Citation Nr: 20021641 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 08-19 752A DATE: March 26, 2020 ORDER From May 24, 2006, a 20 percent disability rating for right shoulder arthritis is granted, but a rating in excess of 20 percent is denied. FINDING OF FACT Throughout the entire period on appeal, the Veteran’s right shoulder disability has been manifested by complaints of pain and loss of motion, but an ability to move the arm at least 80 degrees. CONCLUSION OF LAW From May 24, 2006, the criteria for a 20 percent rating, but no higher, for right shoulder arthritis, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5201, 5203. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1979 to March 1988. In July 2010, the Veteran testified at a hearing before the Board; the transcript is of record. In September 2010, the Board remanded the claim to afford the Veteran a VA examination to determine the severity of her right shoulder disability. In September 2010, the agency of original jurisdiction (AOJ) obtained the requested VA examination. However, in April 2014, the Board found that the September 2010 VA examination was inadequate as the information the Board requested was largely absent from the examination report. The Board remanded the claim for a new VA examination. In October 2015, the AOJ obtained the requested examination. However, in February 2017, the Board noted that the examiner failed to note the severity of the Veteran’s shoulder pain for each range of motion (ROM) exercise. As such, the examination was found to be inadequate. The Board, once again, remanded the claim for a new VA examination. In April 2017, the AOJ obtained a VA examination to determine the severity of the Veteran’s right shoulder disability. However, in May 2018, the Board found the examination inadequate and remanded the claim for a new examination. The Board notes that the Veteran was afforded a VA examination in March 2019. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). As indicated in the discussion below, the examiner performed a thorough physical evaluation of the Veteran, reviewed the Veteran’s pertinent medical history, and provided findings responsive to the applicable rating criteria. Thus, the Board finds the exam adequate to decide the increased rating issue. See generally Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As such, the Board finds that substantial compliance with the Board’s remand directives has been accomplished. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). In her August 2019 Appellate Brief, the Veteran, through her representative, stated that she was dissatisfied with the VA examiner/examination. Specifically, the Veteran stated that the non-physician examiner is not shown to have any particular expertise, experience, training, or competence in commenting on orthopedic disorders. Rather, the contract examiner was identified merely as a nurse practitioner (NP). Absence of competence renders her assessment no more probative than the appellant’s lay assertions that there is worsening of her right shoulder condition. The appropriate examiner to evaluate a shoulder disability is an orthopedist, preferably an orthopedic surgeon. For these reasons, the contract examination in 2019 is inadequate for VA purposes. However, as noted above and below, the Board finds sufficient evidence within the examination when paired with the totality of the record to properly adjudicate the Veteran’s increased rating claim. Regarding the examiner’s credential, the Board is entitled to presume the competence of VA examiners and the adequacy of their opinions. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011). Here, the Board does not find any objective indication that the examiner is not competent or that the exam was otherwise inadequate. With regard to the merits of the issue in appellate status, the Veteran’s right shoulder arthritis is rated 10 percent disabling, from May 24, 2006, and 20 percent disabling, from September 26, 2010. As will be discussed below, the Board finds that the Veteran’s right shoulder arthritis warrants a 20 percent for the entire period contemplated by this appeal, but a rating in excess is not warranted. A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Board will consider whether separate ratings may be assigned for separate periods of time based on the facts found, a practice known as “staged ratings.” Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Because the Veteran is right arm dominant, the right shoulder disability is rated as the major joint. The Veteran’s right shoulder disability is rated under 38 C.F.R. § 4.71a, DCs 5203-5201. Hyphenated codes are used when a rating for a particular disability under one DC is based upon rating of the residuals of that disability under another DC. 38 C.F.R. § 4.27. Diagnostic Code 5203 provides that malunion or impairment of function of the clavicle warrants a 10 percent rating, nonunion without loose movement warrants a 10 percent rating, nonunion with loose movement warrants a 20 percent rating, and dislocation warrants a 20 percent rating. 38 C.F.R. § 4.71a, DC 5203. Under DC 5201, a 30 percent rating is assigned for limitation of arm motion to midway between side and shoulder level. A 40 percent rating is assigned for limitation of arm motion to 25 degrees from side. Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, DC 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate DCs, the compensable limitation of motion should be rated under the appropriate DCs for the specific joint or joints involved. 38 C.F.R. § 4.71a. Diagnostic Code 5200 provides that ankylosis of the scapulohumeral articulation is to be rated as follows: favorable ankylosis, with abduction to 60 degrees, can reach mouth and head, 30 percent for the major shoulder and 20 percent for the minor shoulder; intermediate ankylosis, between favorable and unfavorable, 40 percent for the major shoulder and 30 percent for the minor shoulder; unfavorable ankylosis, abduction limited to 25 degrees from side, 50 percent for the major shoulder and 40 percent for the minor shoulder. A Note provides that the scapula and humerus move as one piece. 38 C.F.R. § 4.71a. Under DC 5202, other impairment of the minor extremity humerus warrants a 70 percent rating for loss of the humerus head (flail shoulder). A 50 percent rating is warranted for nonunion of the humerus (false flail joint). A 40 percent rating is warranted if there is fibrous union of the humerus. A 20 percent rating is warranted for recurrent dislocation of the humerus at the scapulohumeral joint with frequent or infrequent episodes and guarding of all arm movements or guarding of movement only at the shoulder level. A 20 percent evaluation may also be assigned for malunion of the humerus with deformity. 38 C.F.R. § 4.71a, DC 5202. Normal range of motion (ROM) of the shoulder is as follows: forward elevation (flexion) to 180 degrees; abduction to 180 degrees; internal rotation to 90 degrees; and external rotation to 90 degrees. 38 C.F.R. § 4.71, Plate I. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, including degree of disability, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. In June 2006, the Veteran underwent a right shoulder MRI. The MRI revealed signal abnormality in the rotator cuff tendons which suggested tendonitis versus tendinosis. In August 2007, the Veteran was afforded a VA examination to determine the nature and etiology of her right shoulder condition. The Veteran stated during service, she lifted extremely heavy parts such as transmissions engines and axles, and was not provided an atomic lift, etc. She reported using appropriate lifting techniques. The examiner noted that on December 16, 1987, the Veteran complained of her right shoulder being painful. She complained of her right shoulder hurting all the time. She complained of different muscle pulls etc. especially in the sacral area. The examiner opined that the Veteran’s shoulder pain is caused or a result of her activity in the military to include heavy lifting of mechanical parts working with two and a half ton vehicles etc. In October 2007, the Veteran was afforded a VA examination to determine the nature and etiology of her right shoulder disability. The Veteran stated that she injured her right shoulder in 1986 when she threw a softball. She reported chronic pain and weakness. The examiner diagnosed the Veteran with right shoulder degenerative joint disease (DJD). Physical examination revealed right sided abduction to 120 degrees with pain present and flexion to 135 degrees. The Veteran’s external rotation was to 85 degrees and internal rotation to 35 degrees with pain present. Physical examination of the left shoulder revealed 180 degrees of abduction, 145 degrees of flexion, 90 degrees of external rotation, and 70 degrees of internal rotation, all without pain. The ROM was not additionally limited following repetitive use. Impingement and stability testing and supraspinatus strength were all normal, bilaterally. Imaging revealed minimal osteoarthritis at the AC joint. On June 23, 2010, the Veteran was seen for an orthopedic consult. The examiner diagnosed the Veteran with intermittent right shoulder pain. The Veteran reported pain in her right upper shoulder, at times. However, at the time of the evaluation, her shoulder was not bothering her. On the day of the exam, she had full ROM. On June 28, 2010, the Veteran’s forward flexion and abduction were 150 degrees, adduction was to 30 degrees, and internal and external rotation were 80 and 90 degrees, respectively. During her July 2010 Board hearing, the Veteran stated that, on a daily basis, her right shoulder became stiff and sore. She also reported overused of the shoulder. The Veteran stated that pain caused bad headaches on the right side. She also reported tingling and numbness. In September 2010, the Veteran was afforded a VA examination to determine the severity of her right shoulder disability. The Veteran stated while in the military, she threw a softball and had a rotator cuff injury. Ever since the incident, she has had issues with her right shoulder. The Veteran stated that the pain in the right shoulder was activity related, occurred every day, and interfered with her sleep, at times. She also had difficulty doing housework such as vacuuming and even a riding lawnmower caused pain. She also reported pain with ROM to her side. She did not report instability and never had surgery on her shoulder. The Veteran took Motrin which did not help her pain. The examiner diagnosed the Veteran with impairment syndrome, right shoulder with likely supraspinatus tear. The Veteran is right hand dominant. She reported flareups which were activity related. Examination of the right shoulder demonstrated pain free abduction to six degrees and a total ROM to 90 degrees. The Veteran’s forward flexion was pain free to 80 degrees and was able to flex to 150 degrees. The Veteran experienced pain at all ranges of motion during external rotation, and her ROM ended at 30 degrees. Internal rotation, which was pain free, ended at l5 degrees. She had positive impingement testing, normal stability testing, and 4/5 supraspinatus strength which was reduced compared to her contra lateral side. She also had tenderness to palpation of her AC joint and osteophytes that could be palpated at her AC joint. Her ROM remained unchanged over time, and she experienced pain at previously stated ROM. Imaging revealed AC joint arthrosis and some cystic type changes over the rotator cuff, imprint would be on the glenohumeral head. In June 2014, the Veteran was afforded a VA examination to determine the severity of her right shoulder disability. The Veteran stated that her pain radiated from her right lower back, up, and to her shoulder. She experienced pain with movement. The examiner confirmed the Veteran’s DJD, right shoulder diagnosis. The Veteran is right hand dominant. She did not report flare-ups that impacted the function of her shoulder. The Veteran’s right shoulder forward flexion was to 170 degrees with objective evidence of painful motion beginning at 170 degrees; abduction was to 165 degrees with objective evidence of painful motion beginning at 165 degrees. The examiner did not test the Veteran’s left shoulder ROM. The Veteran was able to perform repetitive-use testing with three repetitions. There was no additional functional limitation in ROM of the shoulder following repetitive-use testing. However, she experienced functional loss and/or functional impairment of the shoulder. She also experienced right shoulder functional loss, functional impairment and/or additional limitation of ROM of the shoulder after repetitive use, to include less movement than normal and pain on movement. Regarding Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011) criteria, the examiner stated with repetitive use in real life situation, the Veteran may have gain or loss in ROM. The examiner was unable to state exact degree lost or gained since it would be of mere speculation. She did not have ankylosis, guarding, or localized tenderness or pain on palpation of joints/soft tissue/biceps tendon of either shoulder. Right shoulder muscle strength testing was normal. Hawkins’ Impingement, Empty-can, External rotation/Infraspinatus strength, and Lift-off subscapularis tests were all negative. The Veteran did not have a history of mechanical symptoms or recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint. Crank apprehension and relocation test were negative. The Veteran did not have an AC joint condition or any other impairment of the clavicle or scapula or tenderness on palpation of the AC joint. Cross-body adduction test was negative. She did not have a joint replacement and/or other surgical procedures. There were no other pertinent physical findings, complications, conditions, signs, scars, and/or symptoms related to her condition. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. Imaging revealed right shoulder degenerative or traumatic arthritis. The Veteran’s shoulder condition did not have an impact on her ability to work. The Veteran also underwent a peripheral nerve condition examination. The Veteran did not have any symptoms in her right and/or left upper extremities that were attributable to any peripheral nerve condition. Her right and left upper extremities muscle strength testing and sensory and reflex exams were normal. She did not have trophic changes (characterized by loss of extremity hair, smooth, shiny skin, etc.) attributable to peripheral neuropathy. The Veteran did not use an assistive device as a normal mode of locomotion, and functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. There were no other pertinent physical findings, complications, conditions, signs, and/or symptoms related to her condition. The Veteran’s nerve condition did not have an impact on her ability to work. In October 2015, the Veteran was afforded a VA examination to determine the severity of her right shoulder disability. She reported pain on a daily basis, which limited the use of her right shoulder. She took Tramadol and Ibuprofen prn and Tylenol PM every night for pain and sleep. The examiner confirmed the Veteran’s right shoulder impingement syndrome and acromioclavicular joint osteoarthritis diagnoses. The Veteran is right hand dominant. She reported flare-ups of the shoulder, to include increased pain with overuse of the shoulder. She also reported functional loss or functional impairment which affected overhead activities and driving her truck. Right shoulder forward flexion was to 170 degrees; abduction to 120 degrees; external rotation to 60; and internal rotation to 90 degrees. The ROM itself contributed to functional loss which affected her overhead activities and activities of daily living. Pain was noted on flexion, abduction, and external rotation and caused functional loss. There was no evidence of pain with weight bearing or objective evidence of crepitus. There was objective evidence of localized tenderness or pain on palpation of the AC joint, subacromial space. The Veteran was able to perform repetitive use testing with at least three repetitions. There was no additional functional loss or ROM after three repetitions. The Veteran was not examined immediately after repetitive use over time or during a flare-up. As such, the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time and during a flare-up. Pain significantly limited functional ability with repeated use over a period of time or during a flare-up. As the exam was not performed after repetitive use or during a flare-up, the examiner was unable to describe in terms of ROM. There were additional contributing factors of disability, to include disturbance of locomotion. The Veteran’s right shoulder muscle strength testing was normal. There was no reduction in muscle strength or muscle atrophy. The Veteran did not have ankylosis. The examiner suspected a rotator cuff condition. Hawkins’ Impingement and External Rotation/Infraspinatus Strength tests were positive. The Veteran’s Empty-can and Lift-off Subscapularis tests were negative. The examiner did not suspect shoulder instability, dislocation, or labral pathology. However, the examiner suspected a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition, i.e., the Veteran had a right shoulder AC OC. The clavicle or scapula condition did not affect ROM of the shoulder (glenohumeral) joint. The Veteran experienced right shoulder tenderness on palpation of the AC joint. Cross-body adduction test was positive. The Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus or malunion of the humerus with moderate or marked deformity. There were no other pertinent physical findings, complications, conditions, signs, scars, or symptoms related to her shoulder condition. She did not use any assistive devices, and functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. Imaging revealed degenerative or traumatic arthritis. There were no other significant diagnostic test findings or results. The Veteran’s disability did not have an impact on her ability to work. In April 2017, the Veteran was afforded another VA examination to determine the severity of her right shoulder disability. The Veteran reported right shoulder pain on a daily basis. The pain increased with any overhead activities. She denied any issues with her left upper extremity. The examiner confirmed the Veteran’s right shoulder impingement syndrome and acromioclavicular joint osteoarthritis diagnosis. She reported flare-ups of the shoulder, to include increased pain with use of the right upper extremity. She also reported functional loss or functional impairment of the joint or extremity which affected her tolerance for overhead activities, e.g. washing her hair. Right shoulder forward flexion was to 80 degrees; abduction to 90 degrees; external rotation to 50; and internal rotation to 90 degrees. The ROM itself contribute to functional loss, i.e., it affected overhead activities. Pain was noted on flexion and abduction and caused functional loss. There was no evidence of pain with weight bearing or objective evidence of crepitus. There was objective evidence of localized tenderness or pain on palpation of the AC, bicipital groove, and upper trapezius. Left shoulder ROM was normal with no pain noted on exam. There was no evidence of left shoulder pain with weight bearing, objective evidence of crepitus, or objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. Because of pain exacerbation, the Veteran was unable to perform right shoulder repetitive use testing with at least three repetitions. She was able to perform repetitive use testing with at least three repetitions with the left shoulder. There was no additional functional loss or ROM after three repetitions. Regarding her right shoulder, the Veteran was not examined immediately after repetitive use over time or during a flare-up. As such, the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time and during a flare-up. Pain significantly limited functional ability with repeated use over a period of time. As the exam was not performed after repetitive use or during a flare-up, the examiner was unable to describe in terms of ROM. Regarding her left shoulder, the Veteran was not examined immediately after repetitive use over time or during a flare-up. Therefore, the examination is neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time or during a flare-up. There were additional contributing factors of right shoulder disability, to include disturbance of locomotion. There were no additional contributing factors of the left shoulder. Muscles strength testing was normal, bilaterally. The Veteran did not have muscle atrophy or ankylosis. The examiner suspected a right shoulder rotator cuff condition. Hawkins’ Impingement test was positive. The Veteran’s Empty-can, Lift-off Subscapularis, and External Rotation/Infraspinatus Strength tests were negative. The examiner did not suspect shoulder instability, dislocation, or labral pathology or clavicle; scapula, acromioclavicular (AC) joint or sternoclavicular joint condition; or conditions or impairments of the humerus. The Veteran did not have malunion of the humerus with moderate or marked deformity. There were no other pertinent physical findings, complications, conditions, signs, scars, or symptoms related to her shoulder condition. She did not use any assistive devices, and functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. Imaging revealed degenerative or traumatic arthritis. There were no other significant diagnostic test findings or results. The Veteran’s disability did not have an impact on her ability to work. In March 2019, the Veteran was afforded a VA examination to determine the severity of her right shoulder disability. The Veteran stated that her shoulder pain remained the same as it was during the last evaluation and past 18 months. Her right shoulder pain was 1/10 at rest, and at times, 7/10 during activity. The pain was achy and burning, and at times, her shoulder was sore when she touched it. The examiner confirmed the Veteran’s degenerative arthritis diagnosis. She reported flare-ups of the shoulder which could happen up to two times per week. She stated that throwing things usually caused intense pain, but she avoided throwing things to reduce the risk of having a flare-up. Her last flare-up was in 2018. She also reported functional loss or functional impairment. She stated that driving made her right shoulder go numb, and she was unable to throw things or pick-up anything heavy. The Veteran’s right shoulder forward flexion was to 110 degrees; abduction to 130 degrees; external rotation to 30; and internal rotation to 50 degrees. The ROM itself contribute to functional loss, i.e., she was unable to throw things or pick-up anything heavy, and due to her limited ROM, she was limited with activities of daily living. Pain was noted on flexion, abduction, and internal and external rotation but did not result in/cause functional loss. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue or objective evidence of crepitus. There was evidence of pain with weight bearing. The Veteran’s left shoulder ROM was all normal and pain was not noted on the exam. There was no evidence of pain with weight bearing, objective evidence of crepitus, or objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was objective evidence of pain on passive ROM testing but no objective evidence of pain when the joint was used in non-weight bearing. The opposing joint is undamaged with no exam abnormalities. The Veteran was able to hold her right arm above her head, and this resulted in moderate pain with forward flexion. The examiner stated that the pain became worst with anything above 110 degrees of forward flexion. Bilaterally, the Veteran was able to perform repetitive-use testing with at least three repetitions. There was no additional loss of function or ROM after three repetitions. The Veteran’s right and left shoulders were not examined immediately after repetitive use over time or during a flare-up. Therefore, the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time or during a flare-up. Because the exam was not conducted after repetitive use over time or during a flare-up, the examiner was unable to say, without mere speculation, if pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over a period of time or during a flare-up. The examiner further stated that there was no conceptual or empirical basis for making such a determination without directly observing function under these conditions. The examiner was unable to describe in terms of ROM. She stated that it was not possible to determine, without resorting to mere speculation, to estimate loss of ROM, because there was no conceptual or empirical basis for making such a determination without directly observing function under these conditions. There were no additional contributing factors of the disability. Right shoulder muscle strength testing revealed active movement against some resistance, and the reduction in muscle strength was entirely due to her shoulder condition. Left shoulder muscle strength testing was normal. Bilaterally, the Veteran did not experience muscle atrophy. She did not have ankylosis; a rotator cuff condition; shoulder instability, dislocation, or labral pathology; a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition; or loss of head, nonunion, or fibrous unions of the humerus. There were no other pertinent physical findings, complications, conditions, signs, scars, or symptoms related to her shoulder condition. She did not use any assistive devices, and functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. Imaging revealed degenerative or traumatic arthritis. The Veteran’s condition had an impact on her ability to work. In the last 12 months, she lost zero to one-week of work time. Additionally, due to her shoulder condition, she was unable to perform heavy lifting. Based on the evidence of record and due to the inadequacies of the September 2010, October 2015, and April 2017 VA examinations, the Board will afford the Veteran the benefit of the doubt and award a 20 percent rating, but no more, from May 24, 2006, thus the entire appeal period. However, the Board finds that a disability rating in excess of 20 percent is not warranted for any period contemplated by this appeal. Under DC 5201, a 30 percent rating is warranted for limitation of motion of the major shoulder to midway between side and shoulder level. Here, at worse, the Veteran demonstrated abduction limited to 90 degrees. The record does not indicate the Veteran’s limitation of right shoulder motion is restricted to midway between side and shoulder level even when accounting for functional loss. Thus, a rating in excess of 20 percent under DC 5201 is not warranted. The Board recognizes that, under DeLuca v. Brown, 8 Vet. App. 202 (1995), VA must consider “functional loss” of a musculoskeletal disability separately from consideration under the DCs. “Functional loss” may occur because of pain, weakness, excess fatigability, incoordination and flare-ups, pursuant to 38 C.F.R. §§ 4.40, 4.45, and 4.59 and the Court’s holding in DeLuca v. Brown, supra. In this case, the Veteran experienced impairment of the right shoulder, to include less movement than normal, pain on movement, and pain which affected her activities such as driving, throwing, and picking up heavy things. However, given the extent of shoulder motion, i.e., flexion, at worst to 80 degrees and abduction limited to 90 degrees, the Board finds that there is no evidence of a disability picture that is commensurate to a limitation of flexion to the extent necessary to establish entitlement to higher disability ratings, even after taking pain into full consideration. See DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45, 4.71a, DC 5201. Additionally, the Board finds that the effects of pain reasonably shown to be due to her right shoulder disability is contemplated in the 20 percent rating. Further, the Board has also considered the application of DC 5200 for disabilities involving ankylosis of the scapulohumeral articulation and DC 5203 impairment of the clavicle/scapula to include nonunion with loose movement. The evidence does not show that the Veteran’s right shoulder condition manifestations have included ankylosis. During her 2015 and 2017 VA examinations, the examiners suspected a clavicle or scapula impairment. However, the evidence does not show that the Veteran’s right shoulder clavicle or scapula disability manifested with malunion, nonunion, or dislocation. Therefore, the Veteran is not entitled to a higher rating under DCs 5200 and 5203. Additionally, the Veteran does not have scars associated with her right shoulder disability. Therefore, a separate rating under 7800, 7801, 7802, 7804, 7805, or 7806 is not warranted. The evidence of record does not demonstrate that the right shoulder disability has manifested in fibrous union, nonunion, or loss of head of the humerus nor did the Veteran undergo a total shoulder joint replacement; thus, the Board finds that ratings in excess of 20 percent under DCs 5202 and 5051 are not warranted. The Veteran reported experiencing tingling and numbness. However, during her June 2014 peripheral nerve examination, the Veteran did not have any symptoms in her right and/or left upper extremities that were attributable to any peripheral nerve condition. Additionally, her right and left upper extremities muscle strength testing and sensory and reflex exams were normal. As such, the Board finds that the Veteran does not have a right upper extremity peripheral nerve condition diagnosis. Therefore, a separate rating cannot be granted for right upper extremity peripheral nerve condition. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Additionally, the Veteran stated that due to her shoulder pain, she experienced migraine headaches. In November 2006, the Veteran was denied service connection for migraine headaches. She did not appeal the decision. As such, service connection for migraine headaches is not on appeal. Under DC 5003, degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. The Veteran has a current diagnosis of right shoulder arthritis, as confirmed by X-ray evidence. However, the Veteran has already received a compensable rating under the appropriate DC. Assigning a separate rating under DC 5003 would constitute pyramiding, as DC 5201 rates based on limitation of motion, including limitation of motion caused by pain, and this includes arthritic pain. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Further, the rating criteria under DC 5003 specifically directs that degenerative arthritis be rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. See 38 C.F.R. § 4.71a DC 5003. The Board acknowledges the Veteran and her representative’s statements regarding the severity of the Veteran’s condition to be both competent and credible. However, as lay persons, they do not have the training or expertise to render a competent opinion which is more probative than the VA examiner’s opinion on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the Board finds that the lay opinions by themselves are outweighed by the VA examiner’s findings. The Board finds that the current rating criteria reasonably describe the Veteran’s disability level and symptomatology associated with the right shoulder disability. Therefore, the benefit of the doubt doctrine is not applicable, and the claim for a rating in excess of 20 percent must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. M.W. KREINDLER Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Moore The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.