Citation Nr: 18154803 Decision Date: 11/30/18 Archive Date: 11/30/18 DOCKET NO. 11-21 407 DATE: November 30, 2018 ORDER Entitlement to service connection for rheumatoid arthritis of the bilateral elbows, wrists, hands and fingers, to include as secondary to service-connected left shoulder disability is denied. Entitlement to service connection for a disability characterized by chest pain, to include paroxysmal supraventricular tachycardia (PSVT) is denied. Entitlement to a disability rating higher than 20 percent for a left shoulder disability is denied. FINDINGS OF FACT 1. The Veteran does not have a current diagnosis of arthritis in the right elbow, left elbow, right wrist, or left wrist. 2. The Veteran’s arthritis of the hands and fingers, diagnosed many years after service separation, was not incurred in service and is not otherwise etiologically related to it or to his service-connected left shoulder disability. 3. The Veteran’s currently diagnosed PSVT manifested by chest pain was not incurred in service and is not otherwise etiologically related to it. 4. For the entire period on appeal, the Veteran’s left shoulder has been manifested by x-ray evidence of mild degenerative changes, pain, flexion no worse than 110 degrees, and abduction no worse than 100 degrees. CONCLUSIONS OF LAW 1. The criteria to establish service connection for bilateral elbow and wrist arthritis have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria to establish service connection for bilateral hand and finger arthritis have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 3. The criteria to establish service connection for a heart disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 4. The criteria for a rating higher than 20 percent for a left shoulder disability are not met or approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.71a, DCs 5201 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1963 to August 1982. In September 2016, the Board remanded the above-mentioned issues, as well as issue of entitlement to service connection for chronic prostatitis, for further development, to include providing the Veteran with VA examinations. Subsequently, in an August 2017 rating decision the RO increased the Veteran’s left shoulder disability rating to 20 percent for the entire period on appeal, effective September 17, 2008. The Board notes that the 20 percent rating does not constitute a full grant of the benefit sought by the Veteran and that higher ratings are available and as such the Veteran’s claim for increased rating higher than 20 percent for a left shoulder disability remains on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). Additionally, in a September 2018 rating decision, the RO granted service connection for chronic prostatitis. The RO’s grant of service connection is considered a full grant of the benefits on appeal for the Veteran’s chronic prostatitis claim. As such, this issue is no longer before the Board for appellate consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). The Board below limits he discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may alternatively be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a) (2017). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.310(b) (2017); Allen v. Brown, 8 Vet. App. 374 (1995). The Veteran is currently diagnosed with arthritis of the hands and fingers, which is also known as degenerative joint disease, and is a “chronic disease” under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) for “chronic” in-service symptoms and “continuous” post-service symptoms apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The presumptive service connection provisions based on “chronic” in-service symptoms and “continuity of symptomatology” after service under 38 C.F.R. § 3.303(b) are interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Kahana, 24 Vet. App. at 433-34. A Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Id. at 1287 (quoting 38 U.S.C. § 5107 (b)). Arthritis of the Elbows and Wrists The Veteran asserts that he has bilateral elbow and wrist arthritis related to his service-connected left shoulder disability. However, the weight of the evidence demonstrates that the Veteran does not have arthritis in either his right or left elbow or wrist, or symptoms in those joints that cause functional impairment of earning capacity. With regard to the Veteran’s contention that he has rheumatoid arthritis, the Board finds no objective evidence showing that he was ever diagnosed with rheumatoid arthritis in any joint. The Board recognizes that in the past that rheumatoid arthritis was suspected based on his reported pain with unknown etiology, the Veteran’s blood work results in November 1996 and June 2007 confirmed that he did not have rheumatoid arthritis. Furthermore, during a June 2017 VA examination, x-rays of the wrists and elbows were negative for arthritis; range of motion of both elbows and wrists was normal; and there was no functional impairment associated with the reported pain. In the absence of competent proof of a current disability, there is no valid claim of service connection. In analyzing this claim, the Board recognizes that the Veteran is competent to report his observable symptoms and signs of elbows and wrists conditions; however, his lay statements are not competent to establish that he has a current disability, as he is not shown to be competent to render a medical diagnosis, and the reported symptoms do not show functional impairment, and objective x-ray evidence does not show arthritis in either the elbow or wrist joints. He therefore has not met the threshold element of any service connection claim, which is a current disability. For the reasons and bases discussed above, the preponderance of the evidence is against the Veteran’s service connection claims for bilateral elbow and wrist conditions, and they therefore must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Arthritis of the Hands and Fingers The Veteran asserts that he has arthritis of the hands and finger secondary to his service-connected left shoulder disability. The Veteran’s service treatment records are silent to any complaints of problems with the hands or fingers. A service treatment note dated in June 1968 simply state “Right-hand: No evidence of fracture or dislocation.” He separated from service in 1982. During a March 1984 orthopedic evaluation for rating purposes for the Veteran’s service-connected left shoulder, the examiner noted that the Veteran had normal range of motion in both hands, with excellent grip, and x-rays showed no abnormalities. Post-service private medical treatment records dated in December 1994 show right index finger degenerative narrowing of the right 2nd DIP joint, but otherwise negative. Additional treatment records dated in February 1995 show that the Veteran complained of right hand first digit problems, and show that in March 1995 he underwent a surgery for excision of soft tissue mass in the right index finger, DIP joint, and right thumb IP joint dorsal. This operation was the result of the Veteran’s complaints of pain and findings of growing mass in those areas. The preoperative diagnosis was clinically mass right thumb and index fingers with a ganglion cyst. Thereafter, private treatment records dated in June 1996 show that the Veteran complained of discomfort of the right index finger, and the medical professional stated, “I think what he is having is a postsurgical arthritic-type discomfort.” Private treatment records dated in November 1996 contain blood work results that showed a rheumatoid factor lower than 20 IU/ML which was noted to be indicative of no evidence of rheumatoid arthritis. In April 2003, the possibility of rheumatoid arthritis was again raised due to the Veteran’s reports of pain, which was concluded to be due to “unknown factor.” Private treatment records dated in May 2007 show continued complaints of right hand pain for six months that had become worse. Additional blood work results dated in June 2007 were negative for rheumatoid arthritis. Thereafter, treatment records dated in December 2007 indicate that the Veteran complained of right and middle finger pain. X-rays of the right hand revealed evidence of arthritis in distal metacarpals over every joint to varying degree, and the assessment was osteoarthritis in the right middle finger. Past medical history indicated “significant for arthritis in multiple joints including in his hands, otherwise negative.” The treatment records at the time further noted that joints, bones, and muscles of the left hand, middle and ring finger, were all within normal limits. In his October 2009 claim, the Veteran stated that his rheumatoid arthritis spread to his hands and fingers, and in a report of general information dated in November 2009, it was noted that he clarified that his claim was for rheumatoid arthritis in his hands and fingers secondary to his left shoulder. Private treatment records dated in February 2011 show a list of chronic diagnosis, which includes osteoarthritis, generalized, involving multiple joints. During a June 2011 VA examination for genitourinary conditions, the Veteran reported that he had a history of arthritis in the shoulders, elbows, and hands. Additional private treatment records dated in July 2011 indicate that by the Veteran’s lay reports he has arthritis in his shoulders, elbows, right hand, and fingers. Throughout the pendency of the appeal, beginning in August 2011, the Veteran submitted many internet medical articles and journals regarding rheumatoid arthritis and its ability to spread to other joints. In his August 2011 substantive appeal, the Veteran indicated that VA separated his claim for increase for a left shoulder disability into two claims, one for service connection for arthritis in his other joints. He then stated that VA concluded that there was no evidence in-service of arthritis of the other joints, to include his hands and fingers, which was due to the fact that he was never received any treatment for it during service, because he believes that the progression was “not far enough” and he was on medication for his shoulder. Again, the Board finds no evidence of rheumatoid arthritis; rather he is diagnosed with osteoarthritis. In June 2017, the Veteran underwent VA hand and finger examinations and the examiner confirmed that the only evidence of arthritis is for osteoarthritis and concluded that no blood results in the record show diagnosis of rheumatoid arthritis. The Veteran stated that he was never told he had a diagnosis of rheumatoid arthritis, but thought it was a possibility given that it was spreading to other joints. During the examination of the Veteran’s hands and fingers, the examiner confirmed diagnoses of osteoarthritis in the right and left hands and fingers. The examiner stated that based on the Veteran’s lay reports, the date of diagnosis was in the 1980s along with diagnoses of ganglion cysts. The examiner again noted that the Veteran stated he was never told that he had rheumatoid arthritis, but just assumed it could be, the way it progressed to different joints, but no blood work pertaining to “RA” confirmed it. It was therefore noted that there is no evidence of rheumatoid arthritis in any joint, to include in his service-connected left shoulder, that could have spread to other joints. There is evidence of a current disability. The Veteran has a current diagnosis of osteoarthritis in both the right and left hands and fingers. See e.g., June 2017 VA examination report. However, there is no evidence of a diagnosis of arthritis during service. There is also no evidence of chronic symptoms of arthritis in service or within the first post-service year. Moreover, there is no evidence of continuing symptoms of arthritis since service separation. In fact, an orthopedic evaluation conducted approximately two years after service contains negative x-rays of the hands. The first indication of possible arthritis in the hands and fingers was not shown until 1994, and the competent medical evidence suggests that, at least with regard to the right hand, the arthritis was a residual of surgery and not service or a service-connected disability. Accordingly, service connection on a presumptive basis is not warranted. The Board finds further that there is no competent evidence of a nexus between the Veteran’s current hand and finger osteoarthritis and his service or a service-connected disability. The June 2017 examiner opined that the Veteran’s osteoarthritis of the hands and fingers was less likely than not related to service or the service-connected left shoulder disability. The examiner noted that the absence of relevant complaints in service. In addition, the examiner indicated that the Veteran’s left shoulder pain was likely due to a chronic strain, and complaints of pain in other joints were not related to his service-connected disability. Moreover, the whole theory of entitlement the Veteran raised was based on his own belief that he had rheumatoid arthritis that could spread from one joint to another, which is not supported by the competent medical evidence. In this regard, while the Veteran is competent to describe current symptoms he experiences at any time, he does not have the requisite medical expertise needed to provide a competent opinion regarding causation of a complex medical condition such as arthritis, and its relationship to active service and or a service-connected disability. Rendering such opinions requires specialized medical knowledge of the musculoskeletal system, which the Veteran is not shown to have. Regarding the medical literature articles submitted by the Veteran, the Court has held that “generally, an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise is too general and inconclusive.” Mattern v. West, 12 Vet. App. 222, 228 (1999) (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)). Medical treatise evidence may indicate enough of a basis of a generic relationship to establish “a plausible causality based on objective facts.” Mattern, 12 Vet. App. at 228 (citing Wallin v. West, 11 Vet. App. 509, 514 (1998)). In the present case, the articles and medical literature are of no probative value because no medical expert has opined regarding such a nexus in this particular Veteran or even concluded that the Veteran had rheumatoid arthritis that is related to service or a service-connected disability. This general article citing relationships between disorders is of much less probative value than the specific examination findings and diagnostic assessments of record in this case that show evidence that is against finding that the Veteran has a diagnosis of rheumatoid arthritis or that his osteoarthritis is related to service or the service-connected left shoulder disability. The articles are outweighed by the medical evidence, and VA examination report and opinion that were case specific, and provided opinions with rationale based on the facts of this case. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for arthritis of the hands and fingers, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. Heart Disability The Veteran also asserts that he has a heart disability, diagnosed as PSVT, that had its onset during service. The Veteran’s service treatment records show that he made numerous complaints of chest pain. A treatment note dated in April 1969 indicates that the Veteran was with a 3-day history of a cold, and complaints of nocturnal left anterior chest aching pain for the previous two-months. Examination of the chest was normal, the heart had no rubs or murmurs, and the Veteran was ordered to apply hot soaks nightly to his chest. Chest x-rays in July 1963, March 1967, and June 1981 were within normal limits. Multiple reports of medical examinations, to include in June 1963, March 1967, June 1971, October 1973, April 1974, and February 1978, show normal heart, and the Veteran denied palpitation or pounding heart, any heart trouble, or chest pain or pressure. Post-service radiographic report dated in March 1984 indicates that the Veteran’s cardiac size was enlarged with a left ventricular configuration. The lungs were clear, and there was evidence of previous granulomatous infection. It was further noted that there was some blunting seen at the right costophrenic angle which may be due to old pleural thickening, and some blunting at the left costovertebral angle. Subsequent March 1993 and August 1996 radiology studies of the chest were negative. On an immunization questionnaire dated in November 1996, the Veteran answered “no” to the question of whether he had any chronic illnesses such as diabetes, hypertension, or heart disease. Private treatment records dated in October 2001 indicate that the Veteran complained of chest pain. Examination of the heart showed mild degree of reversibility inferolateral wall and proximal inferoseptal wall, suggestive of reversible ischemia. An exercise test associated with the myocardial perfusion imaging study revealed very good exercise tolerance, hypertensive response to exercise, and negative treadmill test for ischemia. Additional private treatment records dated in July 2006 indicate that the Veteran’s medical history was negative for any heart or lung disease, and subsequent private treatment records continuously show normal heart with no murmur, no rubs, and no gallops. VA treatment records dated in April 2013 show that the Veteran’s chest was clear with regular heart sounds. Additional VA treatment records dated in September 2013 indicate that the Veteran will have a chest CT, but denied any acute symptoms at the time of the appointment, specifically no chest pain. X-rays revealed no acute cardiac or pulmonary abnormality. In an addendum, it was noted that possible aneurysm was discussed with the Veteran. Private treatment records dated a day later indicate that the Veteran had a history of left chest wall pain, and a CT of the chest revealed calcified left hilar nodes from old granulomatous disease present in the left lower lobe. No pericardial or pleural effusion. Lungs were clear of infiltrate or suspicious mass. The impression was old granulomatous disease, otherwise negative CT scan. During a September 2013 VA examination for muscle injuries, it was noted that the Veteran had a left sided chest wall pain intermittently dating to the early 1960s, but he was mostly pain free unless he was sitting or lying on his left side. It was described as dull pain in different locations left lateral (underneath axilla), posterior (subscapular), and anterior to the left. There was no associated shortness of breath and the pain lasted between five and fifteen minutes. The Veteran reported that he went to the emergency room in 1983 and had a stress test, but was told the chest pain was not cardiac. He continued to be followed by his primary care physician and was later told he had chest wall pain. He indicated that he had pain only when he slept on his left side or if he rested his left arm on an arm rest. The Veteran denied a history of hypertension, diabetes, or hyperkeratosis lenticularis perstans, as well as any family history of premature coronary artery disease. Upon examination, there was no abnormality on inspection or palpation of the left rib cage/chest wall, and no tenderness or swelling. The impression was recurrent chest pain. The examiner opined that the condition was less likely than not related to service because the Veteran had intermittent back pain with progression of pain that he dated back to the 1960s, and this pain was likely musculoskeletal in nature. It was further noted that the pain appeared to be positional and related to certain movements of the left shoulder. The examiner further explained that there was no history of trauma or antecedent event, and the pain was positional and did not impair function. In addition, the examiner noted that while the in-service complaints in 1976 were for scapular pain, during this examination, the complaints were mostly of musculoskeletal pain with only occasional scapular pain. In addition, it was noted that the Veteran was taking Celebrex, arthritis medication, which he stated helped with this pain as well. Lastly, the examiner noted that the Veteran presented with axial back pain most likely related to facet arthritis. A private ECG dated in October 2013 shows normal myocardial perfusion with no reversible defect to suggest ischemia and normal left ventricle wall motion with an ejection fraction of 50 percent. A November 2013 echocardiogram report from the Heart Center of Memphis revealed borderline concentric left ventricular hypertrophy, overall left ventricular systolic function low-normal with an EF between 50-55 percent, diastolic filling pattern indicating impaired relaxation, trace to mild mitral regurgitation, and no evidence of pulmonary hypertension. In addition, beginning November 2013, treatment records showed dyspnea with fatigue, history of sinus tachycardia, PSVT, and thallium scans negative for ischemia. In December 2013, the Veteran submitted internet articles describing what is left ventricular hypertrophy and valvular heart disease. In a letter dated in December 2014, a nurse from the Heart Center of Memphis noted that the Veteran was initially referred for evaluation in November 2013. Due to symptoms noted during a normal stress test, a 24-hour Holter monitor and echocardiogram were obtained, which showed sinus rhythm with episodes of tachycardia. The Veteran was prescribed medication and was followed up since that time with no additional complaints. In November 2015, the Veteran submitted additional medical literature describing what is PSVT. In a correspondence attached to the medical literature, the Veteran indicated that it proved that his heart condition was misdiagnosed due to lack of proper tools and or failure to utilize the proper tools. Subsequent to the Board’s September 2016 remand, the Veteran underwent a VA examination for heart conditions in June 2017, at which time the examiner confirmed a diagnosis of PSVT since 2016. The Veteran reported that the onset of the disability was in the 1960s when he began having left sided chest pain, but was told everything was okay. He further reported that not long ago, he saw a cardiologist who told him he had irregular heartbeat and gave him some medications, which helped. He noted that he no longer had any chest pain, but had an occasional shortness of breath. The examiner indicated that the PSVT was of an unknown etiology. On physical examination, the Veteran’s heartrate was 84 with regular rhythm. Point of maximal impact was 4th intercostal space and heart sounds were normal. There was no evidence of Jugular-venous distension, auscultation of the lungs was clear, peripheral pulses were normal, and there was no evidence of peripheral edema. An echocardiogram dated in May 2017 was reviewed, which showed no evidence of cardiac hypertrophy or dilatation, LVEF was 55 percent, and wall motion and thickness was normal. A May 2017 EKG revealed a T-wave abnormality, and the examiner noted that inferior ischemia should be considered. However, an addendum stated that this was a computer read report, an upon review, the Veteran did not have any other signs or symptoms of ischemia. The examiner opined that the chest pains reported by the Veteran were felt to be musculoskeletal with no mention of arrhythmia, and although the Veteran may very well have PSVT, there was no documentation that supports this diagnosis. Based on the foregoing, the Board finds that the preponderance of the evidence is against the claim. Although there is evidence of a current heart disability and complaints of chest pain in service, the competent and credible medical evidence indicates that there is no relationship between the two. No medical professional has linked the Veteran’s PSVT to the chest pain in service. The June 2017 VA examiner had an opportunity to examine the Veteran and review his claims file, to include those chest pain complaints in service prior to rendering the opinion that the Veteran’s PSVT is less likely related to his miliary service. The Board finds the 2017 opinion to be highly probative in this case. The Veteran has not submitted a medical opinion favorable to his claim. Regarding the medical literature articles submitted by the Veteran, the Court has held that “generally, an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise is too general and inconclusive.” Mattern, supra. In the present case, the articles and medical literature are of no probative value because no medical expert has opined regarding such a nexus in this particular Veteran or even concluded that the Veteran had a heart disease that is related to his complaints of chest pain in-service. This general article citing relationships between disorders is of much less probative value than the specific examination findings and diagnostic assessments of record in this case that show evidence that is against finding that the Veteran PSVT and reported chest pain are causally or etiologically related to service. The articles are outweighed by the medical evidence, and VA examination report and opinion that were case specific, and provided opinions with rationale based on the facts of this case. Accordingly, the weight of the competent and credible evidence demonstrates no relationship between the current PSVT and the Veteran’s active duty service. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a disability characterized by chest pains, to include PSVT, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. Increased Rating Claim Disability evaluations are determined by comparing a veteran’s present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon 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 is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran’s condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Where the veteran is appealing the rating for an already established service-connected condition, her present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 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). Left Shoulder The Veteran is left-hand dominant. His left (major) shoulder is rated pursuant to DC 5009-5201. Under DC 5201, limitation of motion of the major extremity at the shoulder level warrants a 20 percent rating. Limitation of motion midway between the side and shoulder level warrants a 30 percent rating for the major extremity. Where motion is limited to 25 degrees from the side, a 40 percent rating is warranted for the major extremity. 38 C.F.R. § 4.71a, DC 5201. Normal range of motion of the shoulder is flexion from 0 to 180 degrees, abduction from 0 to 180 degrees, and internal and external rotation from 0 to 90 degrees. 38 C.F.R. § 4.71a, Plate I. 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). Nonetheless, 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) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Turning now to the evidence, in May 2009, the Veteran underwent a VA examination to determine the severity of his left shoulder disability. It was noted that the Veteran was a left-hand dominant, and reported that he hurt his shoulder many years ago, but was not sure how. He further reported that the pain waxed and waned anywhere from 0 out of 10 to 8 out of 10 in severity. He stated that in the examination room his pain was 0 out of 10, but when he was in the waiting room, it was 8 out of 10. He reported flare-ups, which he described as increase in pain when sleeping on his left shoulder. He did not use any type of brace or cane, or had any surgery, but indicated that he received physical therapy, injections, and was prescribed medications, with little help. He further reported that the shoulder affected his activities of daily living, making it difficult for him to use his left upper extremity and raise his arm over his head. However, he stated that he could use his left shoulder for greater than two hours, and was not employed but did not look for a job and indicated that it did not affect his employment. Upon physical examination, range of motion of the left shoulder revealed forward flexion to 160 degrees with pain noted at 150 degrees; lateral abduction to 170 degrees without pain; internal rotation to 90 degrees; and, external rotation to 90 degrees, both without pain. Muscle strength testing was 4/5 strength with supraspinatus, 5/5 strength with infraspinatus subscapularis, and the examiner noted that the Veteran had pain with testing the supraspinatus. Speed and O’Brien’s tests were negative. Hawkin’s impingement sign was positive. X-rays of the left shoulder revealed normal boney alignment, no fractures, and no dislocations. The assessment was left shoulder rotator-cuff tendonitis, mild, and impingement syndrome, mild. The examiner concluded that it was conceivable that the Veteran could have increased pain that could further limit function as described particularly after using his shoulder for a long period of time, but it was not feasible to attempt to express any of this in terms of additional limitation of motion as these matters could not be determined with any degree of medical certainty. Private treatment records dated in July 2011 show that the Veteran indicated he had “arthritis pain” in his shoulders, and stated that the over-the-counter medication were no longer helpful. During a September 2013 VA examination for muscle injuries, muscle strength testing was normal for shoulder abduction. X-rays revealed normal alignment with minor degenerative changes at the AC joint with small inferior marginal osteophytes noted at the left AC joint, with some narrowing of the AC joint. Private treatment records dated in May 2017 show reports of shoulder pain; however, the records indicate that the Veteran reported pain in the right shoulder. No treatment for the left shoulder was noted. In June 2017, the Veteran underwent an additional VA examination to determine the severity of his left shoulder disability. The examiner confirmed a diagnosis of left shoulder strain and noted that the Veteran was left-hand dominant. The Veteran reported that his pain began in-service, and had been the same since the date of onset in the 1960s. He described symptoms of pain when raising his arm above the head. It was noted that he was prescribed Celebrex 100mg twice daily, which he indicated “helps a lot.” He reported flare-ups, which were described as increased pain two to three times a month during the winter months. He further reported functional impairment that was described as inability to raise his left arm above his head. Upon physical examination, range of motion of the shoulder revealed flexion to 110 degrees; abduction to 100 degrees; external rotation to 90 degrees; and, internal rotation to 40 degrees. The examiner noted that range of motion itself contributed to functional loss, since the Veteran was unable to reach above his head. Pain was noted on flexion and abduction, but there was no objective evidence of localized tenderness or pain on palpation. There was also no evidence of pain with weight-bearing or objective evidence of crepitus. The Veteran was unable to perform repetitive-use testing with at least three repetitions, which did not result in additional loss of function or range of motion. The examiner indicated that the examination was not conducted immediately after repetitive use over time or during a flare-up and as such was neither medically consistent or inconsistent with the Veteran’s statements. Muscle strength testing was normal throughout with no reduction in muscle strength or muscle atrophy. There was no ankylosis. Rotator cuff condition, shoulder instability, dislocation, or labral pathology was not suspected. There was no loss of head, nonunion, or fibrous union of the humerus, or malunion of the humerus with moderate or marked deformity. After a careful review of the evidence, both lay and medical, the Board finds that a rating higher than 20 percent for the service-connected left shoulder disability is not warranted. As noted above, to warrant a rating higher than 20 percent for the left (major) shoulder, there must be limitation of motion of the arm to midway between the side and shoulder level. However, throughout the pendency of the appeal, since September 2008, the evidence does not show such limitation of the left shoulder, even considering pain and the effect of repetitive motion. In that regard, the Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, a rating higher than 20 percent for the Veteran’s service-connected left shoulder disability is not warranted on the basis of functional loss due to pain in this case, as the Veteran’s symptoms are supported by pathology consistent with the assigned 20 percent rating, but no higher. Even after taking into consideration the Veteran’s complaints of intermittent pain and reports of flare-ups, the Board finds that the effects of pain and limitation of motion reasonably shown to be due to the service-connected left shoulder disability are contemplated in the current 20 percent rating assigned. In this regard, even when considering the reported flare-ups, this does not more nearly approximate limitation of motion of the arm to midway between the side and shoulder level. In addition, the Board finds no competent evidence of ankylosis of the left shoulder (DC 5200), or recurrent dislocation or malunion of the humerus (DC 5202). Accordingly, the preponderance of the evidence reflects that a rating higher than 20 percent is not warranted for the Veteran’s service-connected left shoulder disability. (Continued on the next page)   Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Yaffe, Associate Counsel