Citation Nr: 18145713 Decision Date: 10/29/18 Archive Date: 10/29/18 DOCKET NO. 16-14 285 DATE: October 29, 2018 ORDER Entitlement to an increased rating greater than 10 percent for service-connected low back strain is denied prior to December 5, 2016. Entitlement to an increased rating of 20 percent effective December 5, 2016 for service-connected low back strain is granted, subject to the laws and regulations governing monetary awards. Entitlement to an increased rating of 10 percent effective May 24, 2012 for service-connected left knee patellofemoral pain syndrome with arthritis is granted, subject to the laws and regulations governing monetary awards. Entitlement to an increased rating greater than 10 percent for the entire period on appeal for service-connected left knee patellar femoral pain syndrome with arthritis is denied. Entitlement to an increased rating of 10 percent effective May 24, 2012 for service-connected right knee patellofemoral pain syndrome with arthritis is granted, subject to the laws and regulations governing monetary awards. Entitlement to an increased rating greater than 10 percent for the entire period on appeal for service-connected right knee patellar femoral pain syndrome with arthritis is denied.   REMANDED Entitlement to service connection for a left shoulder disability is remanded. FINDINGS OF FACT 1. Prior to December 5, 2016, the Veteran’s service-connected low back strain manifested as forward flexion limited to at most 75 degrees with pain beginning at 75 degrees, extension to 25 degrees, right and left lateral flexion to 25 degrees, and right and left lateral rotation to 25 degrees, for a combined range of motion of 200 degrees with no evidence of ankylosis or neurological deficits. 2. Effective December 5, 2016, the Veteran’s service-connected low back strain manifested as forward flexion to 55 degrees, extension to 25 degrees, right lateral flexion to 15 degrees, left lateral flexion to 15 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees with pain, for a combined range of motion of 170 degrees and no evidence of ankylosis or neurological deficits. 3. For the entire period on appeal, the Veteran’s left knee patellofemoral pain syndrome with arthritis manifested as flexion limited to at most 115 degrees with pain, full extension, and no evidence of instability, recurrent subluxation, or ankylosis. 4. For the entire period on appeal, the Veteran’s right knee patellofemoral pain syndrome with arthritis manifested as flexion limited to at most 115 degrees with pain, full extension, and no evidence of instability, recurrent subluxation, or ankylosis. CONCLUSIONS OF LAW 1. Prior to December 5, 2016 the criteria for entitlement to an increased rating greater than 10 percent for service-connected low back strain have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2017). 2. Effective December 5, 2016, the criteria for entitlement to an increased rating of 20 percent, but no greater, for service-connected low back strain have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2017). 3. Effective May 24, 2012, the criteria for a rating of 10 percent, but no greater, for the Veteran’s service-connected left knee patellofemoral pain syndrome with arthritis have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2017). 4. For the entire period on appeal, the criteria for a rating in excess of 10 percent for the Veteran’s service-connected left knee patellofemoral pain syndrome with arthritis have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2017). 5. Effective May 24, 2012, the criteria for a rating of 10 percent, but no greater, for the Veteran’s service-connected right knee patellofemoral pain syndrome with arthritis have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2017). 6. For the entire period on appeal, the criteria for a rating in excess of 10 percent for the Veteran’s service-connected right knee patellofemoral pain syndrome with arthritis have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1982 through September 2005. The Board notes that the Veteran was granted a single 10 percent rating for bilateral patellofemoral pain syndrome with arthritis from May 24, 2012 through July 30, 2013, and two separate 10 percent ratings thereafter. However, as will be discussed further below, the Board finds that the Veteran’s knee disabilities are best characterized as two separate ratings for the entire period on appeal. Accordingly, the Board has recharacterized the issues as listed on the title page. The RO also certified for appeal issues for increased ratings for the right shoulder condition and posttraumatic stress disorder (PTSD), as well as service connection for bilateral elbow arthritis. That is, however, incorrect, as the Veteran expressly limited her appeal to the left shoulder, back, and knee issues listed above. See March 2016 VA Form 9. Also, the Veteran did not properly perfect an appeal concerning an issue on the amount of retroactive payment. In March 2013 an award action was taken based on a US Coast Guard Audit Error Worksheet that resulted in a retroactive payment of $13,126.37 based on Concurrent Retirement and Disability Pay (CDRP). An additional payment was sent to her in July 2013. The Veteran did submit a notice of disagreement in April 2013; however, she did not submit a substantive appeal following the August 2016 Statement of the Case (SOC). The Board notes she did submit a VA Form 9 in November 2014 purporting to appeal this issue, but that does not follow proper appellate procedure which requires an appeal after the SOC is issued, not before. The SOC clearly stated her NOD was the “first step” in an appeal to the Board, and she had to file a formal appeal to complete her appeal. Since she did not do so, the Board has no jurisdiction over this issue. The Board notes that significant evidence has been received since the last Statement of the Case. However, the Veteran waived RO review of the newly obtained evidence in October 2018. Accordingly, the Board may proceed with appellate review. Increased Rating 1. Entitlement to an increased rating greater than 10 percent for a service-connected low back strain The Veteran asserts that her service-connected lumbar spine strain warrants a rating in excess of 10 percent. Specifically, she argues that she experienced pain on a daily basis due to her back disability. The Veteran’s service connected low back strain is rated as 10 percent disabling under Diagnostic Code 5237, applying to lumbosacral spine strains. Diagnostic Code 5237 is rated under the General Rating Formula for Injuries and Diseases of the Spine. Prior to December 5, 2016 Prior to December 5, 2016, the Veteran’s lumbar spine strain is rated as 10 percent disabling for forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour. VA treatment records dated in October 2013 reflect the Veteran reported experiencing a back spasm and pain in her upper back. On physical evaluation, her thoracolumbar spine range of motion demonstrated normal forward flexion, extension 70 percent of normal (21 degrees), and lateral bending and rotation 80 percent of normal (24 degrees). See 38 C.F.R. § 4.71a, Plate I, for normal ranges of spine motion. The Veteran was afforded a VA examination to evaluate the severity of her lumbar spine strain in March 2014. Range of motion testing produced the following results: forward flexion to 75 degrees with pain beginning at 75 degrees; extension to 25 degrees with pain beginning at 25 degrees; right and left lateral flexion to 25 degrees with pain beginning at 25 degrees; and right and left lateral rotation to 25 degrees with pain beginning at 25 degrees. This resulted in a combined range of motion of 200 degrees. No additional limitation of motion was demonstrated after repetitive use testing, but there was evidence of pain on movement. She reported flare ups when bending, stooping, and doing general housework; however, the examiner noted that while flare ups could lead to additional pain, weakness, fatigability, and incoordination, additional range of motion loss could not be provided without resorting to mere speculation because the examination was not being performed during a flare up. The examiner found no tenderness to palpation, muscle spasm, or guarding. Muscle strength and neurological testing was normal, and there was no evidence of radiculopathy. The Veteran did not have ankylosis. VA treatment records reflect the Veteran had normal back range of motion in early September 2016, but a later September 2016 record noted her range of motion for the thoracolumbar spine was limited and she experienced tenderness to palpation. An October 2016 VA treatment record noted the Veteran had normal back range of motion. The Board finds that a rating in excess of 10 percent prior to December 5, 2016 for the Veteran’s low back strain is not warranted. There is no evidence that, prior to December 5, 2016, the Veteran’s low back strain manifested as forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis to warrant a 20 percent disability rating. VA treatment records and the March 2014 VA examination reflect that the Veteran’s forward flexion was limited to, at most, 75 degrees. In October 2013, her combined range of motion for the thoracolumbar spine was 207 degrees, and she had a combined range of motion of 200 degrees during the March 2014 VA examination. Although a September 2016 VA treatment record noted the Veteran’s range of motion was limited and she had tenderness to palpation, no actual results of range of motion testing were included in the record and there is no evidence the tenderness caused abnormal gait or abnormal spinal contour. There is also no evidence that the Veteran had muscle spasm or guarding so severe that it resulted in abnormal gait or abnormal spinal contour. The Board has considered whether the Veteran could be granted a higher rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The record does not reflect that the Veteran has been diagnosed with intervertebral disc syndrome or has ever been prescribed bed rest by a physician due to incapacitating episodes. While she may voluntarily choose to limit activity due to increased pain, that is not how VA defines an incapacitating episode. Additionally, the Board has considered whether the Veteran would be entitled to a separate compensable rating for radiculopathy. None of the Veteran’s VA treatment records reflect she has ever complained of radicular symptoms or been diagnosed with radiculopathy. Moreover, the March 2014 VA examination found no evidence of radiculopathy on physical examination. Accordingly, as there is no evidence the Veteran has been diagnosed with radiculopathy, a separate compensable rating is not warranted. In considering these rating criteria, the Board has considered functional loss due to 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). In making this determination, the Board considered the Veteran’s statements regarding her symptoms, VA examination reports, and VA treatment records. The Board certainly sympathizes with the Veteran’s statements that her back pain has been ongoing for over 30 years; however, while she reported increased pain with flare-ups, she has not suggested that the flare-ups cause any additional difficulty with range of motion or other functional impairment. As such, while the record shows low back pain and difficulty with bending, stooping, and doing general housework, the evidence does not show that her symptoms and flare-ups produce functional loss that is manifested by adequate evidence of disabling pathology for higher ratings. See 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Indeed, the Veteran did not experience additional limitation of motion after repetitive use testing, and her disability rating is already based on the extent to which her symptoms reduce range of motion. In light of the Veteran’s reported symptoms and the medical evidence, the Board finds that the Veteran is not entitled to a higher rating for her lumbar spine disability. Entitlement to an increased rating greater than 10 percent for service-connected lumbar spine strain prior to December 5, 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. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Effective December 5, 2016 The Veteran was afforded a VA examination on December 5, 2016 to evaluate the severity of her low back strain. The examiner noted that the Veteran’s low back strain had progressed, and she now had mild scoliosis and mild disc space narrowing at L3 through L4 and L5 through S1 levels. The Veteran described flare-ups of pain as feeling like a “Charlie horse” and reported flare-ups limited standing, sitting, bending, and lifting. Range of motion testing results reflected forward flexion to 55 degrees, extension to 25 degrees, right and left lateral flexion to 15 degrees, and left and right lateral rotation to 30 degrees, for a combined range of motion of 170 degrees. Pain on examination caused functional loss with forward flexion, extension, and right and left lateral flexion. There was no objective evidence of localized tenderness or pain on palpation or pain with weight bearing. Repetitive use testing reflected no additional limitation of range of motion or additional factors causing functional loss. The examiner noted that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time, and while pain reduced functional ability after repetitive use over time, there was no additional loss of range of motion. As for flare-ups, the examination was medically consistent with the Veteran’s statement describing functional loss during a flare-up, but flare-ups causing pain, fatigue, and lack of endurance did not result in additional limitation of range of motion. Physical examination reflected muscle spasm not resulting in abnormal gait or abnormal spinal contour, no guarding, and no tenderness to palpation. Neurological testing was normal without evidence of muscle atrophy or radiculopathy. There was no evidence of ankylosis. The Veteran did not have a diagnosis of intervertebral disc syndrome. The Board finds that, effective December 5, 2016, an increased rating of 20 percent for the Veteran’s low back strain is warranted. The evidence reflects that the Veteran’s forward flexion was limited to 55 degrees with pain during the December 2016 VA examination. Accordingly, a 20 percent rating under the General Rating Formula for Diseases and Injuries of the Spine is warranted. The evidence does not reflect the Veteran is entitled to an increased rating of 40 percent for her service-connected low back strain. There is no evidence the Veteran has ever experienced forward flexion limited to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. The only results of range of motion testing contained in the claims file are the measurements taken during the December 2016 VA examination. The Veteran’s range of motion during the examination was forward flexion to 55 degrees with pain. Accordingly, there is no evidence the Veteran’s forward flexion was limited to anywhere near 30 degrees to warrant an increased, 40 percent, rating. Additionally, at no point during the period on appeal has there been evidence of ankylosis. The Board has considered whether the Veteran could be granted a higher rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The record does not reflect that the Veteran has been diagnosed with intervertebral disc syndrome or has ever been prescribed bed rest by a physician due to incapacitating episodes. While she may voluntarily choose to limit activity due to increased pain, that is not how VA defines an incapacitating episode. Additionally, the Board has considered whether the Veteran would be entitled to a separate compensable rating for radiculopathy. None of the Veteran’s VA treatment records reflect she has ever complained of radicular symptoms or been diagnosed with radiculopathy. Moreover, the December 2016 VA examination found no evidence of radiculopathy on physical examination. Accordingly, as there is no evidence the Veteran has been diagnosed with radiculopathy, a separate compensable rating is not warranted. In considering these rating criteria, the Board has considered functional loss due to 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). In making this determination, the Board considered the Veteran’s statements regarding her symptoms, VA examination reports, and VA treatment records. The December 2016 VA examiner noted the Veteran’s complaints of pain, weakness, fatigability, and incoordination after repetitive use over time and during flare-ups, but estimated the Veteran experienced no additional loss of range of motion. As such, while the record shows low back pain and difficulty with sitting, standing, bending, and lifting, the evidence does not show that her symptoms and flare-ups produce functional loss that is manifested by adequate evidence of disabling pathology for higher ratings. See 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Indeed, the Veteran’s disability rating is already based on the extent to which her symptoms reduce range of motion. In light of the Veteran’s reported symptoms and the medical evidence, the Board finds that the Veteran is not entitled to a higher rating for her lumbar spine disability. In summary, entitlement to an increased rating of 20 percent, but no greater, for the Veteran’s service-connected low back strain is warranted effective December 5, 2016. 2. Entitlement to an increased rating greater than 10 percent for service-connected left knee patellar femoral pain syndrome with arthritis 3. Entitlement to an increased rating greater than 10 percent for service-connected right knee patellar femoral pain syndrome with arthritis The Veteran asserts that her left and right knee patellofemoral pain syndrome with arthritis warrant ratings in excess of 10 percent. As noted in the introduction, the Board has recharacterized the Veteran’s left and right knee disabilities as two separate disabilities for the entire period on appeal. VA treatment records reflect the Veteran underwent a bilateral knee x-ray on March 24, 2012 that indicated she had degenerative arthritis of her knees bilaterally. See March 2014 VA examination (noting x-rays taken in August 2013 showed mild degenerative changes to both knees which had not changed since the May 24, 2012 x-rays). VA treatment records dated May 2012, just after the May 24, 2012 x-rays, noted the Veteran had pain in her knees bilaterally with limited range of motion. As the Veteran demonstrated bilateral knee arthritis with painful limitation of motion at the time of her May 24, 2012 diagnosis, the Board finds that two separate 10 percent ratings for painful limitation of motion under 38 U.S.C. § 4.59 and Diagnostic Code 5003 were warranted effective May 24, 2012. The Board turns to whether the Veteran’s right and left knee patellofemoral syndrome with arthritis warrant ratings greater than 10 percent for the entire period on appeal. After a full review of the claims file in conjunction with the applicable laws and regulations, the Board finds that entitlement to increased ratings greater than 10 percent for right and left knee patellofemoral pain syndrome with arthritis are not warranted. VA treatment records dated May 2012 noted the Veteran’s bilateral knee range of motion was limited, but did not record the results of range of motion testing. The Veteran was afforded a VA examination in March 2014 to evaluate her right and left patellofemoral pain syndrome with arthritis. She reported that she did not seek treatment for her knee pain, but experienced flare-ups of pain with cold weather and climbing stairs. Range of motion testing for the right knee reflected flexion to 125 degrees with pain beginning at 125 degrees and full extension without pain. The Veteran’s left knee demonstrated flexion to 125 degrees with pain at 125 degrees and full extension without pain. There was no additional loss of range of motion with repetitive use testing. The examiner noted the Veteran had functional loss due to less movement than normal and pain after repetitive use. There was no evidence of tenderness to palpation of either knee. Neurological and muscle strength testing was normal. The Veteran did not have a history of recurrent patellar subluxation or dislocation or meniscal injuries, and all joint stability testing was normal. VA treatment records reflect the Veteran continued to report progressing knee pain and difficulty with ambulation, but the records do not contain the results of range of motion testing. The Veteran was afforded a VA examination to evaluate the severity of her right and left knee patellofemoral pain syndrome with arthritis in August 2016. She reported flare-ups with cold weather, climbing stairs, and prolonged walking. She did not report having any functional loss or impairment of the joint after repeated use over time. Range of motion testing for the Veteran’s right and left knees reflected flexion to 120 degrees with pain and full extension, with no evidence of pain with weight bearing bilaterally. There was mild tenderness to palpation over the patella bilaterally. The Veteran was able to perform repetitive use testing with no additional loss of range of motion. The examiner noted the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss following repetitive use over time, because it was not possible to estimate loss of range of motion or describe loss of function without resorting to mere speculation. As for flare-ups, the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss due to flare-ups, because it was not possible to estimate loss of range of motion or describe loss of function without resorting to mere speculation. Neurological and muscle strength testing were normal with no evidence of muscle atrophy. There was no history of ankylosis, recurrent subluxation, lateral instability, or recurrent effusions. All joint stability testing performed was normal. There was no evidence of shin splints and the Veteran had no history of meniscal conditions. VA treatment records reflect the Veteran continued to report knee pain. In September 2016, she reported knee pain, but physical evaluation revealed full range of motion bilaterally and no effusions. A VA treatment record dated later in September 2016 noted her bilateral knees had no edema, erythema, ecchymosis, and no effusions. There was no tenderness to palpation, her range of motion was full, there was no valgus/varus laxity, and her anterior/posterior drawer test was negative, but she had patellar grind bilaterally. The Veteran underwent a full knee evaluation at the end of September 2016. She reported that her knees felt stiff and sore in the morning, but would loosen up a little bit. She continued to report pain with ambulation and when climbing stairs. He right knee had no swelling or effusion, and ligament testing reflected all her ligaments were intact. Her range of motion reflected flexion to 115 degrees and full extension with pain, and reported she could not flex her knee further secondary to pain. There was tenderness to palpation, normal patellar tracking, a positive patellar grind test, and crepitus with active extension. The Veteran’s left knee had normal alignment without swelling or effusion. Her active range of motion was also flexion to 115 degrees secondary to pain and full extension. Her left knee was stable with all ligaments intact. She had normal patellar tracking, a positive patellar grind test, and crepitus with active extension. There was no evidence of neurovascular deficits. In October 2016, the Veteran reported knee pain with ambulation, but her range of motion was normal with no effusions. In consideration of the medical evidence, the Board finds that ratings in excess of 10 percent are not warranted under Diagnostic Code 5260. The Veteran’s right and left knee patellofemoral pain syndrome with arthritis manifested as x-ray evidence of arthritis, but very slight limitations of motion with pain. The evidence throughout the entire period on appeal does not show compensable limitation of motion, or flexion limited to 45 degrees. The evidence shows that her flexion was, at worst, limited to 115 degrees bilaterally with pain. Accordingly, only a 10 percent rating is warranted for painful limitation of motion. Moreover, the Veteran has had normal extension throughout the period on appeal; therefore, a separate rating based on limitation of extension is not warranted. The Board has considered whether the Veteran would be entitled to a separate compensable rating under any other diagnostic code applying to the knees. Diagnostic Codes 5258 and 5259 are not applicable as the Veteran does not have any meniscus disabilities. Diagnostic Code 5257 is not applicable because the Veteran has not reported any episodes of “giving way” and ligamentous testing throughout the period on appeal has shown no objective evidence of lateral instability or subluxation. See September 2016 VA treatment record (noting the Veteran’s knees were stable with all ligaments intact). Finally, Diagnostic Code 5256 is not applicable as there is no evidence either of the Veteran’s knees are ankylosed, or that her symptoms are severe enough to be analogous to ankylosis. While the Veteran reported she experienced flare-ups of pain with ambulation and climbing stairs, she never reported that the pain further limited her range of motion. The March 2014 VA examiner noted that her reported flare-ups could additionally limit her range of motion, but could not provide additional functional impairment in terms of limitation of motion. However, the December 2016 VA examiner noted that the Veteran’s reports of flare-ups were consistent with the physical examination, and she did not experience any additional loss of range of motion. The Board notes that the Veteran reported to her primary care physician in September 2016 that her knee pain radiated down her legs and she believed she may have shin splints. She was not diagnosed with shin splints during that evaluation. Additionally, the VA examiner found no evidence or history of shin splints during the December 2016 VA examination. Accordingly, the Board finds the Veteran’s right and left knee patellofemoral pain syndrome with arthritis is fully compensated by her assigned 10 percent disability ratings. The Board additionally has considered whether the Veteran is entitled to higher ratings due to functional impairment under the provisions of 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). In making this determination, the Board considered the Veteran’s statements regarding her symptoms, VA examination reports, and VA treatment records. While the record shows bilateral knee pain and difficulty with ambulation and climbing the stairs, the evidence does not show that her symptoms and flare-ups produce functional loss that is manifested by adequate evidence of disabling pathology for higher ratings. See 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Indeed, the December 2016 VA examiner noted that the Veteran did not experience additional functional loss after repetitive use over time or with a flare-up, and her separate 10 percent disability ratings are already based on the extent to which her symptoms reduce range of motion. In light of the Veteran’s reported symptoms and the medical evidence, the Board finds that the Veteran is not entitled to higher ratings for her right and left knee patellofemoral syndrome with arthritis. In summary, entitlement to separate 10 percent disability ratings for service-connected right and left knee patellofemoral pain syndrome with arthritis effective May 24, 2012 is warranted. For the entire period on appeal, the criteria for entitlement to increased ratings greater than 10 percent for service-connected right and left knee patellofemoral pain syndrome have not been met. As the preponderance of the evidence is against assignment of any higher rating, the benefit-of-the doubt doctrine is not applicable. 38 U.S.C. § 5107(b) (2012); Gilbert, 1 Vet. App. at 49. REASONS FOR REMAND 1. Entitlement to service connection for a left shoulder disability is remanded. The Veteran claims service connection for a left shoulder disability. Service treatment records reflect the Veteran reported bilateral shoulder pain several times while on active duty, and was diagnosed with rhomboid muscle spasms. Post-service VA treatment records indicate the Veteran has continued to report bilateral shoulder pain. The Veteran was afforded VA examinations to evaluate her shoulder in March 2014 and December 2016. Both examinations reflected the Veteran’s left shoulder had limited range of motion with pain and tenderness to palpation. As the Veteran reported left shoulder pain several times while on active duty service and she continues to experience shoulder pain with limited range of motion, the evidence of record meets the low threshold outlined by McLendon v. Nicholson and the Veteran should be afforded a VA examination to determine the etiology of her left shoulder disability. The matter is REMANDED for the following action: Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any left shoulder disability. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including her September 1982 diagnosis of rhomboid muscle spasms and multiple reports of shoulder pain. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Parsons, Associate Counsel