Citation Nr: 20022011 Decision Date: 03/30/20 Archive Date: 03/30/20 DOCKET NO. 11-31 997 DATE: March 30, 2020 ORDER For the period from December 11, 2014, to September 27, 2017, entitlement to a 10 percent rating, but no higher, for left knee instability associated with patellofemoral syndrome, is granted. For the period from September 28, 2017, onward, entitlement to an increased rating in excess of 10 percent for left knee instability is denied. Entitlement to an increased rating in excess of 10 percent for left knee disability featuring painful motion with functional loss associated with patellofemoral syndrome, is denied. For the period prior to August 14, 2018, entitlement to an increased 20 percent rating, but no higher, for right shoulder supraspinatus tear and tendinosis with superior labral degenerative disease (previously characterized and rated as myositis, right trapezius muscle), featuring painful motion with functional loss, is granted. For the period from August 14, 2018, onward, entitlement to an increased rating in excess of 20 percent for right shoulder supraspinatus tear and tendinosis with superior labral degenerative disease (previously characterized and rated as myositis, right trapezius muscle), is denied. FINDINGS OF FACT 1. Throughout the period prior to December 11, 2014, the Veteran’s service-connected left knee disability was not manifested by joint instability. 2. Throughout the period from December 11, 2014, to September 27, 2017, the Veteran’s service-connected left knee disability included slight lateral instability of the joint; it did not include any greater degree of lateral instability of the joint. 3. Throughout the period from September 28, 2017, onward, the Veteran’s service-connected left knee lateral instability has not been of greater than a slight degree. 4. Throughout the rating period on appeal, the Veteran’s service-connected left knee disability has been manifested by functional impairment featuring no more than slight instability (with no instability prior to December 11, 2014) and painful motion. It has -not- been manifested by ankylosis; more than slight instability (with no instability prior to December 11, 2014) or recurrent subluxation; dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion; symptomatic removal of semilunar cartilage; flexion limited to 45 degrees; extension limited to the 10 degree position; tibia and fibula impairment; nor genu recurvatum. 5. Throughout the rating period prior to August 14, 2018, the Veteran’s service-connected right (major) shoulder disability was manifested by functional impairment from painful motion confirmed by objective clinical observation; it was not manifested by limitation of motion of the major arm to midway between the side and shoulder level, nor was the impairment of Muscle Group I moderately severe in degree. 6. Throughout the rating period from August 14, 2018, onward, the Veteran’s service-connected right (major) shoulder disability has not been manifested by limitation of motion of the major arm to midway between the side and shoulder level; nor has the impairment of Muscle Group I been moderately severe in degree. CONCLUSIONS OF LAW 1. Throughout the appeal period from December 11, 2014, to September 28, 2017, the criteria for a 10 percent rating, but no higher, for left knee lateral instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 2. Throughout the appeal period from September 28, 2017, onward, the criteria for a rating in excess of 10 percent for left knee lateral instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 3. Throughout the rating period on appeal, the criteria for a rating in excess of 10 percent for the Veteran’s left knee disability (apart from separately rated lateral instability), featuring painful limitation of motion associated with patellofemoral syndrome, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256-5263. 4. Throughout the rating period prior to August 14, 2018, the criteria for an increased 20 percent rating, but no higher, for right shoulder supraspinatus tear and tendinosis with superior labral degenerative disease (previously characterized and rated as myositis, right trapezius muscle), including shoulder joint disability and impairment of Muscle Group I, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, 4.73, Diagnostic Codes 5021-5201 and 5301. 5. Throughout the rating period from August 14, 2018, onward, the criteria for a rating in excess of 20 percent for right shoulder supraspinatus tear and tendinosis with superior labral degenerative disease (previously characterized and rated as myositis, right trapezius muscle), including shoulder joint disability and impairment of Muscle Group I, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, 4.73, Diagnostic Codes 5021-5201 and 5301. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from August 1995 to May 1998. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a March 2012 rating decision by the St. Petersburg, Florida, Department of Veterans Affairs (VA) Regional Office (RO) that continued a 10 percent rating for left knee disability and continued a 10 percent rating for right shoulder disability. This case was previously before the Board in December 2015, when these issues remaining on appeal were remanded to the Agency of Original Jurisdiction (AOJ) for additional development. Most recently, this case was again before the Board in July 2019. The Board resolved a separate issue with a final decision at that time (and explained the resolution of another matter that was withdrawn by the Veteran at the AOJ level), while the left knee and right shoulder rating issues remaining on appeal were again remanded for additional evidentiary development. The Board’s July 2019 remand directed that the Veteran be provided an opportunity to attend new VA examinations to develop more adequate findings with regard to the Veteran’s functional loss associated with the joint disabilities on appeal. In November 2019, during the processing of the remand, the AOJ documented in the claims-file that the requested examinations were “Cancelled at Veteran’s Request.” As the Veteran has declined to report for the new VA examinations, the Board shall proceed with appellate review on the basis of the evidence of record in the absence of the sought additional examination findings regarding functional impairment. During the processing of the Board’s December 2015 remand, an August 2018 RO rating decision granted an increase in disability compensation ratings for the Veteran’s left knee disability by awarding a separate compensable 10 percent rating for instability of the left knee, in addition to the 10 percent rating already in effect for the left knee disability on the basis of functional limitation of motion due to pain. As both of these ratings are part of the Veteran’s ongoing appeal for further increased disability compensation for the left knee disabilities, both left knee rating issues have been certified to the Board and are addressed by the Board in this decision. Also, during the processing of the Board’s December 2015 remand, the RO’s April 2019 rating decision granted an increased 20 percent rating for the Veteran’s right shoulder disability on appeal, effective from August 14, 2018. As discussed below, this decision came following the development of medical evidence that indicated that the Veteran’s service-connected right shoulder disability not only featured muscle impairment, but also included degenerative changes of the right shoulder. The Board notes that the RO has accepted that the right shoulder disability on appeal now includes associated degenerative changes (not limited to muscle injury) and has recharacterized the identification of the service-connected disability entity in accordance. The Board’s appellate review now proceeds with consideration of the complete service-connected right shoulder disability including all pertinent diagnoses and impairments. In May 2015, a videoconference Board hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran’s claims file. The Board notes that the Veteran’s former representative, that had previously been assisting her with her VA benefit claims, has withdrawn from representing the Veteran. The Veteran’s former representative provided notice to VA and to the Veteran of the intention to withdraw in November 2019; the withdrawal was then completed with notice provided in December 2019. VA accepted the withdrawal, and the Veteran, with notice of this withdrawal, has not appointed a new representative. Increased Rating Disability ratings are determined by comparing a Veteran’s symptomatology during the pertinent period on appeal 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 shall be applied under a particular diagnostic code, the higher rating will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. An exception to this rule applies when the rating criteria are successive. In such a case, all the requirements of the lower levels must be met before a higher level is awarded, and 38 C.F.R. §§ 4.7 and 4.21 do not apply. Johnson v. Wilkie, 30 Vet. App. 245 (2018). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. With a claim for an increased initial rating, separate staged ratings may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In a claim for increase in a previously established rating, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Lay evidence may be competent to address any matter not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises or statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). The Board has reviewed all of the evidence in the Veteran’s claims file, with an emphasis on the evidence pertinent to the issue on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all contents of 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. Gonzalez 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 claim. 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 the history supports a higher rating during the rating period on appeal. Additional references to the Veteran’s left knee and right shoulder health are presented in evidence of record beyond that discussed below, including in VA medical reports associated with the Veteran’s treatment. The additional evidence of record does not present findings that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision. Special Considerations for Musculoskeletal Disability Ratings Generally, in evaluating musculoskeletal disabilities, consideration must be given to additional functional limitation due to factors such as pain, weakness, fatigability, and incoordination. See 38 C.F.R. §§ 4.40 and 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The United States Court of Appeals for Veterans Claims (Court) has held that diagnostic codes predicated on limitation of motion do not prohibit consideration of a higher rating based on functional loss due to pain on use or due to flare-ups under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See Johnson v. Brown, 9 Vet. App. 7 (1996); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. Pain may be taken into consideration when rating functional loss. However, pain on motion is not, itself, functional loss, but may result in functional loss only if it limits the ability to perform “the normal working movements of the body with normal excursion, strength, speed, coordination[, or] endurance.” 38 C.F.R. § 4.40. Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997) (citing 38 C.F.R. § 4.40). 38 C.F.R. § 4.40 (functional loss due to pain is to be rated at the same level as the functional loss when flexion is impeded); see Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint.” The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. Correia, 28 Vet. App. at 169-170. In Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), the Court addressed the adequacy of medical opinions that decline to present clear estimations by citing that such estimations would be “mere speculation.” The Court explained that case law and VA guidelines do not require direct observation of functional impairment after repetitive use or during a flare-up as a prerequisite to offering a DeLuca opinion. DeLuca v. Brown, 8 Vet. App. 202 (1995). Indeed, it is not expected that such observation will usually occur; therefore, VA examiners should offer opinions based on estimates derived from information procured from all relevant sources, including the lay statements of Veterans. VA examiners have a duty to elicit information from the Veteran when attempting to describe functional loss associated with pain during unobserved exacerbations. If a non-speculative opinion still cannot be offered, the VA examiner must explain the basis for this conclusion. It must be apparent that the inability to provide an opinion without resorting to speculation reflects the limitation of knowledge in the medical community at large and not a limitation (whether based on lack of expertise, insufficient information, or unprocured testing) of the individual examiner. 38 C.F.R. § 4.71a, Diagnostic Code 5010, evaluates traumatic arthritis established by X-ray findings and advises the evaluator to rate as degenerative arthritis under Diagnostic Code 5003. Under Diagnostic Code 5003, arthritis established by X-ray findings is rated on the basis of limitation of motion of the affected joints. When, however, the limited motion of the specific joint or joints involved would be noncompensable under the appropriate diagnostic codes, a 10 percent rating is assigned for each involved major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 (degenerative arthritis) and 5010 (traumatic arthritis). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, however, arthritis is rated as 10 percent disabling when shown by X-ray evidence of the involvement of two or more major joints or two or more minor joint groups, or as 20 percent disabling when shown by x-ray evidence of the involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Id. Finally, it is the intention of the VA rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. Consideration of 38 C.F.R. § 4.59 is not limited to cases involving arthritis, thereby providing for the possibility of a rating based on painful motion of a joint, regardless of whether the painful motion stemmed from joint or periarticular pathology. Burton v. Shinseki, 25 Vet. App. 1 (2011). 1. For the period prior to December 11, 2014, entitlement to a compensable rating for left knee instability associated with patellofemoral syndrome is denied. 2. For the period from December 11, 2014, to September 28, 2017, entitlement to a 10 percent rating, but no higher, for left knee instability associated with patellofemoral syndrome, is granted. 3. For the period from September 28, 2017, onward, entitlement to an increased rating in excess of 10 percent for left knee instability is denied. 4. Entitlement to an increased rating in excess of 10 percent for left knee disability featuring painful motion with functional loss associated with patellofemoral syndrome, is denied. The Veteran asserts that her service-connected left knee disability warrants a higher rating. The beginning of the rating period on appeal in this matter is the date of the Veteran’s filing of the left knee disability claim on appeal: July 6, 2011. Throughout the period on appeal, the Veteran’s left knee disability has been rated 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5260. Hyphenated diagnostic codes are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27. The first four numbers reflect the diagnosed disability. The second four numbers, after the hyphen, identify the criteria used to evaluate that disability. When an unlisted disease or injury is encountered, it will be rated by analogy under a diagnostic code built up using the first 2 digits from that part of the Rating Schedule most closely identifying the body part or system affected and by using 99 for the last 2 digits. 38 C.F.R. § 4.27. Effective from September 28, 2017, a separate further rating of 10 percent has been assigned for instability of the left knee under 38 C.F.R. § 4.71a, Diagnostic Code 5257. 38 C.F.R. § 4.71a includes multiple diagnostic codes that evaluate impairment resulting from knee disorders, including Diagnostic Code 5256 (ankylosis), Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability) , Diagnostic Code 5258 (dislocated semilunar cartilage) , Diagnostic Code 5259 (symptomatic removal of semilunar cartilage), Diagnostic Code 5260 (limitation of flexion), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (genu recurvatum). Under Diagnostic Code 5256, a 30 percent rating may be assigned for ankylosis of a knee at a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. A 40 percent rating may be assigned for ankylosis of a knee in flexion between 10 degrees and 20 degrees. A 50 percent rating may be assigned for ankylosis of a knee between 20 degrees and 45 degrees. A 60 percent rating may be assigned for extremely unfavorable ankylosis of a knee in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a; Diagnostic Code 5256. Diagnostic Code 5257 provides for a 10 percent rating for slight recurrent subluxation or lateral instability of the knee, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Under Diagnostic Code 5258, a 20 percent rating is assigned for dislocated semilunar cartilage with frequent episodes of ‘locking,’ pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, removal of semilunar cartilage that is symptomatic warrants a 10 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Flexion of the leg limited to 60 degrees warrants a 0 percent rating, flexion limited to 45 degrees warrants a 10 percent rating, flexion limited to 30 degrees warrants a 20 percent rating, and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Extension limited to 5 degrees warrants a 0 percent rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Flexion of the knee to 140 degrees is considered full and extension to 0 degrees is considered full. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5262, a 10 percent rating is available when there is malunion of the tibia and fibula with slight knee or ankle disability; a 20 percent rating is available when there is malunion of the tibia and fibula with moderate knee or ankle disability; a 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability; and a maximum rating of 40 percent is warranted for nonunion of the tibia and fibula with loose motion, requiring brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Under Diagnostic Code 5263, a 10 percent rating is warranted for genu recurvatum. 38 C.F.R. § 4.71a, Diagnostic Code 5263. Separate ratings may be assigned for knee disability under Diagnostic Code 5257 and 5003 where there is x-ray evidence of arthritis in addition to recurrent subluxation or lateral instability. See generally VAOPGCPREC 23- 97 and VAOPGCREC 9-98. A precedent opinion by VA General Counsel holds that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260 and a compensable limitation of extension under Diagnostic Code 5261, provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 09-04; 69 Fed. Reg. 59990 (2004). Rating under Diagnostic Codes 5256, 5258, 5259, 5262, 5263 is inappropriate in this case as the Veteran’s left knee disability does not include the pathology required in the criteria for those Diagnostic Codes (ankylosis, dislocated semilunar cartilage, symptomatic removal of semilunar cartilage, malunion or nonunion of tibia or fibula, or genu recurvatum). 38 C.F.R. § 4.71a. A December 2011 VA examination report shows that the Veteran “complains of intermittent left knee pain felt over the anterior and anterolateral aspect of the knee. The pain is precipitated by prolonged walking, squatting, climbing stairs, and exposure to cold weather. The pain can reach up to 9/10 on the pain scale.” The Veteran reported “no limitation of motion,” but described “[o]ccasional swelling and locking of the knee as well as cracking sensations.” The Veteran described taking Motrin when needed for pain, using a brace on the knee, and occasionally limping. The Veteran indicated that “[t]he pain does not interfere with her ADLs.” The December 2011 VA examination report presents examination findings featuring “normal gait,” “no swelling, deformity, or muscle atrophy” of the left knee, “a brace” observed on the left knee, “mild tenderness over the lateral joint line,” and a “[p]ositive patellar compression test.” The VA examiner noted that “[t]he knee is stable with intact collateral and cruciate ligaments.” Range of motion testing revealed left knee flexion “from 0-130 degrees with no pain and 1+ crepitus, especially when she squats.” The same findings were also reported for the right knee. The VA examiner noted that “[r]epetitive motion of … the [left] knee did not produce additional limitation of motion due to pain, weakness, fatigue, lack of endurance, or incoordination.” Additionally: “X-rays of the left knee taken on December 02, 2011, were normal.” A diagnostic impression of “Left knee patellofemoral syndrome” was recorded. The VA examiner commented that the left knee disability is “less likely as not to impact physical and sedentary employment.” A December 2014 VA examination report confirms the diagnosis of left knee patellofemoral pain syndrome. The Veteran described that “[i]t cracks sometimes and she has pain when going down stairs. Pain is 7/10.” She denied flare-ups. The Veteran did describe functional impairment, specifically: “I am unable to do certain activities like extended walks or biking or skiing, climbing stairs.” Later in the report, the Veteran also described “pain with climbing stairs.” The December 2014 VA examination report presents examination findings featuring “All normal” ranges of motion for the left knee, with “[n]o pain noted on exam.” However, there was “evidence of pain with weight bearing,” and there was “objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue” for the “lateral LEFT knee.” On repetitive use testing, the VA examiner found that “No,” there was -not- “additional functional loss or range of motion after three repetitions.” The VA examiner noted that the Veteran’s left knee was “being examined immediately after repetitive use over time,” and that “No,” it was -not- the case that “pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time.” All pertinent muscle strength was revealed to be normal upon clinical testing. There was no muscle atrophy, ankylosis, joint instability, recurrent patellar dislocation, ‘shin splints’ (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, nor “any other tibial and/or fibular impairment.” There was no meniscal condition nor crepitus. There were not “any other pertinent physical findings.” The VA examiner found “No,” there was no functional impact from the left knee disability for occupational tasks. During the Veteran’s May 2015 Board hearing, she testified that she had recently had new problems with her left knee. She described that the knee had “gone out” twice, resulting in a visit to an emergency room and a visit to a VA medical facility. She described that “the first time I fell in December and I had been experiencing some sharp knee pain those last couple of days and my knee gave out … and I fell and I sprained it so I was on crutches for at least 3 months….” The Veteran further described that “then a month and a half ago” she experienced another incident in which her “knee gave out and as a result … I fell down and I went to the emergency room and they X-Ray’d it. They bandaged it up but I have a little bit of a limp because of that now ….” The Veteran’s representative asked her to confirm that “[t]he issue with your knee giving out, is that something that you are only recently experiencing over the last couple of months?” The Veteran confirmed: “Yes.” The Veteran’s representative asked whether “that’s an increase in something that you did not have prior to December of 2014?” The Veteran replied: “Well, no, I mean I had pain and crackling and crepitus and, you know, limited mobility, but …[i]t hadn’t really given out to the point where I would fall down.” The Veteran underwent a new VA examination of the left knee in September 2017. The VA examiner confirmed a diagnosis of left knee patellofemoral syndrome. The Veteran reported that the symptomatology “[f]lares up in humid weather which causes difficulty walking up stairs,” with a frequency of “2x weekly,” duration “1-5 days,” and severity “severe.” The Veteran described the functional loss as featuring “limited mobility.” Clinical testing during the September 2017 VA examination revealed left knee ranges of motion were “All Normal.” Pain was noted “on rest / non-movement,” and also on “Flexion” and “Extension.” There was also “objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue” located “medial to patella.” There was “evidence of pain with weight bearing” and “objective evidence of crepitus.” Repetitive use testing revealed no additional loss of function or range of motion after three repetitions. The September 2017 VA examiner noted that the left knee was -not- “being examined immediately after repetitive use over time,” and the VA examiner stated that “[t]he examination is neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time.” The VA examiner was “[u]nable to say without mere speculation” whether or not the Veteran’s left knee has “pain, weakness, fatigability or incoordination significantly limit[ing] functional ability with repeated use over a period of time.” The VA examiner also noted that the left knee was -not- “being examined during a flare up,” and the VA examiner stated that “[t]he examination is neither medically consistent or inconsistent with the Veteran’s statements describing functional loss during a flare up.” The VA examiner was “[u]nable to say without mere speculation” whether or not the Veteran’s left knee has “pain, weakness, fatigability or incoordination significantly limit[ing] functional ability with flare-ups.” The September 2017 VA examination report shows that “No,” there was not any “reduction in muscle strength” in the left knee. There was no muscle atrophy, and there was no ankylosis. Significantly, the September 2017 VA examination report shows that joint stability testing revealed that “Yes,” there was “joint instability” of the left knee featuring “1+ 0-5 millimeters” of “Lateral instability” upon testing. The VA examiner characterized the Veteran’s history as featuring “recurrent subluxation” of “Slight” severity, and “lateral instability of “Slight” severity. There was no history of recurrent effusion. The VA examiner noted that the Veteran made occasional use of crutches, but attributed this to “ankle sprain.” The September 2017 VA examiner documented that imaging studies of the left knee revealed “degenerative or traumatic arthritis.” The VA examiner noted that the Veteran’s described limitations regarding “standing, walking stairs and walking distances” resulted in “0-1 week work time lost in last 12 months” associated with the “functional impact.” The VA examiner confirmed that there was “objective evidence of pain on passive range of motion testing,” but “no objective evidence of pain when the joint is used in non-weight bearing.” The VA examiner otherwise found no pertinent findings or abnormalities involving the left knee. Examining the evidence of record, the Board has focused particular attention upon the evidence concerning the onset of instability in the Veteran’s left knee. The Veteran is currently in receipt of a 10 percent rating for left knee instability under Diagnostic Code 5257, effective from September 28, 2017. This 10 percent rating for instability only covers a recent portion of the rating period on appeal, and the Board’s appellate review must consider whether a rating for instability is warranted at any other time during the rating period on appeal. The currently assigned 10 percent rating for instability was assigned by the AOJ with an effective date corresponding to the date of the September 2017 VA examination report documenting demonstrated clinical observation of slight lateral instability of the left knee. However, the Board finds that credible evidence strongly suggests that the instability observed in September 2017 was present significantly earlier than that time. During the Veteran’s May 2015 Board hearing before the undersigned, the Veteran testified that her left knee “has gone out … a few times.” She described two then-recent incidents in which she experienced a fall and injury when “my knee gave out,” specifying that “the first time I fell in December I had been experiencing some sharp knee pain those last couple of days ….” The Veteran’s testimony identifies December 2014 as the month of onset for the left knee instability. Notably, a January 13, 2015, VA treatment report shows that the Veteran reported that she “took a fall about three weeks ago.” The Board has carefully considered the Veteran’s May 2015 testimony that she was experiencing impairment from left knee joint instability in light of (1) the fact that left knee joint instability was clinically confirmed on the next VA left knee rating examination, (2) that the Veteran is competent to report her experience of left knee pain and instability having onset in December 2014, and (3) the absence of significantly contrary indications of record. The Board notes that the Veteran underwent a VA rating examination of her left knee on December 10, 2014, that revealed no joint instability, but it is significant that the Veteran’s reported onset of left knee pain and instability is indicated to have occurred later in December 2014, -after- the VA examination took place. Resolving reasonable doubt in the Veteran’s favor, the Board finds that the left knee instability clinically demonstrated in the September 2017 VA examination report is reasonably shown to have had its onset in December 2014, at some point after the VA examination conducted on December 10, 2014. The Board finds that it is reasonable to resolve doubt in the Veteran’s favor to conclude that the criteria for a 10 percent rating for left knee instability under Diagnostic Code 5257 have been met from the day after the December 2014 VA examination. The Board finds that a 10 percent rating for left knee instability under Diagnostic Code 5257 is warranted from December 11, 2014, onward. This results in a grant of the Veteran’s appeal to the extent that the Board here awards an increased 10 percent rating for instability of the left knee for the period from December 11, 2014, to September 28, 2017 (ending with the period for which entitlement to a 10 percent rating for left knee instability has already been established). To this extent, the appeal is granted. For the period prior to December 11, 2014, the evidence does not show that the Veteran’s left knee disability involved impairment associated with joint instability. Indeed, the Veteran’s testimony has indicated that the pertinent onset of instability causing falls occurred after December 10, 2014, and the VA rating examination report of December 10, 2014, shows that there was no left knee instability as of that time. Accordingly, the Board finds that no compensable rating for left knee instability under Diagnostic Code 5257 is warranted for the period prior to December 11, 2014. Additionally, the Board finds that the evidence does not show that the Veteran’s left knee disability has manifested in more than slight joint instability at any time. The September 2017 VA rating examination of the left knee identified a degree of instability characterized as ‘slight’ based upon detailed clinical findings, and there is no significantly contrary indication of record. The Board finds that no rating in excess of 10 percent is warranted for the Veteran’s left knee instability at any time. Turning now to consider left knee impairment beyond joint instability, the Board finds no evidence showing that the Veteran’s left knee disability manifested in limitation of motion meeting the criteria for any increased rating on the basis of limited flexion or extension. Clinical testing has consistently revealed no limitation of flexion or extension of the left knee meeting the criteria for any compensable rating. The Veteran’s experience of pain noted on clinical testing is accounted for in the existing award of a 10 percent rating for the left knee disability under Diagnostic Code 5299-5260, which is the minimal compensable rating for limitation of motion of the joint in accordance with the provisions of 38 C.F.R. § 4.59. The 10 percent rating under Diagnostic Code 5299-5260 is already in effect for the entirety of the rating period on appeal. The evidence of record does not demonstrate further impairment from pain or other factors meeting the criteria for any higher rating. Although the examination reports of record do not provide all of the information the Board might prefer to consider to inform a determination regarding functional loss in accordance with the Court’s holdings in Correia and Sharp, the Board is unable to consider such information because the Veteran declined to report for a new VA examination that was to be afforded to her for the purpose of developing evidence in this regard. The Board finds that no increased ratings are warranted under Diagnostic Codes 5260 or 5261 for limitation of flexion or extension. Rating under Diagnostic Codes 5256, 5258, 5259, 5262, 5263 is inappropriate in this case as the Veteran’s left knee disability does not include the pathology required in the criteria for those Diagnostic Codes (ankylosis, dislocated semilunar cartilage, symptomatic removal of semilunar cartilage, malunion or nonunion of tibia or fibula, or genu recurvatum). 38 C.F.R. § 4.71a. In summary, the Board finds that a new/increased 10 percent rating for left knee instability is warranted for the period from December 11, 2014, to September 28, 2017, but no other new or increased ratings for the left disability are warranted in this case. 5. For the period prior to August 14, 2018, entitlement to an increased 20 percent rating, but no higher, for right shoulder supraspinatus tear and tendinosis with superior labral degenerative disease (previously characterized and rated as myositis, right trapezius muscle), featuring painful motion with functional loss, is granted. 6. For the period from August 14, 2018, onward, entitlement to an increased rating in excess of 20 percent for right shoulder supraspinatus tear and tendinosis with superior labral degenerative disease (previously characterized and rated as myositis, right trapezius muscle), is denied. The Veteran asserts that her service-connected right shoulder disability warrants higher ratings. The beginning of the rating period on appeal in this matter is the date of the Veteran’s filing of the right shoulder disability claim on appeal: September 8, 2011. The disability ratings previously assigned for the Veteran’s right shoulder have been awarded under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5021-5201. Before the AOJ’s April 2019 rating decision, the AOJ had previously characterized the rating of this disability with reference to the different provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5021-5301. As discussed below, the Board finds that the AOJ’s recent recharacterization of the rating appropriately identifies the provisions of Diagnostic Code 5021-5201 as the most appropriate rating criteria for application for the Veteran’s right shoulder disability throughout the rating period in this case. Hyphenated diagnostic codes are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27. The first four numbers reflect the diagnosed disability. The second four numbers, after the hyphen, identify the criteria used to evaluate that disability. For the portion of the rating period prior to August 14, 2018, a 10 percent rating is currently in effect for the right shoulder disability. For the portion of the rating period from August 14, 2018, onward, a 20 percent rating is currently in effect for the right shoulder disability. Diagnostic Code 5021 provides that myositis is rated on limitation of motion of the affected parts, as degenerative arthritis (except for gout). The Board notes that the evidence shows that the Veteran is right-handed / right arm dominant. Under Diagnostic Code 5201, when motion of the major (dominant) arm is limited at the shoulder level (i.e., 90 degrees), a 20 percent rating is warranted. When motion of the major arm is limited midway between the side and shoulder level, a 30 percent rating is warranted. When motion of the major arm is limited to 25 degrees from the side, a maximum 40 percent rating is warranted. 38 C.F.R. § 4.71a. The Rating Schedule also provides that a normal range of motion of the shoulder is 0 degrees to 180 degrees on flexion and abduction, 0 degrees to 90 degrees on internal rotation, and 0 degrees to 90 degrees on external rotation. 38 C.F.R. § 4.71, Plate I. The Board notes that 38 C.F.R. § 4.71a additionally provides Diagnostic Codes 5200 (ankylosis of scapulohumeral articulation), 5202 (other impairment of humerus), and 5203 (impairment of clavicle or scapula) for rating “the shoulder and arm.” However, none of these other rating criteria are for application in this case as the evidence does not indicate that the Veteran’s pertinent service-connected right shoulder / trapezius disability features the types of impairment contemplated by these other provisions. 38 C.F.R. § 4.73, Diagnostic Code 5301, Muscle Group I, for injuries to the extrinsic muscles of the shoulder girdle provides a noncompensable rating for slight functional loss, a 10 percent rating for moderate functional loss, a 30 percent rating for moderately severe functional loss for the dominant arm, and a 40 percent rating for severe functional loss of the dominant arm. The Veteran is right-handed. Muscle Group I injuries impact the upward rotation of scapula and elevation of the arm above shoulder level. 38 C.F.R. § 4.56 provides factors to be considered in classifying a muscle injury as slight, moderate, moderately severe, or severe. Under 38 C.F.R. § 4.56, muscle disabilities are evaluated as follows: (a) An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. (b) A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. (c) For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. Under Diagnostic Codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe, or severe as follows: (1) Slight disability of muscles --(i) Type of injury. Simple wound of muscle without debridement or infection. (ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section. (iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue. (2) Moderate disability of muscles --(i) Type of injury. Through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. (ii) History and complaint. Service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. (iii) Objective findings. Entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. (3) Moderately severe disability of muscles --(i) Type of injury. Through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. (4) Severe disability of muscles --(i) Type of injury. Through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d). The assignment of a particular diagnostic code is completely dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). The Board must consider whether a higher rating is warranted under any other applicable Diagnostic Code or permitted combination of separate ratings under multiple Diagnostic Codes. Assigning separate compensable ratings for the same symptoms/functional impairment under different diagnoses would violate the prohibition against pyramiding in 38 C.F.R. § 4.14. A December 2011 VA rating examination report shows that the Veteran reported “constant pain in her right shoulder, which flares up on above-shoulder activities and movements of the shoulders.” The report notes that the Veteran is “right handed.” The Veteran’s description indicated that “[t]he pain is felt over the posterior aspect of the shoulder and is accompanied by some stiffness and limitation of motion.” She indicated that the “pain can reach up to 9/10 on the pain scale,” but “[t]he pain does not interfere with her ADLs,” and there had been “[n]o incapacitating episodes in the last year.” Clinical “[e]xamination of the right shoulder in December 2011 showed no swelling, deformity, or muscle atrophy.” The VA examiner noted that there was “tenderness over the acromioclavicular joint and the adjacent upper trapezius muscle,” but there was “[n]o spasm.” Range of motion testing revealed: “flexion from 0-160 degrees with pain starting at 110 degrees. Abduction is 0-150 degrees with pain at 110 degrees. External rotation is 0-90 degrees and internal rotation 0-50 degrees with pain at 40 degrees.” There were “no sensory, motor, or reflex abnormalities.” The VA examiner found that “[r]repetitive motion of … the shoulder … did not produce additional limitation of motion due to pain, weakness, fatigue, lack of endurance, or incoordination.” Following x-ray imaging, a medical impression of “[r]ight shoulder degenerative arthritis of the acromioclavicular joint” was confirmed. The VA examiner commented that the right shoulder disability is “less likely as not to impact physical and sedentary employment.” A December 2014 VA rating examination report focuses upon the Veteran’s muscle impairment diagnosed as: “Right trapezius muscle myositis.” The report identifies that the impairment affects specifically “Group I” for the Veteran’s right side. The impairment was identified as: (1) a “Lowered threshold of fatigue” on an “Occasional” basis, and (2) “Fatigue-pain” on an “Occasional” basis. Muscle strength testing revealed no abnormalities. No other pertinent physical findings, complications, conditions, signs, or symptoms were found by the VA examiner. The VA examiner recorded the Veteran’s functional impact by noting that “[s]he states she cannot sit for prolonged times and is unable to concentrate.” Another section of this report notes that the Veteran reported that the pain reached her neck as well, and “she says it is related to her shoulder and migraine pain,” rather than any further pathology of the neck. The VA examiner confirmed that the Veteran’s symptoms feature “RIGHT trapezius pain and this is similar pain [to] that described in her neck as the conditions are the same and overlapping. There is no objective finding of any cervical neck condition.” The VA examination report further confirms no significant distinct impairment of the neck upon clinical testing. A September 2017 VA fee-basis rating examination report confirms the diagnoses of degenerative arthritis of the right shoulder and right trapezius muscle myositis. The Veteran’s recorded symptom complaints featured “pain” and “stiffness.” The Veteran denied flare-ups and denied “having any functional loss or functional impairment of the joint….” Right shoulder range of motion testing revealed “All Normal” results, with “[n]o pain noted on exam.” The VA examiner stated that “No,” it was -not- the case that there was “objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.” Repetitive use testing was performed and revealed no additional loss of function or range of motion after three repetitions. The VA examiner expressed an inability to identify any extent of unobserved functional loss occurring outside of the time of the examination; the Board notes that the report otherwise documents that the Veteran denied having any flare-ups of symptomatic impairment of the right shoulder disability. The VA examiner noted that “[t]here is no objective evidence of pain on passive range of motion testing,” and “[t]here is no objective evidence of pain when the joint is used in non-weight bearing.” The VA examiner indicated that there were no “additional contributing factors of disability,” selecting “None” on the form for the section to identify such. Muscle strength testing revealed no abnormalities. Diagnostic imaging confirmed degenerative arthritis of the right shoulder. Following complete and thorough testing, the VA examiner found that “No,” the Veteran does -not- “have any other pertinent physical findings, complications, conditions, signs or symptoms….” The VA examiner noted that the Veteran’s right shoulder caused functional impairment resulting in “0-1 week work time lost in last 12 months.” A September 2018 VA examination report addresses the Veteran’s right shoulder disability in terms of both the muscle impairment (again confirmed to involve Muscle Group I) and joint disability diagnoses. The muscle examination report shows that examination revealed no clinical findings of functional limitation or impairment of the affected musculature, but the VA examiner noted that “[t]he veteran has physical limitation of overhead activities and carrying/lifting.” For the right shoulder joint, the VA examiner diagnosed “[s]upraspinatus tear and tendinosis” and “[s]uperior labral degenerative disease.” The VA examiner noted that the Veteran described “constant aching, that radiates from the shoulder blade, 4/10.” The Veteran reported that “her worst pain [is] in the morning 8/10.” The report documents that the Veteran otherwise denied flare-ups, but described functional impairment in the following terms: “I have difficulties to ma[k]e a bed, pointing or demonstrating in the classroom, lifting things, putting plates on the shelves, dropping things lately.” The September 2018 VA examiner’s clinical testing of the right shoulder revealed “All Normal” results with no decrease in range of any manner of motion. However, the VA examiner noted “[p]ain … on exam but does not result in/cause functional loss,” and this involved “[a]bduction” and “[e]xternal rotation.” The VA examiner noted that there was no evidence of pain with weight bearing. The VA examiner did find “objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue,” describing “tenderness to palpation at supraspinatus fossa and lipoma like mass,” with “no tenderness above the fossa.” The report also documents “objective evidence of crepitus.” Repetitive use testing was completed and revealed no further limitation. The VA examiner did note the presence of “pain on passive range of motion,” and “pain when the joint is used in non-weight bearing.” The VA examiner expressed an inability to identify any extent of unobserved functional loss occurring outside of the time of the examination. (The Board again notes that the Veteran has declined to report for a new VA examination with interview that was planned for the purpose of obtaining a more adequate medical estimation of the extent of any functional impairment beyond the extent observed during VA examinations.) The September 2018 VA examiner recorded that no muscle strength deficits were revealed by strength testing. However, a right shoulder rotator cuff condition was suggested by the Veteran’s “Positive” result for the “Empty-can Test” during clinical examination. However, there was no joint instability or other manner of impairment of the shoulder, including: clavicle, scapula, acromioclavicular joint, sternoclavicular joint, humerus, or the glenohumeral joint. The VA examiner stated “No,” there was -not- any “other pertinent physical findings, complications, conditions, signs, symptoms and scars.” The VA examiner recorded the Veteran’s functional impact as featuring “physical limitation of overhead activities and carrying/lifting.” The VA examiner also noted that the mass observed in the Veteran’s right shoulder “is a LIPOMA” and “is not related to her right shoulder musculoskeletal condition.” The September 2018 VA examination report contains clinical findings with some discussion of distinctions in pathologies. Noted impairments of the Veteran’s neck are attributed to a diagnosis of degenerative arthritis of the cervical-spine, not the service-connected right shoulder disability. The VA examiner also states that “[t]here is not [any] association between her chronic trapezius strain and her glenohumeral joint condition (supraspinatus/labrum condition).” The VA examiner states: “[t]he veteran’s current right shoulder symptoms had absence of the cardinal signs and symptoms of muscle disability due to right shoulder muscle injury (Chronic trapezius muscle strain).” The VA examiner continues: “The veteran’s physical limitation of overhead activities and carrying/lifting are due to non-service connected condition of right glenohumeral joint called Right Supraspinatus tear and tendinosis / Superior labral degenerative disease.” However, the Board notes that the Veteran’s service-connected right shoulder disability has been characterized by the AOJ as encompassing the “supraspinatus tear and tendinosis with superior labral degenerative disease.” The Board notes that the March 2012 RO rating decision in this case denied entitlement to a rating in excess of 10 percent for the right shoulder / trapezius disability, but stated: “Since you demonstrate painful motion of the arm at the shoulder, the minimum compensable evaluation of 10 percent is assigned.” At that time, the disability rating assigned was based upon Diagnostic Code 5021-5301. The Board again notes that the provisions of Diagnostic Code 5021 direct that the disability is to be rated “on limitation of motion of affected parts, as arthritis, degenerative….” Significantly, Diagnostic Code 5301 does -not- provide ratings based upon limitation of motion. Rather, limitation of motion of the arm at the shoulder (the impairment the RO acknowledged in the March 2012 RO rating decision as the subject of this matter) is rated through the provisions of Diagnostic Code 5201, that is expressly designated for the purpose of rating “limitation of motion” of the “arm” in the rating section for “the shoulder and the arm.” It is important to note, then, that the minimum compensable rating for limitation of motion under Diagnostic Code 5201 (or, in this case, Diagnostic Code 5021-5201) is 20 percent for the shoulder joint. The RO later essentially acknowledged this when, in the April 2019 RO rating decision, it granted a 20 percent rating for the right shoulder disability, changing the assigned Diagnostic Code to 5021-5201, and writing: We have assigned a 20 percent evaluation for your myositis, right trapezius muscle based on: Painful motion of the shoulder. (38 C.F.R. § 4.59 allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint. Since you demonstrate painful motion of the arm at the shoulder, the minimum compensable evaluation of 20 percent is assigned. The Board finds, consistent with the RO’s own findings in the March 2012 and April 2019 rating decisions, that the Veteran’s painful motion of the right shoulder has qualified for the “minimum compensable rating” for the joint throughout the rating period on appeal. The Board finds that the correct application Diagnostic Code 5021 throughout the rating period on appeal results in rating “on limitation of motion” of the shoulder, for which the minimum compensable rating is 20 percent under Diagnostic Code 5021-5201 throughout the rating period on appeal. Accordingly, the Board finds that an increased 20 percent rating is warranted for the Veteran’s right shoulder / trapezius disability for the entire period on appeal prior to August 14, 2018 (ending with the date from which a 20 percent rating has already been assigned by the RO). To this extent, the appeal is granted. The Board finds that the evidence of record does not otherwise demonstrate that the criteria for any rating in excess of 20 percent for the right shoulder disability have been met. The evidence does not show that the Veteran’s arm has been limited to midway between the side and shoulder level. Although the examination reports of record do not provide all of the information the Board might prefer to consider to inform a determination regarding functional loss in accordance with the Court’s holdings in Correia and Sharp, the Board is unable to consider such information because the Veteran declined to report for a new VA examination for the purpose of developing evidence in this regard. Additionally, the Board finds that the evidence featuring the VA examination findings does not indicate cardinal signs and symptoms with impairment consistent with greater than a “Moderate” degree of impairment of Muscle Group I’s function. The Board notes that clinical examinations have revealed no decrease in strength, coordination, or significant function of the muscles during repeated clinical inspections over the period on appeal. With attention to the provisions of 38 C.F.R. § 4.56(d) concerning identification of moderately severe disability of muscles: the Board finds no evidence of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side, nor do the examination reports indicate tests of strength and endurance compared with sound side demonstrate positive evidence of impairment or an inability to keep up with work requirements. The Board finds that no rating in excess of 20 percent is warranted for the right shoulder / trapezius disability at any time during the period on appeal. To this extent, the appeal is denied. In summary, the Board finds that an increased 20 percent rating is warranted for the Veteran’s right shoulder disability for the period on appeal prior to August 14, 2018. The Board finds that no rating in excess of 20 percent is warranted during any portion of the rating period on appeal, including both the period of the newly increased 20 percent rating prior to August 14, 2018, and the period of the previously established 20 percent rating from August 14, 2018, onward. The Board notes that the rating period on appeal for the right shoulder disability in this case begins with the date of the Veteran’s filing of the claim raising the issue: September 8, 2011. Because the Board has determined that the right shoulder disability was more disabling than the previously-assigned 10 percent disability rating reflected at the time of the September 2011 claim, the Board has carefully considered whether any effective date prior to September 8, 2011, is warranted for the increased rating being awarded in this decision. The Board must consider whether any increased rating for the right shoulder / trapezius disability is warranted in the one-year period prior to the September 8, 2011, date of the claim for increase. The Court and VA’s General Counsel have interpreted the laws and regulations pertaining to the effective date for an increase as providing that, if the increase occurred within one year prior to the claim, the increase is effective as of the date the increase was factually ascertainable. 38 U.S.C. § 5110(b)(2); Harper v. Brown, 10 Vet. App. 125 (1997); 38 C.F.R. § 3.400(o)(1)(2); VAOPGCPREC 12-98 (1998). In reviewing the pertinent evidence, the Board has considered whether any worsening of the right shoulder / trapezius disability is shown to have occurred within one year prior to the claim to warrant a grant of the increased rating effective from prior to the date of the claim. However, the Board finds no evidence making it factually ascertainable that the Veteran’s right shoulder / trapezius disability underwent an increase in severity to newly meet the criteria for an increased rating on any identifiable date within a year prior to the September 8, 2011, date of claim. Accordingly, entitlement to the increased rating awarded in this decision cannot be effective from any date earlier than the date of the claim: September 8, 2011. Increased Ratings Conclusion The Board has partially granted the Veteran’s appeal, establishing entitlement to some of the benefits sought as discussed above. Also as discussed above, the preponderance of the evidence is against awarding any additional or further increased ratings this case. The Board has considered whether there is any other basis for granting further increased and/or additional ratings but has found none. As the preponderance of the evidence is against assignment of any further increased and/or additional ratings in this case, 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). Neither the Veteran nor his former representative has raised any other issues, nor have any other issues been reasonably raised by the record in connection with the disabilities for consideration in this appeal. See Doucette v. Shulkin, 28 Vet. App. 366 (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). M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Barone, Counsel 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.