Citation Nr: 1754322 Decision Date: 11/28/17 Archive Date: 12/07/17 DOCKET NO. 09-03 888 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Whether new and material evidence has been presented to reopen a claim for entitlement to service connection for a left shoulder disability, and, if so, whether service connection is warranted. 2. Entitlement to service connection for a cervical spine disability. 3. Entitlement to a rating greater than 20 percent for degenerative disc disease with intervertebral disc syndrome, lumbar spine ("thoracolumbar spine disability"). 4. Entitlement to a rating greater than 10 percent for right knee strain ("right knee disability"). 5. Entitlement to a rating greater than 10 percent for left knee strain with degenerative joint disease ("left knee disability"). 6. Entitlement to a rating greater than 10 percent prior to June 11, 2010 and 20 percent thereafter for degenerative joint disease of the right shoulder ("right shoulder disability"). 7. Entitlement to an initial rating greater than 10 percent for radiculopathy, left lower extremity. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Parsons, Associate Counsel FINDINGS OF FACT 1. In a September 2003 rating decision, service connection for a left shoulder disability was denied. The Veteran did not perfect an appeal from this denial, nor was new and material evidence submitted within one year. 2. Additional evidence received since the September 2003 rating decision is neither cumulative nor redundant, and raises a reasonable possibility of substantiating the Veteran's service connection claim for a left shoulder disability. 3. The Veteran's left shoulder disability is as likely as not related to service. 4. The Veteran's cervical spine disability is not etiologically related to an in-service injury or disease or a service-connected condition. 5. The Veteran's thoracolumbar spine disability manifested as limitation of forward flexion to no less than 45 degrees with no evidence of ankylosis. 6. The Veteran's right knee disability manifested as limitation of flexion to 95 degrees with pain, limitation of extension to 5 degrees without pain, and no evidence of subluxation or instability. 7. The Veteran's left knee disability manifested as limitation of flexion to 105 degrees with pain, limitation of extension to 5 degrees with pain, and no evidence of subluxation or instability. 8. Prior to June 11, 2010, the Veteran's right shoulder disability manifested as normal range of motion with signs of crepitus and no additional functional loss due to painful motion. 9. From June 11, 2010 through November 9, 2016, the Veteran's right shoulder disability manifested as flexion to 130 degrees and abduction with 110 degrees with functional loss due to pain. 10. Effective November 9, 2016 and thereafter, the Veteran's right shoulder disability manifested as flexion to 95 degrees and abduction to 70 degrees with painful motion. 11. The Veteran's radiculopathy, left lower extremity manifested as mild constant pain, moderate intermittent pain, moderate paresthesia, and mild numbness with mild left side sciatic nerve involvement. CONCLUSIONS OF LAW 1. The September 2003 rating decision is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.104, 3.156, 20.302 (2017). 2. Evidence received since the September 2003 rating decision is new and material to the service connection claim for a left shoulder disability; therefore, the claim is reopened. 38 U.S.C. § 5108 (West 2012); 38 C.F.R. § 3.156(a) (2017). 3. The criteria for service connection for a left shoulder disability have been met. 38 U.S.C. §§ 1101, 1112, 1113, 1110, 1131, 1137, 1154, 5107 (2012); 38 C.F.R. § 3.102, 3.303, 3.307 (2017). 4. The criteria for service connection for a cervical spine disability have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1110, 1131, 1137, 1154, 5107 (2012); 38 C.F.R. § 3.102, 3.303, 3.307, 3.310 (2017). 5. The criteria for an increased rating greater than 20 percent for the Veteran's service-connected thoracolumbar spine disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71(a), Diagnostic Code 5242 (2017). 6. The criteria for an increased rating greater than 10 percent for the Veteran's service-connected right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71(a), Diagnostic Code 5024 (2017). 7. The criteria for an increased rating greater than 10 percent for the Veteran's service-connected left knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71(a), Diagnostic Code 5024 (2017). 8. Prior to June 11, 2010 the criteria for an increased rating greater than 10 percent for the Veteran's service-connected right shoulder disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71(a), Diagnostic Code 5201 (2017). 9. From June 11, 2010 through November 9, 2016, the criteria for an increased rating greater than 20 percent for the Veteran's service-connected right shoulder disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71(a), Diagnostic Code 5201 (2017). 10. Effective November 9, 2016, the criteria for an increased rating of 30 percent, but no greater, for the Veteran's service-connected right shoulder disability have been met. 38 U.S.C.A. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71(a), Diagnostic Code 5201 (2017). 11. The criteria for an increased rating greater than 10 percent for the Veteran's service-connected left leg radiculopathy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.123, 4.124a, Diagnostic Code (DC) 8520 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1981 through March 2002. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision issued by a Department of Veterans Affairs (VA) regional office (RO). The Veteran appeared before the undersigned Veterans Law Judge in a September 2015 Travel Board hearing. A transcript is of record. In an April 2011 rating decision, the RO increased the Veteran's disability rating for his radiculopathy, left lower extremity to 10 percent disabling, effective August 18, 2006. Similarly, in a June 2016 rating decision, the RO increased the Veteran's right shoulder disability to 20 percent effective December 2014. In September 2016, the RO issued a rating decision granting an earlier effective date for the Veteran's right shoulder disability, assigning the 20 percent rating retroactively to June 11, 2010. Both the April 2011 and June 2016 rating decisions properly informed the Veteran they were partial grants of the issues on appeal and he was provided with Supplemental Statements of the Case. After the Board hearing, the Veteran submitted private medical records in November 2015. The RO continued to develop the claims, and additional evidence was submitted after the November 2016 Supplemental Statement of the Case. However, the Veteran waived Agency of Original Jurisdiction (AOJ) review in a written waiver dated November 2017. Therefore, the Board can proceed with the adjudication of the appeal. 38 C.F.R. §§ 19.31, 19.37, 20.1034. The Veteran has requested a temporary total rating for a planned right shoulder surgery, and has requested expedited action based on financial hardship. This is REFERRED to the RO for action. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Thus, the Board need not discuss any potential issues in this regard. Further, the Veteran has not alleged any deficiency with the conduct of his hearing before the undersigned with respect to the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). In this regard, the Federal Circuit ruled in Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016) that a Bryant hearing deficiency was subject to the doctrine of issue exhaustion as laid out in Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Thus, the Board need not discuss any potential Bryant problem because the Veteran has not raised that issue before the Board. I. New and Material Evidence In order to establish jurisdiction over the issues of entitlement to service connection for a left shoulder disability, the Board must first consider whether new and material evidence has been received to reopen the claim. 38 U.S.C. § 5108 (2012). The Board must proceed in this fashion regardless of the RO's actions. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996) and VAOPGCPREC 05-92. The Veteran seeks to reopen his claim for service connection for a left shoulder disability. The RO issued a decision in September 2003 denying this claim. The Veteran did not initiate an appeal as to the rating decision, nor did he submit new and material evidence within one year. Therefore, the rating decision became final. At the September 2003 rating decision, the evidence pertaining to the Veteran's left shoulder disability consisted of his service medical records, lay statements, and the July 2003 VA examination. In August 2006, the Veteran filed a new claim for service connection for a left shoulder disability. Since the September 2003 denial, the Veteran has submitted medical records recording his complaints of left shoulder pain. Specifically, in September 2006, the Veteran submitted a private treatment record dated October 2003 indicating x-rays of his left shoulder showed a type 3 acromion with an anterior slope and some mild degenerative changes in the AC joint. The Board finds the October 2003 medical record to be both new and material, and the claim for entitlement to service connection for a left shoulder disability is reopened. II. Service Connection Service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service; and (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). In addition, certain chronic diseases, such as arthritis, may be presumed to have been incurred during service if they become manifested to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2017). Moreover, certain chronic diseases, such as arthritis, may be presumed to have been incurred during service if they are established by way of continuity of symptomatology under 38 C.F.R. § 3.303(b). Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board."). However, the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a), such as arthritis. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Left Shoulder Disability The Veteran claims that his left shoulder disability is etiologically related to service. Specially, he asserts that his strict fitness regimen of several hundred push-ups a day, along with his physically demanding job as a medic, caused his current disability. Resolving reasonable doubt in the Veteran's favor, the Board finds that the evidence is at least in equipoise as to whether he has experienced continuity of left shoulder symptomatology since service. Initially, the Veteran's current diagnoses include bursitis and degenerative joint disease of the left shoulder AC joint. Accordingly, the Board finds that the chronic disease provisions apply. See 38 C.F.R. § 3.309(a); Walker, supra. Service treatment records are silent for any complaints of or treatment for a left shoulder disability. The Veteran first filed a claim for his left shoulder disability in April 2003, one year after separating from active duty. He was afforded a VA examination for his left shoulder in July 2003. He was diagnosed with bilateral shoulder bursitis. However, no imaging of the Veteran's left shoulder was conducted, and the examiner offered no opinion addressing the etiology of his left shoulder disability. An October 2003 private medical record noted the Veteran experienced left shoulder pain while painting, although he reported experiencing shoulder pain prior to the incident. X-rays taken at the time showed mild degenerative changes in the AC joint. The Board finds the July 2003 VA examination and October 2003 x-ray report provide credible evidence of continuity of symptomatology shortly after service. The Board also finds the Veteran's consistent reports of left shoulder pain since service to both VA adjudicators and various medical professionals to be both competent and credible. During his July 2003 VA examination, the Veteran reported that he experienced no acute shoulder injury during service, but associated his shoulder pain to repetitive physical exercising over his 21 years of service. In his August 2008 Notice of Disagreement, he reiterated the same contentions. In February 2012, the Veteran testified at a Decision Review Officer (DRO) hearing. He reported that his left shoulder began hurting approximately 12 years prior. The Veteran appeared before the undersigned at a September 2015 Travel Board hearing. During his hearing, he testified that he believed his shoulder disability was due to his daily fitness regimen in the Air Force. The Veteran also explained the gap in his treatment records, explaining that he stopped seeing doctors for his shoulder pain because he was told there were no treatment options other than shoulder surgery, and he was not ready to have surgery. The Board considered the negative nexus opinion provided by a VA examiner in December 2014. The examiner noted the Veteran had AC joint degenerative joint disease bilaterally. The examiner opined it was less likely than not that the Veteran's currently diagnosed left shoulder disability was etiologically related to his active duty service because there was no documentation to support his history of continuous symptoms until October 2003. The examiner reasoned that there was no documentation to support any relationship between the acute symptoms diagnosed in October 2003 and his active duty service. The Board finds this opinion to be inadequate as it relies exclusively on the lack of medical documentation in the Veteran's records. Further, the examiner noted the Veteran was treated for acute left shoulder pain, but discounted his credible lay statements and did not discuss the degenerative changes found on the October 2003 x-rays, a year and 6 months following his separation from active duty service. As such, the Board does not find this exam to be of probative evidentiary value. In summary, the Board finds the medical evidence showing degenerative changes of his left shoulder in October 2003, coupled with his competent and credible assertions of continuity of left shoulder symptomatology since service, provide probative evidence that his left shoulder disability is etiologically related to his active duty service. Resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for presumptive service connection for a left shoulder disability under 38 C.F.R. § 3.303(b) have been met. Cervical Spine Disability The Veteran claims that his cervical spine disability is related to his physically demanding job as a medic during active duty service. Alternatively, he claims his neck disability is secondary to his service-connected right shoulder. After a thorough review of the record, the Board finds that the Veteran's current cervical spine disability is not etiologically related to his active duty service. Service treatment records are silent for any complaints of or treatment for a cervical spine disability. Similarly, the Veteran's private and VA medical records do not contain any complaints of cervical spine pain until May 2011. A May 2011 MRI of the Veteran's cervical spine showed a very mild broad based bulge at his C3-4 vertebra, a mild broad based disc bulge at his C4-5 vertebra and mild left-sided bony foraminal narrowing, an annular tear and focal protrusion with a right-sided component causing some right ventral cord remolding without myelopathic lesion at his C5-6 vertebra, with both left and right neural foramina showing severe narrowing, and an annualr tear and focal central protrusion touching the ventral cord on the right side without remolding at his C6-7 vertebra. His nerve root sleeves were widely patent. None of the Veteran's private or VA physicians has provided a nexus statement linking his cervical spine disability to his active duty service. Initially, the Board notes that the Veteran was not diagnosed with degenerative arthritis of the spine until 2011. See May 2011 MRI report and December 2014 VA examination. Therefore, the record does not reflect that the Veteran was diagnosed with arthritis of the cervical spine to a compensable degree within one year of separation from active duty. There is also no evidence showing manifestations of arthritis during or within the first year after service. Thus, the presumptive service connection provision of 38 C.F.R. §§ 3.307(a)(3) and 3.309(a) for chronic disabilities are not applicable. In December 2014, the Veteran was afforded a VA examination to determine the etiology of his cervical spine disability. He reported experiencing neck pain and numbness that radiated to the right medial scapula area beginning in the early 1990s. He also reported neck stiffness and headaches. He also reported experiencing chronic neck pain that subsided somewhat in 2000, but continued to have stiffness. The examiner noted the Veteran had a current diagnosis of cervical spine degenerative arthritis. The examiner opined it was less likely than not that the Veteran's currently diagnosed cervical spine disability was etiologically related to his active duty service because there were no reports of a neck disability during active duty, and the Veteran was not diagnosed with degenerative arthritis until 2011. As such, there was no way to provide a relationship between the Veteran's current cervical spine disability and any event or injury during active duty. The examiner also provided an opinion as to whether the Veteran's cervical spine condition was secondary to his service-connected right shoulder disability. The examiner opined it was less likely than not that the Veteran's cervical spine disability was secondary to his right shoulder disability because a rotator cuff strain and a cervical disc bulge were two separate disease entities and there was no connection between the two disabilities and one did not cause or aggravate the other. The Board finds the VA examiner's opinion to be probative medical evidence because, after a full review of the record, the examiner concluded there was no objective evidence to show the Veteran's cervical spine disability, diagnosed nine years after separation from active duty, was either directly related to his active duty service or secondary to his right shoulder disability. During his September 2015 Board hearing, the Veteran testified that running while on active duty, along with lifting patients while a medic, caused his cervical spine disability. While the Board recognizes the Veteran's assertions that his disability is related to service and is competent to testify as to events that occurred in military service, the Veteran is not competent to conclude that any condition he has now is connected to his service. Although the Veteran is competent to provide opinions on some medical issues, based on his medic training, the specific disabilities in this case, musculoskeletal issues, fall outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although the Board recognizes that the Veteran served as a medic, and received some level of medical training, he has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or competent opinion as to medical causation for a musculoskeletal disorder. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating orthopedic disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). There are many different possible musculoskeletal issues, and a person without the requisite expertise is not competent to diagnose among them or to provide an etiology. Therefore, the Board finds that the Veteran's statements of record cannot be accepted as competent evidence sufficient to establish service connection for his disability. The elements for service connection for a cervical spine disability have not been met. Accordingly, service connection for the claimed disability is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against this claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53. III. Increased Ratings Thoracolumbar Spine Disability The Veteran's thoracolumbar spine disability is rated 20 percent disabling under Diagnostic Code 5242. The Veteran was afforded a VA examination to evaluate the severity of his service-connected thoracolumbar spine disability in February 2007. Physical examination revealed no evidence of radiating pain, no muscle spasm, and no tenderness to palpation. The Veteran had flexion to 90 degrees, extension to 20 degrees, left and right lateral flexion to 30 degrees, and left and right rotation to 30 degrees. The examiner also found the Veteran's joint function was not additionally limited by pain, weakness, lack of endurance, or incoordination after repetitive use and he had normal spine curvature. In June 2010, the Veteran was afforded another VA examination for his thoracolumbar spine disability. Again, physical examination revealed no evidence of radiating pain on movement. There was evidence of muscle spasm not producing abnormal gait. There was no evidence of guarding, weakness, atrophy, or ankylosis. The examiner found tenderness in the low back but the Veteran's spinal contour was normal and his muscle tone was preserved. Range of motion testing revealed the Veteran had flexion to 80 degrees, extension to 25 degrees, left and right lateral flexion to 25 degrees, and left and right rotation to 25 degrees. There was evidence of pain throughout range of motion testing, but no further limitation of motion noted after repetitive use testing. The Veteran was afforded a third VA examination to evaluate his thoracolumbar spine disability in March 2012. Physical examination showed the Veteran had flexion to 50 degrees with pain at 50 degrees, extension to 15 degrees with pain at 15 degrees, right lateral flexion to 15 degrees with pain at 15 degrees, left lateral flexion to 20 degrees with pain at 20 degrees, and left and right rotation to 25 degrees with pain at 25 degrees. There was no evidence of further limitation of motion after repetitive use testing. The Veteran had functional loss due to less movement than normal, pain, disturbance of locomotion, interference with sitting, standing, and weight bearing. The examiner found evidence of guarding or muscle spasm resulting in abnormal gait, and decreased sensation in the Veteran's left thigh, but all other neurological testing was normal. A July 2015 MRI of the Veteran's thoracolumbar spine showed moderate to severe lower lumbar disc degeneration with disc osteophyte complexes contributing to lateral recess narrowing, most pronounced on the left at the L4-5 vertebra with suspected low-grade impingement of the transisting left L5 nerve roots. There was no evidence of severe central stenosis. The MRI also showed moderate lower lumbar facet hypertrophy with grade one degenerative restolisthesis on L3 and L4, several levels of trace facet effusions and foraminal stenosis most pronounced on the left at L5-S1 with flattening of the exiting left L5 nerve root. The Veteran was afforded a final VA examination for his thoracolumbar spine in April 2016. He had forward flexion to 85 degrees, extension to 20 degrees, right and left lateral flexion to 30 degrees, and left and right rotation to 30 degrees. Repetitive motion testing revealed no further limitation. There was no evidence of pain with weight bearing, but there was evidence of tenderness or pain on palpation along the lumbar spine and paraspinal muscles. There was evidence of muscle spasm and localized tenderness not resulting in abnormal gait or abnormal spinal contour, and there was no evidence of guarding. There was no ankylosis. The Veteran had Intervertebral Disc Syndrome, but his symptoms did not require bed rest prescribed by a physician within the last 12 months. VA treatment records from January 2017 noted the Veteran's thoracolumbar flexion was limited 50% (45 degrees), extension was limited 50% (15 degrees), left and right lateral flexion was limited 25% (approximately 22 degrees), and left and right rotation was limited 25% (approximately 22 degrees). The Veteran continued to seek both private and VA treatment for his thoracolumbar spine disability. However, none of those records provide the results of range of motion testing. At no point during the period on appeal has the Veteran's thoracolumbar spine disability manifested as forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine to warrant a higher, 40 percent, rating. In considering these rating criteria, the Board has considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, an increased evaluation for the Veteran's service-connected thoracolumbar spine disability is not warranted on the basis of functional loss due to pain for the period on appeal. The Veteran's symptoms are contemplated by the 20 percent rating assigned. Although the March 2012 VA examiner found flexion and extension of the Veteran's thoracolumbar spine produced pain, he had flexion to 50 degrees with pain at 50 degrees. Further, the April 2016 VA examiner found no evidence of pain with weight bearing. Regarding the possibility of a higher rating due to intervertebral disc syndrome rated under Diagnostic Code 5243, the Veteran's record does not indicate he was ever prescribed bed rest by a physician. Although the April 2016 VA examination noted the Veteran had intervertebral disc syndrome, the record contains no evidence that the Veteran experienced incapacitating episodes. The Board notes that VA examinations and both VA and private medical records noted the Veteran had decreased sensation and radicular symptoms of his left lower extremity. However, as is discussed further below, the Veteran is already in receipt of a separate compensable rating for radiculopathy of his left leg. The Veteran's lay statements and testimony have been considered in this decision. However, it is the objective findings of his disability upon which ratings are based. Thus, entitlement to an increased rating greater than 20 percent for a thoracolumbar spine disability is not warranted. As the preponderance of the evidence is against assignment of any higher rating, the benefit-of-the doubt doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53-56. Right and Left Knee Disabilities The Veteran's left knee disability is rated as 10 percent disabling under Diagnostic Codes 5003-5024; his right knee disability is rated 10 percent disabling under Diagnostic Codes 5099-5024. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27 (2016). Diagnostic Code 5024 addresses tenosynovitis, which is to be rated as limitation of motion of affected parts as arthritis, degenerative. See 38 C.F.R. § 4.71a, Diagnostic Code 5024 (2016). After a full review of the record, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for either his left or his right knee disability. The Veteran was afforded a VA examination to determine the severity of his knee disabilities in March 2012. Range of motion testing for his right knee indicated he had flexion to 95 degrees with pain at 95, and extension to 5 degrees with no objective signs of pain. His left knee had flexion to 105 degrees with painful motion at 105, and extension to 5 degrees with painful motion at 5. He did not experience any additional functional loss or additional limitation in range of motion after repetitive use testing. Both knees had pain on palpation, but normal muscle strength and no evidence of instability, subluxation, dislocation, or meniscus tears. In April 2016, the Veteran was afforded another VA examination to evaluate his knee disabilities. The Veteran reported feeling limited with squatting and kneeling. Range of motion testing revealed he had normal range of motion bilaterally with no objective evidence of pain and no pain with weight bearing. The Veteran's right knee showed tenderness on palpation below the patella, and his left knee showed tenderness on palpation along the medial side of the joint. Both knees had the same range of motion after repetitive use testing. Muscle strength testing was normal. Physical examination revealed no evidence of ankylosis, instability, subluxation, or meniscus tears. VA treatment records indicate the Veteran continued to complain of and receive treatment for his knee disabilities. However, none of these medical records contain the results of range of motion testing. In 2017, he underwent physical therapy in an attempt to improve his knee pain, but none of his physical therapy records indicate the Veteran had any evidence of instability, locking, popping, or other symptoms that would show his knee disabilities were worse than was reported on his VA examinations. In November 2016, the Veteran was diagnosed with a small tendon injury in his left knee and issued a knee brace. A VA treatment record dated March 2016 noted the Veteran's left knee had active range of motion to 120 degrees. A later March 2017 VA treatment record noted the Veteran's active and passive range of motion for the left knee were within normal limits with no effusion. During his September 2015 Board hearing, the Veteran testified that his knees constantly felt stiff, and that he had crepitus, buckling, and pain. In regard to limitation of motion, in order to warrant a schedular evaluation in excess of 10 percent for his knee disabilities under Diagnostic Codes 5260, there would need to be evidence of limitation of flexion to 45 degrees. The March 2012 VA examination showed his left and right knees had limitation of flexion to 105 degrees and 95 degrees, respectively. The April 2016 VA examination noted the Veteran had normal range of motion in both knees. In order to warrant a schedular evaluation in excess of 10 percent under Diagnostic Code 5261, there must be evidence of limitation of extension to 10 degrees. The March 2012 VA examination showed the Veteran had extension to 5 degrees, with evidence of pain on his left knee. The April 2016 VA examination indicated both Veteran's knees had full range of extension. He is currently rated for limitation of flexion, and, although he could get separate ratings under Diagnostic Code 5261 for limitation of extension, he has never shown limitations to 10 degrees, which is what is needed for a separate, compensable evaluation. Thus, any evaluation greater than 10 percent is not warranted under Diagnostic Codes 5260 or 5261. In addition, as flexion and extension of the knees have not been shown to have been limited to 30 and 10 degrees even with consideration of painful motion, separate ratings for limitation of flexion and extension of the knees are not warranted. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261, respectively; VAOPGCPREC 9-2004 (Sept. 17, 2004). The Board further finds that there is no basis for the assignment of ratings in excess of those upheld or awarded herein based on consideration of any of the factors addressed in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, 8 Vet. App. at 204-7. The Court has recently held, however, that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. During his September 2015 Board hearing, he reported he could not run or climb ladders, but did not require the use of an assistive device to ambulate. The Board notes that the Veteran did not report any episodes of locking, and there was no objective evidence of ankylosis. Therefore, Diagnostic Code 5256 is not applicable. Id. Nor have there been any medical findings of dislocation or removal of the semilunar cartilage of the right knee, impairment of the tibia or fibula, or genu recurvatum. In the absence of such findings, evaluating the Veteran's knees under Diagnostic Codes 5258, 5262, or 5263 is not appropriate. Furthermore, the Board has considered the rating criteria under DC 5257, which provides ratings for recurrent subluxation or lateral instability of the knee. The Board acknowledges the Veteran's reports of instability or buckling. However, the Board considers the determination as to the existence and severity of knee recurrent subluxation or lateral instability beyond its own competence to evaluate based upon its own knowledge and expertise. It follows that the Veteran's lay reports of instability of the knees are also not competent evidence, although the Veteran's observed symptoms may be useful to an expert in evaluating the Veteran's condition. See Jandreau v. Nicholson, 492 F.3d 1372 (2007); Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). The medical professionals in this case have the requisite medical expertise to render significantly probative opinions as to the existence of recurrent subluxation and lateral instability of the knees. The March 2012 VA examination, April 2016 VA examination, and VA treatment records show no objective evidence of instability or subluxation. Thus, the Board concludes that a separate rating under Diagnostic Code 5257 is not applicable. 38 C.F.R. § 4.71a; see generally VAOPGCPREC 23-97. In sum, the Board finds the criteria for an increased rating greater than 10 percent for either his left or right knee disability for the entire period on appeal have not been met. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against these claims, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53. Right Shoulder Disability The Veteran's service-connected right shoulder disability is currently rated as 10 percent disabling prior to June 11, 2010 and 20 percent thereafter under Diagnostic Code 5201. The Veteran is right handed. Prior to June 11, 2010 The Veteran was afforded a VA examination in February 2007 to determine the severity of his right shoulder disability. He reported localized pain occurring approximately once a week that lasted up to two hours. He also reported the pain was elicited by physical activity, especially throwing a football, and was relieved by rest. The examiner noted his shoulder showed signs of crepitus. Range of motion testing revealed he had normal range of motion for flexion, abduction, external rotation, and internal rotation. His joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination. The medical evidence of record does not demonstrate that, prior to June 11, 2010, the Veteran was unable to raise his arm above shoulder level to warrant a higher, 20 percent rating. As such, entitlement to an increased rating greater than 10 percent for the Veteran's right shoulder disability prior to June 11, 2010, is not warranted. In considering these rating criteria, the Board has considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). While the provisions of 38 C.F.R. § 4.59 establish that the Veteran is entitled to a minimum compensable evaluation for painful motion without demonstration of additional functional loss, a 10 percent rating is already assigned here. Although the Veteran reported experiencing occasional localized pain, he had full range of motion without evidence of painful motion on the February 2007 VA examination. Thus, an increased evaluation for the Veteran's service-connected right shoulder disability is not warranted on the basis of functional loss due to pain or weakness in this case. Accordingly, an increased rating greater than 10 percent for a right shoulder disability prior to June 11, 2010, is not warranted. As the preponderance of the evidence is against assignment of any higher rating, the benefit-of-the doubt doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53-56. June 11, 2010 through November 9, 2016 On June 11, 2010, the Veteran was afforded a VA examination for his right shoulder. He reported weakness, stiffness, lack of endurance, fatigability, tenderness, and pain. He reported flare ups approximately once a week caused by physical activity and sleeping on his right side. Range of motion testing revealed normal range of motion for flexion, abduction, external rotation, and internal rotation, but there was pain throughout. Range of motion after repetitive use testing showed decreased range of motion with flexion to 170 degrees, and normal range of motion for abduction, external rotation, and internal rotation. Physical examination revealed tenderness and guarding of movement, but no evidence of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, malalignment, draining, or subluxation. The Veteran was afforded another VA examination for his right shoulder in March 2012. Range of motion testing revealed flexion to 160 degrees with pain at 160, and abduction to 175 degrees with pain at 175. There was no additional loss of motion or functional loss due to pain after repetitive use testing. The examiner noted the Veteran's right shoulder showed atrophy of disuse with his right bicep measuring three centimeters less than his left, and reduced muscle strength on shoulder flexion and abduction. In December 2014, the Veteran was afforded a VA examination for his left shoulder, but physical examination of his right shoulder was also conducted. The Veteran's range of motion at the time for his right shoulder was flexion to 130 degrees, abduction to 110 degrees, external rotation to 80 degrees, and internal rotation to 90 degrees. He had a decreased ability to reach overhead, but no evidence of pain with weight bearing or localized tenderness or pain with palpation to the shoulder. There was no additional functional loss after repetitive use testing and he did not report experiencing flare ups. During his September 2015 Board hearing, he demonstrated that he could raise his arm to shoulder level, but complained of pain. There is no evidence to suggest that between June 11, 2010 and November 9, 2016, the Veteran experienced range of motion limited to midway between his side and shoulder level. As such, a rating in excess of 20 percent for the Veteran's right shoulder disability is not warranted. In considering these rating criteria, the Board has considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). While the provisions of 38 C.F.R. § 4.59 establish that the Veteran is entitled to a minimum compensable evaluation for painful motion without demonstration of additional functional loss, a 20 percent rating is already assigned here. Evaluations in excess of the minimum compensable rating must be based on demonstrated functional impairment approximating the rating criteria. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. Thus, an increased evaluation for the Veteran's service-connected right shoulder disability is not warranted on the basis of functional loss due to pain or weakness in this case. Accordingly, a rating in excess of 20 percent for a right shoulder disability from June 11, 2010 to November 9, 2016, is not warranted. As the preponderance of the evidence is against assignment of any higher rating, the benefit-of-the doubt doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53-56. Effective November 9, 2016 On November 9, 2016, the Veteran was afforded a VA examination for his right shoulder disability. Range of motion testing revealed he had flexion to 95 degrees, abduction to 70 degrees, external rotation to 65 degrees, and internal rotation to 80 degrees with pain throughout. There was no additional functional loss after repetitive use testing. The examiner found that the range of motion itself did not contribute to functional loss and there was no reduction in muscle strength, no muscle atrophy, and no ankylosis. The Veteran was afforded a final VA examination for his right shoulder in May 2017. His range of motion at the time was flexion to 75 degrees, abduction to 30 degrees, external rotation to 90 degrees, and internal rotation to 30 degrees. Pain noted on the examination caused functional loss and there was evidence of pain with weight bearing. However there was no evidence of ankylosis. Upon review of the record, affording the Veteran reasonable doubt, the Board finds that a 30 percent rating, but no higher, is warranted for the Veteran's right shoulder disability since November 9, 2016. The November 2016 VA examination found right shoulder range of motion to be forward flexion to 95 degrees and abduction to 70 degrees. Although the Veteran did not meet the criteria for a 30 percent rating for limitation of motion midway between side and shoulder level on the November 2016 VA examination for limitation of flexion, the Veteran's abduction was to 70 degrees, quite a significant decrease from prior examinations. Affording the Veteran reasonable doubt, the Board finds a higher rating under Diagnostic Code 5201 is warranted. Further, the Veteran's range of motion for flexion and abduction were 75 degrees and 30 degrees, respectively, on the May 2017 VA examination. The Board finds an evaluation in excess of 30 percent is not warranted for the rating period since November 9, 2016. As noted above, the Veteran is right handed and under Diagnostic Code 5201, a 40 percent disability rating is warranted for the major arm when the Veteran is unable to raise the arm beyond 25 degrees. The medical evidence reflects that at no point was the Veteran's right shoulder limited to 25 degrees of flexion or abduction. The medical evidence reflects that, at worst, the Veteran's range of motion was limited to 75 degrees with pain of flexion and abduction to 30 degrees with pain. As such, a 40 percent rating is not warranted for this period under Diagnostic Code 5201. In considering these rating criteria, the Board has considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, an increased evaluation for the Veteran's service-connected right shoulder disability is not warranted on the basis of functional loss due to pain or weakness in this case. The Veteran's symptoms are contemplated by the 30 percent rating assigned herein. Radiculopathy, Left Lower Extremity The Veteran's radiculopathy, left lower extremity is rated as 10 percent disabling under Diagnostic Code 8520. The Veteran was afforded a VA examination for his radiculopathy, left lower extremity in June 2010. He reported pain, numbness, and weakness of the leg, but did not have paresthesia. Neurological examination showed the Veteran had sensory deficit of the left lateral thigh and left lateral leg. The examiner diagnosed him with radiculopathy, left lower extremity with sciatic nerve as the most likely involved peripheral nerve. In March 2012, the Veteran was afforded a VA examination for his thoracolumbar spine. Neurological testing showed decreased sensation in his left thigh, but all other neurological testing was normal. He had a positive straight leg raise test on the left leg and reported mild constant pain to his left lower extremity, moderate intermittent pain, moderate paresthesia, and mild numbness. The examiner diagnosed him with mild left side sciatic nerve involvement. The Veteran was afforded a final VA examination for his thoracolumbar spine and radiculopathy, left lower extremity in April 2016. Neurological examination showed hypoactive deep tendon reflexes in his left leg, decreased left thigh, knee, lower leg, ankle, foot, and toe sensation. He had a negative straight leg raise and reported no constant pain, mild intermittent pain, mild paresthesia, and mild numbness. He was diagnosed with mild radiculopathy, left lower extremity. VA treatment records indicate that in July 2015, the Veteran had symmetric decreased lower extremity deep tendon reflexes. A VA treatment record dated September 2016 noted the Veteran complained of increasing radicular symptoms, describing the pain as an "electric shock" to his left leg when shifting pedals while driving. In January 2017, he reported increased left lower extremity tingling. During his September 2015 Board hearing, the Veteran testified that most of his left leg felt numb and sitting for long periods caused pain. He also reported having no reflexes in his left leg and a related loss of function and muscle tone. After a complete review of the medical records, the Board finds the Veteran's radiculopathy, left lower extremity, manifests as mild incomplete paralysis of the sciatic nerve. The overwhelming medical evidence indicates the Veteran experienced only mild pain, numbness, and tingling. There is no evidence the Veteran experienced involvement of any nerve other than his sciatic nerve. As such, a rating under a different diagnostic code is not warranted. The Board finds that the April 2016 VA examination is the most probative evidence of record as it best represents the Veteran's disability picture. That examination established that the Veteran's radiculopathy, left lower extremity, was best characterized as mild partial paralysis of the sciatic nerve. Although the March 2012 VA examination noted he had moderate intermittent pain and paresthesia, the Veteran's constant pain was reported as mild. Further, the VA examiners in March 2012 and April 2016 classified his radiculopathy as mild. A higher, 20 percent rating, is not warranted unless the radiculopathy manifests as moderate incomplete paralysis of the sciatic nerve. There is no evidence in the record to indicate the Veteran has moderate partial paralysis. As such, entitlement to a rating in excess of 10 percent for radiculopathy, lower left extremity, is not warranted. As the preponderance of the evidence is against assignment of any higher rating, the benefit-of-the doubt doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53-56. ORDER New and material evidence having been submitted, the claim for service connection for a left shoulder disability is reopened. Entitlement to service connection for a left shoulder disability is granted. Entitlement to service connection for a cervical spine disability is denied. Entitlement to an increased rating greater than 20 percent for a thoracolumbar spine disability is denied. Entitlement to an increased rating greater than 10 percent for a right knee disability is denied. ORDER (Continued) Entitlement to an increased rating greater than 10 percent for a left knee disability is denied. Entitlement to an increased rating greater than 10 percent for a right shoulder disability prior to June 11, 2010, is denied. Entitlement to an increased rating greater than 20 percent for a right shoulder disability from June 11, 2010 through November 9, 2016, is denied. Entitlement to a rating of 30 percent for a right shoulder disability, but no greater, effective November 9, 2016, is granted, subject to the laws and regulations governing monetary awards. Entitlement to an increased rating greater than 10 percent for radiculopathy, left lower extremity, is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs