Citation Nr: 18148220 Decision Date: 11/07/18 Archive Date: 11/07/18 DOCKET NO. 09-02 103 DATE: November 7, 2018 ORDER Entitlement to higher initial ratings for disc dessication at L4-L5 with associated disc space narrowing and disc bulge at L4-L5 is denied. Entitlement to a rating in excess of 10 percent for left lower extremity radiculopathy prior to March 14, 2014, is denied. Entitlement to a 20 percent disability rating, and no higher, for left lower extremity radiculopathy from March 14, 2014, and no earlier, is granted. Entitlement to a higher rating for right knee retropatellar pain syndrome is denied. Entitlement to a 10 percent rating, and no higher, for right knee lateral instability from March 2, 2012, is granted. Entitlement to a higher rating for left knee retropatellar pain syndrome is denied. Entitlement to a higher rating for left knee laxity is denied. Entitlement to a higher rating for hypertension is denied. Entitlement to higher initial ratings for right shoulder disability is denied. Entitlement to higher initial ratings for bilateral pes planus is denied. The appeal as to the issue of entitlement to service connection for PTSD is dismissed. FINDINGS OF FACT 1. Prior to April 5, 2017, the Veteran had forward flexion of the thoracolumbar spine to more than 30 degrees; from April 5, 2017, his forward flexion has been limited to 20 degrees. 2. The Veteran had mild left lower extremity radiculopathy prior to March 14, 2014, and no more than moderate radiculopathy symptoms thereafter, due to his service-connected back disability. 3. The Veteran has not had objective neurological findings of bowel, bladder, or right lower extremity symptoms due to his service-connected back disability. 4. Giving the Veteran the benefit of the doubt, he had slight, and not more severe, right knee instability from March 2, 2012. 5. Throughout the rating period on appeal, the Veteran has had forward flexion of the right knee greater than 30 degrees and had full extension. 6. Throughout the rating period on appeal, the Veteran has had no more than slight left knee lateral instability. 7. Throughout the rating period on appeal, the Veteran’s hypertension, which is controlled by medication, has not resulted in a diastolic pressure predominately 100 or more, or systolic pressure predominantly 160; moreover, he has not had a history of diastolic pressure predominantly 100 or more. 8. Throughout the rating period on appeal, the Veteran’s right shoulder disability has not had recurrent dislocations, loss of head, nonunion, or fibrous union; his range of motion was more than to the shoulder level prior to April 5, 2017, and more than to 25 degrees thereafter. 9. Throughout the rating period on appeal, the Veteran’s bilateral pes planus has been manifested by pain but has not been manifested by marked deformity, swelling on use, characteristic callosities, marked inward displacement, severe spasm of the tendo achillis on manipulation, or pronounced symptoms which are not improved by orthopedic shoes or appliances. 10. In a written statement received by VA in June 2017, prior to the promulgation of a Board decision in the matter, the Veteran expressed his intent to withdraw his appeal seeking service connection for PTSD. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation for a low back disability in excess of 20 percent disabling prior to April 5, 2017, and 40 percent disabling thereafter, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.10, 4.31, 4.59, 4.71a, DC 5237. 2. The criteria for a rating in excess of 10 percent prior to March 14, 2014, for left lower extremity radiculopathy is denied; the criteria for a rating of 20 percent, and no higher, for moderate left lower extremity radiculopathy from March 14, 2014, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.10, 4.31, 4.59, 4.124a, DC 8520. 3. The criteria for an initial evaluation for retropatellar pain syndrome of the right knee, in excess of 10 percent disabling, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.10, 4.31, 4.59, 4.71a, DCs 5019-5260. 4. The criteria for a separate rating for slight right knee lateral instability from March 2, 2012, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.10, 4.31, 4.59, 4.71a, DC 5257. 5. The criteria for an initial evaluation for retropatellar pain syndrome of the left knee, in excess of 10 percent disabling, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.10, 4.31, 4.59, 4.71a, DCs 5256-5263. 6. The criteria for an initial evaluation in excess of 10 percent for left knee laxity have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.10, 4.31, 4.59, 4.71a, DCs 5257. 7. The criteria for an initial compensable evaluation for hypertension have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.10, 4.31, 4.59, 4.71a, DC 7101. 8. The criteria for an initial evaluation for right shoulder dislocation, post-operative (dominant) in excess of 10 percent disabling prior to April 5, 2017 and 20 percent disabling thereafter, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.10, 4.31, 4.59, 4.71a, DCs 5003-5202. 9. The criteria for an initial evaluation for bilateral pes planus in excess of 10 percent disabling prior to April 5, 2017 and 30 percent disabling thereafter, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.10, 4.31, 4.59, 4.71a, DC 5276. 10. Regarding the claim seeking service connection for PTSD, the criteria for withdrawal of an appeal by the appellant are met; the Board has no further jurisdiction in this matter. 38 U.S.C. §§ 7104, 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1999 to November 2006. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. These matters were most recently before the Board in March 2017 when they were remanded for further development. The Board finds that there has been substantial compliance with the mandates of its remand. During the pendency of the appeal, the Appeals Management Center (AMC), in a September 2017 rating decision, granted an increased rating of 40 percent for the Veteran’s spine disability, a 30 percent rating for the Veteran’s bilateral pes planus, a 20 percent rating for the Veteran’s left lower extremity radiculopathy, a 20 percent rating for the Veteran’s right shoulder dislocation, and a separate 30 percent rating for the Veteran’s right shoulder limitation of motion with degenerative joint disease. Withdrawal The Board has jurisdiction where there is a question of law or fact on appeal to the Secretary. 38 U.S.C. § 7104; 38 C.F.R. § 20.101. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision in a matter. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or his representative. 38 C.F.R. § 20.204. In a signed written statement received by VA in June 2017, the Veteran expressed his desire to withdraw his appeal ("I would like to withdraw my claim for PTSD”). Hence, there is no allegation of error of fact or law for appellate consideration in this matter. Accordingly, the Board does not have jurisdiction to consider an appeal in the matter, and the appeal must be dismissed. Increased Rating Legal Criteria Rating Disabilities in general Disability evaluations are determined by comparing a Veteran’s present symptomatology with criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran’s condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Terms such as “slight”, “moderate”, “severe”, “marked”, and “pronounced” are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just” as contemplated by the requirements of the law. 38 C.F.R. § 4.6. The Board is not bound by a clinician’s use of a term. Under 38 C.F.R. § 3.400 (o)(2), the effective date in a claim for an increased rating will be one year prior to the date of receipt of the increased rating claim provided that the evidence reflects a worsening of the disability during that one year time period. See Gaston v. Shinseki, 605 F.3d 979 (Fed. Cir. 2010). Thus, the Board has considered the evidence from one year prior to the date on which the Veteran filed a claim to determine whether it reflects a worsening during that period. It is possible that a particular piece of evidence demonstrates that the Veteran suffered from the symptoms of a disability or rating level earlier than the date of the examination, opinion, or diagnosis. See DeLisio v. Shinseki, 25 Vet. App. 45, 56 (2011) (holding that “entitlement to benefits for a disability or disease does not arise with a medical diagnosis of the condition, but with the manifestation of the condition and the filing of a claim for benefits for the condition” (citing 38 U.S.C. § 5110(a)); Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010) (holding that “it is the information in a medical opinion, and not the date the medical opinion was provided that is relevant when assigning an effective date”). In McGrath v. Gober, 14 Vet. App. 28 (2000), the Court held that when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the examination reports noting pertinent findings. The Board has also considered the history of the Veteran’s disabilities prior to the rating period on appeal to see if it supports a higher rating during the rating period on appeal Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Reference to the Veteran’s disabilities is presented in additional evidence of record beyond the most detailed pertinent evidence discussed by the Board in this decision. The additional evidence of record does not present findings concerning the Veteran’s disabilities that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision 1. Entitlement to an increased initial evaluation for a low back disability, rated as 20 percent disabling prior to April 5, 2017 and as 40 percent disabling thereafter. The Veteran’s low back disability is rated effective from November 8, 2006. Under the rating criteria for the spine, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or the combined range of motion of the cervical spine not greater than 170 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted when there is forward flexion of the thoracolumbar spine of 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted when there is unfavorable ankylosis of the entire spine. In addition, intervertebral disc syndrome may be evaluated based on incapacitating episodes, depending on which method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. A January 2008 VA examination report reflects that the Veteran reported low back pain and that for activities, he wears an elastic lumbar support with a plastic rigid plate or lumbar portion in the back. He reported that he does not have to be on bedrest for his back pain and does not have increased limitation with repetitive use of the back. Upon examination, he had active and passive flexion to 45 degrees with low back pain, and extension to 30 degrees which was nontender. He had bilateral lateral bend to 30 degrees, and nontender bilateral rotation to 30 degrees. Upon repetitive motion of the spine, the Veteran noted some low back pain on each cycle with maximum flexion. As the Veteran had forward flexion greater than 30 degrees, an increased rating is not warranted. Subsequent clinical records note also reflect complaints of the back, to include that the Veteran reported having an aching pain for four days but that it was improving (October 2009), that his pain was a level three out of ten (January 2010), that he reported increased back pain (March 2010), that he had decreased range of motion with straight leg raising (February 2011), and that despite his back disability, he played basketball (e.g. June 2011 and October 2011). A March 2012 VA examination report reflects that the Veteran complained of pain which he described as a 5-10 out of 10 and located mostly on the left side. He reported that he takes over-the-counter medication and will occasionally use a brace. His reported that his ADLS were generally not limited but with increased pain he will limit them to the bare essentials. He reported that his walking was limited to ¼ mile and his standing was limited to 30 minutes. He reported one week of self-imposed bed rest. The Veteran had flexion to 90 degrees with objective evidence of pain beginning at 90 degrees, extension to 20 degrees with objective evidence of pain beginning at 20 degrees, bilateral lateral flexion to 20 degrees with objective evidence of pain at 20 degrees, and bilateral lateral rotation to 20 degrees with objective evidence of pain at 20 degrees. It was noted that pain with forward flexion diminished as the Veteran stretched. The Veteran described his extension pain as mild, and his lateral flexion as being pain as worse on the left. After repetitive use testing, there was no decrease in range of motion. The Veteran was noted to have less movement than normal, pain on movement, disturbance of locomotion, and interference with sitting, standing, and/or weight-bearing. He did not have IVDS with incapacitating episodes. He was noted to occasionally use a brace for lumbar support. Again, as he had forward flexion greater than 30 degrees, an increased rating is not warranted. Subsequent clinical record note complaints of pain, to include a May 2013 record which reflects that the Veteran reported that his back hurts when he sits longer than 20-30 minutes but that the pain is relieved with standing (May 2013). A June 2013 mental health record reflects that he has hobbies of playing softball and basketball, and a May 2014 record which reflects that he swims for exercise, and that his pain does not interfere with his work because the flexibility of his job allows him to stand up and walk around if needed. A March 2014 VA examination for the Veteran’s back reflects that the Veteran was currently employed at an administrative job and was able to handle employment. He reported pain which increases with bending, lifting, and prolonged activities of walking, standing, and sitting. He did not report flare-ups. He had flexion to 90 degrees with objective evidence of pain at 35 degrees, extension to 10 degrees with objective evidence of pain at 0 degrees, bilateral lateral flexion to 20 degrees with pain beginning at 10 degrees, lateral rotation to 20 degrees with pain beginning at 20 degrees. He was noted to have less movement than normal, pain on movement, disturbance of locomotion, and interference with sitting, standing, and/or weight-bearing. He did not have IVDS with incapacitating episodes. He occasionally used a brace. Again, as he had forward flexion greater than 30 degrees, an increased rating is not warranted. A January 2015 VA clinical record reflects that the Veteran’s flexion was decreased by 60 percent, extension by 50 percent, rotation by 30 percent, and lateral flexion by 30 percent, all due to pain. Thus, he had 36 degrees of flexion, 15 degrees of extension, and more than 20 degrees of rotation and lateral flexion. This limitation of flexion does not warrant a higher rating, as he had forward flexion greater than 30 degrees. May 2015 VA clinical records reflect that the Veteran’s gait was normal, his station and coordination were normal, and he could walk on toes and heels. His flexion was noted to be decreased by 40 percent due to pain, his extension was noted to be decreased by 40 percent due to pain, his rotation was noted to be decreased by 10 percent due to pain, and his lateral flexion was noted to be decreased by 20 percent due to pin. This is indictive that he had more than 50 degrees of flexion, 18 degrees of extension, more than 25 degrees of rotation, and more than 20 degrees of lateral flexion. It was noted that the pain intensity of the low back decreased from 8.7 out of 10 to a 4 out of 10 under care, and that the duration of the pain reduction was increasing from a few hours initially to a day or more towards the end of treatment. The Veteran reported that the pain prevents him from heavy lifting, walking more than ¼ of a mile, standing more than 10 minutes initially and more than 20 -30 minutes after treatment, occasionally disturbs his sleep, and restricts his sex life, his social life, and his traveling. A June 2015 record reflects that the Veteran reported back pain which includes extreme pressure and sometimes stabbing pain, and pain worsened over the past few years. The Veteran reported that the pain is worsened by prolonged standing, sitting, or extending himself in any direction. The Veteran mentioned that the pain has increased in severity to the point where the Veteran “can’t function normally including taking shower and sleeping”. The Veteran contended that he was unable to work due to chronic pain, spends 4-5 hours a day in bed (he stated that lying in bed helped his pain), and has pain which is a 9 out of 10. He also reported that he takes 3 to 4 diclofenac per day, and had been attending two chiropractic session per week. The Veteran reported that he is no longer able to play sports. He also reported that his pain is relieved somewhat with a TENS unit. It was noted that the Veteran had symptoms consistent with somatic symptom disorder. The Board notes that despite the Veteran’s assertions in June 2015 that he was no longer able to play sports, function normally, exert himself in any direction, or work due to back pain, a February 2016 VA clinical record reflects that he had been playing basketball in February 2016. The Board finds that playing basketball is inconsistent with the Veteran’s 2015 statement as to the severity of his back and is indicative that his symptoms, were either incorrectly characterized in 2015, or that while perhaps temporarily severe in 2015, they were no longer of such severity in 2016. A January 2017 VA clinical record reflects that the Veteran reported two days of lower back pain on the right side of such severity that he could not straighten up to walk. However, additional records reflect that the pain was more of a flank or abdominal pain rating from the rib cage to the hip/groin area. An April 2017 VA examination report reflects that the Veteran had forward flexion to 20 degrees, extension to 10 degrees, lateral flexion to 15 degrees bilaterally, and lateral rotation to 20 degrees bilaterally. It was noted that he was unable to bend and lift, unable to engage in manual labor, and unable to perform repetitive bending, lifting, or prolonged standing and walking. He was able to engage in sedentary/sitting activities to include employment. Testing could not be performed on passive and non-weight bearing. This April 2017 VA examination report is the first evidence that the Veteran met the rating criteria for a rating in excess of 20 percent. Moreover, it is against a finding that a rating in excess of 40 percent is warranted because the examination report shows that the Veteran did not have ankylosis. Moreover, he did not have IVDS with incapacitating episodes as defined by VA regulation. Finally, the Board has considered whether separate ratings for associated objective neurological abnormalities of his spine disability are warranted. The 2008, 2012, 2014, and 2017 VA examination reports all reflect no bowel or bladder problems/changes due to his back disability. With regard to radiculopathy, the Veteran is separately rated for left lower extremity radiculopathy associated with his spine disability. It is rated as 10 percent disability prior to April 5, 2017, and 20 percent disabling thereafter. The 2008 VA examination found no neurological deficits. It was noted that the Veteran had pain in the left leg but that MRI showed no nerve root compression. Thus, without objective findings, a separate rating is not warranted. The 2012 VA examination found that the Veteran had no radiculopathy of the right lower extremity, but had mild symptoms of left lower extremity radiculopathy involving the sciatic nerve. The 2014 VA examination reports reflect no radiculopathy of the right lower extremity, and moderate radiculopathy of the left, which included normal reflexes, decreased lower leg/ankle sensory examination and thigh/knee sensory examination, mild constant pain, moderate intermittent pain, and moderate paresthesias and/or dysesthesias. The 2017 VA examination report also reflects no radiculopathy for the right lower extremity, and moderate radiculopathy of the left lower extremity, which included normal sensory examination, mild numbness, mild constant pain, moderate intermittent pain, and moderate paresthesias and/or dysesthesias. Based on the foregoing, the Board finds that a 20 percent rating and no higher is warranted for left lower extremity moderate incomplete paralysis of the sciatic nerve effective from March 14, 2014, the first date upon which it is ascertainable that the Veteran had moderate radiculopathy symptoms due to his back disability. The Board finds that an earlier date, and/or a higher rating is not warranted based on the complaints and clinical findings noted above. The Board also finds that the evidence is against a finding of right lower extremity radiculopathy; thus, a separate rating is not warranted for radiculopathy on the left. 2. Entitlement to an increased initial evaluation for retropatellar pain syndrome of the right knee, currently rated as 10 percent disabling. The Veteran’s right knee disability is rated as 10 percent disabling under DC 5019-5260. The Veteran would be entitled to a higher rating if he had flexion limited to 30 degrees or less. A May 2008 VA examination report reflects that the Veteran had no deformities, no swelling, and no palpable tenderness of the knees. He had full extension without pain, and 0 to 100 degrees of flexion without pain. He had no laxity or instability. Range of motion did not produce any weakness, fatigue or incoordination. The Veteran reported that he has right knee pain that comes and goes, is usually sharp, occasional aches, and averages a 6 out of 10 with flare-up. The pain was aggravated by cold or wet weather, walking for one mile, standing for 45 minutes or longer, and stairs climbing. The Veteran reported that he takes ibuprofen which does not help with flare-ups. He did not use assistive devices, and his knee, to include with flare-up (which did not cause further limitation) did not bother his occupation, or daily activities. Upon x-ray, there was no significant radiographic abnormality. Thus, the evidence is against a finding of a higher rating. A March 2012 VA examination report reflects that the Veteran reported pain as a 3 out of 10 to 10 out of 10. He also reported clicking, popping, grinding, and stiffness, but no locking. There was no swelling, heat, or redness. The Veteran reported that he has a feeling of giving way causing him to stumble, but he is able to catch himself. He treated with over-the-counter NSAIDs. The Veteran used a knee sleeve on occasion. He reported that walking was limited to ¼ mile and standing limited to 30 minutes. He reported that his ADLs are difficult but that he is able to accomplish them. He also reported having flare-ups approximately once a week causing him to seek bed rest, ice, and heat for 30 minutes. He did not seek medical attention. Upon examination, to include repetitive use, he had flexion to 140 degrees with objective evidence of pain beginning at 140 degrees. He had no limitation of extension and no objective evidence of painful motion on extension. He had full muscle strength, and normal anterior, posterior, stability. He had medial lateral instability of 1+, which the Board finds is no more than slight. The clinician noted that the Veteran had -5 degrees of extension (hyperextension). Based on the foregoing, the Board finds that Veteran is not entitled to an increased rating for his range of motion but is entitled to a separate 10 percent rating for lateral instability under DC 5257 effective from the March 2, 2012 VA examination report which is the first probative evidence of instability. An April 2017 VA examination report reflects that the Veteran reported generalized knee pain. His range of motion was all normal, to include after repetitive use. There was evidence of pain with weight bearing and localized tenderness or pain on palpation of the joint. There was objective evidence of crepitus. The Veteran had full muscle strength and no atrophy. There was no history of recurrent subluxation. All stability testing results were normal. The Veteran again reported that he was unable to stand and walk for prolonged periods. The Board finds that a higher rating is not warranted as the evidence showed only 1+ instability, and there is not evidence of a more severe instability. The Board has also reviewed the clinical records which note that the Veteran, despite his statements to examiners as to pain, was able to continue to play basketball. Records reflect that he was playing basketball in June 2011, September 2011 (played three days in a row), October 2011 (he had twisted his left ankle, and he requested a left shoulder brace for when he participates in his leisure activities), that he reported hobbies of basketball and softball in June 2013, and that he was playing basketball in February 2016. The Board, although not a medical body, finds that playing basketball reasonably involves extensive use of the knees. In denying an increased rating (other than the rating for instability), the Board has considered the clinical findings, to include the Veteran’s ranges of motion after repetition, complaints of flare-ups or lack thereof, and the factors espoused in DeLuca v. Brown, 8 Vet. App. 202 (1995). See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). The Veteran had flexion to 100 degrees in 2008, 140 degrees in 2012, and 140 degrees in 2017; he had full extension. Even with consideration of pain and other symptoms, the evidence does not support a finding that his symptoms cause functional limitations analogous to flexion limited to 30 degrees or less, or extension limited to 10 degrees or greater. Moreover, his flare-ups were not of the severity and frequency to cause limitation to such an extent as to warrant a higher rating. 3. Entitlement to an increased initial evaluation for retropatellar pain syndrome of the left knee, currently rated as 10 percent disabling. The Veteran’s left knee disability is rated as 10 percent disabling under DC 5099-5014. The Veteran would be entitled to a higher rating if he had flexion limited to 30 degrees or less, and/or extension limited to 10 degrees or more. A May 2008 VA examination report reflects that the Veteran had patellar tenderness and a positive grind test. There was no effusion. The Veteran had nontender range of motion of -5 degrees to 90 degrees. From 90 degrees to 140 degrees, there was mild tenderness but no guarding or grimacing. In 30 degrees of flexion, there was 1+ medial and lateral laxity. The anterior drawer and Lachman’s was negative. Repetitive motion of the knee produced no loss of motion, weakness, fatigability, pain or incoordination. The Veteran reported that he has pain with prolonged flexion of the knee when he is sitting. He denied locking or giving way, and reported occasional minimal swelling. When the knee hurts, he used an ace-wrap. He did not have incapacitating episodes. A March 2012 VA examination report reflects that the Veteran reported pain as a 3 out of 10 to 10 out of 10. He also reported clicking, popping, grinding, and stiffness, but no locking. There was no swelling, heat, or redness. The Veteran reported that he has a feeling of giving way causing him to stumble, but he is able to catch himself. He treated with over-the-counter NSAIDs. The Veteran used a knee sleeve on occasion which he alternated with the other knee. He reported that walking was limited to ¼ mile and standing limited to 30 minutes. He reported that his ADLs are difficult but that he is able to accomplish them. He also reported having flare-ups approximately once a week causing him to seek bed rest, ice, and heat for 30 minutes. He did not seek medical attention. Upon examination, to include repetitive use, he had flexion to 140 degrees with objective evidence of pain beginning at 140 degrees. He had no limitation of extension and no objective evidence of painful motion on extension. He had full muscle strength, and normal anterior, posterior, stability. He had medial lateral instability of 1+, which the Board finds is no more than slight. The clinician noted that the Veteran had -5 degrees of extension (hyperextension). As noted above, the Board has also reviewed the clinical records which reflect that the Veteran, despite his statements to VA examiners as to pain and his limitations, was able to continue to play basketball, which the Board finds involves extensive use of the knees. Again, the records reflect that he was playing basketball in June 2011, September 2011 (played three days in a row), October 2011 (he had twisted his left ankle, and he requested a left shoulder brace for when he participates in his leisure activities), that he reported hobbies of basketball and softball in June 2013, and that he was playing basketball in February 2016. Based on the foregoing, the Board finds that Veteran is not entitled to an increased rating for his range of motion. (The Veteran is separated rated for laxity (i.e. lateral instability) under DC 5257 which is discussed separately below). An April 2017 VA examination report reflects that the Veteran reported generalized knee pain. His range of motion was all normal, to include after repetitive use. There was evidence of pain with weight bearing and localized tenderness or pain on palpation of the joint. There was objective evidence of crepitus. The Veteran had full muscle strength and no atrophy. There was no history of recurrent subluxation. All stability testing results were normal. The Veteran again reported that he was unable to stand and walk for prolonged periods. In denying an increased rating, the Board has considered the clinical findings, to include the Veteran’s ranges of motion after repetition, complaints of flare-ups or lack thereof, and the factors espoused in DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran had flexion to 140 degrees, and full extension. Even with consideration of pain and other symptoms, the evidence does not support a finding that his symptoms cause functional limitations analogous to flexion limited to 30 degrees or less, or extension limited to 10 degrees or greater. Moreover, his flare-ups were not of the severity and frequency to cause limitation to such an extent as to warrant a higher rating. 4. Entitlement to an increased initial evaluation for left knee laxity, currently rated as 10 percent disabling. The Veteran’s left knee laxity is rated as 10 percent disabling under DC 5257 effective from November 2006. The Veteran would be entitled to a higher rating if he had moderate or severe recurrent subluxation or lateral instability. The Board finds, based on review of the evidence, that an increased rating is not warranted. The May 2008 VA examination report reflects that the Veteran denied giving way of the knee. Upon examination, the Veteran had 1+ medial and lateral laxity. The March 2012 VA examination report reflects that the Veteran had normal anterior stability, normal posterior stability, but 1+ (0-5 millimeters) of medial-lateral instability. There was no evidence of recurrent patellar subluxation/dislocation. The April 2017 VA examination report reflects that the Veteran had normal stability on all stability testing (Lachman’s – anterior instability, posterior drawer, medial, and lateral). The evidence is against a finding of anything more than slight lateral instability; thus a higher rating is not warranted. 5. Entitlement to an initial compensable evaluation for hypertension. Service connection for hypertension was granted in a June 2008 RO rating decision. A non-compensable rating was assigned effective November 8, 2006, the day following separation from service. The Veteran’s hypertension is evaluated under DC 7101 which provides that a 10 percent rating is warranted for diastolic pressure predominately 100 or more; systolic pressure predominately 160 or more, or if there is a history of diastolic pressure predominately 100 or more and the individual requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. A 40 percent rating is warranted for diastolic pressure predominantly 120 or more. A 60 percent rating is warranted for diastolic pressure predominantly 130 or more. The Veteran was prescribed medication for his hypertension in approximately 2005. The Board has reviewed the records prior to that time to determine if he had a diastolic pressure predominantly 100 or more, but finds that he did not. For example, the following blood pressure readings were noted in his service treatment records (STRs): December 1999:107/72 May 2000: 132/72 June 2000: 136/66 September 2000: 144/76 March 2001: 132/70 April 2001: 111/58 August 2001: 129/97 January 2002 :144/80, 148/77 February 2002: 146/106 March 2002: 139/78, 124/52 April 2002: 129/90 May 2002: 130/82, 120/90 October 2002: 128/76 November 2002: 120/70 March 2003: 130/90 October 2003: 120/79 December 2003: 138/98 January 2004: 132/77 March 2004: 132/89 April 2004: 133/84 September 2004 records reflect that the Veteran had seen a dentist and told that his blood pressure was elevated and he should be seen for a follow up. Additional September 2004 blood pressure readings were noted as follows: 139/84, 135/85, 122/76, 124/70, and 121/77. He was not on any medication at that time. Another blood pressure reading the next month (October 2004) when he was seen for back pain was 143/98. A January 2005 record for symptoms of a cough with greenish phlegm reflected that he was taking HCTZ; his blood pressure was 132/77. A September 2006 Report of Medical History record reflects he was not taking any medication and had had some isolated high blood pressure readings in the past. His blood pressure was 117/68. Thus, the evidence is against a finding that the Veteran had a history of diastolic pressure predominantly 100 or more. A November 2007 VA record notes that the Veteran had a diagnosis of hypertension, was on medication for such, and that his blood pressure was 142/71. A December 2007 record reflects a blood pressure of 117/67. A January 2008 VA examination report reflects that the Veteran reported that he started medication for high blood pressure in 2006. On VA examination, his blood pressure readings were 140/80, 136/80, and 138/82. Between 2008 and 2012, the clinical records are also against a finding of diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more. For example, the following blood pressures levels were found: August 2008: 132/79 September 2008: 121/72 February 2009: 144/90 March 2009: 147/87 October 2009: 151/85 January 2010: 136/70, 120/72 March 2010: 144/92 June 2010: 145/94 August 2010: 133/80 February 2011: 146/77, 124/78 May 2011: 144/101 November 2011: 114/72 On VA examination in April 2012, the Veteran reported that he was diagnosed with hypertension in service and treatment was initiated with HCTZ but that he was not compliant with medication until after he separated from service. It was noted that he did not have a history of blood pressure elevation to predominantly 100 or more. His readings of 127/79 (November 2011), 114/72 (November 2011), and 122/72 (April 2012) were noted. Between 2012 and 2018, the clinical records are also against a finding of diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more. April 2015 record reflect blood pressure readings of 142/84 and 136/82. It was noted that home blood pressure monitoring revealed 155/106 and 157/98. Home log record reports in the clinical records reflect some blood pressure readings with a systolic level over 160 and a diastolic level over 100; however, a May 2015 VA clinical record reflects that the Veteran’s position of the arm when self-measuring his blood pressure was not ideal. A June 2015 record reflects that the Veteran is meeting the goal of less than 140/90 for his blood pressure readings and cites numerous levels from May 2015 which all noted systolic levels under 160 and diastolic under 100. In addition, the following levels have been noted: February 2015: 155/90 June 2015: 136/66 October 2015: 144/99 February 2016: 170/98, 137/76 December 2016: 149/84 January 2017: 148/71 February 2017: 138/70 On VA examination in February 2018, the Veteran reported that his blood pressure was currently well controlled and that his home blood pressure readings were in the 130s/80s. In addition, the following blood pressure readings were noted 135/78 (August 2017), 138/78 (February 2018), and 130/80 (February 2018). In view of the above, the Board finds that the Veteran’s hypertension is properly assigned a non-compensable rating. Although the Veteran requires medication for control of his hypertension, he does not have a history of diastolic pressure predominantly 100 or more. In addition, as set forth above, almost all of his diastolic pressure readings have been less than 100 and almost all of his systolic pressure readings have been less than 160. Accordingly, the disability does not meet the criteria for a compensable rating. 6. Entitlement to an increased initial evaluation for right shoulder dislocation, post-operative (dominant), rated as 10 percent disabling prior to April 5, 2017 and as 20 percent disabling thereafter. The Veteran’s right shoulder dislocation, postoperative, is evaluated as 10 percent disabling prior to April 5, 2017 under DC 5203, and as 20 percent disabling thereafter under DCs 5003-5202. (He is also separately rated disability for right shoulder limitation of motion with degenerative joint disease as 30 percent disabling from April 5, 2017 under DC 5003-5201.) The Veteran is right handed; thus, his right shoulder is his major shoulder for rating purposes. The Veteran would be entitled to a 20 percent rating under DC 5203 if he had nonunion or dislocation of the clavicle or scapula. The Veteran would be entitled to a rating in excess of 20 percent under DC 5202 if he had recurrent dislocation with frequent episodes and guarding of all arm movements (30 percent), had fibrous union of the humerus (50 percent), had nonunion of the humerus (60 percent), or had loss of head of the humerus (80 percent). The Board has also considered whether a rating for limitation of motion of the arm is warranted prior to April 2017, and if a rating in excess of 30 percent thereafter is warranted. Under DC 5201, a 20 percent rating is warranted where the arm is limited in motion to shoulder level. A 30 percent rating is warranted where the arm is limited in motion to midway between the side and shoulder level. A 40 percent rating is warranted where the arm is limited in motion to 20 degrees from the side. A January 2008 VA examination report reflects that the Veteran had had numerous right shoulder dislocations after the initial dislocation in service, and that he had had arthroscopic surgery [in service], had not had any dislocations since the surgery, and “is quite happy with his surgery.” It was noted that he continues to have some sensation of instability or subluxation of the right shoulder and he has some pain the right shoulder with activities. The Veteran complained of some sensation of instability or subluxation and some pain and decreased motion secondary to pain with activities. He did not complain of weakness and was able to reach overhead without difficulty, although he reported an increase in pain with putting a shirt on over his head, and with reaching forward. He did not have incapacitating flare-ups of pain, or use a brace. Upon examination, there was external rotation to 20 degrees, flexion from 0 to 120 degrees which was non tender, and further flexion from 120 to 180 with tenderness. He also had nontender abduction from 0 to 90 degrees and further abduction from 90 to 180 degrees with some tenderness. Repetitive use and passive testing did not change the range of motion. He was diagnosed with mild instability of the shoulder and activity-related pain. Records in 2011 reflect that the Veteran was able to play basketball, and even after dislocating his left shoulder in June 2011, was able to take his son to the batting cages and took a “few swings” himself. A March 2012 VA examination report reflects that the Veteran reported no dislocations of the right shoulder after separation from service, but complained of continued pain, locking, stiffness, clicking, and popping. His pain was a 3-4 out of 10 to a 10 out of 10. There was no swelling, heat, or redness. The Veteran reported flare-ups occurring approximately once every 1.5 to 2 weeks causing him to rest the shoulder. He does not seek medical care, become incapacitated, or seek bed rest. Upon examination, he had flexion to 170 degrees with objective evidence of pain beginning at 170 degrees, he had full abduction to 180 degrees with objective evidence of pain beginning at 180 degrees, to include after repetitive use. The Veteran had full muscle strength. The examiner found that the Veteran had mild crepitus, but no laxity in the right shoulder. He had a positive apprehension test, and impingement sign. The examiner found that the Veteran did not have guarding of the shoulder. An April 2017 VA examination report reflects that the Veteran did not report flare-ups of the shoulder or arm. He reported that he was unable to engage in overhead work. He had flexion of the right shoulder to 30 degrees, external rotation to 10 degrees and internal rotation to 60 degrees. He had full muscle strength. He had positive Hawkins’ impingement test, empty-can test, external rotation/infraspinatus strength test, and lift-off subscapular test. There was not a history of recurrent subluxation of the right shoulder during the rating period on appeal. He did have a positive crank apprehension and relocation test. He did not have loss of head, nonunion, or fibrous union of the humerus. He did not have malunion of the humerus with moderate or marked deformity. The Board finds that higher ratings are not warranted under DCs 5203 or 5202. The evidence does not support a finding of dislocation or nonunion with loss movement; thus, a rating in excess of 10 percent is not warranted for the period rated under DC 5203 prior to April 5, 2017. With regard to DC 5202, the evidence is against a finding of recurrent dislocation with frequent episodes and guarding of all arm movements, loss of head of the humerus, nonunion of the humerus, or fibrous union of the humerus; thus a rating in excess of 20 percent is not warranted for the period on appeal from April 5, 2017. The evidence is also against a finding of recurrent dislocations during the rating period. The Board has also considered whether a rating prior to April 2017 is warranted under DC 5201, but finds that it is not. The evidence as noted above, is against such a finding of limitation of motion to shoulder level or more severe; he had flexion to 120 degrees in 2008 and to 170 degrees in 2012. Moreover, with regard to complaints of pain and 38 C.F.R. § 4.59, the Board finds that his complaints are adequately compensated under DC 5202 which notes ‘guarding”; “guarding” considers complaints of pain. He is also not entitled to a rating in excess of 30 percent from April 2017 because his range of motion was not limited to 25 degrees. 7. Entitlement to an increased initial evaluation for bilateral pes planus, rated as 10 percent disabling prior to April 5, 2017 and as 30 percent disabling thereafter. The Veteran’s bilateral pes planus is rated as 10 percent disabling prior to April 5, 2017, and as 30 percent disabling thereafter under DC 5276. DC 5276 provides for a 30 percent rating for severe bilateral acquired flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, an indication of swelling on use; characteristic callosities. A 50 percent evaluation is assigned for pronounced bilateral acquired flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the Achilles tendon on manipulation, not improved by orthopedic shoes or appliances. The criteria for evaluating pes planus are not expressly written in the conjunctive as there is no “and” in the listed symptoms. Accordingly, it is not expected that all cases of pes planus will show all the findings specified. See Dyess v. Derwinski, 1 Vet. App. 448, 455-56 (1991) (applying 38 C.F.R. § 4.21 when evaluating pes planus). See also Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007) (the cases in which the Court has indicated that 38 C.F.R. § 4.21 applies are those in which the diagnostic criteria are not clearly joined in the conjunctive). Essentially the criteria for pes planus list symptoms equating to mild, moderate, severe and pronounced pes planus. Additionally, the criteria for evaluating pes planus are not successive in nature; thus, it is not necessary that all criteria be met for a lower rating to allow for the next higher rating. See Tatum v. Shinseki, 23 Vet. App. 152, 155-56 (2009). The rating criteria that most accurately reflects the Veteran’s disability picture is of the most importance here. See 38 C.F.R. § 4.7. The Board finds based on the evidence of record, and summarized below, that the evidence is against a finding of increased rating for any period on appeal. A January 2008 VA examination report reflects that the Veteran’s feet were negative for callouses and negative for ulcerations. He had normal weightbearing and normal standing and walking. There was no pain on manipulation. It was noted with regard to his pes planus that there were “no complaints.” The Board notes than another January 2008 VA examination report reflects that there was tenderness of palpation of both Achilles tendons, and some tenderness of the plantar surface of the left heel. A March 2012 VA examination report reflects that the Veteran reported that his pain is a 0-1 out of 10 to a 7 out of 10. He was not treated for his feet. He did not have swelling, heat, or redness. He had no unsteadiness or falling. It was noted that he uses over-the-counter insoles and takes over-the-counter NSAIDS. He reported that his ADLs are not limited but can be difficult because his walking is limited to ¼ of a mile and standing is limited to 30 minutes. The Veteran had pain on use, and pain with manipulation. He did not have characteristic calluses, and symptoms were relieved with arch supports. He did not have extreme tenderness of the plantar surface, did not have decreased longitudinal arch height on weight-bearing, did not have objective evidence of marked deformity of the foot, did not have marked pronation of the foot, did not have weight-bearing line fall over or medial to the great toe, did not have inward bowing of the Achilles tendon, and did not have marked inward displacement or severe spasm of the Achilles tendon. The examiner also noted that the Veteran can “heel/toe”, has mild tenderness to palpation of the left heel plantar aspect and the bilateral mid arches, had no abnormal wear to the shoes, had no evidence of abnormal weight being, and had no pes planus with non-weight bearing. An April 2017 V examination report reflects that the Veteran had pain on use, pain on manipulation, but no swelling on use and no characteristic callouses. He had used arch supports but remained symptomatic. He did not have extreme tenderness of the plantar surfaces. He did not have marked pronation, did not have weight-bearing line over or medial to the great toe, did not have inward bowing of the Achilles tendon, and did not have marked inward displacement and severe spams of the Achilles tendon on manipulation. It was noted that the Veteran was unable to stand and walk for prolonged periods. There was evidence of pain on passive range of motion testing and in non-weight bearing. In sum, the evidence is against a finding that the Veteran’s bilateral pes planus was manifested in symptoms warranting a disability rating in excess of 10 percent prior to April 5, 2017. While he had pain with manipulation and use, such is considered in the 10 percent rating. Moreover, he did not have the symptoms noted as examples for a severe disability or pronounced disability. In addition, the Board again notes that despite the Veteran’s reported symptoms and limitations due to pain, he was able to play basketball on several occasions, which the Board finds entails extensive use of the feet. (See June 2011, September 2011, October 2011, June 2013, February 2016 VA clinical records.) Since April 5, 2017 the Veteran’s pes planus symptoms have not more nearly approximated pronounced bilateral acquired flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the Achilles tendon on manipulation, not improved by orthopedic shoes or appliances. Conclusion With all of the Veteran’s disabilities on appeal, the Board has considered the Veteran’s complaints of pain; however, even considering his complaints, the Board finds that he is not entitled to increased ratings. Pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). Rather, pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Id at 43; see 38 C.F.R. § 4.40. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). The Veteran’s flare-ups have not been shown to be of such severity and frequency to cause limitation to such an extent as to warrant higher ratings. Even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). The Board also acknowledges that the Veteran has had training and duties in the medical profession. Nonetheless, the Board finds the objective clinical examinations to be more probative than his contentions. Based upon the evidence in this case, the exact onset of the Veteran’s current symptoms/level of disability cannot be determined with any certainty. The earliest that that it can be factually ascertained that he met the criteria for the assigned ratings are the dates he was examined by VA examiners noted above. The Board has also considered that the Veteran’s representative, in an August 2018 brief, raised the issue of whether extra-schedular ratings are warranted. However, and importantly, this was a general contention without specifics as to how the applicable rating criteria do not encompass the Veteran’s symptoms. The Court has held on multiple occasions, that the Board generally must consider referral for extra-schedular consideration only “‘[w]here there is evidence in the record that shows exceptional or unusual circumstances or where the veteran has asserted that a schedular rating is inadequate.’” Yancy v. McDonald, 27 Vet. App. 484, 493 (2016) (quoting Colayong v. West, 12 Vet. App. 524, 536 (1999); see also Thun v. Peake, 22 Vet. App. 111, 115 (2008) (“When either a claimant or the evidence of record suggests that a schedular rating may be inadequate, the Board must specifically adjudicate the issue of whether referral for an extraschedular rating is warranted.”), aff’d sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In other words, although “[e]xtraschedular rating consideration is a component of [an] appellant’s claim for an increased rating,” Brambley v. Principi, 17 Vet. App. 20, 23 (2003), the Board is not obligated to analyze whether referral is warranted if “§ 3.321(b)(1) [is] neither specifically sought by [the claimant] nor reasonably raised by the facts found by the Board,” Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff’d, 226 Fed. Appx. 1004 (Fed. Cir. [*370] 2007); see also Robinson v. Mansfield, 21 Vet. App. 545, 552 (2008) (holding that the Board is required to consider all issues raised by a claimant or reasonably raised by the evidence of record), aff’d sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009). In the present claims, the Board finds that it is not required to analyze whether referral for an extra-schedular rating is warranted because the Veteran has failed to make a specific argument and failed to identify inadequacies in the rating criteria. Moreover, for those disabilities which are rated based on level of severity such as slight, moderate, or severe, the criteria is broad enough to encompass all symptomology. As the preponderance of the evidence is against the claims for which the Board did not provide an increased or separate rating above, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Wishard