Citation Nr: 1800996 Decision Date: 01/09/18 Archive Date: 01/19/18 DOCKET NO. 12-30 956 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an increased rating for patellofemoral pain syndrome of the left knee with degenerative joint disease (hereinafter, "left knee disability"), currently evaluated at 10 percent disabling. 2. Entitlement to an increased rating for the residuals of a fracture of the right clavicle with degenerative joint disease (hereinafter, "right shoulder disability"), currently evaluated at 10 percent disabling. 3. Entitlement to an increased rating for hemorrhoids, currently evaluated as non-compensable. REPRESENTATION Appellant represented by: Ryan A. Spencer, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD RLBJ, Associate Counsel INTRODUCTION The Veteran served honorably in the United States Army from December 1977 to December 1997. These issues arrive before the Board of Veterans' Appeals (Board) on appeal of a February 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. During the pending of the appeal, the Veteran moved and the Winston-Salem, North Carolina RO, is currently the agency of original jurisdiction (AOJ) of this appeal. In August 2017, the Veteran appeared at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the Veteran's hearing testimony is located in the Veterans Benefit Management System (VBMS). The Veteran's entire claims file is found on the VBMS and/or Legacy Content Manager (LCM) databases. The record reflects that the AOJ issued a recent rating decision in August 2017 that denied several additional claims. The Veteran submitted a timely notice of disagreement of this decision in October 2017. While the AOJ has not yet issued a statement of the case addressing these issues, the record reflects that the AOJ has acknowledged the notice of disagreement. Accordingly, the Board will not take jurisdiction over this issue at this time. FINDINGS OF FACT 1. Prior to August 7, 2017, the Veteran's left knee disability was not manifested by recurrent subluxation or lateral instability. 2. On and after August 7, 2017, the Veteran's left knee displayed severe lateral instability. 3. For the appeal period prior to October 17, 2017, the Veteran's left knee disability symptoms have been manifested by painful motion of a major joint group with limitation of flexion greater than 45 degrees and limitation of extension less than 5 degrees. 4. On and after October 17, 2017, the Veteran's left knee was limited to -16 degrees of extension. 5. On and after October 17, 2017, the Veteran's left knee was limited to 25 degrees of flexion. 6. For the appeal period prior to August 7, 2017, the Veteran's right shoulder disability symptoms have been manifested by painful motion of a major joint group; limitation of motion of the right shoulder to midway between side and shoulder level is not shown. 7. From August 7, 2017 onward, the Veteran's right shoulder disability displayed unfavorable ankylosis of his dominant arm; abduction of the right arm is limited to 25 degrees from his side. 8. From August 2008 thru October 2017, the Veteran's service-connected hemorrhoids was manifest as mild or moderate in severity. 9. On and after October 17, 2017, the severity of the Veteran's service-connected hemorrhoid symptoms have been manifested as large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. CONCLUSIONS OF LAW 1. Prior to August 7, 2017, the criteria for a separate disability rating for lateral instability or subluxation of the left knee are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5257 (2017). 2. On August 7, 2017, the criteria for a separate disability rating of 30 percent for lateral instability of the left knee were met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2017). 3. Prior to October 17, 2017, the criteria for a rating in excess of 10 percent for patellofemoral pain syndrome of the left knee with degenerative joint disease are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261 (2017). 4. On October 17, 2017, the criteria for a separate disability rating of 20 percent for extension limitation of the left knee were met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261 (2017). 5. On October 17, 2017, the criteria for a separate disability rating of 20 percent for flexion limitation of the left knee were met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2017). 6. Prior to August 7, 2017, the criteria for a rating in excess of 10 percent for a right shoulder disability were not met. 38 U.S.C.A. §§ 1155, 5110 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.344, 4.3, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5200 (2017). 7. On August 7, 2017, the criteria for a separate disability rating of 50 percent for a right shoulder disability were met. 38 U.S.C.A. §§ 1155, 5110 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.344, 4.3, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5200 (2017). 8. Prior to October 17, 2017, the criteria for compensable rating for service-connected hemorrhoids were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.14, 4.114, Diagnostic Code 7336 (2017). 9. On October 17, 2017, the criteria for a 10 percent schedular rating for service-connected hemorrhoids were met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.14, 4.114, Diagnostic Code 7336 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VCAA Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a)(2016). The VCAA required notice provisions were accomplished by a September 2008 letter, which informed the Veteran of the information and evidence not of record that is necessary to substantiate the claim, the information and evidence that the VA will seek to provide, and the information and evidence the Veteran is expected to provide. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). The letter also informed the Veteran how disability ratings and effective dates are established. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Pertinent to the VA's duty to assist, the record also reflects that the VA has undertaken appropriate actions to obtain all relevant evidence material to these claims. The AOJ has secured the Veteran's service treatment records (STRs), government treatment records, and all identified and available private treatment records. For his part, the Veteran has submitted personal statements, and arguments from his representative. For the issues found on the title page, the Veteran was afforded VA examinations near the outset and middle of the claim period, October 2008 and February 2012. The Board finds that these VA examinations (and the reports provided) are thorough, supported by a clear rationale, based on a review of the claims folder, and supported by the clinical evidence of record. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also 38 U.S.C.A. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4). Additionally, these VA examiners considered the Veteran's lay assertions in reaching their conclusion. Additionally, in August 2017, the Veteran submitted several disability benefits questionnaires (DBQs) containing more recent clinical findings pertaining to the issues on appeal. The foregoing examination report, along with other evidence of record, is sufficient to rate the issues on appeal under the appropriate rating criteria. For the increased rating issues on appeal, neither the Veteran, nor his representative, has advanced any procedural arguments in relation to VA's duties to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015) (holding that "absent extraordinary circumstances . . . we think it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran . . ."). Ultimately, the Board concludes that the VA has fulfilled its duty to assist the Veteran in this case. There is no error or issue that precludes the Board from addressing the merits of this appeal. Lastly, the Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). II. General Considerations for an Increased Rating Claim Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. § 4.1 (2017). The Rating Schedule is primarily a guide in the evaluation of disabilities resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. Separate Diagnostic Codes (DCs) identify the various disabilities and each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.10. As such, each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. When there is a question as to which evaluation should be applied to a Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where, as here, entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. As such, instances in which a veteran is seeking an increased rating from a previously adjudicated rating, the relevant focus for adjudicating the claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). In the instant appeal, the Veteran sought an increased rating for the disabilities found on the title page on August 8, 2008. See Veteran's Statement in Support of Claim. Thus, the relevant temporal focus for the disabilities in question dates back to August 2007. Moreover, the Board acknowledges that a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. Hart, 21 Vet. App. at 509-10; Fenderson v. West, 12 Vet. App. 119, 126 (1999). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran's lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev'd on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). In reaching the decisions contained herein, the Board has considered all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. Id. III. Left Knee Disability In his August 2008 Statement in Support of Claim, the Veteran requests an increased rating for his left knee disability because of continued pain and discomfort. The AOJ originally granted service connection for the left knee disability in April 1998, assigning a 10 percent rating based on painful motion. A. Applicable Regulations and Case Law Because he has experienced painful motion in his left knee, a minimum compensable rating, or 10 percent, has been warranted for the Veteran's left knee disability for the duration of the appeal period. See 38 C.F.R. § 4.59 ("It is the intention to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint"); see also Burton c. Shinseki, 25 Vet. App. 1, 4-5 (2011) (applying § 4.59 in non-arthritis contexts). The Board will now consider other knee-specific DCs to determine whether the Veteran's left knee disability symptoms warrant a rating beyond 10 percent. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran's left knee disability is rated under 38 C.F.R. § 4.71a. The Board will consider whether the Veteran can receive higher ratings for his left knee under all applicable diagnostic codes. Pursuant to Diagnostic Code (DC) 5010, traumatic arthritis, substantiated by X-ray findings, should be rated as degenerative arthritis. Degenerative arthritis established by X-ray findings is rated under DC 5003, which is rated based on the limitation of motion under the appropriate diagnostic code for the specific joint involved, or in this case, DC 5260 for limitation of leg flexion or DC 5261 for limitation of leg extension. Where there is X-ray evidence of arthritis and limitation of motion, but not to a compensable degree, a 10 percent rating is assigned for each major joint affected. 38 C.F.R. § 4.71, DC 5003. The knee is considered a major joint. 38C.F.R. § 4.45. Ratings for arthritis cannot be combined with ratings based on limitation of motion of the same joint. See 38 C.F.R. § 4.71a. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." See Dorland's Illustrated Medical Dictionary, 28th edition, p. 86. Under DC 5256, ankylosis of the knee in a favorable angle in full extension, or in slight flexion between 0 and 10 degrees warrants a 30 percent rating. Ankylosis of the knee in flexion between 10 and 20 degrees warrants a 40 percent rating. Ankylosis of the knee in flexion between 20 and 45 degrees warrants a 50 percent rating. Extremely unfavorable ankylosis of the knee, in flexion at an angle of 45 degrees or more warrants a 60 rating. See 38 C.F.R. § 4.71a. Under DC 5257, knee impairment with recurrent subluxation or lateral instability is rated 10 percent when slight, 20 percent when moderate, and a maximum 30 percent when severe. See 38 C.F.R. § 4.71a. Diagnostic Code 5258 provides for a 20 percent rating for history of dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. See 38 C.F.R. § 4.71a. Normal range of motion (ROM) of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a noncompensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and, a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. See 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, a noncompensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and, a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees. See 38 C.F.R. § 4.71a, DC 5261. The Veteran cannot receive ratings for his left knee disability under both DC 5258 and DC 5261 and/or 5260 without violating the rule against pyramiding. A precedential opinion of VA Office of General Counsel, which is binding on the Board, has determined that limitation of motion is a relevant consideration under DC 5259, which also addresses disability of semilunar cartilage. See VAOPGCPREC 9-98. By analogy, limitation of motion is also a consideration under DC 5258. Separate ratings under DC 5258 and DC 5260 and/or 5261 (the DCs which address limitation of flexion and extension of the leg) are therefore precluded due to the prohibition against pyramiding. 38 C.F.R. § 4.14. As noted previously, the Board also must consider pain, weakness, excess motion, incoordination, excess fatigability, and other functional limitation factors when determining the appropriate rating for a disability using the limitation of motion diagnostic codes. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). In addition, VA examiners should test involved joints for pain on both active and passive motion, in weight-bearing and non weight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158 (2016). B. Lay and Medical Evidence for Left Knee During an October 2008 VA examination, the provider noted 110 degrees of flexion, crepitus, and pain during McMurray's testing. The provider also noted pain during 60 to 100 degrees of left knee flexion. Additionally, the provider noted that 20 degrees of flexion was lost with repetition, which was due to pain. There was no joint effusion noted at this VA examination. The impression of the VA provider was the presence of degenerative arthritis in the left knee; however, x-rays were not performed to confirm the impression. Subsequent medical records in March 2009 show that the Veteran developed cartilaginous thinning involving the posterior aspect of the patella in the left knee. In February 2012, Dr. B. examined the Veteran's left knee disability. Dr. B. noted that the Varus and Valgus tests were negative. The Veteran did not have palpable effusion. After studying the Veteran's x-ray imaging, Dr. B. diagnosed retro patella arthritis for the left knee. During his August 2017 Board testimony, the Veteran commented extensively about specific symptoms arising from his left knee disability. The Veteran testified that, "when I'm walking, it don't bend." The Veteran testified that he endured weekly occurrences of his left knee "going out." The Veteran indicated that he did not experience flare ups because the pain was "pretty much constant." He indicated that a provider at an Arizona military installation suggested that he undergo left knee replacement in 2009. However, review of the medical evidence of record does not contain any recommendation that the Veteran undergo such procedure. In August 2017, Dr. R. examined the Veteran's left knee disability. Dr. R. noted severe lateral instability. Dr. R. noted moderate patellar dislocation and frequent episodes of the left knee "locking." Dr. R. noted that ankylosis of the left knee was present in 1985; however, she did not report ankylosis after conducting her examination. During the examination, the Veteran reported 10/10 for pain. Dr. R. reported that pain prevented any ROM testing of the Veteran's left knee. The Veteran reported regular use of a brace and cane. Dr. R. concluded that left knee function had not diminished to the point where amputation (with prosthesis) would equally serve the Veteran. In October 2017, Dr. S. examined the Veteran's left knee disability. At that time, the Veteran displayed 80 degrees of flexion and -11 degrees of extension; pain accompanied all movement. After repetitive testing, the Veteran displayed 58 degrees of flexion and -12 degrees of extension. Dr. S. noted that pain was present during weight-bearing and non weight-bearing. No joint effusion was palpable; but, crepitus was noted during motion. Dr. S. noted disturbance of locomotion, interference with sitting, and interference with standing. During flare-ups, Dr. S. noted that ROM was limited to 25 degrees flexion and -16 degrees extension. The Veteran's lateral stability was normal; Dr. S. reported that, "the ligaments of both knees are still tight and stable." The Veteran reported regular use of a brace at this examination. Dr. S. reported the presence of degenerative or traumatic arthritis in the left knee, and his report was based on imaging studies. C. Analysis for Left Knee Diagnostic Code 5256 During the relevant appeal window, the Veteran has undergone multiple knee examinations; none of the providers have identified or noted left knee immobility. In August 2017, Dr. R. did not perform ROM testing, because the Veteran displayed pain with all movement at the examination. Still, Dr. R. did not note immobility or ankylosis of the left knee. Two months later, in October, Dr. S conducted ROM testing. Despite pain with all movement, the report from Dr. S. contains detailed ROM findings. While detailing various ROM findings with both weight-bearing and non-weight bearing, Dr. S. added that the Veteran had ankylosis of the knee in flexion at 11 degrees. With respect to the findings that the Veteran has ankylosis of the left knee, the Board finds the conclusion to be outweighed by the remainder of the evidence. As identified by the ROM results above, the Veteran did not demonstrate the immobility of the left knee. See Dorland's Illustrated Medical Dictionary, 28th edition, p. 86. Ultimately, because the Veteran displayed some left knee ROM throughout the claim period, a disability rating for ankylosis is not warranted under DC 5256. Diagnostic Code 5257 During the applicable medical examinations (noted above), the Veteran maintained consistent reports of instability in his left knee. Also, the Veteran repeatedly reported left knee instability led to his use of a brace and/or cane. See, e.g., August 2017 Hearing Testimony. Despite the Veteran's consistent reports of instability, the Board must look to the medically competent examination reports on left knee stability. See Jandreau, 492 F.3d 1372. The October 2008 examination report does not provide evidence for a stability determination. While pain was observed with McMurray's testing, the Veteran had a negative Drawer's test and the collateral ligaments were noted to be without laxity. In February 2012, Dr. B. noted that the Varus and Valgus tests were negative. Moreover, Dr. B. noted that the collateral ligaments were stable with negative anterior or posterior drawers testing. Similarly, Lachmanns test was negative with no pivot shifting. In light of the foregoing, the Board concludes that entitlement to a separate disability evaluation based on lateral instability or subluxation of the left knee is not warranted for the period prior to August 7, 2017. Dr. R. was the first provider to note instability during the applicable claim period. In an August 7, 2017 examination report, Dr. R. noted severe lateral instability, 10-15 millimeters. The Board observes that Dr. S. noted in a subsequent October 2017 examination report that the Veteran ligaments of both knees were "still tight and stable." However, given the prior findings on August 7, 2017, and the Veteran's report of instability during his Board hearing, the Board will grant him the benefit of the doubt and award a separate 30 percent rating is warranted for the Veteran's left knee instability, effective August 7, 2017. Diagnostic Code 5258 After consideration of all the lay and medical evidence of record, the Board notes that the Veteran has repeatedly reported pain and "locking" episodes to providers, in statements, and during Board hearing testimony. Nevertheless, the Board concludes that a separated disability rating under DC 5258 is not warranted. The criteria under Diagnostic Code 5258 are conjunctive, not disjunctive; without joint effusion consideration of a separate evaluation under Diagnostic Code 5258 is not warranted. None of the competent medical providers identified or noted effusion into the left knee joint. On the contrary, the October 2008 VA examination report notes that there was no effusion. Similarly, in February 2012, Dr. B. observed that no effusion was palpable. Likewise, Dr. S. observed in August 2017, that there was currently no joint effusion palpable. Absent a medically competent report of left knee joint effusion, a higher or separate disability rating under DC 5258 is not warranted. See 38 C.F.R. § 4.71a. Diagnostic Codes 5260 and 5261 In October 2008, the VA provider noted 20 degrees of lost flexion with repetition; however, the Veteran had recorded range of flexion between 60 and 110 degrees even with consideration of this pain. As the Veteran's flexion was not limited to 30 percent or less, a higher evaluation under Diagnostic Code 5260 is not warranted based on this examination. In February 2012, Dr. B. identified the ROM limits as 0 and 120 degrees. These findings are consistent with noncompensable range of flexion and extension under DCs 5260 and 5261 as the flexion lower than 45 degrees or extension greater than 10 degrees is not shown. In August 2017, Dr. R did not perform ROM testing, because the Veteran was experiencing a great deal of pain with all left knee movement. However, Dr. R. did identify "less movement than normal" and "pain on movement." The October 2017 clinical measurements provided by Dr. S is the first competent evidence to support, separate compensable disability ratings under DCs 5260 (flexion) and 5261 (extension). See 38 C.F.R. § 4.71a. The Board notes that the VA General Counsel has held that separate ratings may be assigned under DC 5260 and DC 5261 for disability of the same joint. VAOPGCPREC 9-2004 (September 17, 2004). The Board also notes that ratings for arthritis cannot be combined with ratings based on limitation of motion of the same joint. See 38 C.F.R. § 4.71a. While exploring the functional loss during flare-ups of the Veteran's left knee disability, Dr. S. noted that ROM during flexion was limited to 25 degrees. Dr. S also noted that flare-ups resulted in an extension limit of -16 degrees. The Board concludes that, under both DCs 5260 and 5261, a separate 20 percent disability rating is warranted for these ROM measurements, effective date October 17, 2017. A rating greater than 20 percent based on limitation of flexion is not warranted as the record does not show limitation of flexion to 15 degrees or less as contemplated by a higher rating under Diagnostic Code 5260. Likewise, a rating greater than 20 percent based on limitation of extension is not warranted as the record does not show limitation of extension to 20 degrees or more as contemplated by a higher rating under Diagnostic Code 5261. IV. Extraschedular Consideration for Left Knee Disability The rating schedule represents, as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. See 38 C.F.R. § 3.321(a), (b) (2017). To afford justice in exceptional situations, an extraschedular rating can be provided. See 38 C.F.R. § 3.321(b). The Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted in Thun v. Peake, 22 Vet. App. 111 (2008). First, the AOJ or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the AOJ or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the C&P Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. The symptoms associated with the Veteran's left knee disability (lateral instability and limited ROM) are contemplated by the 30 and 20 percent ratings assigned under DCs 5257, 5260 and 5261. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms" is not required and referral for consideration of an extraschedular rating for left knee disability is not warranted. 38 C.F.R. § 3.321 (b)(1). For these reasons, referral for consideration of an extraschedular rating is not warranted for this left knee disability claim. V. Analysis for Right Clavicle The Veteran seeks an increased rating for his service-connected right shoulder disability, which is currently assigned a 10 percent rating under 38 C.F.R. § 4.71a, DC 5203. Diagnostic Code 5203 provides for (major or minor arm) impairment of clavicle or scapula with malunion at 10 percent, with nonunion without loose movement at 10 percent, with nonunion with loose movement at 20 percent, dislocation at 20 percent, or rate on impairment of function of contiguous joint. Id. In October 2008, the Veteran underwent a VA examination for his right shoulder disability. At that time the Veteran reported, "constant aching at clavicle. Able to lift no more than 20 lbs for a few minutes at a time." The VA provider noted a healed fracture of the clavicular shaft. The VA provider also noted normal glenohumeral alignment and degree of rotation. The VA provider concluded that, "there are mild degenerative changes of the glenohumeral joint." The impression of the VA provider, "right should healed clavicular fracture with degenerative arthritis." The October 2008 VA examination results for Veteran's right shoulder disability were as follows: there was no deformity. The active ROM included, 125 degrees flexion, 55 degrees of extension, 120 degrees abduction, 70 degrees internal rotation, 70 degrees external rotation. There was no crepitus, effusion or impingement. There was pain noted from 100 to 125 degrees of flexion. Pain was also present at 55 degrees extension and 120 degrees abduction. In February 2012, the Veteran underwent an examination for his right shoulder disability. Dr. B. noted that the Veteran did not display "frozen shoulder." Dr. B. diagnosed, "right clavicle fracture healed while misaligned." Dr. B. reported that impingement, rotator cuff, and instability tests were all negative. Using the results of a sonogram, Dr. B. did not find effusion. While viewing the x-ray results, Dr. B. noted, "beginning AC joint arthritis." Dr. B. identified the following ROM: 180 degrees of abduction, 80 degrees of inner rotation, and 80 degrees outer rotation ability. Dr. B. noted that, although these movements could be performed, they clearly caused the Veteran pain. There were no functional limitations or early fatigue noted after three repetitions. In August 2017, the Veteran submitted a Disability Benefits Questionnaire (DBQ) at the Board hearing before the undersigned VLJ. The DBQ examination of the Veteran's right shoulder disability was conducted by Dr. R. on August 7, 2017. Dr. R. reviewed the Veteran's claims file prior to completing the DBQ. In the Functional Impact section of the DBQ, Dr. R. notes that the Veteran could not lift the right arm without assistance. Dr. R. also noted that the Veteran's right hand grip strength is severely diminished. Importantly, Dr. R. noted that ROM testing could not be performed because the Veteran needed to use his left hand to lift and move the right shoulder. Dr. R. reported that the Veteran experiences severe pain with right shoulder motion in any direction, including flexion, abduction, external rotation, and internal rotation. Dr. R. noted that abnormal ROM contributed to functional loss. Although Dr. R. did not identify muscle atrophy for the Veteran's right shoulder disability, she did conclude that, "ROM is 0." Importantly, Dr. R. noted that the Veteran's right shoulder disability demonstrated, "ankylosis in abduction at 25 degrees or less from side (unfavorable ankylosis)." During the applicable claim period, the Veteran underwent three medically competent examinations for his right shoulder disability, as identified and explored above. In October 2008, the VA provider noted a healed fracture, with no deformity and normal glenohumeral alignment. In February 2012, Dr. B. noted a healed and misaligned fracture. In August 2017, Dr. R. reported, "malunion of clavicle or scapula." In other words, at no time during the claim period did the Veteran's right shoulder disability demonstrate nonunion with loose movement, which would be necessary for an increased, 20 percent rating under 38 C.F.R. § 4.71a, DC 5203. When rating limitation of motion of the arm, a distinction is made between major (dominant) and minor extremities. In this case, review of the record reveals the Veteran is right-hand dominant. See, e.g., August 2017 Board Hearing Transcript. Therefore, the Veteran's right shoulder disability affects the major extremity. Under 38 C.F.R. § 4.71a, DC 5200 (ankylosis of scapulohumeral articulation), the maximum, 50 percent disability rating is warranted when unfavorable ankylosis limits arm abduction (major) to 25 degrees from the side. The Board finds that the weight of the probative, competent, and credible evidence supports a conclusion that the Veteran's right shoulder disability has resulted in unfavorable ankylosis. Because abduction is limited to 25 degrees, the Veteran's dominant-arm disability warrants a separate 50 percent rating, effective August 7, 2017. The October 2008 VA examination noted 120 degrees of right should abduction; therefore, there was no evidence to support the minimum, 30 percent disability rating under award 38 C.F.R. § 4.71a, DC 5200 as ankylosis is not shown. . In February 2012, Dr. B. noted 180 degrees of abduction ability. Again, ankylosis is not shown. Accordingly, the criteria for a higher rating based on ankylosis is not met prior to August 7, 2017. Likewise, the evidence prior to August 7, 2017, including range of motion findings during the October 2008 and February 2012 examination, does not show limitation of motion of the arm at a level midway between the side and shoulder level as warranted by a higher evaluation under DC 5201. Ultimately, August 7, 2017 is the earliest point in the claim period were the Veteran demonstrates the criteria for a (50 percent) disability rating under 38 C.F.R. § 4.71a, DC 5200. At that examination, the Veteran displayed symptomatology with the functional equivalent of unfavorable ankylosis of the scapulohumeral articulation with abduction limited to 25 percent from the side. VI. Analysis for Hemorrhoids. The Veteran seeks an increased rating for his service-connected hemorrhoids. Currently, the Veteran maintains a 0 disability rating, which is assigned to mild or moderate hemorrhoids, pursuant to 38 C.F.R. § 4.114, DC 7336. A 10 percent rating is assigned for large or thrombotic, irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrences. A maximum 20 percent rating is assigned for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. See 38 C.F.R. § 4.114, DC 7336. In October 2008, the Veteran underwent a VA examination to determine the severity of his service-connected hemorrhoid disability. The VA provider identified three external hemorrhoids; they were not thrombotic. The VA provider noted a history of blood in with defecation multiple times a week. The VA provider did not identify anemia, fissures, or redundant tissue, which would be necessary for a compensable rating under 38 C.F.R. § 4.114, DC 7336. In February 2012, the Veteran underwent an examination, which was conducted by Dr. B. He diagnosed, "hemorrhoids I - II stage, ventral mucosa prolapse, normal anal folds, and normal rectal sigmoidoscopy." There were no additional notations that would support a compensation rating for the Veteran's service-connected hemorrhoid disability. In October 2017, the Veteran underwent an examination in Mittenaar, Germany. At that time, the provider did not find anemia or persistent bleeding. However, the provider did note that the Veteran's hemorrhoid symptoms included, " large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences." Based on a review of the Veteran's longitudinal medical records and examinations, the Board finds that the Veteran was not entitled to a compensable evaluation, under DC 7336, until October 17, 2017. Between August 2007 and October 2017, the Veteran's hemorrhoid symptoms warranted a non-compensable "mild" or "moderate" descriptor. See 38 C.F.R. § 4.114, DC 7336. The Board concludes that, after October 17, 2017, the Veteran's service-connected disability warrants a 10 percent rating under DC 7336 as the record shows symptoms consistent with large or thrombotic, irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrences. However, at no time during the appeal, have the Veteran's hemorrhoids been manifested by persistent bleeding and with secondary anemia, or with fissures as contemplated by a higher rating. See 38 C.F.R. § 4.114, DC 7336. VII. Extraschedular Consideration for Hemorrhoids The Board has additionally considered whether an extraschedular rating is warranted for the Veteran's hemorrhoids. As the Court has explained in Thun v. Peake, 22 Vet. App. 111, 115-116 (2008), a "determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b)(1) is a three-step inquiry." If the AOJ or Board determines that (1) the schedular evaluation does not contemplate the claimant's level of disability and symptomatology, and (2) the disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization, then (3) the case must be referred to an authorized official to determine whether, to accord justice, an extraschedular rating is warranted. Id; see also 38 C.F.R. § 3.321 (b)(1). Neither the AOJ nor the Board is permitted to assign an extraschedular rating in the first instance; rather, the matter must initially be referred to those officials who possess the delegated authority to assign such a rating. See Anderson v. Shinseki, 22 Vet. App. 423, 427-8 (2009); Floyd v. Brown, 9 Vet. App. 88, 96-97 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before the VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun, 22 Vet. App. 111. In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected hemorrhoids disability on appeal with the established criteria found in the rating schedule. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule. In that case, the assigned schedular evaluation is adequate and, therefore, no extra-schedular referral is required. Thun, 22 Vet. App. 111; VAOGCPREC 6-96 (Aug. 16, 1996). Here, the evidence does not show such an exceptional disability picture that the schedular 10 percent evaluation may be inadequate. The Veteran's hemorrhoid symptoms include the need to push them back into the anus after defecation. See August 2017 Hearing Transcript. Diagnostic Code 7336 specifically considers hemorrhoids with "excessive redundant tissue"; therefore, this symptom is considered within the diagnostic criteria. Ultimately, a comparison between the level of severity of the Veteran's 10 percent evaluation with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptoms for his service-connected hemorrhoids. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected hemorrhoid disability, under the provisions of 38 C.F.R. § 3.321 (b)(1), have not been met. VIII. TDIU Where a claimant, or the record, raises the question of unemployability due to the disability for which an increased rating is sought, then part of the increased rating claim is an implied claim for TDIU. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran does not contend, and the evidence does not show, that he is unemployable due to his service connected disabilities. Accordingly, a TDIU claim has not been raised and, therefore, no action pursuant to Rice is necessary. Id. ORDER Prior to August 7, 2017, a separate rating for recurrent subluxation or lateral instability of the left knee is denied. From August 7, 2017, a separate disability rating of 30 percent for lateral instability, is granted for the left knee disability. Prior to October 17, 2017, a rating in excess of 10 percent for patellofemoral pain syndrome of the left knee with degenerative joint disease is denied. From October 17, 2017, a disability rating of 20 percent for a flexion limitation, but no higher, is granted for the left knee disability. From October 17, 2017, a disability rating of 20 percent for an extension limitation, but no higher, is granted for the left knee disability. Prior to August 7, 2017, a rating in excess of 10 percent for residuals of a fracture of the right clavicle with degenerative joint disease is denied. From October 17, 2017, a disability rating of 50 percent, but no higher, is granted for the residuals of a fracture of the right clavicle. Prior to October 17, 2017, a compensable evaluation for hemorrhoids is denied. From October 17, 2017, a 10 percent disability rating but no greater, is granted for service-connected hemorrhoids. ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs