Citation Nr: 1805107 Decision Date: 01/25/18 Archive Date: 02/05/18 DOCKET NO. 14-04 360 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUES 1. Entitlement to compensation under 38 C.F.R. § 1151 for a low back disability resulting from an injury sustained in the course of training and rehabilitation services under 38 C.F.R. § 31. 2. Entitlement to compensation under 38 C.F.R. § 1151 for a nerve condition of the bilateral lower extremities resulting from an injury sustained in the course of training and rehabilitation services under 38 C.F.R. § 31. 3. Entitlement to service connection for a left knee disability. 4. Entitlement to a disability rating in excess of 20 percent for a right knee disability. 5. Entitlement to a disability rating in excess of 20 percent for residuals of a left clavicle fracture. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his fiancé ATTORNEY FOR THE BOARD David R. Seaton, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1974 to April 1976. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho. These matters were previously before the Board, and, in April 2016, the Board remanded this matter for further development. Further development in substantial compliance with the Board's remand instructions has been completed. FINDINGS OF FACT 1. The Veteran has a current back disorder which was caused by a learning activity while participating in VA vocational training. 2. The Veteran does not have a current diagnosis of radiculopathy or a peripheral nerve condition of the lower extremities and did not manifest a diagnosis during the pendency of the appeal. 3. A medical nexus has not been established between a current left knee disability and an in-service incurrence; a current left knee disorder did not manifest within one year of separation of service; continuity of symptomology since separation from service has not been established; and a current left knee disability is not proximately due to or aggravated by a previously service-connected disability. 4. The Veteran's right knee did not manifest in any of the following symptoms: ankylosis; severe recurrent subluxation or lateral instability; a cartilage condition; flexion functionally limited to 45 degrees or less; extension functionally limited to 10 degrees or more; a tibia or fibula impairment; or genu recurvatum. 5. The Veteran's right knee range of motion is painful with arthritis diagnosed. 6. The Veteran's left arm did not manifest in functional limitation of motion to 25 degrees from the side. CONCLUSIONS OF LAW 1. The criteria for compensation under 38 C.F.R. § 1151 for a low back disability resulting from an injury sustained in the course of training and rehabilitation services under 38 C.F.R. § 31 have been met. 38 U.S.C. § 1151 (2012); 38 C.F.R. § 358 (2017). 2. The criteria for compensation under 38 C.F.R. § 1151 for radiculopathy or a peripheral nerve condition of the bilateral lower extremities resulting from an injury sustained in the course of training and rehabilitation services under 38 C.F.R. § 31 have not been met. 38 U.S.C. § 1151 (2012); 38 C.F.R. § 358 (2017). 3. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.303, 3.309; 3.310 (2017). 4. The criteria for a disability rating in excess of 20 percent for right knee instability have not been met. 38 U.S.C. §1155 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5256-5263 (2017). 5. The criteria for a separate 10 percent rating for a right knee disability have been met. 38 U.S.C. §1155 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2017). 6. The criteria for a disability rating in excess of 20 percent for a left clavicle fracture have not been met. 38 U.S.C. §1155 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). In this case, required notice was provided, and neither the Veteran, nor his representative, has either alleged, or demonstrated, any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders, 129 U.S. 1696 (2009). Thus, adjudication of his claim at this time is warranted. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service treatment records, VA treatment records, Social Security Administration (SSA) records, and private treatment records have been obtained. Additionally, the Veteran testified at a personal hearing before the Board, and a transcript of the hearing is of record. Unfortunately, the judge who conducted that hearing is no longer with the Board. In November 2015, the Board sent the Veteran a letter informing him of this and asking him if he wished to attend another hearing before a Veterans Law Judge who would render a determination in his case. He declined to have a second hearing, requesting that a decision be made quickly in his case. The Veteran was also provided with several VA examinations, and neither the Veteran nor his representative has objected to the adequacy of any of the examinations conducted during this appeal. See Sickels v. Shinseki, 643 F.3d, 1362, 1365-66 (Fed. Cir. 2011) (holding that although the Board is required to consider issues independently raised by the evidence of record, the Board is still "entitled to assume" the competency of a VA examiner and the adequacy of a VA opinion without "demonstrating why the medical examiners' reports were competent and sufficiently informed"). The Board notes that this matter was previously remanded in order to associate additional treatment records with the claims file and to provide the Veteran with an additional VA examination. Further development in substantial compliance with the Board's remand instructions has been completed. As described, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). There is no prejudice to the Veteran in adjudicating this appeal, Because VA's duties to notify and assist have been met. Back and Radiculopathy At issues is whether the Veteran is entitled to compensation under 38 C.F.R. § 1151 for a low back disability with bilateral radiculopathy resulting from an injury sustained in the course of training and rehabilitation services under 38 C.F.R. § 31. The Veteran injured his back in 1980 while attending barber school which was the Veteran's designated vocational and rehabilitation training. The Veteran filed a claim for compensation, and this claim was denied by the RO. The Veteran appealed. In June 1981, the Board denied the Veteran's claim for compensation, because the Board found that the Veteran's injury was not incurred during a learning activity; and the Board found that it was highly questionable whether a permanent disability resulted from the injury. The Veteran filed another claim, and, in December 2012 the RO denied the Veteran's claim. It is slightly ambiguous, but it appears that the RO reopened the Veteran's claim and denied the matter on the merits. The Veteran appealed. The Veteran's service treatment records show he sought treatment in November 1974 after injuring his back lifting a table. The Veteran underwent physical therapy in November 1974. At the Veteran's separation examination, his spine was evaluated as normal. In a survey of medical history provided contemporaneously with the separation examination, the Veteran denied having then, or having ever had, recurrent back pain. In an April 1980 written statement, the Veteran reported that he injured his back in November 1974. Treatment records from April 1980 indicate that the Veteran sought treatment for back pain radiating down his legs. After conservative treatment failed, the Veteran underwent a lumbar myelogram under local anesthesia in June 1980 and a lumbar laminectomy with the removal of a herniated disc under general anesthesia in July 1980. In a June 1980 written statement, the Veteran reported that he injured his back in May 1980 while attending barber college under a program authorized under 38 C.F.R. § 31. The Veteran indicated that he sought treatment at a VA facility, and that these treatments were ineffective. In a July 1980 written statement, the manager of the Veteran's barber college indicated that the training curriculum required students to maintain their station including occasionally moving their barber's chairs. A September 1980 certificate of attending physician, indicates that the Veteran sought treatment for back pain from June 1980 to September 1980 from a naturopathic doctor. The naturopathic doctor indicated that the Veteran reported to his office complaining of severe lumbosacral and cervico-dorsal pain, and that the results of Lasque and Patrick-Fabere tests appeared negative; and that, after conservative care was unsuccessful, the naturopathic doctor noted an impression of a possible disc lesion and referred the Veteran to a medical doctor for further treatment. In an September 1980 written statement, the Veteran reported that his back had been permanently damaged, and, in a September 1980 VA Form 9, the Veteran reported that he injured his back during a period of service and later injured his back in April 1980 while picking up a barber's chair. An October 1980 statement from the Veteran's acquaintance indicated that the Veteran injured his back while attempting to lift a barber's chair. The Veteran testified at a Board hearing in October 1980 that he injured his back while attempting to lift a barber's chair in April 1980, but that he also injured his back several times prior to the injury in 1980. See October 1980 Transcript. SSA records dating back to 2006 indicated that the Veteran reported back pain. In an October 2011 VA examination evaluating the severity of the Veteran's knee and clavicle disabilities, the Veteran reported injuring his back in barber school in 1979, and that he underwent surgery as a result. He asserted that he had continued to experience back pain ever since. In a November 2011 notice of disagreement, the Veteran reported that his back was permanently worsened by surgery provided by the VA in 1980. In a November 2011 written statement, the Veteran's mother reported that the Veteran had back surgery in 1980, and that he had experienced problems with his back ever since. The Veteran also submitted additional written statements from his acquaintances indicating that he had back problems. In a June 2012 written statement the Veteran reported that he injured his back in April 1980 while lifting a barber's chair; that he underwent back surgery; and that he has continued to manifest back pain ever since. The Veteran also reported that he injured his back during his period of service. The Veteran underwent a VA examination in October 2012. The Veteran reported that he injured his back picking up a desk in 1974, and that he injured his back again in 1980 while trying to move a barber's chair. The Veteran also indicated that he underwent back surgery in 1980, and that he had manifested back pain ever since. The examiner referenced an X-ray conducted in October 2012 which included an impression of degenerative changes normal for the Veteran's age. The examiner was unable to opine whether the Veteran's current back disorder was caused by the incident in 1980 without resorting to mere speculation. In a January 2013 notice of disagreement, the Veteran reported that his back was permanently worsened in surgery provided by the VA in 1980. In a September 2013 written statement, the Veteran reported that his back was permanently worsened in surgery provided by the VA in 1980. In a February 2014 written statement, the Veteran reported that his back was permanently worsened in surgery provided by the VA in 1980, and that rehabilitation attempts have failed to heal his condition. In a July 2015 written statement, the Veteran's acquaintance indicated that the Veteran manifested back pain. In a June 2015 written statement the Veteran's mother reported that he injured his back in April 1980 while lifting a barber's chair; that the Veteran underwent back surgery; and that he has continued to manifest back pain ever since. At a personal hearing in July 2015, the Veteran testified that he injured his back while attempting to lift a barber's chair in April 1980, and that he subsequently underwent back surgery. The Veteran claimed that he continued to experience back problems ever since. See July 2015 Transcript. The Veteran underwent a VA examination in June 2016. The examiner opined that the Veteran's back condition was not due solely to an acute injury sustained during a period of VA vocational training in April 1980, the subsequent laminectomy, or any failure of VA care before, during, or after the injury or the surgery. The examiner went on to state that the April 1980 incident did lead to an acute herniated disc, but the Veteran's current condition represents the natural progression of that injury and surgery superimposed with age related degenerative changes. The examiner indicated that, according to pertinent medical literature, the July 1980 laminectomy was conducted in compliance with standard practice at the time. Finally, the examiner indicated that the Veteran's claims of continual pain since the surgery in 1980 cannot be confirmed, or denied, by the medical evidence of record. In a June 2016 notice of disagreement the Veteran reported that he injured his back in April 1980 while lifting a barber's chair; that he underwent back surgery; and that he has continued to manifest back pain ever since. The Veteran also reported that he injured his back during his period of service. The weight of the evidence indicates that the Veteran is entitled to compensation under 38 U.S.C.A. § 1151. The evidence of record quite clearly demonstrates that the Veteran injured his back while participating in VA rehabilitation at barber's college in April 1980. While previously it was unclear whether this resulted in a permanent disability a June 2016 VA examination indicated the Veteran's current back disability is the natural progression of the injury in April 1980 and subsequent surgery. The remaining issue to discuss is whether an injury incurred while moving a barber's chair at barber's school constitutes a learning activity. 38 C.F.R. § 3.361(d)(3) provides that to establish that the provision of training and rehabilitation services or a CWT program proximately caused a veteran's additional disability or death, it must be shown that the veteran's participation in an essential activity or function of the training, services, or CWT program provided or authorized by VA proximately caused the disability or death. The veteran must have been participating in such training, services, or CWT program provided or authorized by VA as part of an approved rehabilitation program under 38 U.S.C. chapter 31 or as part of a CWT program under 38 U.S.C. 1718. It need not be shown that VA approved that specific activity or function, as long as the activity or function is generally accepted as being a necessary component In July 1980, the manager of the Veteran's barber college indicated that the training curriculum required students to maintain their station including occasionally moving their barber's chairs. While the Board notes that it previously did not consider this to be a learning activity upon reconsideration, the Board finds that the July 1980 statement from the manager of the training facility is a sufficient basis to find that moving the barber's chair constitutes the use of equipment implicit in the performance of a task that the trainee must learn to perform, and it is, therefore, a learning activity. As such, the criteria for compensation under 38 C.F.R. § 1151 for a low back disability resulting from an injury sustained in the course of training and rehabilitation services under 38 C.F.R. § 31 have been met. The Board notes that the Veteran has also claimed to have manifested radiculopathy associated with his permanent back disability. Nevertheless, the Veteran underwent a VA examination in June 2016 which indicated that the Veteran did not have a diagnosis of radiculopathy or any other peripheral nerve condition of the lower extremity. The examiner further noted that the Veteran underwent electromyography in June 2016 which indicated that bilateral lower extremity did not show any denervation, and the motor action potentials were within normal limits. The impression of the study indicated that there was no evidence for generalized peripheral neuropathy or radiculopathy of the bilateral lower extremities. Finally, the medical evidence of record does not contain an objective test or diagnostic procedure during the pendency of the appeal rebutting the findings of the June 2016 electromyography. The existence of a current disability or a disability during the pendency of the appeal is the cornerstone of a claim for a VA disability compensation. See Degmetich v. Brown, 104 F.3d 1328 (1997). As such, compensation for a nerve condition of the bilateral lower extremities is denied. Left Knee At issue is whether the Veteran is entitled to service connection for a left knee disorder. The weight of the evidence indicates that he is not. In seeking VA disability compensation, a Veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131. "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. Furthermore, service connection can be established through application of statutory presumptions, including for chronic diseases, like arthritis and organic diseases of the nervous system, when manifested to a compensable degree within a year of separation from service or by demonstrating continuity of symptomology since separation of service. 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted on a secondary basis for a disability that was not incurred or aggravated by service but was due to or proximately caused by a previously service-connected disability. 38 C.F.R. § 3.310. The Veteran asserted at a personal hearing before the Board in July 2015 that his left knee condition was due to rigorous physical training he had to perform during his period of service. The Veteran reported that his treating VA physician told him that left knee condition was medically linked to his previously service-connected right knee condition. See July 2015 Transcript. Although the Veteran sought treatment for a right knee condition, the Veteran's service treatment records are silent for reports of or treatment for a left knee disability. The Veteran's lower extremities were evaluated as normal during his service separation examination. In a survey of medical history provided contemporaneously with the separation examination, the Veteran reported a history of a trick or locked knee, but the Veteran clarified that his problems was with his right knee. The survey of medical history was otherwise silent for problems with the Veteran's left knee. The Veteran continued to seek treatment for his right knee in May 1976, but did not seek treatment for his left knee at that time. A June 1976 treatment record indicates that the Veteran manifested laxity in his left knee. The Veteran underwent a VA examination in August 1976. The examiner indicated that the function of all of the Veteran's joints was good with full range of motion throughout. The examiner indicated that there was slight tenderness between the right knee cap and tibial tubercle, and that the tibial tubercle on the right was slightly more prominent than on the left. The examiner diagnosed the Veteran with a the residuals of an old injury of the right knee, but the Veteran was not diagnosed with a left knee disability. The Veteran underwent another VA examination in August 1978 at which he was diagnosed with a right knee condition, but not with a left knee disability. The Veteran's treatment records indicate that the Veteran began to be treated for bursitis of the left knee in 1979. The Veteran underwent another VA examination in October 2003. The Veteran reported that both of his knees periodically gave out resulting in falls one to two times per year. The examiner diagnosed the Veteran with bilateral chondromalacia of the knees. In a January 2004 written statement, the Veteran indicated that he had bilateral chondromalacia, and that his left knee had been bothering him for years. In a May 2004 written statement, the Veteran claimed that chondromalacia usually manifests bilaterally, and that, therefore, his left knee disability was connected to his right knee. In another May 2004 written statement, the Veteran reported that his left knee disability was due to rigorous military training that he underwent during his period of service. The Veteran reiterated these contentions in subsequent written statements. SSA records from 2006 indicate that the Veteran manifested knee problems. A June 2006 VA treatment record indicates that the Veteran manifested chronic pain in both knees as well as a diagnosis of chondromalacia in both knees. Subsequent treatment records indicated that the Veteran continued to manifest this condition thereafter. In a July 2006 written statement, the Veteran's girlfriend of five years (since July 2001) indicated that the Veteran's knees had continued to become progressively worse since she met the Veteran. The Veteran underwent another VA examination in August 2006. The Veteran reported bilateral knee pain. The examiner indicated that it is at least as likely as not that the Veteran had chondromalacia and degenerative joint disease of his left knee, but the examiner did not opine on the etiology of the condition. The Veteran underwent another VA examination in October 2011. The Veteran reported pain in his knees that was more than he could bear. The Veteran also claimed that his knees will occasionally give out, but he did not report any flare-ups. The examiner did not discuss the etiology of the Veteran's left knee disability. In written statements drafted in November 2011, the Veteran's acquaintances indicated that the Veteran had problems with both of his knees. In a July 2015 written statement, the Veteran's acquaintance indicated that the Veteran had trouble with both of his knees. In a July 2015 written statement, the Veteran's mother indicated that he separated from service in 1976, and had experienced nothing but trouble with both of his knees. The Veteran underwent another VA examination in June 2016. The examiner noted that the underwent rigorous physical training during his period of service. Nevertheless, the Veteran denied having any chronic knee pain during a period of service. The examiner opined that the Veteran's left knee condition was less likely than not related to an in-service injury. The examiner noted that there was some evidence of laxity of the left knee, but this was a developmental circumstance unrelated to physical training. The examiner indicated that laxity creates an increased probability of later developing knee disabilities, but there is no evidence that it began to manifest within one year of separation from service. The examiner opined that the Veteran's left knee condition was less likely than proximately caused by a previously service-connected disability, because the Veteran's left knee disability is more likely than not related to age rather than an altered gait caused by the Veteran's right knee. The examiner indicated that over the course of two or three decades an altered gait can accelerate degeneration in a contralateral joint, but in these cases the index joint typically manifests considerably more degenerative changes. The examiner opined that this was not the case for this Veteran. The examiner further noted that the Veteran's right knee did not aggravate his left knee disability for the same reason. The Veteran is clearly manifesting a current left knee disability, and he has made credible reports of rigorous training during a period of service that could be considered an in-service incurrence. Additionally, the Veteran has a previously service-connected disability that can cause a disability in the left knee. Nevertheless, the weight of the evidence indicates that the Veteran is not entitled to service connection for a left knee disability. The Veteran's treatment records are silent for reports of or treatment for a left knee disability. The Veteran's service separation examination evaluated the Veteran's lower extremities as normal, and, in a contemporaneous survey of his medical history, the only reported problems with his right knee and not his left. Additionally during a June 2016 VA examination, the Veteran specifically admitted that he did not manifest chronic knee pain during his period of service. The Veteran did manifest laxity in his left knee within one year of separation from service, but a June 2016 VA examination indicates that this only increases the risk of a manifestation of a left knee disability and is not a left knee disability in and of itself. The Veteran was not diagnosed with a left knee disability until 1979. In June 2016, a VA examiner opined that it is less likely than not that the Veteran's left knee disorder was related to a period of service or proximately due to or aggravated by a previously service-connected disability. The Board finds this this opinion persuasive and affords it great weight, because it is based on the sufficient facts and data and reliable principles and methods. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Here, the weight of the probative evidence of record simply fails to demonstrate a medical link between the issue on appeal and the Veteran's period of active service, of which there is also no record of a diagnosis within one year of separation, and the Veteran's current left knee disorder is not proximately due to or aggravated by an in-service incurrence. As such, service connection for a left knee disability is denied. Increased Disability Rating The Veteran contends that he is entitled to multiple increased disability ratings. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Right Knee At issue is whether the Veteran is entitled to an increased disability rating for a right knee disability. The Veteran first filed for service connection in May 1976, and, in September 1976, the RO granted service connection and assigned a disability rating of 10 percent based on the criteria for Diagnostic Code 5257 effective the day after separation from service. The Veteran's disability rating was subsequently increased to 20 percent. The Veteran filed an increased rating claim in June 2011, which was denied, and he appealed. Disability ratings for knee disabilities are assigned pursuant to Diagnostic Code 5003, and Diagnostic Codes 5256-5263. Diagnostic Code 5256 (ankylosis) is not raised by the record, because the Veteran's examinations of record and treatment records indicate that the Veteran manifested some range of motion throughout the period on appeal. Diagnostic Codes 5258 and 5259 are not raised by the record either, because both Diagnostic Codes evaluate cartilage conditions; and a June 2016 VA examination indicated that the Veteran did not have and never had a cartilage condition of the knee. Diagnostic Code 5262 (impairment of tibia and fibula) is not raised by the record, because a June 2016 VA examination indicated that the Veteran did not manifest any tibial or fibular impairment. Finally, Diagnostic Code 5263 (genu recurvatum) is not raised by the record, because the medical evidence of record does not indicate a diagnosis of genu recurvatum. Therefore, the pertinent Diagnostic Codes that the Board shall consider are Diagnostic Codes 5003, 5257, 5260, 5261. 38 C.F.R. § 4.71a. Under Diagnostic Code 5257, a disability rating of 20 percent is assigned for moderate recurrent subluxation or lateral instability of the knee, and a disability rating of 30 percent is assigned for severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under Diagnostic Code 5260, a disability rating of 10 percent is assigned when a knee disability manifests in flexion limited to 45 degrees or less, and a disability rating of 20 percent is assigned when a knee disability manifests in flexion limited to 30 degrees. A disability rating of 30 percent is assigned when a knee disability manifests in flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a disability rating of 10 percent is assigned when a knee disability manifests in extension to 10 percent, and a disability rating of 20 percent is assigned when a knee disability manifests in extension to 15 percent. A disability rating of 30 percent is assigned when a knee disability manifests in extension to 20 percent, and a disability rating of 40 percent is assigned when a knee disability manifests in extension to 30 percent. Finally, a disability rating of 50 percent is assigned when a knee disability manifests in extension to 45 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Under Diagnostic Code 5003, a disability rating of 10 percent is assigned when a major joint manifests limitation of motion objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Diagnostic Code 5003 also provides disability ratings in the absence of limitation of motion, but neither of these disability ratings are raised by the record. They each require involvement of two major joints or joint groups, and the Veteran's disability rating only effects one major joint; the right knee. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Veteran's statements and treatment records throughout the period on appeal suggest that the he has experienced multiple right knee symptoms including: pain, difficulty standing, and giving way. In a June 2011 increased rating claim, the Veteran reported that his knee disability was severe enough that he could barely walk or stand on it, and that after 45 minutes of walking the pain in his knees becomes too much to bear. The Veteran reiterated this claim in July 2011. In a July 2011 written statement, the Veteran claimed that his knee problems had increased in severity. The Veteran claimed that he could only stand for 40 minutes or less, and he claimed that the time was actually closer to half an hour. The Veteran reported that his knees were painful, and that they gave out while walking. The Veteran reiterated these contentions in multiple written statements submitted by himself as well as his acquaintances. The Veteran underwent a VA examination in October 2011 at which he asserted the pain in his knees that was more than he could bear. The Veteran also claimed that his knees would occasionally give out, but he did not report any flare-ups. The Veteran's flexion was measured to 140 degrees or greater, and his extension was to zero degrees or manifested any degree of hyperextension. The examiner indicated that there was no objective evidence of pain on motion, but the Veteran was not able to perform repetitive-use testing with three repetitions. The examiner indicated that as the examiner provided resistance, the Veteran reported he was unable to extend knees against any resistance, and that - when the examiner asked the Veteran to perform repetitive motion without resistance - the Veteran claimed that his knees were too weak and hurt too much. The examiner noted the following functional impairment: weakened movement; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight-bearing. The examiner also indicated that muscle strength testing indicated the Veteran had less than normal strength, but that the Veteran had active movement against some resistance. Joint stability tests were normal, and there was no history of subluxation and dislocation. The examiner noted that the Veteran used assistive devices. In a July 2015 written statement, the Veteran's acquaintance indicated that the Veteran had trouble with both of his knees. In a July 2015 written statement, the Veteran's mother indicated that the Veteran manifested trouble in both of his knees. The Veteran testified at a personal hearing before the Board in July 2015 that he was experiencing multiple knee symptoms including: pain including pain on range of motion, difficulty standing for more than 20 minutes, and giving way. The Veteran indicated that he needs assistive devices to walk. See July 2015 Transcript. The Veteran underwent another VA examination in June 2016 at which he was diagnosed with arthritis in the right knee. The Veteran's flexion was measured to 90 degrees, and his extension was measured to zero degrees. The examiner indicated that the Veteran's range of motion contributed to a functional loss of an inability to squat or crouch. The examiner indicated that there was evidence of pain with weight bearing. The Veteran was unable to perform repetitive use testing with at least three repetitions, and the examiner opined that the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner indicated that the following factors contributing to the Veteran's disability: less movement than normal due to ankylosis, adhesions, etc.; atrophy of disuse; disturbance of locomotion; and interference with sitting and standing. The examiner also indicated that muscle strength testing indicated the Veteran had less than normal strength, but that the Veteran had active movement against some resistance. Joint stability testing was normal, and the examiner indicated that there was no history of recurrent subluxation. The Veteran reported the use of assistive devices. The weight of the evidence indicates that the Veteran is not entitled to a disability rating in excess of 20 percent under Diagnostic Code 5257. In order to be assigned a disability rating in excess of 20 percent under Diagnostic Code 5257, the Veteran must manifest severe recurrent subluxation or lateral instability of the knee. The VA examinations of record indicate that the Veteran's right knee has not manifested in subluxation or lateral instability. Therefore, the evidence does not establish that the Veteran manifested severe subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Veteran is not entitled to a separate compensable disability rating under Diagnostic Codes 5260 or 5261. In order to be assigned a separate compensable disability rating, the Veteran must manifest either a flexion limited to 45 degrees or less or an extension limited to 10 degrees or more. The Veteran's flexion and extension were measured multiple times during the period on appeal, but the Veteran's extension consistently measured less than 10 degrees; and his flexion was consistently measured more than 45 degrees. Therefore, the weight of the evidence indicates that the criteria for a separate disability rating under Diagnostic Codes 5260 or 5261 have not been met. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability. 38 C.F.R. § 4.45. Even if range of motion was slightly limited by pain however, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. The weight of the evidence indicates that the Veteran is not entitled to a separate compensable disability rating under Diagnostic Codes 5260 or 5261 even after taking additional functional impairment into consideration. The Board notes that the VA examinations of record indicate that the Veteran manifested additional functional loss and was unable to perform three repetitions of range of motion testing due to pain and weakness. Nevertheless, a finding that the Veteran's inability to perform repetitive range of motion testing due to weakness is contradicted by the result of strength testing. The results of testing did reveal that the Veteran had less than normal strength, but both examinations indicated that the Veteran was able to perform active movement against some resistance. Therefore, the Board finds that the Veteran's inability to perform repetitive range of motion testing was due to pain alone, and, as previously noted, pain alone is not sufficient to warrant a higher disability rating. See Mitchell. Therefore, the Veteran is not entitled to a separate compensable disability rating under Diagnostic Codes 5260 or 5261 even after taking additional functional impairment into consideration. The weight of the evidence indicates that the Veteran is entitled to a separate 10 percent rating under Diagnostic Code 5003. The evidence of record clearly indicate that the Veteran's range of motion is limited by pain. Therefore, the criteria for a separate compensable disability rating under Diagnostic Code 5003 has been met. Left Clavicle At issue is whether the Veteran is entitled to a disability rating of 20 percent during the pendency of the appeal. The weight of the evidence indicates that the Veteran is not entitled to a disability rating in excess of 20 percent. The Veteran first filed for service connection in May 1976, and, in September 1976, the RO granted service connection and assigned a noncompensable disability rating effective the day after separation from service. The Veteran's disability rating was subsequently increased to 20 percent. The Veteran filed an increased rating claim in June 2011, and, in November 2011, the RO denied the Veteran's claim. The Veteran appealed. Disability ratings for impairments of the shoulders and arms are evaluated under Diagnostic Codes 5200-5203. The Veteran has already been assigned a disability rating of 20 percent throughout the period on appeal, and, therefore, Diagnostic Code 5203 does not provide an adequate basis for an increased disability rating; because a disability rating of 20 percent is the maximum disability rating under this diagnostic code. Diagnostic Code 5200 is not raised by the record, because the evidence does not establish that the scapula and humerus move as one piece; which is required by that diagnostic code. Diagnostic Code 5202 (impairment of the humerus) is not raised by the record, because the medical evidence of record does not establish that the Veteran has an impairment of the humerus. Therefore, the only remaining diagnostic code left for the Board to consider as criteria for an increased disability rating is Diagnostic Code 5201. 38 C.F.R. § 4.71a. Diagnostic Code 5201 assigns different disability ratings based on whether the disability impacts the dominant or non-dominant arm. The Board notes that the Veteran is right handed, and that the disability impacts the Veteran's left side. As such, the Board shall only consider the criteria for the non-dominant arm. Under Diagnostic Code 5201, a disability rating of 20 percent is assigned when the Veteran manifests in limitation of motion of the non-dominant arm at the shoulder level or midway between the side and shoulder level, and a disability rating of 30 percent is assigned when the Veteran manifests in limitation of motion of the non-dominant arm to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The Veteran's treatment records and statements show that he has experienced left clavicle problems throughout the period on appeal, including pain and limited use of his left arm. The Veteran underwent a VA examination in October 2011 at which he reported that his left shoulder had been the same since 2002. He acknowledged that he could raise his right arm above 90 degrees, and he denied flare-ups. The Veteran's range of motion measurements were as follows: flexion of 90 degrees with objective evidence of pain at 70 degrees; and abduction to 70 degrees with objective evidence of pain at 60 degrees. The Veteran was able to perform three repetitions of range of motion testing without additional loss of range of motion. The examiner noted the following functional loss: less movement that normal; weakened movement; and pain on movement. Muscle strength testing revealed normal strength. In a July 2015 written statement, the Veteran's acquaintance indicated that the Veteran had trouble using his left arm. The Veteran testified at a personal hearing before the Board in July 2015 that he had trouble reaching above his head, as movement of his arm above 90 degrees caused shooting pain in his arm. See July 2015 Transcript. The Veteran underwent another VA examination in June 2016. The Veteran's range of motion measurements were as follows: Flexion to 70 degrees; abduction to 60 degrees; external rotation and internal rotation to 40 degrees. The Veteran was unable to perform repetitive range of motion testing due to pain. The examiner indicated that pain resulted in additional functional loss. Muscle strength testing revealed less than normal strength, but the Veteran was able to perform active movement against some resistance. The weight of the evidence indicates that the Veteran is not entitled to a disability rating in excess of 20 percent. In order to meet the criteria for an increased disability rating, the Veteran must manifest limitation of motion of the left arm to 25 degrees from the side. The Veteran's range of motion was measured multiple times throughout the period on appeal, and the Veteran's range of motion of the left arm was always in excess of 25 degrees from the left side. Therefore, the criteria for a disability rating of 30 percent have not been met. The weight of the evidence indicates that the Veteran is not entitled to a disability rating in excess of 20 percent even after taking additional functional impairment into consideration. The Board notes that the VA examinations of record indicate that the Veteran manifested additional functional loss. Nevertheless, the examiner's indicated that the Veteran's functional loss was due to pain. As previously noted, pain alone is not sufficient to warrant a higher disability rating. See Mitchell. Additionally, the results of testing revealed either normal strength or the ability to perform active movement against some resistance. This further demonstrates that the Veteran's inability to perform repetitive range of motion testing was due to pain alone. Therefore, the Veteran is not entitled to a disability rating in excess of 20 percent even after taking additional functional impairment into consideration. ORDER Compensation under 38 C.F.R. § 1151 for a low back disability resulting from an injury sustained in the course of training and rehabilitation services under 38 C.F.R. § 31 is granted. Compensation under 38 C.F.R. § 1151 for peripheral neuropathy of the bilateral lower extremities resulting from an injury sustained in the course of training and rehabilitation services under 38 C.F.R. § 31 is denied. Service connection for a left knee disability is denied. A separate disability rating of 10 percent for a right knee disability under Diagnostic Code 5003 for is granted, subject to the laws and regulations governing the award of monetary benefits. A disability rating in excess of 20 percent for a right knee disability under Diagnostic Code 5257 is denied. A disability rating in excess of 20 percent for a left clavicle fracture is denied. ____________________________________________ MATTHEW W. BLACKWELDER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs