Citation Nr: 20037592 Decision Date: 06/02/20 Archive Date: 06/02/20 DOCKET NO. 14-22 376 DATE: June 2, 2020 ORDER Service connection for an upper-gastrointestinal (GI) disorder is denied. Service connection for a left shoulder disorder is denied. Service connection for a right hand disorder is denied. Service connection for a low back disorder is denied. Service connection for a bilateral or unilateral knee disorder is denied. Service connection for a bilateral or unilateral ankle disorder is denied. Restoration of a 20 percent rating for a right shoulder disability since May 1, 2015, is dismissed as moot. Prior to January 14, 2012, a rating higher than 10 percent for the right shoulder disability is denied. Since January 14, 2012, a rating higher than 20 percent for the right shoulder disability is denied. FINDINGS OF FACT 1. An upper-GI disorder is not related to service and is not proximately due to, a result of, or aggravated by, a service-connected disability. 2. A left shoulder disorder is not related to service and is not proximately due to, a result of, or aggravated by, a service-connected disability; arthritis of the left shoulder is not presumed to be related to service. 3. A right hand disorder is not related to service and is not proximately due to, a result of, or aggravated by, a service-connected disability; arthritis of the right hand is not presumed to be related to service. 4. A low back disorder is not related to service and is not proximately due to, a result of, or aggravated by, a service-connected disability; arthritis of the thoracolumbar spine is not presumed to have been related to service. 5. A bilateral or unilateral knee disorder is not related to service and is not proximately due to, a result of, or aggravated by, a service-connected disability; arthritis of the bilateral knees is not presumed to have been related to service. 6. A bilateral or unilateral ankle disorder is not related to service and is not proximately due to, a result of, or aggravated by, a service-connected disability; arthritis of the bilateral ankles is not presumed to have been related to service. 7. The RO has already restored the rating for the right shoulder to 20 percent, effective January 14, 2012. 8. Prior to January 14, 2012, the Veteran’s right shoulder disability was manifested by painful motion with forward flexion and abduction to at least to shoulder height. 9. Since January 14, 2012, the Veteran’s right shoulder disability was manifested by painful motion with forward flexion and abduction to at least 45 degrees. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for an upper-GI disorder have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2019). 2. The criteria for entitlement to service connection for a left shoulder disorder have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2019). 3. The criteria for entitlement to service connection for a right hand disorder have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2019). 4. The criteria for entitlement to service connection for a low back disorder have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2019). 5. The criteria for entitlement to service connection for a bilateral or unilateral knee disorder have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2019). 6. The criteria for entitlement to service connection for a bilateral or unilateral ankle disorder have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2019). 7. The issue of entitlement to restoration of a 20 percent disability rating for the service-connected right shoulder disability lacks legal merit. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.951, 4.71a, Diagnostic Code 5201 (2019). 8. Prior to January 14, 2012, the criteria for a disability rating higher than 10 percent for the right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (2019). 9. Since January 14, 2012, the criteria for a disability rating higher than 20 percent for the right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a veteran (the Veteran) who had active duty service from March 1984 to February 1987. This appeal comes before the Board of Veterans’ Appeals (Board) from a January 2019 Order of the United States Court of Appeals for Veterans Claims (CAVC). The appeal originated from a March 2011 rating decision of the RO in Detroit, Michigan, and from a January 2015 rating decision of the VA Evidence Intake Center in Newnan, Georgia, on behalf of the RO in Detroit, Michigan. In August 2017, the Veteran presented testimony at a Board hearing, chaired by the undersigned Veterans Law Judge, and accepted such hearing in lieu of an in-person hearing before a Member of the Board. See 38 C.F.R. § 20.700(e) (2019). The Veteran was informed of the basis for the RO’s denial of his claims and he was informed of the information and evidence necessary to substantiate each claim. A transcript of the hearing is associated with the claims file. 38 C.F.R. § 3.103 (2019). This matter was previously before the Board, and adjudicated in a decision dated March 2018. In that decision, the Board denied each claim. The Veteran appealed that decision to the Veterans Court. In an Order dated January 2019, pursuant to a Joint Motion for Remand, the Veterans Court vacated the Board’s March 2018 decision and remanded these claims back to the Board for development consistent with the Joint Motion. In March 2018, the Board remanded this appeal for additional evidentiary development to address the matters agreed to in the Joint Motion. The appeal has since been returned to the Board for further appellate action. Service Connection VA law provides that, for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during a period of war, or other than a period of war, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation, except if the disability is a result of the veteran’s own willful misconduct or abuse of alcohol or drugs. 38 U.S.C. §§ 1110, 1131 (West 2014). Entitlement to service connection on a direct basis requires (1) evidence of current nonservice-connected disability; (2) evidence of in-service incurrence or aggravation of disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current nonservice-connected disability. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Saunders v. Wilkie, 886 F.3d 1356 (2018). Service connection on a secondary basis requires (1) evidence of a current nonservice-connected disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability caused or aggravated the current nonservice-connected disability. 38 C.F.R. § 3.310. For specific enumerated diseases designated as “chronic” there is a presumption that such chronic disease was incurred in or aggravated by service even though there is no evidence of such chronic disease during the period of service. In order for the presumption to attach, the disease must have become manifest to a degree of 10 percent or more within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Presumptive service connection for the specified chronic diseases may alternatively be established by way of continuity of symptomatology under 38 C.F.R. § 3.303(b). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a) Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. See Barr, 21 Vet. App. at 308-09. A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 (‘sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer’); 38 C.F.R. § 3.159(a)(2). After the evidence has been assembled, it is the Board’s responsibility to evaluate the entire record. 38 U.S.C. § 7104(a) (West 2014). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2018). A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), Gilbert at 54. Entitlement to service connection for an upper-GI disorder, to include a hiatal hernia. Entitlement to service connection for a left shoulder disorder. Entitlement to service connection for a right hand disorder. Entitlement to service connection for a back disorder. Entitlement to service connection for a bilateral knee disorder. Entitlement to service connection for a bilateral ankle disorder. An August 13, 2010, Upper-GI and Small Bowel Series reveals a hiatal hernia with reflux at the gastroesophageal junction (Record 05/22/2012 at 79). A September 8, 2010, X-ray of the right hand reveals a tiny metallic density of the soft tissue palmar aspect of the second and third metacarpal (Record 05/22/2012 at 77). A September 8, 2010, X-ray of the right knee reveals a possible chronic tear involving the quadriceps tendon. The left knee had osteoarthritis (Record 05/22/2012 at 71-2). A September 14, 2010, X-ray of the left ankle is negative. The right ankle had a small calcaneal spur (Record 05/22/2012 at 73, 75). A September 14, 2010, X-ray of the spine reveals sacro-coccygeal segments were in normal alignment without fracture. Sacroiliac joints had normal appearance. There was a moderate degree of degenerative change with bony spurs and narrowing of the disc space and degenerative change of facet joints at L5-S1 (Record 05/22/2012 at 74). A September 24, 2010, X-ray of the lumbar spine reveals moderate spondylosis with degenerative disc disease at L5-S1 (Record 05/22/2012 at 68). A September 2010 VA examination reveals the Veteran’s complaint that he had been having pain in the abdomen and discomfort in the left upper abdominal area almost daily for the last 3 years. The pain was mostly related to eating food. The Veteran stated that he was not taking any specific medications. The examiner opined that the possible inflammatory changes of the jejunum and duodenum were not likely related to service. The rationale was that the Veteran was treated only once in service for abdominal symptoms and that no chronic intestinal condition was noted. There were no chronic intestinal conditions noted in the civilian medical records immediately after he came out of the service. The September 2010 examiner also noted that the Veteran reported pain in both knee joints for the last nearly 23 years. The Veteran denied any direct injuries to the knee joints. The examiner diagnosed degenerative joint disease involving both knee joints, which was not likely related to an in-service right knee condition, but was most likely related to early degenerative process of aging. The examiner reasoned that, though there was documentation of right knee pain syndrome in service, there was no chronic right knee condition noted subsequently, and no chronic right knee condition in the civilian medical records immediately after he left active military service. The September 2010 examiner noted that the Veteran said he had been having low back pain since his active military service. The Veteran denied any direct injuries to the lower back bones. The examiner diagnosed degenerative disc disease involving the lumbar spine, which was not likely related to low back condition in active military service, but was most likely related to early degenerative process of aging. The examiner reasoned that, although there is documentation of low back pain secondary to running in service, there were no chronic low back conditions subsequently. There is no chronic low back condition in the civilian medical records immediately after he left active military service (Record 09/24/2010). A November 27, 2010, MRI of the right lower extremity reveals a preexisting chronic patellofemoral tracking abnormality sequela. An MRI of the low back reveals mild central stenosis due to short pedicles compounded by a large bulge at L5-S1 which contributes to moderate to severe foraminal stenosis (Record 12/28/2010). A June 7, 2011, Emergency Department Discharge Summary (referred to elsewhere as VISTA record) reveals that the Veteran was treated for complaint of back pain. No opinion was rendered regarding a relationship between the back pain and service or a service-connected disability (Record 03/12/2020). An October 24, 2011, VA Primary Care Note reveals an intermediate grade partial thickness interstitial tear within the supraspinatus insertion far distally associated with mild peritendineum-bursitis and outlet stenosis of the left shoulder (Record 12/22/2019). A January 2012 VA Examination of the right shoulder includes a diagnosis of a right shoulder rotator cuff tear. Although the left shoulder was evaluated in that examination, no diagnosis was rendered for the left shoulder (Record 01/14/2012). A February 2012 VA Examination reveals a diagnosis of GERD. According to the Veteran, since the time of military service he was having stomach pain mostly in the left upper abdomen associated with nausea. He thought the food that he was eating in the military was messing up his stomach. Since that time, he was having symptoms of left upper abdomen discomfort, mostly after he eats food, sometimes associated with nausea. The examiner opined that GERD was not related to the remote and transient symptoms of nausea, vomiting, and dyscrasia in service. At the Board hearing, the Veteran testified that he had 2 falls, 1 in basic training, off of the obstacle course, and another when he was working in a watchtower and had a slip and fall injury, tumbling down, sustaining injuries of both shoulders, knees, and his back. He also testified that the ankles and knees were more of a wear-and-tear injury. As to why he did not report several of the injuries in service, the Veteran reported that it was the culture at the time, and that he was a naive soldier that was trying to stay and finish his term of service, and he didn't want to be put out for anything that was going to hamper that (Record 02/24/2012). In the January 2019 Joint Motion, the parties found that the medical evidence was largely inadequate when the Board denied these claims in March 2018. Specifically, the parties found that the February 2012 VA examination was inadequate with respect to GERD claim; a September 2010 opinion was inadequate with respect to the back and knee claims; the Board failed to provide examinations regarding the right hand and bilateral ankles; and the Board provided inadequate reasons and bases for its finding that the Veteran did not have a left shoulder disability. Regarding all issues, the parties agreed that there were outstanding VA treatment records that must be obtained. In August 2019, the Board remanded the appeal with instructions to obtain outstanding treatment records and to provide medical opinions regarding each of the service connection claims. The March 2020 Supplemental Statement of the Case indicates that these instructions were completed. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders). A January 2020 VA esophageal examination reveals a diagnosis of GERD with date of diagnosis in 2009. The condition was found to have no impact on the Veteran’s occupational function (Record 01/24/2020). The examiner opined that GERD was less likely as not related to service. The rationale was that there was no injury or disease in service related to GERD (Record 01/24/2020). A January 2020 VA knee examination determined that the Veteran has bilateral degenerative arthritis. However range of motion was normal. Muscle strength was full. There was no muscle atrophy. There was no subluxation or lateral instability; and, there were no meniscal conditions. There was no impact on occupational function (Record 01/24/2020). The examiner opined that the condition was less likely than not related to service. The rationale was that the Veteran did not incur an injury or disease of the knees in service (Record 01/24/2020). A January 2020 VA ankle examination determined that the Veteran has no current diagnosis. Range of motion was full. Muscle strength was full. There was no muscle atrophy. There was no impact on occupational function (Record 01/24/2020). The examiner opined that the condition was less likely than not related to service. The rationale was that the Veteran did not incur an injury or disease of the knees in service (Record 01/24/2020). A January 2020 VA back examination determined that the Veteran had a mild sprain. However range of motion was normal. Muscle strength was full. There was no muscle atrophy. There was no impact on occupational function (Record 01/24/2020). The examiner opined that the condition was less likely than not related to service. The rationale was that the Veteran did not incur an injury or disease of the knees in service (Record 01/24/2020). A January 2020 VA shoulder examination determined that the Veteran had a rotator cuff tear on the left shoulder in 2011. While range of motion was decreased, this did not contribute to functional loss. Muscle strength was full. There was no muscle atrophy. There was no impact on occupational function (Record 01/24/2020). The examiner opined that the condition was less likely than not related to service. The rationale was that the Veteran did not incur an injury or disease related to the disorder in service (Record 01/24/2020). A January 2020 VA hand examination determined that the Veteran has does not have a current hand disorder; that he was treated in service for a bruise, but there were no residuals. Range of motion was normal. Muscle strength was full. There was no muscle atrophy. There was no impact on occupational function (Record 01/24/2020). The examiner opined that the condition was less likely than not related to service. The rationale was that the Veteran did not incur an injury or disease associated with the hand in service (Record 01/24/2020) After a review of all of the evidence, the Board finds that a current left shoulder disorder is not related to service. The Board also finds that current disorders of the knees, ankles, low back, right hand, and upper-GI tract are not related to service or to any service-connected disability. Regarding the presumptive provisions, the Veteran has been diagnosed with a hiatal hernia. While peptic ulcers are included among the presumptive diseases, hiatal hernias are not. The Board acknowledges that arthritis has been diagnosed with respect to several joint disorders; however, there is no manifestation of arthritis to a degree of 10 percent or more within 1 year of service separation. Notably, the rating criteria for degenerative arthritis and traumatic arthritis require X-ray evidence in order to substantiate a 10 percent rating. See 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Codes 5003, 5010. The first such evidence comes decades after service. Therefore, the presumption of service connection for certain chronic diseases does not attach. With respect to each disorder for which a diagnosis has been established, VA has obtained a medical opinion regarding etiology. Each opinion is against a relationship between the claimed disorder and service. There is no medical opinion that purports to relate any of the claimed disorders to service or to a service-connected disability. The only evidence in favor of this element comes from the Veteran’s lay statements and testimony. In addition, the only evidence of a current left shoulder disorder comes from the Veteran’s lay statements. Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 (‘sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer’); 38 C.F.R. § 3.159(a)(2). The Board finds that relating a current diagnosis of a disease process such as arthritis to service, or to a service-connected disability, such as the Veteran’s right shoulder disability, is not the equivalent of relating a broken bone to a concurrent injury to the same body part (Jandreau, at 1377). Such an opinion requires specialized training and knowledge. As already noted, establishing the presence of diagnosis requires X-ray evidence. Therefore, the onset of arthritis is not a lay-observable event. Accordingly, the Veteran’s lay statements are not competent evidence of an etiologic relationship between the claimed joint disorders and service or service-connected disability. Simply establishing that he experienced pain in service and pain after service is not sufficient to establish a nexus. While arthritis can be established by continuity of symptomatology after service, continuity of symptomatology requires: (1) that one of the enumerated diseases was “noted” during service or within the presumptive period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the post-service disability and the post-service symptomatology.” Barr v. Nicholson, 21 Vet. App. 303, 307 (2007), abrogated on other grounds by Walker v. Shinseki, 708 F.3d 1331 (2013). Notation in service requires a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “Chronic.” While notation need not be made in medical reports, the regulation specifically states: “This rule does not mean that any manifestation of joint pain[...] in service will permit service connection of arthritis[...] first shown as a ClearCut clinical entity, at some later date. 38 C.F.R. § 3.303(b). The Board finds that there was no notation of arthritis in service, or for decades after service. The Veteran has not provided evidence of such notation, nor has he asserted that such notation occurred. Moreover, there is no competent evidence of a relationship between continuous symptoms after service and current arthritis. Therefore, the provisions regarding continuity of symptomatology do not establish incurrence of chronic arthritis in service. The Veteran testified that he did not report or seek treatment for certain injuries in service, when he was treated for others, and that this was because he did not want to hamper his ability to finish his term. He essentially maintains that he provided inaccurate information while he was in service, withholding information of certain injuries, because it suited his needs at the time, but that the conflicting information he now provides should be accepted as accurate. The Board simply notes that his admitted history of providing inaccurate information regarding having sustained additional unreported injuries in service diminishes the credibility of his statements. Regarding the upper-GI disorder, while the Veteran is competent to report his symptoms, such as reporting episodes of heartburn, he is not competent to comment on the cause of those symptoms or the chronic nature of the disorder causing them. Indeed, in his description of incurring a hiatal hernia during a fall, he appears to mistake a hiatal hernia, i.e., a hernia between the thoracic cavity and the abdominal cavity, for a hernia in the abdominal muscles, such as an umbilical hernia. The Board finds that the Veteran’s lay statements are not competent evidence of an etiologic relationship between current hiatal hernia and service or a service-connected disability. In sum, the claimed disorders of the upper-GI tract, right hand, left shoulder, low back, bilateral knees, and bilateral ankles are not related to service or to a service-connected disability. In light of these findings, the Board finds that service connection for the claimed disorders is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Increased Rating—Restored Rating Disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran’s condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria”). Prior to reducing a disability rating, VA is required to comply with several regulations applicable to all rating-reduction cases, regardless of the rating level or the length of time that the rating has been in effect. See 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.13 (2018); see Brown v. Brown, 5 Vet. App. 413, 420 (1993). These provisions impose a clear requirement that VA rating reductions be based upon review of the entire history of the disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Such review requires VA to ascertain, based upon review of the entire recorded history of the condition, whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations. Thus, in any rating reduction case, not only must it be determined that an improvement in a disability has actually occurred but also that the improvement actually reflects an improvement in the ability to function under the ordinary conditions of life and work. See Faust v. West, 13 Vet. App. 342, 350 (2000). When a disability has not become stable and is likely to improve, and the disability rating has not continued at the same level for at least five years, a reexamination disclosing improvement in that disability will warrant a reduction in its rating. 38 C.F.R. § 3.344(c). The duration of the disability rating at issue is measured by the effective date assigned for that rating until the effective date of the actual reduction. Brown, 5 Vet. App. at 418 (1993). If a reduction in a service-connected disability rating is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, the RO must issue a rating proposing the reduction and setting forth all material facts and reasons. 38 C.F.R. § 3.105(e). A period of 60 days is allowed for response. Id. Furthermore, the effective date of the reduction will be the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires. 38 C.F.R. § 3.105(e), (i). Entitlement to restoration of a 20 percent rating for a right shoulder disability since May 1, 2015. Entitlement to a disability rating higher than 10 percent for the service-connected right shoulder disability prior to January 14, 2012. Entitlement to a disability rating higher than 20 percent for the service-connected right shoulder disability from January 14, 2012, to present. In a December 2012 rating decision, VA granted service connection for a right shoulder disability and assigned an initial disability rating of 10 percent under Diagnostic Code 5019-5201, effective May 25, 2010. In a November 2013 rating decision, VA increased the rating for the right shoulder to 20 percent, effective June 24, 2013, the date of receipt of a claim for increase. In an August 2014 rating decision, the RO proposed a reduction of the rating for the right shoulder disability from 20 percent to 10 percent. In a January 2015 rating decision, the RO nominally implemented the reduction of the rating to 10 percent, effective May 1, 2015. However, the most recent rating code sheet from March 17, 2020, shows the reduction never occurred. Indeed, the associated March 17, 2020, rating decision shows the right shoulder was increased from 10 to 20 percent, effective January 14, 2012, corresponding to a VA examination of that date; so, it appears the RO restored the rating prior to transfer to the Board. The Board interprets any ambiguity regarding this rating action in favor of the claim and finds that a 20 percent rating has been in effect since January 14, 2012. Diagnostic Code 5201 pertains to limitation of motion of the shoulder. A rating of 40 percent for the major arm (30 percent minor) is assigned where motion is limited to 25 degrees from the side. A rating of 30 percent for the major arm (20 percent minor) is assigned where motion is limited to midway between the side and shoulder level. A rating of 20 percent for either arm is assigned where motion is limited to shoulder level. 38 C.F.R. § 4.71a, Diagnostic Code 5201. A September 14, 2010, X-ray of the right shoulder was negative (Record 05/22/2012 at 70). A January 2012 VA Shoulder Examination includes a diagnosis of a right shoulder rotator cuff tear. Symptoms were said to include pain and excess fatiguability. The Veteran reported that the right shoulder was subject to flares once or twice per week, lasting several hours. Range of motion was measured to 170 degrees on forward flexion, with pain onset at 135 degrees. Abduction was measured to 170 degrees with pain onset at 160 degrees. After 3 repetitions, measurements were unchanged. There was no additional limitation in range of motion. Strength was 4/5 on abduction and normal on forward flexion. The right shoulder condition was found to limit the Veteran’s ability to lift objects (Record 01/14/2012). An October 26, 2013, VA Shoulder Examination reveals a diagnosis of right rotator cuff tear. Range of motion on forward flexion was to 100 degrees with onset of pain at 80 degrees. Abduction was measured to 80 degrees with onset of pain at 70 degrees. After 3 repetitions, forward flexion was measured to 100 degrees and abduction was measured to 75 degrees. There was no additional limitation of motion after 3 repetitions. Muscle strength was normal. The functional impact as reported by the Veteran was “I can’t lift more than 10 pounds. Repetitive motions increase my pain. I have to take a break every 15 minutes due to the pain” (Record 10/26/2013). An April 2014 VA examination reveals baseline pain in the shoulders was 9/10 and the Veteran reported that he was in a flare of right shoulder pain at the time of the examination. The Veteran rated his pain at 6/10 during non-flares. Range of motion was measured to 150 degrees on forward flexion and 140 degrees on abduction. Objective evidence of painful motion was at 150 degrees forward flexion and 140 degrees abduction. Range of motion was unchanged after 3 repetitions. Strength was normal on abduction and forward flexion. An MRI showed a partial -thickness shallow tear measuring approximately 4 x 8 millimeters, involving the anterodistal supraspinatus tendon insertional footprint. The impact on the ability to work was that he would complain of bilateral shoulder pain with lifting heavy objects overhead. He reported that he used to work in the industry moving heavy palettes, pushing them with a cart. The Veteran worked stocking merchandise but had not worked since 2009. The Veteran was able to push, pull, and lift 20-50 pounds on an occasional basis. Both shoulders had well-developed deltoids, biceps, triceps and trapezius muscles on inspection (Record 04/18/2014 at 3). A January 2020 VA examination reveals that the Veteran is right-arm dominant. Range of motion was from 0 to 170 degrees on flexion and abduction. External rotation was from 0 to 90 degrees. This range of motion was found not to contribute to functional loss. There was no objective evidence of pain with weight bearing. There was no additional functional loss after three repetitions. Pain, weakness, fatigability and incoordination did not significantly limit functional ability with repeated use over a period of time. There was no reduction in muscle strength and no atrophy. There was no impact of the condition on the Veteran’s ability to work (Record 01/24/2020). After a review of all of the evidence, the Board finds that there is no rating reduction at issue and that no increased ratings are warranted in this case. The rating reduction implemented in January 2015 was subsequently restored in March 2020. Accordingly, the rating restoration claim is moot. At no time has the forward flexion or abduction of the Veteran’s right shoulder been so limited as to prevent him from exceeding shoulder height. Under VA regulations, shoulder height is considered to be 90 degrees. See 38 C.F.R. § 4.71a, Plate I. The evidence demonstrates that in October 2013 and January 2020, the Veteran’s range of motion exceeded that specified for a higher 30 percent rating. Thus, the criteria for a rating in excess of 20 percent have not been more nearly approximated during these periods than the criteria for a 20 percent rating. The Board understands that the Veteran’s right shoulder is painful, and that this pain impacts his ability to lift and manipulate objects. However, it is important to note that, while pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Id. at 38; see 38 C.F.R. § 4.40. This functional loss is measured by testing of range of motion in accordance with the rating schedule. In this case, the testing does not demonstrate functional loss greater than is compensated by the currently assigned ratings. While the provisions of 38 C.F.R. § 4.59 establish that the Veteran is entitled to a compensable evaluation for his painful motion, such has already been assigned for the entire period. Evaluations in excess of the minimum compensable rating must be based on demonstrated functional impairment. In sum, the Board finds that the RO has already restored the rating for the right shoulder to 20 percent, effective January 14, 2012; that prior to January 14, 2012, the Veteran’s right shoulder disability was manifested by painful motion with forward flexion and abduction to at least to shoulder height; and that since January 14, 2012, the Veteran’s right shoulder disability was manifested by painful motion with forward flexion and abduction to at least 45 degrees. The Board therefore concludes that, the appealed rating restoration is moot; that, prior to January 14, 2012, a rating higher than 10 percent is not warranted; and, that since January 14, 2012, a rating higher than 20 percent is not warranted. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. However, a preponderance of the evidence is against any higher ratings than awarded here. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (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). JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Cramp 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.