner also noted that the Veteran would have at least a 5 degree change in right shoulder flexion and right shoulder abduction during flare-ups or when the right shoulder was used repeatedly over a period of time. The examiner noted that the right shoulder disability restricted activities of the shoulder above shoulder level and with overhead use. At issue is whether a disability rating in excess of 20 percent is warranted for the Veteran's right shoulder disability. The Board finds that it is not. The evidence of record consistently shows that the Veteran was able to raise his arm to shoulder level throughout the appeal period. While he described flare-ups of pain with activity, there is no evidence that these flare-ups caused motion of the arm to be limited to midway between the shoulder and side. The May 2011 VA examination report specifically noted that, after three repetitions, while the Veteran experienced pain, there was no additional limitation of function of his right shoulder. The July 2017 examiner indicated that the Veteran would have at least a 5 degree change in right shoulder flexion and right shoulder abduction during flare-ups (i. e., flexion limited to 130 degrees and abduction to 115 degrees). Therefore, the Board concludes that the Veteran has always maintained the functional equivalent of motion of his right arm in excess of midway between his side and his shoulder. As such, a disability rating in excess of 20 percent at any time during the appeal period is not warranted under Diagnostic Code 5201. Furthermore, no other manifestation of the Veteran's right shoulder disability is shown by any of the pertinent evidence of record. Rating Analysis for Right and Left Knee Disabilities The Veteran is currently in receipt of 10 percent ratings for the right and left knee disabilities due to osteoarthropathy with limitation of motion. The 10 percent ratings assigned to each knee contemplate pathology productive of painful motion. 38 C.F.R. § 4.59 (2017). They are also consistent with flexion of the leg limited to 45 degrees. In order to warrant a higher evaluation, the evidence must approximate the functional equivalent of flexion of the leg limited to 30 degrees or less. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, degenerative arthritis is rated on the basis of limitation of motion of the specific joint involved. When limitation of motion is noncompensable, a 10 percent rating is for application for each major joint. In the absence of limitation of motion, a maximum schedular 20 percent rating is assigned for degenerative arthritis of two or more major joints or two or more minor joint groups, with occasional incapacitating episodes. Diagnostic Code 5010 directs that traumatic arthritis is to be rated as degenerative arthritis. Flexion of the leg is rated noncompensable when limited to 60 degrees, 10 percent when limited to 45 degrees, 20 percent when limited to 30 degrees, and 30 percent when limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Other diagnostic codes provide rating criteria used to evaluate ankylosis, recurrent subluxation or lateral instability, dislocated cartilage, limitation of extension, impairment of the tibia and fibula, and genu recurvatum. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5257, 5258, 5259, 5261, 5262, and 5263. In October 2004, the Veteran underwent a VA examination. On examination, both knees were normal in outline and symmetric in form and function. There was no heat, redness, or tenderness. No effusion was detected. There was no muscle atrophy. Sensory perception and deep tendon reflexes were within normal limits. Drawer and McMurray tests were negative. Range of motion was full without restriction or pain, with flexion to 140 degrees and extension to 0 degrees. Pain, weakness, lack of endurance, fatigue, or incoordination did not impact further on the range of motion. There was no evidence of recurrent subluxation or locking pain. X-rays revealed minimal bilateral knee osteoarthropathy. The Veteran was afforded another VA examination in May 2007. During the evaluation, it was noted that the Veteran walked without assistance and did not use knee braces. During the examination, repetitive use with three repetitions showed no additional loss of motion by pain, fatigue, weakness, or lack of endurance. He experienced pain at the anterior lateral aspect of the knees. There was occasional popping but no effusion, erythematous changes, giving way, or locking. There was flare-up of knee pain when squatting or performing heavy lifting. There were no episodes of dislocation. The inability to lift heavy objects and squat limited his occupational and daily activities. Upon range of motion testing, right knee flexion was limited to 135 degrees, and extension to 0 degrees. Further motion was precluded due to pain. There was tenderness on examination. The left knee extended to 0 degrees and flexed to 140 degrees, with some pain at 140 degrees. There was tenderness on examination. No instability of either knee was noted. In May 2011, the Veteran underwent a VA examination. At that time, the Veteran described increased pain, locking, popping, and cracking. He reported giving way, instability, pain, stiffness, weakness, incoordination, locking, and tenderness. There were weekly, severe flare-ups. He was unable to stand for more than a few minutes. He could only walk less than a mile and used no assistive devices. On examination, the Veteran's gait was antalgic. Neither knee demonstrated instability. There was objective evidence of pain with active motion of the right and left knees with left flexion to 90 degree and extension to 0 degrees and right flexion to 85 degrees and extension to 0 degrees. There was no additional limitation of after three repetitions of motion. There was no ankylosis. McMurray's and Lachman's tests were negative. During a December 2016 VA knee examination, the Veteran reported continued knee pain, worse on the right. Flare-ups were noted to include increased pain. The Veteran also stated that he had difficulty standing for longer than 5-10 minutes, climbing stairs more than 1-2 flights, and being in any one position for too long. Upon range of motion testing, right knee flexion was limited to 100 degrees, and extension to 0 degrees. The left knee extended to 0 degrees and flexed to 110 degrees. There was objective evidence of pain with weight bearing and tenderness to palpation of the joint. Upon repetitive use testing, there was no additional functional loss or range of motion. There was no muscle atrophy or ankylosis. There was also no history of recurrent subluxation or lateral instability of either knee. A history of effusion was also not reported. The Veteran also did not have a meniscal condition. Most recently, the Veteran underwent a VA examination in July 2017. During the evaluation, the Veteran reported that he occasionally used a cane and had difficulty with climbing stairs, walking, and standing. Flare-ups were noted to involve increased pain and decreased rating of motion. Upon range of motion testing, both knee were normal (i. e., flexion limited to 140 degrees and extension to 0 degrees). There was pain during flexion, but not on weight bearing. Upon repetitive use testing, there was no additional functional loss or range of motion. There was no ankylosis, subluxation, or lateral instability of either knee. The Veteran also did not have a meniscal condition. At issue here is whether a disability rating in excess of 10 percent is warranted for either knee at any point during the appeal period. The current evaluation is consistent with painful motion. 38 C.F.R. § 4.59. In order to warrant a higher rating, there must be the functional equivalent of limitation of flexion to 30 degrees. See DeLuca, supra; 38 C.F.R. § 4.7. Separate evaluations may be assigned for compensable limitation of extension, subluxation, or instability. The Board finds that disability rating in excess of 10 percent are not warranted. Under the criteria of Diagnostic Code 5260, the Veteran never demonstrated the functional equivalent of flexion limited to 30 degrees in order to warrant a higher disability rating under these criteria. Throughout the appeal period, he maintained flexion to, at worst, 85 degrees and, while the Veteran complained of pain and other symptoms, they did not affect his functional ability to flex both of his knees in excess of 30 degrees. The VA examination reports revealed that, following repetitive movement, the Veteran maintained flexion in excess of 30 degrees of each knee. The Veteran has reported that he experienced weekly flare-ups that he described as severe and limiting his ability to walk distances. However, he has not asserted, and there is no other evidence to suggest, that these flare-ups caused flexion to be functionally limited to 30 degrees or less in either knee. As such, a rating in excess of 10 percent under Diagnostic Code 5260 is not warranted. Furthermore, there is no evidence of ankylosis, impairment of the cartilage, limitation of extension, impairment of the tibia and fibula, or genu recurvatum. With regard to other impairment of either knee, the VA examinations discussed above indicated no presence of subluxation or instability of either knee. In May 2011, the Veteran reported giving way and instability. However, on examination, instability of either knee was not demonstrated. The Veteran has not described any specific incidents of falls or subluxations. As such, the Board concludes that the preponderance of the evidence is against a finding that either of the Veteran's knee disabilities is manifested by recurrent subluxation or lateral instability, and higher evaluations than those already assigned are not warranted. In sum, the Board finds that the medical evidence prepared by a skilled professional is more probative and credible than the contradicted lay evidence. Similarly, there is no evidence of limitation of extension. For these reasons, the Board finds that higher ratings in excess of 10 percent of the Veteran's right and left knee disabilities are not warranted for the entire initial rating period on appeal. Finally, the Board notes that neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (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). Moreover, as noted in the Introduction section above, a January 2017 rating decision granted a TDIU effective January 13, 2009 (the day following the Veteran's last day of employment). That award constitutes a full grant of the benefit sought, and the issue is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997) (holding that where an appealed claim of service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of the claim concerning "downstream" issues, such as the compensation level assigned for the disability and the effective date). ORDER An evaluation in excess of 20 percent for degenerative disc disease of the cervical spine is denied. An evaluation in excess of 20 percent for degenerative arthritis of the right shoulder is denied. An evaluation in excess of 10 percent for right knee osteoarthropathy is denied. An evaluation in excess of 10 percent for left knee osteoarthropathy is denied. ____________________________________________ L. M. BARNARD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs