Citation Nr: 18146854 Decision Date: 11/01/18 Archive Date: 11/01/18 DOCKET NO. 03-28 112 DATE: November 1, 2018 ORDER Entitlement to service connection for a left shoulder disability, to include as secondary to a service-connected disability, is denied. Prior to April 26, 2016, an increased disability rating in excess of 30 percent for right (minor) shoulder dislocation is denied. On and after April 26, 2016, an increased disability rating in excess of 20 percent for right (minor) shoulder dislocation is denied. From January 24, 2008, to April 26, 2016, entitlement to a separate disability rating of 20 percent for infrequent dislocation, right (minor) shoulder is warranted. Throughout the appeal period, entitlement to a disability rating in excess of 20 percent for infrequent dislocation, right (minor) shoulder is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is denied. FINDINGS OF FACT 1. The Veteran’s left shoulder disability was not incurred during, and is not otherwise related to, the Veteran’s period of active service. 2. Symptoms of the Veteran’s left shoulder disability have not been continuous since separation from service, and the disability did not manifest to a compensable degree in the year following separation from service. 3. The Veteran’s left shoulder disability is not due to, and has not been aggravated by, his service-connected right shoulder disability. 4. Prior to April 26, 2016, the Veteran’s right (minor) shoulder dislocation manifested with symptoms that resulted in limitation of motion to no more than midway between side and shoulder level. Limitation of motion did not more nearly approximate to 25 degrees from side and ankylosis of the right shoulder was not present. 5. On and April 26, 2016, the Veteran’s right (minor) shoulder dislocation manifested with symptoms that resulted in limitation of motion to no more than midway between side and shoulder level. Limitation of motion did not more nearly approximate to 25 degrees from side and ankylosis of the right shoulder was not present. 6. From January 24, 2008, to April 26, 2016, the Veteran’s infrequent dislocation, right (minor) shoulder is manifested by frequent dislocations at the scapulohumeral joint that results in guarding of all arm movements. 7. Throughout the appeal period, the Veteran’s infrequent dislocation, right (minor) shoulder has not been manifested by fibrous union of, nonunion of, or loss of head of the humerus. 8. The Veteran does not meet the schedular criteria for a TDIU and he has not been rendered unemployable due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left shoulder disability, to include as secondary to a service-connected disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2017). 2. Prior to April 26, 2016, the criteria for a disability rating in excess of 30 percent for right (minor) shoulder dislocation, recurrent are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.14, 4.71a, DC 5201 (2017). 3. On and after April 26, 2016, the criteria for a disability rating in excess of 20 percent for right (minor) shoulder dislocation, recurrent are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.14, 4.71a, DC 5201 (2017). 4. From January 24, 2008, to April 26, 2016, the criteria for a separate disability rating of 20 percent for infrequent dislocation, right (minor) shoulder were met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.14, 4.71a, DC 5202 (2017). 5. Throughout the appeal period, the criteria for a disability rating in excess of 20 percent for infrequent dislocation, right (minor) shoulder have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.14, 4.71a, DC 5202 (2017). 6. The criteria for entitlement to a TDIU are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16(a); 4.16(b) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from January 1976 to January 1979. In June 2016, during the pendency of the Veteran’s appeal, the RO issued a rating decision that granted entitlement to a separate 20 percent rating for infrequent dislocation, right shoulder, effective April 26, 2016, and reduced the Veteran’s rating for right shoulder dislocation, recurrent from 30 to 20 percent effective the same date. A notification letter sent to the Veteran on June 30, 2016 stated that because the reduction did not reduce his overall benefit payment that a 60-day due process period was not required. The Veteran has not expressed disagreement with the reduction of his right shoulder disability and did not appeal the determination within one year of notice to the Veteran; accordingly, the Board will not address the propriety of the reduction of the Veteran’s right shoulder dislocation, recurrent, effective April 26, 2016. Entitlement to Service Connection for a Left Shoulder Disability The Veteran has argued that his current left shoulder disability is due to his active service, either on a direct basis or as secondary to his service-connected right shoulder disability. Unfortunately, the evidence of record weighs against the claim for service connection and it must be denied. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). In addition, certain chronic disabilities are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. A left shoulder strain is not listed as a chronic disease under 38 C.F.R. § 3.309, and therefore the provisions of 38 C.F.R. § 3.303(b) are not applicable in this case. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). While arthritis is considered to be a “chronic disease,” and the Veteran has been diagnosed with degenerative joint disease of the bilateral shoulders, the evidence does not indicate that such a disability was incurred in service or within one year of separation from service; therefore, the provisions of 38 C.F.R. § 3.303(b) are not applicable. Service connection may also be awarded for any disability which is proximately due to or the result of, or is otherwise aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. “When aggravation of a veteran’s non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation.” Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran entered active duty service in January 1976. The Veteran’s service medical records indicate that the Veteran reported left shoulder pain for approximately one week in September 1977. The Veteran reported a history of shoulder pain and was scheduled to see an orthopedic physician later that month. The Veteran underwent a physical examination on August 8, 1978. The only defect noted was recurrent dislocations of his right shoulder. On September 22, 1978, the Veteran was seen at the orthopedic clinic for a repeat visit regarding his right shoulder that was “dislocated again.” The Veteran was advised regarding surgery on his right shoulder. In December 1978, prior to his discharge from service, the Veteran indicated that his condition had not changed since his most recent physical examination. In September 1980, the Veteran underwent a VA examination regarding his claim for service connection for his right shoulder disability. The Veteran reported that a section of tank tread “fell on his right shoulder, dislocating the joint.” No left shoulder disability was reported by the Veteran. Physical examination indicated the presence of a scar to the Veteran’s right shoulder, but no limitations of the Veteran’s left shoulder were noted by the examiner. In November 1986, the Veteran was seen for a consultation regarding a motor vehicle accident that he was involved in. The evidence indicates that a truck made a right turn in front of a bus that the Veteran was driving. The truck struck the bus on the driver’s side causing the Veteran to sustain injuries to his back, shoulder, and arm. The diagnosis was a severe shoulder sprain and a severe sprain to his vertebral column. A depiction of the Veteran’s complaints indicates that he suffered injuries to his back, his neck, his right shoulder, and his right hand. During a VA examination in October 1998, the Veteran was noted to have been employed as a security patrolman over the prior five years. He indicated that he had performed this job until February 10, 1998, when he was injured in a fall down an embankment. The Veteran reported that he injured his neck and his left shoulder, and that he sustained contusions over the left side of his body. He reported that he was under the care of an orthopedic surgeon related to these injuries and that he had a probable rotator cuff tear of the left shoulder. The examiner diagnosed the Veteran with a recent cervical strain and possible left rotator cuff tear, non-service related. In January 2008, the Veteran submitted a claim for entitlement to service connection for a left shoulder condition secondary to his service-connection right shoulder condition. During his hearing on appeal, he reported that his current left shoulder condition was due to his right shoulder condition. He stated that he “worked with [his] left arm so much trying to compensate, [his] left arm is weaker than [his] right.” In September 2013, the Veteran submitted an x-ray of his left shoulder, dated March 25, 2008. He reported that he was losing his ability to use his left arm and that his condition was causing him chronic pain. In February 2015, the Veteran was seen for a physical medicine and rehabilitation consultation at the Long Beach VA Medical Center (VAMC). The examiner indicated that the Veteran had degenerative joint disease of his bilateral shoulders and a trial of acupuncture was offered to the Veteran. In March 2015, the Veteran was seen again for a physical medicine and rehabilitation consultation at the Long Beach VAMC. The Veteran reported increased pain in his bilateral shoulders. The Veteran’s physician opined that the Veteran’s increased pain in his shoulders was due to his use of a manual wheelchair, rather than a self-propelled wheelchair. In September 2017, the Veteran underwent a VA examination regarding his bilateral shoulders. The examiner opined that the Veteran current left shoulder disabilities were less likely than not due to, or the result of, any incident of the Veteran’s period of active service. The examiner also opined that the Veteran current left shoulder disabilities were less likely than not caused, or aggravated by, any service-connected disability. The examiner stated that his opinion that the Veteran’s current left shoulder disabilities were less likely than not due to, or the result of, any incident of the Veteran’s period of active service was supported by the Veteran’s normal separation examination of his left shoulder and the fact that the Veteran’s service treatment records report that he only sought treatment for his left shoulder during service once in September 1977. The examiner indicated that the Veteran’s lack of complaints related to his left shoulder at separation and the fact that he was involved in a post-service motor vehicle accident in 1985 and a work-related injury in 1998 occurred supported a finding that the Veteran’s current left shoulder disabilities were less likely than not due to, or the result of, any incident of the Veteran’s period of active service. The 2017 examiner also opined that the Veteran’s current left shoulder disabilities were less likely than not caused, or aggravated by, any service-connected disability. The examiner noted that review of the Veteran’s medical records indicate that the Veteran in May 1999 described suffering an injury to his left shoulder after falling down a hill and that he described it at that time as a work-related injury. The examiner indicated that this injury and statement provided by the Veteran regarding his condition after the injury made it less likely than not that his current left shoulder disabilities were less likely than not caused by any service-connected disability. The 2017 examiner also opined that the Veteran’s current left shoulder disabilities were not aggravated by any service-connected disability. The examiner stated that a baseline for the Veteran’s left shoulder could not be determined and that the evidence indicate a permanent worsening of the Veteran’s left shoulder disabilities beyond the natural progression by his service-connected right shoulder disability. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See Caluza v. Brown, 7 Vet. App. 498 (1995). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the Veteran. Unfortunately, the Board finds that evidence of record weighs against the Veteran’s claim for service connection for a left shoulder disability on a direct and secondary basis. While the evidence indicates that the Veteran suffered an injury to his left shoulder during his active service, the evidence does not indicate that any current left shoulder disability is related to this in-service incident. The Veteran’s subsequent attempts to seek treatment after September 1977 all relate to his right shoulder. At separation, the Veteran did not indicate any problems with his left shoulder. Further, during a VA examination conducted within a year of his separation from service, his left shoulder revealed normal findings. The September 1980 examination did not provide any evidence that the Veteran had degenerative joint disease of the left shoulder or any other left shoulder disability that had manifested during service or since his separation from service. Additionally, no competent evidence of record supports a link between any current left shoulder disability, including degenerative joint disease of his left shoulder or a left shoulder strain, to any incident of his active service. The only competent medical opinion of record indicates that it is less likely than not that the Veteran’s current left shoulder disability is related to his active service. The 2017 examiner opined that the evidence indicated that it less likely than not that any current left shoulder disability is related to any incident of the Veteran’s period of active service. The examiner supported this opinion by noting the Veteran’s lack of complaints regarding his left shoulder at separation, his normal VA examination in September 1980, and his history of a post-service fall injury to the left shoulder. Additionally, none of the competent evidence of record supports a link between any current left shoulder disability and any service-connected disability, including the Veteran’s service-connected right shoulder disability. The 2017 examiner opined that the evidence indicated that it less likely than not that any current left shoulder disability is due to, or aggravated by, a service-connected disability, including any disability of his right shoulder. While the examiner reviewed the record, including the Veteran’s contention that overuse of his left shoulder due to his right shoulder disability caused his left shoulder disability, the examiner stated that the evidence of record, including a statement provided by the Veteran in May 1999, indicates that the Veteran’s current left shoulder disabilities are due to a work-related injury and was not likely due to any service-connected right shoulder disability. The examiner also opined that evidence weighed against a finding that the Veteran’s left shoulder condition was aggravated by his right shoulder based upon his history of his work-related left shoulder injury and the inability to establish a baseline for his left shoulder. While the Veteran’s current physician noted increased pain in the Veteran’s bilateral shoulders, he opined that this increase was due to the Veteran’s use of a manual wheelchair, rather than a self-propelled wheelchair. While the Veteran himself has asserted that his current left shoulder disorder either began during service, or is the result of his service-connected right shoulder disability, the Veteran is not competent to offer an opinion regarding a nexus between his current left shoulder disabilities and his period of service, or between his current left shoulder disabilities and his service-connected right shoulder disabilities. A layperson is competent to report observable symptomatology which comes to him via his senses. See Jandreau v. Nicholson, 492 F.3d 1372 Fed. Cir. 2007); see also Buchanan, at 1331. Some medical issues, however, require specialized training for a determination as to diagnosis and causation, and such issues are therefore not susceptible of lay opinions on etiology, and the Veteran’s lay statements cannot be accepted as competent medical evidence with regard to this issue. See Jandreau, 492 F.3d at 1377 (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). Diagnosing and determining the cause of recurrent shoulder condition, particularly as secondary or aggravated by another shoulder condition, requires interpretation of symptoms, knowledge of orthopedic medical practice, and other specialized expertise and training, which has not been demonstrated by the Veteran in the present case. Based on the examination reports, treatment reports, and the other competent evidence of record, the Board finds the preponderance of the evidence to be against the claim of service connection for a left shoulder disability. The Veteran was not diagnosed with left shoulder disability during service, and no medical expert has provided evidence of a link between service and any current left shoulder diagnosis. Further, the uncontroverted medical evidence offered by the September 2017 VA examiner determined that the Veteran’s current left shoulder disability was not caused by his period of service, or caused or aggravated by the Veteran’s service-connected right shoulder condition. Thus, service connection for a left shoulder disability must be denied on a direct and secondary basis. For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for a left shoulder disability, and the claim must be denied. The benefit-of-the-doubt doctrine is, therefore, not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Ratings Disability evaluations (ratings) are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the entire record to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran’s favor. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Entitlement to an Increased Rating for a Right Shoulder Disability In January 2008, the Veteran requested an increased rating based upon individual unemployability. The Veteran submitted a statement indicating that his service-connected right shoulder disability was causing him to be unable to work. Based upon this claim, a claim for an increased rating for his service-connected right shoulder disability was inferred. At that time, the Veteran’s right shoulder dislocation, recurrent was rated 30 percent disabling under Diagnostic Code 5201. In August 2009, the Veteran’s claim for an increase was denied and his 30 percent rating was continued. The Veteran appealed this decision. In June 2016, the Veteran’s evaluation of 30 percent for right shoulder dislocation, recurrent was reduced to 20 percent. Upon review of the evidence of record, the Board finds that a higher rating is not warranted during either period. The Board finds, however, that a separate 20 percent evaluation is warranted for frequent dislocations of the scapulohumeral joint from the date of claim for increase, rather than date assigned by the June 2016 rating decision. Under Diagnostic Code 5201, a 20 percent rating is warranted for limitation of motion of either the major or minor arm to shoulder level. For the minor arm, a 20 percent rating is also warranted for limitation of motion to midway between the side and shoulder level. For the major arm, a 30 percent rating is warranted for limitation of motion of the major arm to midway between the side and shoulder level. For the minor arm, a 30 percent rating is warranted for limitation of motion of the arm to 25 degrees from the side. A schedular maximum 40 percent rating is warranted for limitation of motion of the major arm to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Normal ranges of motion of the shoulder are forward flexion and abduction from 0 to 180 degrees and internal and external rotation from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. The terms “major” and “minor” are used in the rating criteria to refer to the dominant or nondominant upper extremity. 38 C.F.R. § 4.69. (The Board notes that the rating decision lists the Veteran’s right shoulder as major; however, most of the evidence in the file indicates that the Veteran’s dominant hand is his left hand. This is reported in VA examinations in April 2002, May 2015, and September 2017. The Veteran also states that he is left-handed during his January 2008 Board hearing. See H.T., p. 25.) Accordingly, the Board will consider the Veteran’s right arm as his minor arm for rating purposes. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. See DeLuca v. Brown, 8 Vet. App. 202 (1995). This includes the analysis of additional functional impairment above and beyond the limitation of motion objectively demonstrated involving such factors as painful motion, weakness, incoordination, and fatigability, etc., particularly during times when these symptoms “flare up,” such as during prolonged use, and assuming these factors are not already contemplated in the governing rating criteria. Id. See also 38 C.F.R. §§ 4.40, 4.45 and 4.59. In this regard, manifestation of pain alone does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Veteran’s right shoulder disabilities have been evaluated numerous times during the appeal period. In addition to his regular medical treatment, the Veteran underwent VA examinations that evaluated the severity of his right shoulder disabilities in August 2008, May 2015, June 2016, and September 2017. In August 2008, the Veteran underwent a VA examination regarding his right shoulder. The examiner noted that the Veteran’s left hand was the dominant extremity because he uses the left hand to write, eat, and comb his hair. The Veteran reported that his shoulder pain causes symptoms of weakness, stiffness, giving way, lack of endurance, fatigability and dislocation. He denied swelling, heat, redness, and locking of the shoulder. He reported constant pain in the shoulder that travels down the right arm. He stated that his symptoms decrease his ability to lift or carry heavy objects and causes pain with frequent reaching. Range of motion testing revealed flexion of the right shoulder from 0 to 150 degrees with pain at that point. Abduction on the right was reported to be from 0 to 130 degrees with pain at that point. Additional limitations due to pain, fatigue, weakness, and lack of endurance were noted after repetitive motion. In May 2015, the Veteran shoulder was evaluated again by a VA examiner. The Veteran stated that “felt like his shoulder is not in place.” Range of motion testing revealed right shoulder flexion from 0 to 90 degrees and abduction from 0 to 90 degrees. Additional limitations were not demonstrated after repetitive use testing and the Veteran denied flare-ups of the condition. In June 2016, the Veteran reported a marked increase in pain and limitation of range of motion since the prior examination. He reported popping and clicking of the shoulder and that his condition was causing restriction of his activities of daily living. Right shoulder flexion was reported from 20 to 70 degrees and abduction was also from 20 to 70 degrees. The Veteran reported flare-ups that occur with overhead activities that cause him to be unable to perform overhead motions. The examiner stated that shoulder instability or dislocation was suspected and that the Veteran had a history of recurrent dislocation of the glenohumeral (scapulohumeral) joint. The examiner opined that these were infrequent episodes that caused guarding of all arm movements. The examiner stated that the Veteran’s right shoulder caused functional limitations that precluded overhead movement or activities and reported favorable ankylosis of the right shoulder in abduction up to 60 degrees. In September 2017, the Veteran’s right shoulder condition was evaluated again. The Veteran reported symptoms of shooting pain down his shoulder, numbness, and a lack of strength in his shoulder. During flare-ups, he reported that he has no feeling in his shoulder while he is laying down, that it feels swollen, it feels like it is bone on bone. Right shoulder flexion was reported from 0 to 100 degrees and abduction was also from 0 to 100 degrees. The examiner stated that the right shoulder did not demonstrate additional loss of range of motion after observed repetitive use. While repeated use over time and flare-ups were noted to cause functional impairment of pain, weakness, and lack of endurance, no additional limitation in range of motion was reported. While less movement than normal was reported, ankylosis of the right shoulder was denied. Upon review of the evidence of record, the Board finds that the evidence of record weighs against a finding that the Veteran’s limitation in motion of his right shoulder warrants a rating in excess of 30 percent prior to April 26, 2016, or in excess of 20 percent, thereafter. Prior to April 26, 2016, the Veteran is in receipt of the highest schedular rating available for limitation of range of motion of the non-dominant shoulder under DC 5201. While none of the evaluations indicated that the Veteran’s right shoulder flexion or abduction was limited to 25 degrees or less from his side, even such a finding would not warrant a higher rating under DC 5201 for the minor shoulder. Also, with respect to DC 5201, the Veteran is only entitled to a single disability rating for the right arm for limitation motion at the shoulder joint. In Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013), the Federal Circuit held that 38 C.F.R. § 4.71a, DC 5201 does not provide separate ratings for limitation of motion in the flexion and abduction planes for a single arm, but rather a single rating based on “limitation of motion of” the arm. As such, even though the Veteran has limitation of motion both in flexion and abduction in this case, only a single rating, based on the greatest type of limitation of motion, is warranted. As the Veteran is already receiving the maximum schedular rating for limitation of motion of the minor extremity during this period and the evidence does not support a finding of ankylosis of the right arm, the Board finds that a rating in excess of 30 percent prior to April 26, 2016 is not warranted under DC 5201 or DC 5200. The Board also finds that a rating in excess of 20 percent is not warranted under DC 5201 on and after April 26, 2016. In order to warrant a rating in excess of 20 percent for limitation of motion of the minor arm under DC 5201, the Veteran’s condition would need to more nearly approximate limitation of motion to 25 percent or less from his side. Both VA examinations conducted after April 26, 2016, indicate range of motion well beyond 25 degrees from his side. The 2016 and 2017 VA examinations report that the Veteran had flexion and abduction to at least 70 degrees, including consideration of painful motion and additional limitations due to flare-ups. The Veteran’s VA treatment records after April 26, 2016 also do not indicate limitation of motion that more nearly approximates range of motion to 25 degrees or less for either flexion or abduction. While the 2016 examiner indicated that the Veteran had favorable ankylosis of the right shoulder, the Board finds that the weight of the evidence of record does not support this finding. Ankylosis is defined as immobility and consolidation of a joint due to disease, injury or surgical procedures. See Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). While the Veteran has reported limitation of motion of his right shoulder, the competent evidence of record, including his September 2017 VA examination and subsequent VA treatment records, indicate that the Veteran is able to move his shoulder to some extent. Accordingly, the Board finds that the evidence of record weighs against a rating in excess of 20 percent for the Veteran’s right shoulder on and after April 26, 2016 based upon either DC 5201 or DC 5200. See 38 C.F.R. §§ 4.3, 4.71a, DC 5200, 5201 (2017). The Board, however, finds that the evidence does support separate entitlement to a 20 percent rating for infrequent dislocation, right (minor) shoulder from the date of claim until the separate rating was assigned on April 26, 2016 under DC 5202. The disability that the Veteran initially filed an increased rating claim for has been rated under DC 5201 for limitation of motion of the arm; however, one of the Veteran’s most frequent complaints is related to instability of his arm/shoulder, rather than limitation of motion. In his August 2008 examination, he complained of symptoms of weakness, giving way, and dislocation. This examination, however, did not discuss whether the Veteran was suffering from dislocations of his shoulder, despite his service-connected disability being listed as “right shoulder dislocation, recurrent.” In May 2015, the Veteran reported that he felt like his right shoulder “is not in place” and during examinations in 2016 and 2017 impairment of the glenohumeral/scapulohumeral joint was reported. Under DC 5202, recurrent dislocation of the scapulohumeral joint of the minor upper extremity with infrequent or frequent episodes and guarding of arm movements warrants a 20 percent rating. Fibrous union of the humerus warrants a 40 percent rating. Nonunion of the humerus (false flail joint) warrants a 50 percent rating. Lastly, loss of head of the humerus (flail shoulder) warrants a 70 percent rating-the maximum rating for the minor upper extremity under DC 5202. 38 C.F.R. § 4.71a (2017). The evidence of record indicates that the Veteran has had recurrent dislocations of scapulohumeral joint of the minor upper extremity throughout the appeal period; accordingly, the Board finds that a separate rating of 20 percent is warranted under DC 5202 from January 24, 2008, to April 26, 2016. See 38 C.F.R. §§ 4.3, 4.71a, DC 5202 (2017). The Board notes, however, that a rating in excess of 20 percent is not warranted under DC 5202 throughout the appeal period. To warrant a rating in excess of 20 percent under DC 5202, the record must show the Veteran suffers from either fibrous union, nonunion, or loss of head of the humerus. While the Veteran has reported recurrent dislocations of the shoulder, fibrous union, nonunion, or loss of head of the humerus have not been reported. Moreover, the 2016 and 2017 examiners denied that such a condition was present, and no medical evaluation of record has reported such a condition. Accordingly, the Board finds that a rating in excess of 20 percent is not warranted under DC 5202 throughout the appeal period. See 38 C.F.R. §§ 4.3, 4.71a, DC 5202 (2017). Entitlement to a TDIU A total rating based on unemployability due to service-connected disabilities may be granted where the schedular rating is less than total and the service-connected disabilities preclude the veteran from obtaining or maintaining substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16 (a). Disabilities resulting from a common etiology or a single accident will be considered as one disability. 38 C.F.R. § 4.16 (a)(1). The Veteran’s only service-connected disabilities are right (minor) shoulder dislocation, recurrent, rated 20 percent disabling; infrequent dislocation, right (minor) shoulder, rated as 20 percent disabling; painful right shoulder scar, rated 10 percent disabling; and a non-compensable right shoulder scar. These conditions result in a combined rating of 40 percent, which is below the necessary threshold for a TDIU. (Prior to April 26, 2016, the Veteran’s 50 percent rating also did not meet the criteria for a TDIU on a schedular basis). Accordingly, a TDIU on a schedular basis is denied. See 38 C.F.R. § 4.16 (a). For those veterans who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16 (a), total disability ratings for compensation may nevertheless be assigned when it is found that the service-connected disabilities are sufficient to produce unemployability; such cases should be referred to the Director, Compensation and Pension Service, for extra-schedular consideration. 38 C.F.R. § 4.16 (b). While the Veteran does not meet the criteria for a TDIU on a schedular basis, the Veteran has maintained that his service-connected conditions result in his inability to secure or follow a substantially gainful occupation; therefore, a TDIU on an extraschedular basis must be considered. Unfortunately, the evidence of record does not support that the Veteran is unable to secure or follow a substantially gainful occupation solely due to his service-connected disabilities and referral for extraschedular consideration of TDIU is not warranted. The central inquiry for entitlement to TDIU is “whether the veteran’s service connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to his or her level of education, special training, and previous work experience, but advancing age and the impairment caused by nonservice-connected disabilities are not for consideration in determining whether such a total disability rating is warranted. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2017); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Board finds that the evidence of record does not support that his right shoulder disabilities on their own cause the Veteran to be unable to secure or follow a substantially gainful occupation. In each of the Veteran’s VA examination, the examiner has commented on the Veteran’s functional impairment related to his right shoulder disabilities. The examiners have stated that the Veteran’s right shoulder causes him to be unable to perform any overhead activity, restricts his ability to lift and carry heavy objects, and limits his ability to frequently reach for objects with his right arm. The Board notes, however, that the Veteran’s right arm is not his dominant extremity and that it is impairments related to his nonservice-connected left arm that interfere with his ability to write or other activities necessary for sedentary work. The Board notes that the Veteran indicated on his January 2008 application that he completed high school and had two years of college education, which would prepare him for light and sedentary duty jobs. Even the Veteran himself has indicated that his right shoulder condition by itself does not preclude him from working. In the Veteran’s initial application for TDIU, the Veteran reported that service-connected disabilities related to his right shoulder and neck prevented him from working. The Veteran also indicated in this application that he became too disabled to work after a heart issue in 2001. The Veteran’s medical records document that the Veteran underwent a coronary angiogram and had a stent placed in 2001. The Board notes that the Veteran is not service-connected for a neck disability or a heart disability. The Board finds that the weight of the competent evidence of record does not establish that the Veteran is unable to secure or follow a substantially gainful occupation solely due to his service-connected conditions. While the evidence of record clearly establishes that the Veteran has functional loss due to his right shoulder disability that affects his ability to perform heavy lifting and reaching overhead, the evidence does not indicate that the Veteran is to secure or follow a substantially gainful occupation solely due to his service-connected conditions. Therefore, the Board finds that referral for extraschedular consideration of TDIU is not warranted. 38 C.F.R. § 4.16. Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the appellant of any information and medical or lay evidence that is necessary to substantiate the claim. The Board finds that evidence of record indicates that the duty to notify has been satisfied. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2017). The Board also finds that the duty to assist has been satisfied regarding the issues decided on appeal. VA has made every reasonable effort to obtain all records relevant to the Veteran’s claim, and has fully complied with the Board’s remand directives from December 2014 and August 2017. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The evidence of record includes the Veteran’s VA treatment records, private treatment records, hearing transcripts, statements from the Veteran and his representative, and VA examination reports. The 2017 VA examiner obtained a history from the Veteran and recorded pertinent examination findings. The Board notes that the VA examination reports from 1980 and 2017 are probative regarding the nature and etiology of the Veteran’s current left shoulder condition. In this regard, it is noted that these examinations were provided following review of the claims file, physical examination of the Veteran, and interview of the Veteran. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board also finds the medical examinations of record are adequate to resolve the Veteran’s claims for a higher rating for a right shoulder condition and entitlement to a TDIU. The Board finds that the August 2008, June 2016, and September 2017 VA examinations, in combination with the treatment records associated with the claims file, to be comprehensive and sufficient in addressing the severity of the Veteran’s symptoms and resulting functional impairment caused by the Veteran’s right shoulder disabilities. The Veteran has not identified any outstanding records that are relevant to any of the claims denied in this decision. The Board finds that the duty to assist has, therefore, been satisfied and there is no reasonable possibility that further assistance would be capable of substantiating the claims decided on appeal. 38 U.S.C. § 5103A (a)(2) (2012). T.D. JONES Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P.M. Johnson, Counsel