Citation Nr: 18147478 Decision Date: 11/05/18 Archive Date: 11/05/18 DOCKET NO. 15-33 867 DATE: November 5, 2018 ORDER New and material evidence in support of a claim of entitlement to service connection for a cervical spine (neck) disability has been received and the claim is reopened. New and material evidence in support of a claim of entitlement to service connection for a thoracolumbar spine (back) disability has been received and the claim is reopened. New and material evidence in support of a claim of entitlement to service connection for a right knee disability has been received and the claim is reopened. New and material evidence in support of a claim of entitlement to service connection for a left knee disability has been received and the claim is reopened. Entitlement to service connection for a cervical spine (neck) disability is granted. Entitlement to service connection for a thoracolumbar spine (back) disability is granted. Entitlement to service connection for a right knee disability is granted. Entitlement to service connection for a left knee disability is granted. Entitlement to an initial rating in excess of 10 percent disabling for service-connected left shoulder disability is denied. Entitlement to an initial rating in excess of 10 percent disabling for service-connected right wrist disability, status post fracture with degenerative joint disease, is denied. FINDINGS OF FACT 1. In a December 1987 rating decision, the Regional Office (RO) denied service connection for polyarthralgia of multiple joints (including the spine and knees). The Veteran did not appeal that determination. 2. Evidence received since the December 1987 rating decision is new and material because the evidence had not previously been submitted, is not cumulative or redundant of the evidence of record at the time of the prior rating decision, and raises a reasonable possibility of substantiating the Veteran’s claims of entitlement to service connection for a neck disability, a back disability, and right and left knee disabilities. 3. The Veteran has a cervical spine (neck) disability which is etiologically related to an injury or disease during his active service. 4. The Veteran has a thoracolumbar spine (back) disability which is etiologically related to an injury or disease during his active service. 5. The Veteran has a right knee disability which is etiologically related to an injury or disease during his active service. 6. The Veteran has a left knee disability which is etiologically related to an injury or disease during his active service. 7. The Veteran’s left shoulder disability is manifested by limitation of motion of 125 degrees flexion and 130 degrees abduction, with some functional limitations due to pain. 8. The Veteran’s right wrist disability is manifested by limitation of motion to, at worst, 0 to 25 degrees of palmar flexion and 0 to 35 degrees of dorsiflexion with x-ray evidence of arthritis and objective evidence of painful motion. The Veteran has flare-ups causing pain and loss of grip strength. He had functional limitations due to pain, weakness, and lack of endurance. CONCLUSIONS OF LAW 1. The December 1987 rating decision is final. 38 U.S.C. § 7105 (West 2014); 38 C.F.R. § 20.1103 (2017). 2. The criteria for reopening the claim of entitlement to service connection for a neck disability have been met. 38 U.S.C. §§ 5103A, 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 3. The criteria for reopening the claim of entitlement to service connection for a back disability have been met. 38 U.S.C. §§ 5103A, 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 4. The criteria for reopening the claim of entitlement to service connection for a right knee disability have been met. 38 U.S.C. §§ 5103A, 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 5. The criteria for reopening the claim of entitlement to service connection for a left knee disability have been met. 38 U.S.C. §§ 5103A, 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 6. The criteria for entitlement to service connection for a cervical spine disability have been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2017). 7. The criteria for entitlement to service connection for a back disability have been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2017). 8. The criteria for entitlement to service connection for a right knee disability have been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2017). 9. The criteria for entitlement to service connection for a left knee disability have been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2017). 10. The criteria for entitlement to an initial rating in excess of 10 percent disabling for service-connected left shoulder disability have not been met. 38 U.S.C. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, and 5201 (2017). 11. The criteria for entitlement to an initial rating in excess of 10 percent disabling for service-connected right wrist disability, status post fracture with degenerative joint disease, have not been met. 38 U.S.C. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5214, and 5215 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from May 1975 to July 1986. The Board acknowledges that the issues of entitlement to service connection for an acquired psychiatric disorder (to include depression), tension headaches, and sleep apnea were perfected for appeal in 2017, but have not yet been certified to the Board. The Board’s review of the claims file reveals that the AOJ is still taking action on these issues and has not yet certified the claims to the Board. Therefore, the Board will not accept jurisdiction over them at this time, but they will be the subject of a subsequent Board decision, if otherwise in order. The Veteran submitted evidence relevant to the claims on appeal directly to the Board subsequent to the issuance of the statements of the case on the issues listed above. Because the evidence was submitted directly to the Board without request for remand for consideration of that evidence by the agency of original jurisdiction (AOJ), the Board may proceed to the merits. 38 U.S.C. § 7105(e)(1) (West 2014) (providing that where the substantive appeal was filed on or after February 2, 2013, such evidence is subject to initial review by the Board unless the claimant or the claimant’s representative requests in writing that the AOJ initially review the evidence); see also November 2016 Correspondence (enclosing evidence and requesting Board review of the claims). The record also contains additional medical evidence that is not pertinent to the claims on appeal; rather the evidence relates to the pending psychiatric, headache, and sleep apnea claims. Because that evidence is not pertinent to this appeal, the Board may proceed to the merits of the claims before it. 38 C.F.R. § 20.1304(c). Reopen Claims Based on New and Material Evidence The Veteran filed an initial claim of entitlement to service connection for “spinal problems, joints, broken bone still in risk [sic].” That claim was denied on the merits in a December 1987 rating decision due to lack of evidence of current disabilities of, in pertinent part, the spine or knees. The Veteran did not appeal that determination or submit new and material evidence within one year, so it became final. In May 2012, the Veteran filed a claim of entitlement to service connection for disabilities of the neck, back, wrist, shoulder, and bilateral knees. In a July 2013 rating decision, the RO denied reopening of the back and bilateral knee claims due to the failure of the Veteran to attend scheduled VA examination. The RO denied the neck claim on the merits, having interpreted the 1986 claim and/or the 1987 rating decision as addressing only the thoracic and lumbar spine. The Board finds that the original claim only specified the spine and the Veteran complained of “neck [and] lower back pain” at his August 1987 VA examination, so a neck claim was reasonably encompassed within the 1986 claim and 1987 rating decision. Although the RO did not address reopening of the neck claim, the Board may reach that issue without prejudice to the Veteran because it is being granted. The RO has certified the neck, back, and knee claims as on appeal from a 2015 rating decision. However, following the July 2013 rating decision, roughly two (2) weeks later, the Veteran contacted VA stating that he had “never received the exam appointment scheduled 06/11/2013.” See July 2013 VA 21-0820. Therefore, new examinations were provided to him in March 2014, with additional nexus opinions provided in May 2014. The RO also received records from the Social Security Administration in September 2014. If new and material evidence is received within one year of a rating decision, it does not become final. This evidence was new and material as it showed diagnoses of the claimed conditions, the Veteran’s allegations of in-service injuries and history of symptoms since, as well as nexus opinions. Therefore, the July 2013 rating decision did not become final. The December 1987 rating decision was the most recent, final decision on the merits of the neck, back, and knee claims. A final decision cannot be reopened unless new and material evidence is presented. 38 U.S.C. § 5108. The Secretary must reopen a finally disallowed claim when new and material evidence is presented or secured with respect to that claim. See Shade v. Shinseki, 24 Vet. App. 110, 113 (2010). Evidence is “new and material” if it (1) has not been previously submitted to agency decision makers; (2) relates to an unestablished fact necessary to substantiate the claim; (3) is neither cumulative nor redundant of evidence already of record at the time of the last prior final denial of the claim sought to be opened; and (4) raises a reasonably possibility of substantiating the claim. 38 C.F.R. § 3.156(a). 1. New and material evidence sufficient to reopen a neck disability Since the most recent, final decision on the merits of the neck claim, the record contains new and material evidence including, in particular, evidence of a current neck disability as well as a favorable nexus opinion on the claim. The evidence is new in that it is not cumulative or redundant of previous evidence and, if believed, is sufficient to create a reasonable possibility of substantiating his claim. In making this determination, the Board must presume that newly submitted evidence is credible. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). The evidence of a current neck disability, an in-service event or injury, and the recently submitted positive nexus opinion is enough to reopen under the low threshold of Shade. The claim of entitlement to service connection for a neck disability is reopened. 2. New and material evidence sufficient to reopen a back disability Since the most recent, final decision on the merits of the back claim, the record contains new and material evidence including, in particular, evidence of a current back disability as well as a favorable nexus opinion on the claim. The evidence is new in that it is not cumulative or redundant of previous evidence and, if believed, is sufficient to create a reasonable possibility of substantiating his claim. In making this determination, the Board must presume that newly submitted evidence is credible. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). The evidence of a current back disability, an in-service event or injury, and the recently submitted positive nexus opinion is enough to reopen under the low threshold of Shade. The claim of entitlement to service connection for a back disability is reopened. 3. New and material evidence sufficient to reopen a right knee disability Since the most recent, final decision on the merits of the right knee claim, the record contains new and material evidence including, in particular, evidence of a current right knee disability as well as a favorable nexus opinion on the claim. The evidence is new in that it is not cumulative or redundant of previous evidence and, if believed, is sufficient to create a reasonable possibility of substantiating his claim. In making this determination, the Board must presume that newly submitted evidence is credible. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). The evidence of a current right knee disability, an in-service event or injury, and the recently submitted positive nexus opinion is enough to reopen under the low threshold of Shade. The claim of entitlement to service connection for a right knee disability is reopened. 4. New and material evidence sufficient to reopen a left knee disability Since the most recent, final decision on the merits of the left knee claim, the record contains new and material evidence including, in particular, evidence of a current left knee disability as well as a favorable nexus opinion on the claim. The evidence is new in that it is not cumulative or redundant of previous evidence and, if believed, is sufficient to create a reasonable possibility of substantiating his claim. In making this determination, the Board must presume that newly submitted evidence is credible. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). The evidence of a current left knee disability, an in-service event or injury, and the recently submitted positive nexus opinion is enough to reopen under the low threshold of Shade. The claim of entitlement to service connection for a left knee disability is reopened. Service Connection Generally, service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110 and 1131; 38 C.F.R. § 3.303. In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). There are also provisions relating to continuity of symptomatology (which the Veteran alleges), but the Board will not summarize those or apply them here as the claims are granted based on the above principles. 5. Entitlement to service connection for a neck disability The Veteran claims entitlement to service connection for a neck disability which, he alleges, first manifested during his active service. On January 22, 1980, during his active service, the Veteran was seen for polyarthralgia of unclear etiology characterized in significant part by recurring neck pain over a three (3) year period. The medical professional concluded that there was no objective evidence of an inflammatory process, joint pathology, lupus, psoriasis, or bowel disease to explain the polyarthralgia. This evidence establishes an in-service event or injury involving the neck. As for a current disability, that has been established by VA treatment records as well as a May 2014 VA examination which diagnosed degenerative disc disease of the cervical spine. The remaining element of the Veteran’s claim is a causal nexus between the in-service neck pain and the current neck disability. At the Veteran’s discharge, the November 1985 Report of Medical Examination indicated spine and joints were all normal. However, the physician completing the February 1986 Report of Medical History noted a long history of “polyarthralgia [with] no diagnosis of causation.” An August 1987 VA examination showed full range of motion in all joints, x-rays were normal, and laboratory results were all normal. The examiner diagnosed history of polyarthralgia with insufficient clinical evidence to warrant a diagnosis of any acute or chronic disorder, or residuals thereof. Because it did not directly address the cervical spine, the medical opinions (including a lack of diagnosis) is of limited probative value with respect to the neck claim. The RO obtained a May 2014 opinion from a VA examiner. The examiner opined that the Veteran’s current neck disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner’s rationale was that, despite x-rays and laboratory testing, the only in-service diagnosis given was “arthralgia, which is simply joint pain.” Notably, the examiner did not discuss the January 1980 Orthopedic Consult relied upon by the physician who provided an October 2016 Private Opinion Letter. The October 2016 Private Opinion Letter sets forth a physician’s opinion that “it is as likely as not that [the Veteran’s] back, neck, and multiple joint pain began in service and continues to this day.” He explained that the Veteran’s “complaints of pain while in the Army are consistent with his ongoing and current medical conditions.” He also provided an accurate summary of the available medical evidence including the statement of a physician who opined in January 1980 that the Veteran “appears to be one of those unfortunate ones with real arthralgias and no objective evidence of any inflammatory process or joint pathology.” He also agreed with the March 2014 VA examiner’s opinion that the knee, elbow, back, and wrist conditions were as likely as not incurred or caused by the claimed in-service injury, event or illness. The October 2016 Private Opinion Letter is more thorough and more convincing than the May 2014 VA examiner’s opinion. The sole stated rationale for the May 2014 VA examiner’s opinion is that there was no in-service diagnosis “except for arthralgia.” The private physician indicates that there was evidence of a disease process during service, including based on the January 1980 consult with an orthopedic specialist who characterized the Veteran’s condition as “real arthralgias” despite “no objective evidence of any inflammatory process or joint pathology.” The October 2016 opinion reviews the evidence, including consistent complaints, and concludes that, although not definitively diagnosed during service, the Veteran did have an actual medical condition affecting his spine and joints (to include the neck). The May 2014 VA examiner does not engage with that in-service opinion at all, other than dismissing it as a diagnosis of “joint pain.” The Board agrees with the October 2016 opinion that the January 1980 assessment indicates an actual disease process rather than mere subjective complaints. In any case, simply relying on the absence of an in-service diagnosis is not a sufficient rationale for a negative nexus opinion. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007) (“Not only must the medical opinion clearly consider direct service connection, it must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). The October 2016 opinion is entitled to more probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (“most of the probative value of a medical opinion comes from its reasoning”). For this reason, the evidence is in favor of the Veteran’s claim of entitlement to service connection for a neck disability. The claim is granted. 6. Entitlement to service connection for a back disability The Veteran claims entitlement to service connection for a back disability which, he alleges, first manifested during his active service. On January 22, 1980, during his active service, the Veteran was seen for polyarthralgia of unclear etiology to include back pain. The medical professional concluded that there was no objective evidence of an inflammatory process, joint pathology, lupus, psoriasis, or bowel disease to explain the polyarthralgia. This evidence establishes an in-service event or injury involving the back. As for a current disability, that has been established by VA treatment records as well as a March 2014 VA examination which diagnosed degenerative disc disease and osteoarthritis of the thoracolumbar spine. The remaining element of the Veteran’s claim is a causal nexus between the in-service back pain and the current back disability. At the Veteran’s discharge, the November 1985 Report of Medical Examination indicated spine and joints were all normal. However, the physician completing the February 1986 Report of Medical History noted a long history of “polyarthralgia [with] no diagnosis of causation” and current “[complaints] of lower thoracic [???] pain for last 2 yrs.” An August 1987 VA examination showed full range of motion in all joints, x-rays were normal, and laboratory results were all normal. With respect to the back, the examiner diagnosed history of polyarthralgia with insufficient clinical evidence to warrant a diagnosis of any acute or chronic disorder, or residuals thereof. The March 2014 VA Examiner opined that the Veteran’s back condition was as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran “was seen and treated from 1979-1980 numerous times for multiple joint arthralgias” and that injections provided relief. The examiner also noted that the orthopedic surgery clinic provided a diagnosis of “myofascitis of interspinous process L1-L2 in 1979.” The RO determined that the above opinion was insufficient and obtained a May 2014 addendum to the VA examiner’s opinion. The same VA examiner then provided a negative opinion based on the rationale that the Veteran “was examined and treated numerous times for POLYARTHRALGIAS while in service but was NEVER definitively diagnosed during this time.” (emphasis in original). The Board notes that this opinion fails to explain why the examiner changed her opinion, particularly given that she had previously (and accurately) noted the in-service diagnosis of a “myofascitis of interspinous process L1-L2.” The Veteran submitted an October 2016 Private Opinion Letter which contained a well-reasoned, positive nexus opinion that is summarized in full above. The Board finds that the March 2014 and October 2016 opinions are more convincing than the thinly reasoned May 2014 addendum. The May 2014 opinion regarding the back has a nearly identical rationale to the May 2014 opinion with respect to the neck, so the Board’s above analysis applies to the back opinions with equal force as applied to the neck opinions. Moreover, the Board is concerned that this change in opinion without any discussion of why there was a change came after the RO sought clarification. It suggests the opinion may have changed because of the request, rather than for any overlooked medical evidence or principles. The initial favorable opinion in March 2014 did contain an accurate recitation of the in-service records, so there must be some explanation as to why the examiner changed her mind when looking at those same records a second time. The evidence is in favor of the Veteran’s claim of entitlement to service connection for a back disability. The claim is granted. 7. Entitlement to service connection for a right knee disability The Veteran claims entitlement to service connection for a right knee disability which, he alleges, first manifested during his active service. On January 22, 1980, during his active service, the Veteran was seen for polyarthralgia of unclear etiology to include pain in the knees. The medical professional concluded that there was no objective evidence of an inflammatory process, joint pathology, lupus, psoriasis, or bowel disease to explain the polyarthralgia. This evidence establishes an in-service event or injury involving the right knee. As for a current disability, that has been established by VA treatment records as well as a March 2014 VA examination which diagnosed osteoarthritis of the bilateral knees. The remaining element of the Veteran’s claim is a causal nexus between the in-service knee pain and the current right knee disability. At the Veteran’s discharge, the November 1985 Report of Medical Examination indicated spine and joints were all normal. However, the physician completing the February 1986 Report of Medical History noted a long history of “polyarthralgia [with] no diagnosis of causation.” An August 1987 VA examination showed full range of motion in all joints, x-rays were normal, and laboratory results were all normal. With respect to the knees, the examiner diagnosed history of polyarthralgia with insufficient clinical evidence to warrant a diagnosis of any acute or chronic disorder, or residuals thereof. The March 2014 VA Examiner opined that the Veteran’s bilateral knee condition was as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran “was seen and treated from 1979-1980 numerous times for multiple joint arthralgias” and that injections provided relief.   The RO determined that the above opinion was insufficient and obtained a May 2014 addendum to the VA examiner’s opinion. The same VA examiner then provided a negative opinion regarding the knees with a rationale identical to that for the back (set forth above). The Veteran submitted an October 2016 Private Opinion Letter which contained a well-reasoned, positive nexus opinion that is summarized in full above. The above (Section 6) comparison of the reasoning in the March 2014 and October 2016 opinions with the reasoning in the May 2014 addendum opinion applies to the knee claim with equal force. The May 2014 addendum opinion has an insufficient rationale to warrant probative weight, it represented an unexplained change after the RO indicated dissatisfaction with the March 2014 opinion, and is otherwise less thoroughly reasoned than the March 2014 and October 2016 opinions. The greater weight of the evidence is in favor of the Veteran’s claim of entitlement to service connection for a right knee disability. The claim is granted. 8. Entitlement to service connection for a left knee disability The Veteran claims entitlement to service connection for a left knee disability which, he alleges, first manifested during his active service. The medical evidence and, so, the analysis is identical for both the left and right knees (with respect to service connection), therefore the Board will not repeat for the left knee what has already been said about the right knee. In short, there was an in-service event/illness involving the left knee, the Veteran has osteoarthritis of the left knee, and the March 2014 and October 2016 opinions in favor of the Veteran’s claim are more convincing than the May 2014 addendum opinion against his claim. The claim of entitlement to service connection for a left knee disability is granted. Increased Rating Disability evaluations are assigned to reflect levels of current disability. The appropriate rating is determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 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 Veteran working or seeking work. 38 C.F.R. § 4.2. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. When 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. 38 C.F.R. § 4.7. In evaluating claims for increased ratings, VA must evaluate the veteran’s condition with a critical eye toward the lack of usefulness of the body or system in question. 38 C.F.R. § 4.10. VA has considered the level of the veteran’s impairment throughout the entire period on appeal, including the propriety of staged ratings. O’Connell v. Nicholson, 21 Vet. App. 89 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The factors involved in evaluating and rating disabilities of the joints include weakness, fatigability, incoordination, restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45; see also 38 C.F.R. § 4.59. In assigning disability ratings, the evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also VA Gen. Coun. Prec. 9–2004 (Sep. 17, 2004) (“[T]he key consideration in determining whether rating under more than one diagnostic code is in order is whether the ratings under different diagnostic codes would be based on the same manifestation of disability or whether none of the symptomatology upon which the separate ratings would be based is duplicative or overlapping.”). While the Veteran is competent to report (1) symptoms observable to a layperson (i.e. pain, swelling); (2) a diagnosis that is later confirmed by clinical findings; or (3) a contemporary diagnosis, the Board need not find a lay Veteran competent to render opinions regarding the clinical significance of observable symptoms. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); King v. Shinseki, 700 F.3d 1339, 1344-45 (Fed. Cir. 2012). This Veteran, who lacks medical training, is not competent to opine on the clinical significance of the symptoms of his service-connected disabilities. See, e.g., Jandreau, 492 F.3d at 1377. Therefore, in evaluating the Veteran’s claims, the Board will rely on the medical evidence of record. The Board, however, has considered the Veteran’s subjective reports of symptoms, particularly as they illuminate or underscore the medical opinions of record. 9. Entitlement to an initial rating in excess of 10 percent disabling for service-connected left shoulder disability The Veteran is currently service-connected under DC 5201-5010 for a left shoulder disability with a rating of 10 percent during the relevant time period based on arthritis confirmed by x-rays, limitation of motion, and associated functional limitations. The diagnostic codes applicable to a rating of the shoulder are between DCs 5200-5203. Ratings vary depending on whether the impairment is to the major or minor arm. In this case, the Veteran is right hand dominant, so only the ratings for impairments to the “minor” (left) arm are applicable and will be set forth below. Normal shoulder flexion and abduction is from 0 to 180 degrees (90 degrees at shoulder level), and normal internal and external rotation is from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. Under DC 5200 for ankylosis of the scapulohumeral articulation (the scapula and humerus move as one piece), a 20 percent rating is assigned when the ankylosis is favorable with abduction to 60 degrees such that a person can reach his mouth and head, a 30 percent rating is assigned the arm when the ankylosis is considered to be intermediate that is between favorable and unfavorable, a 40 percent rating is assigned when the ankylosis is considered to be unfavorable, such that abduction is limited to 25 degrees from the side. Under DC 5201 for limitation of motion of the arm, a 20 percent rating is assigned when the range of motion is limited to shoulder level or when the maximum range of motion is limited to midway between side and shoulder level, and a 30 percent rating is assigned when range of motion of the arm is limited to 25 degrees from the side. Under DC 5202 for other impairment of the humerus, when there is malunion of the humerus, a 20 percent rating is assigned with moderate deformity or marked deformity. A 20 percent rating is also assigned when there is recurrent dislocation of the humerus at the scapulohumeral joint, with either infrequent episodes, and guarding of movement only at shoulder level, or with frequent episodes and guarding of all arm movements. A 40 percent rating is assigned when there is fibrous union of the arm; a 50 percent rating is assigned when there is nonunion of (false flail joint) the humerus in the arm; and a 70 percent rating is assigned when there is loss of head of (flail shoulder) the humerus in the arm. Under DC 5203 for impairment of the clavicle or scapula, a 10 percent rating is assigned for malunion or for nonunion without loose movement. When there is nonunion with loose movement, a 20 percent rating is assigned. A 20 percent rating is also assigned when there is dislocation of the clavicle or scapula. The Board also notes that degenerative arthritis is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200, etc.). 38 C.F.R. § 4.71a, DCs 5003 and 5010. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Medical Evidence The most pertinent evidence of the severity of the Veteran’s shoulder disability are the examinations conducted for the purpose of determining the severity of that disability. Medical treatment records are also relevant and have been reviewed, but often do not include findings in the terms used in the rating criteria. A March 2014 VA examination resulted in diagnoses of status post-fracture of the left shoulder, osteoarthritis, and impingement syndrome. The Veteran reported that he did not experience flare-ups. The examiner measured left shoulder flexion at 180 degrees with objective evidence of pain at 180 degrees and left shoulder abduction at 180 degrees with objective evidence of pain at 170 degrees. There was no additional loss of range of motion of the left shoulder (though there was of the right). The Veteran had pain on movement of both shoulders. There was no localized tenderness or pain on palpation of the left shoulder and no guarding of the left shoulder. Muscle strength was normal as were all tests for rotator cuff conditions of the left shoulder. There was no ankylosis. Instability testing was normal on the left. The Veteran did not have an acromioclavicular joint condition or any other impairment of the clavicle or scapula. There were no other pertinent findings, complications, conditions, signs and/or symptoms. In comments, the examiner noted that the Veteran had full range of motion for internal and external rotation of the left shoulder with no objective evidence of painful motion. The shoulder did not impact the Veteran’s ability to work. An April 2015 VA examination included diagnoses of shoulder strain and degenerative arthritis. The Veteran did not report flare-ups or having any functional loss or functional impairment of the left shoulder. Ranges of motion were measured as 125 degrees flexion, 130 degrees abduction, 60 degrees external rotation, and 50 degrees internal rotation. The Veteran ranges of motion do not contribute to a functional loss. There was no pain noted on the examination and there was no objective evidence of localized tenderness or pain on palpation of the joint and associated soft tissue. There was no objective evidence of crepitus. The Veteran could complete repetitive use testing and had no additional loss of range of motion. The Veteran had pain that significantly limited functional ability with repetitive use over a period of time. The additional loss was described by the VA examiner as 125 degrees flexion (i.e., no change), 130 degrees abduction (no change), 50 degrees external rotation (loss of 10 degrees), 45 degrees internal rotation (loss of 5 degrees). Muscle strength was normal, there was no ankylosis, the Hawkins’ impingement test and empty can tests were positive for a rotator cuff condition. There was no shoulder instability, dislocation or labral pathology suspected. There were no conditions or impairments of the humerus. There were no other pertinent findings, complications, conditions, signs and/or symptoms. Private treatment records from 2009 document right shoulder symptoms and detailed range of motion findings, but fail to indicate any symptoms or functional loss with respect to the left shoulder. Analysis The above findings do not support the award of any compensable rating under DCs 5200-5203. The ranges of motion all considerably exceed the ranges specified for a compensable rating and the Veteran does not have any of the other conditions specified in those diagnostic codes. Moreover, he does not have functional impairments typical of shoulder symptoms that would warrant a compensable rating under any of those diagnostic codes. The Veteran does have arthritis of the shoulder joint with objective evidence of painful motion but without loss of range of motion warranting a compensable rating, so the Veteran is entitled to a 10 percent rating under DC 5003. DC 5003 does not provide for ratings in excess of 10 percent in the circumstances of this case (e.g., only one joint involved). The greater weight of the evidence is against granting any disability rating in excess of 10 percent disabling for the left shoulder disability. The claim is denied. 10. Entitlement to an initial rating in excess of 10 percent disabling for service-connected right wrist disability, status post fracture with degenerative joint disease The Veteran’s residuals of a fracture of the right navicular bone are rated as 10 percent disabling under DC 5215-5010. Under DC 5215, a 10 percent rating is warranted for palmar flexion limited in line with the forearm or for dorsiflexion less than 15 degrees. DC 5214 also applies to the wrist, but only in the case of ankylosis. The Veteran does not have ankylosis, so DC 5214 is not applicable. In addition, there are special provisions for rating degenerative arthritis (to include osteoarthritis – DC 5010) under Diagnostic Code 5003. When there is painful motion of a major joint caused by degenerative arthritis that is detected on x-ray, such painful motion will be considered limited motion pursuant to 38 C.F.R. § 4.59. Painful motion is entitled to a minimum 10 percent rating, per joint, combined under Diagnostic Code 5003, even if there is no actual limitation of motion. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). Medical Evidence Private treatment records from 2009 document complaints of progressively worse right wrist pain since 2007. Physical examination in August 2009 revealed dorsiflexion of 0-60 degrees, palmar flexion of 0-60 degrees, and moderate pain on examination. He could not tolerate radial or ulnar flexion. A March 2014 VA examination resulted in diagnoses of status post fracture right wrist and osteoarthritis. The Veteran’s right hand is his dominant hand. The Veteran reported he did not have flare-ups. Range of motion testing revealed palmar flexion of 70 degrees with objective evidence of painful motion at 70 degrees and dorsiflexion of 60 degrees with objective evidence of painful motion at 55 degrees. After repetitive use testing, palmar flexion was 60 degrees and dorsiflexion was 55 degrees. Right wrist radial deviation ends at 20 degrees with objective evidence of painful motion at that point, ulnar deviation ended at 45 degrees with objective evidence of pain at that point. There were contributing factors of pain, weakness, fatigability, and/or incoordination which the examiner expressed in terms of loss of range of motion: palmar flexion – 10 degrees (i.e., 0 to 50 degrees), dorsiflexion 5 degrees (0 to 50 degrees), and no loss of radial deviation or ulnar deviation. The Veteran had functional loss and/or functional impairment contributed to by less movement than normal and pain on movement. The Veteran had localized tenderness or pain on palpation. Muscle strength was normal. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms. An April 2015 VA examination resulted in a diagnosis of arthritis of the right wrist. The Veteran reported flare-ups that caused his wrist to hurt and for him to lose his grip. The Veteran reported functional loss/impairment described as “trouble with picking up a cup of coffee” and that he would “drop it without warning.” Range of motion was 0 to 30 degrees palmar flexion, 0 to 40 degrees dorsiflexion, 0 to 25 degrees ulnar deviation, and 0 to 20 degrees radial deviation. The examiner indicated there was no pain on the examination and no objective evidence of localized tenderness or pain on palpation. The Veteran was able to complete repetitive use testing and there was no loss of range of motion after testing. The examiner indicated that pain, weakness, and lack of endurance caused additional functional loss. The examiner described that functional loss in terms of range of motion with final ranges of 0 to 25 degrees palmar flexion, 0 to 35 degrees dorsiflexion, 0 to 25 degrees ulnar deviation, and 0 to 15 degrees radial deviation. Muscle strength was normal, there was no ankylosis, and there were no other pertinent physical findings, complications, conditions, signs or symptoms. The condition limited his ability to do repetitive tasks with the right wrist such as writing, typing, and manual labor. Analysis The above evidence reveals palmar flexion limited to, at most, 0 to 25 degrees and dorsiflexion limited to, at most, 0 to 35 degrees. Both of these ranges considerably exceed the ranges of motion that would warrant any compensable rating under DC 5215. The limited motion with objective evidence of painful motion and x-ray evidence of arthritis warrants a 10 percent rating under DC 5003. However, no higher rating is warranted. The Veteran does not have ankylosis or any other symptoms that meet, much less exceed, those required for a 10 percent rating under the applicable diagnostic codes. The greater weight of the evidence is against the Veteran’s claim. Entitlement to an initial rating in excess of 10 percent for his right wrist disability is denied. Duties to Notify and Assist The Veteran has not raised any specific issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Therefore, the Board needs to discuss VA’s compliance with the duties to notify and assist. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Kerry Hubers, Counsel