Citation Nr: 20043744 Decision Date: 06/29/20 Archive Date: 06/29/20 DOCKET NO. 15-32 167 DATE: June 29, 2020 ORDER For the entire period of appeal, a disability evaluation in excess of 20 percent for the Veteran’s service-connected left shoulder disability is denied. For the entire period of appeal, a disability evaluation in excess of 20 percent for the Veteran’s service-connected diabetes mellitus is denied. FINDINGS OF FACT 1. The Veteran’s dominant hand is his right hand. 2. For the entire period of appeal, the Veteran’s service-connected left shoulder disability manifested pain, arthritis, flexion between 35 and 105 degrees, abduction between 35 and 95 degrees, without ankylosis, loss of head, nonunion, or fibrous union of the humerus. 3. For the entire period of appeal, the Veteran’s service-connected diabetes mellitus required the use of an oral hypoglycemic agent and a restricted diet but did not require the regulation of activities. CONCLUSIONS OF LAW 1. For the entire period of appeal, the criteria for the assignment of a disability evaluation in excess of 20 percent for a left shoulder disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.69, 4.71, 4.71a, Diagnostic Codes 5003, 5201, 5202. 2. For the entire period of appeal, the criteria for the assignment of a disability evaluation in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.119, Diagnostic Code 7913. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the U.S. Army from August 1964 to September 1969, including service in Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2012 rating decision issued by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The Veteran’s initial hearing request as indicated in his September 2015 Form 9 was later withdrawn in his April 2019 letter to the Board. See 38 C.F.R. § 20.704(e). In June 2019, the Board remanded this appeal for further development, including scheduling the Veteran for VA examinations to evaluate his diabetes mellitus and his left shoulder disability. To the extent that the directed VA examination reports were procured in December 2019, the Board finds that substantial compliance with its remand directives pertaining to the Veteran’s left shoulder and diabetes mellitus claims has been accomplished. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999). This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.902 (2016). See 38 U.S.C. § 7107(b) (2020). Increased Ratings Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. See 38 U.S.C. § 1115; 38 C.F.R. §§ 3.321(a), 4.1, 4.21. Disability evaluations are based upon the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. See 38 C.F.R. § 4.10. Separate diagnostic codes identify the various disabilities. See 38 C.F.R. § 4.27. VA has a duty to acknowledge and to consider all regulations that are potentially applicable to issues raised in the record and to explain the reasons and bases for its conclusions. See Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. See 38 C.F.R. §§ 3.321(a), 4.1, 4.21. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. §§ 4.7, 4.21. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. See 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is the primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether they were raised by the Veteran, as well as the entire history of the Veteran’s disability. See 38 C.F.R. § 4.1, 4.2; Schafrath,1 Vet. App. at 595. Separate evaluations may be assigned for separate periods of time, or staged, where factual findings show distinct time periods during which the Veteran’s disability exhibits symptoms that warrant the application of different ratings. See Fenderson v. West, 12 Vet. App. 119, 126-28 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Additionally, the evaluation of the same disability under several Diagnostic Codes, known as pyramiding, must be avoided. See 38 C.F.R. § 4.14. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. See 38 C.F.R. § 4.40. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. See id. 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 the visible behavior of the veteran undertaking the motion. See id. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. See id. The factors involved in evaluating and rating disabilities of the joints include the following: less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); weakened movement (due to muscle injury, disease, or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination and impaired ability to execute skilled movements smoothly; or pain on movement, swelling, deformity, or atrophy of disuse. See 38 C.F.R. § 4.45. Functional loss caused by pain must be rated at the same level as if that functional loss were caused by some other factor that actually limited motion, such as deformity, atrophy, adhesions, or any of the other factors cited above. See Schafrath, 1 Vet. App. at 592. Consequently, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. See id. Where the veteran is diagnosed with any form of arthritis, painful motion is an important factor of disability, and facial expressions such as wincing exhibited in the presence of pressure on or manipulation of the affected joints, should be carefully noted and related to the affected joints. See 38 C.F.R. § 4.59. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. See id. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See id. 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. See id. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weightbearing and, if possible, with the range of the opposite undamaged joint. See id. When adjudicating disabilities evaluated based upon limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40 and 4.45, pertaining to functional impairment. See DeLuca v. Brown, 8 Vet. App. 202, 205-07 (1995). In applying these regulations, VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, or incoordination. See id. Such inquiry was not to be limited to muscles or nerves, and, if feasible, these determinations were to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. See id. Consideration of 38 C.F.R. § 4.59 is not limited to cases involving arthritis; thus, a rating based on painful motion of a joint may be appropriate regardless of whether the painful motion stemmed from joint or periarticular pathology. See Burton v. Shinseki, 25 Vet. App. 1, 4-5 (2011). However, pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination and endurance to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Although pain may cause functional loss, pain itself does not constitute functional loss and is merely one factor to be considered when evaluating functional impairment. See id. However, 38 C.F.R. § 4.40 does not require a separate rating for pain, but rather provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194, 196 (1997). Once the evidence has been assembled in the record, it is the Board’s responsibility to evaluate the evidence. See 38 U.S.C. § 7104(a). The Board shall consider all lay and medical evidence of record, analyze the credibility and probative value of the evidence, and provide reasons for rejecting any material evidence favorable to the claimant. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). In addressing lay evidence and determining its probative value, the Board must assess both its competency, a legal concept determining whether testimony may be heard and considered, and credibility, a factual determination regarding the probative value of the evidence. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall afford the claimant the benefit of the doubt. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. Where the evidence is in relative equipoise, the claimant shall prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). The preponderance of the evidence must weigh against the Veteran’s claim in order for it to be denied. See Alemany v. Brown, 9 Vet. App. 518, 519-20 (1996). 1. For the entire period of appeal, a disability evaluation in excess of 20 percent for the Veteran’s service-connected left shoulder disability is denied. Disabilities of the shoulder and arm are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5200 to 5203. For rating purposes, a distinction is made between major (dominant) and minor (non-dominant) musculoskeletal groups, and the determination of dominance shall be based upon the evidence of record. See 38 C.F.R. § 4.69. Hyphenated diagnostic codes may be used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. See 38 C.F.R. § 4.27. Under Diagnostic Code 5201, which provides ratings for limitation of motion of the arm, a 20 percent rating is assigned for limitation of motion of the major or minor arm to the shoulder level, or for limitation of motion of the minor arm to midway between the side and shoulder level. A 30 percent rating is warranted for limitation of motion of the major arm to midway between the side and shoulder level, or for limitation of motion of the minor arm to 25 degrees from the side. A schedular maximum of 40 percent is warranted for limitation of motion of the major arm to 25 degrees from the side. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. Standard range of motion of the shoulder is forward elevation (flexion) to 180 degrees and abduction to 180 degrees. See 38 C.F.R. § 4.71, Plate I. Forward flexion and abduction to 90 degrees constitutes the ability to raise an arm to shoulder level. See id. Other impairment of the humerus (shoulder) is rated under Diagnostic Code 5202. A 20 percent rating contemplates malunion of the major or minor humerus with a moderate deformity; malunion of the minor humerus with a marked deformity; recurrent dislocation of the major or minor humerus at the scapulohumeral joint, with infrequent episodes, and guarding of major or minor arm movement only at shoulder level; or recurrent dislocation of the minor humerus at the scapulohumeral joint, with frequent episodes and guarding of all minor arm movements. See 38 C.F.R. § 4.71a, Diagnostic Code 5202. A 30 percent rating contemplates malunion of the major humerus with a marked deformity; or recurrent dislocation of the major humerus at the scapulohumeral joint, with frequent episodes and guarding of all major arm movements. See id. A 40 percent rating contemplates fibrous union of the minor humerus. See id. A 50 percent rating contemplates fibrous union of the major humerus; or nonunion (false flail joint) of the minor humerus. See id. A 60 percent rating contemplates nonunion (false flail joint) of the major humerus. See id. A 70 percent rating contemplates loss of head (flail shoulder) of the minor humerus, and an 80 percent rating contemplates loss of head (flail shoulder) of the major humerus. See id. Degenerative arthritis must be established by X-ray findings and is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. However, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. See id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. See id. In the absence of limitation of motion, X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations, will warrant a 20 percent rating. See id. X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups will warrant a 10 percent rating. See id. The 10 percent and 20 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note 1. The assignment of a particular diagnostic code depends upon the facts of each particular case, and the Board is authorized to choose an appropriate diagnostic code that is supported by both the evidence of record and a sufficiently articulated rationale. See Butts v. Brown, 5 Vet. App. 532, 538-39 (1993). Moreover, service connection for a disability is not severed when the diagnostic code assigned to that disability is revised in order to more accurately reflect the veteran’s relevant medical history, diagnoses, and demonstrated symptomatology. See Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). In this case, a May 2005 rating decision awarded service connection for the Veteran’s left shoulder disability with an evaluation of 20 percent under Diagnostic Code 5202, effective July 24, 2003. The Veteran contends that the severity of his left shoulder disability warrants a disability rating in excess of 20 percent based upon the increased severity of his pain and limited range of motion causing functional impairment. However, for the reasons set forth below, the Board disagrees that a disability rating greater than 20 percent is warranted for the Veteran’s left shoulder disability. During the period on appeal, the Veteran has been afforded four VA examinations to evaluate his left shoulder condition: in September 2010, August 2011, July 2015, and December 2019. In September 2010, the Veteran was afforded a VA examination during which he was diagnosed with left shoulder rotator cuff strain, adhesive capsulitis, and chronic impingement syndrome and was noted to be right hand dominant. Based upon December 2004 X-rays, the Veteran was also diagnosed with some deformity of the glenoid fossa, left scapula, with moderate degenerative changes. The Veteran reported to the September 2010 VA examiner that he suffers from the following left shoulder symptoms: recurrent dislocations, two to three times per year since in-service onset; burning, stabbing pain across the left glenohumeral joint, described as 6 on a scale of 1 to 10; stiffness; locking; weakness; instability or giving way; occasional heat and redness; and flareups of pain with any lifting, stretching, elevating the arm, rolling over in bed, or excessive movements. The Veteran further described the flareups as follows: causing radiation from the left shoulder down into the left forearm; causing sharp pain described as a 10 on a scale of 1 to 10; occurring five to six times per day; lasting from a few minutes to a few days; and alleviation with medication (ibuprofen, Flexeril), rest, and limiting stress to shoulder. The Veteran further reported that he is currently retired but that prior to his retirement, his employment at a telephone company was inhibited by his left shoulder disability which limited him from the following: lifting; overhead lifting; repetitive motions involving the left shoulder; climbing telephone poles; repairing lines; and completing overhead repairs. The Veteran further reported that the pain caused by his left shoulder disability caused him to miss days of work and inhibited his ability to put on a shirt. Upon examination, the September 2010 VA examination report found as follows: deformity of the left deltoid muscle, supraspinatus muscle, infraspinatus muscle; tenderness over the glenohumeral joint, supraspinatus, infraspinatus, and subscapularis; weakness noted in all ranges of motion; increased fatigability with motion; instability; abnormal movements with increased scapular movement initiating at 10 degrees of abduction; guarding with movements or stress; positive Neer and Hawkins-Kennedy tests for impingement syndrome; positive painful arc; noticeable apprehension as guarding of motion and muscle spasm with an apprehension test and positive sulcus sign; and reduced muscle strength in abduction (3+/5), forward flexion (3+/5), external rotation (3+/5); internal rotation (4/5), and extension (4/5). Objectively, range of motion findings for the Veteran’s left shoulder were indicated as follows: forward flexion from 0 to 65 degrees, with painful motion at 35 to 65 degrees, and from 35 to 60 degrees with painful motion after repetitive testing; abduction from 0 to 45 degrees, with painful motion from 40 to 45 degrees, and from 35 to 40 degrees with painful motion after repetitive testing; external rotation from 0 to 20 degrees, with painful motion at 0 to 15 degrees with repetition; and internal rotation from 0 to 30 degrees, with painful motion, and from 0 to 25 degrees with painful motion after repetitive testing. The report further indicated that the Veteran was guarding his left shoulder and suffered from episodes of recurrent dislocation two to three times per year. In August 2011, the Veteran underwent an additional VA examination to evaluate the severity of his service-connected left shoulder disability, during which he was diagnosed with left rotator cuff syndrome with impingement syndrome and adhesive capsulitis and again found to be right hand dominant. The Veteran reported suffering from flareups with lifting, stretching, rolling over in bed or too much movement, which are alleviated with rest, and further reported that his left shoulder condition manifests pain when he climbs and gets in and out of his truck. Objectively, range of motion findings for the left shoulder were measured as follows: flexion with pain and repetition from 0 to 100 degrees; and abduction with pain and repetition from 0 to 90 degrees. No additional limitation in range of motion or functional loss was noted with repetitive use testing. The report further noted functional impairment as less movement than normal and excess fatigability, tenderness on palpation of the AC joint, pain on movement, and localized tenderness or pain on palpation, but no ankylosis, guarding, loss of muscle strength, history of mechanical symptoms, or recurrent dislocation. In addition, the Veteran tested positive for the following: the empty can test; the external rotation/infraspinatus strength test; the lift-off subscapularis test; the crank apprehension and relocation test; and the cross-body test. X-ray results were noted to document arthritis, degenerative joint disease (DJD), and deformity of the glenoid fossa. The August 2011 VA examination report further concluded that the Veteran’s service-connected left shoulder condition limits strenuous physical employment due to significant limited range of motion. In July 2015, the Veteran underwent a third VA examination to evaluate the severity of his service-connected left shoulder disability, during which he was diagnosed with DJD, based upon January 2015 X-rays revealing severe degenerative arthritis of the glenohumeral and the AC joints, with rotator cuff strain, adhesive capsulitis, and impingement syndrome. The Veteran was also again found to be right hand dominant. The July 2015 VA examination report further indicated that the Veteran reported he continues to suffer from constant pain made worse with any physical activity, including exercise, which he describes as an 8 to 10 on a scale of 1 to 10, depending upon his activity level. The Veteran also reported flareups, described as constant pain made worse with any physical activity. Objectively, no evidence of crepitus or of pain with weight bearing was noted, and range of motion findings for the left shoulder were indicated as follows: flexion from 0 to 105 degrees and abduction from 0 to 90 degrees; external rotation from 0 to 70 degrees; and internal rotation from 0 to 90 degrees. No additional functional loss or range of motion was noted after three repetitions. In addition, pain was noted on exam to cause functional loss, to include decreased range of motion for flexion, abduction, and external rotation. Objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue was also noted, as was the Veteran’s subjective report of localized tenderness or pain on palpation of the joint or associated soft tissue on all planes. Additional contributing factors of disability were noted as follows: less movement than normal due to ankylosis, adhesions, etc.; interference with lifting; interference with carrying; and easy fatigability. In addition, a lift-off subscapularis test was positive, indicating that a rotator cuff condition was suspected. However, the July 2015 VA examination report found no evidence of the following: muscle atrophy; instability; dislocation; labral pathology; impairments of the humerus; ankylosis; or any clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint conditions. In December 2019, the Veteran underwent a fourth VA examination to evaluate the severity of his service-connected left shoulder disability, during which he was diagnosed with degenerative joint disease with rotator cuff strain, adhesive capsulitis, and impingement syndrome. The Veteran was also again diagnosed with arthritis documented by X-rays and found to be right hand dominant. The December 2019 VA examination report further noted the following: the Veteran reported that his daily left shoulder pain continues to worsen; the pain is described as achy and sharp, a five on a scale of 1 to 10; movement aggravates his left shoulder and increases the pain to an eight on a scale of 1 to 10; his left arm is weak and will drop; he occasionally holds the left shoulder on his chest to help ease the pain; he receives injections every three to six months to help reduce the pain; he further treats his pain with daily Tylenol, ice, heat, and topical rub as needed. The Veteran denied flareups but reported that he avoids increased or repetitive movement due to pain, to include lifting, carrying, pushing, or pulling. Objectively, evidence of crepitus and pain with weight bearing was noted, as was objective evidence of pain on passive range of motion testing and objective evidence of pain when the joint is used in non-weight bearing. Range of motion findings were measured as follows, with no additional loss of function or range of motion after three repetitions: flexion from 0 to 95 degrees; abduction from 0 to 95 degrees; external rotation from 0 to 50 degrees; and internal rotation from 0 to 55 degrees. Abnormal range of motion was noted to itself contribute to functional loss, and pain was also noted on examination and to cause functional loss with flexion, abduction, external rotation, and internal rotation. Pain, weakness, fatigability, and incoordination were found not to significantly limit functional ability with repeated use over a period of time, and no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue was noted. The Veteran was found to have weakened movement due to muscle or peripheral nerve injury, to include weakness to the left shoulder related to degenerative joint disease with rotator cuff strain, adhesive capsulitis, and impingement syndrome since July 24, 2003. Reduction in muscle strength in forward flexion and abduction was also noted to be 3/5 and entirely due to his service-connected left shoulder condition. In addition, the Veteran again tested positively for the following, indicating suspicion of a rotator cuff condition: the Hawkins impingement test; the empty-can test; the external rotation/infraspinatus strength test; and the lift-off subscapularis test. The cross-body adduction test was also positive, as was an examination for tenderness on palpation of AC joint, indicating suspicion of a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition; however, the Veteran was found not to have an AC joint condition or other impairment of clavicle or scapula impacting range of motion. The report also noted no evidence of ankylosis, shoulder instability, dislocation, loss of head, or malunion of humerus and did not indicate suspicion of labral pathology. Finally, the December 2019 VA examination report noted that the Veteran reported his left shoulder impacted his ability to work as prior to his retirement, he worked as a communications service technician and lost less than one week’s work time lost in his last twelve months. The Veteran further reported that he retired from his employment due to his left shoulder condition which caused him constant pain with movement as well as difficulty lifting, carrying, pushing, or pulling at least ten pounds with the left shoulder and arm. Based upon the foregoing evidence, the Board finds that during the entire period of appeal, the evidence of record indicates that the Veteran’s service-connected left shoulder disability manifested symptoms that more closely approximate the criteria for a disability rating of 20 percent under Diagnostic Code 5202, but do not more closely approximate the criteria for a disability rating of 30 percent under any relevant diagnostic code. As an initial matter, the Board finds that the evidence of record establishes that the Veteran is right-hand dominant, as all four VA examinations indicate right-hand dominance. Lay statements made to medical providers in the context of medical treatment carry a high level of credibility, due to the risk of misdiagnosis inherent in making a false statement. See White v. Illinois, 502 U.S. 346, 355-56 (1992). Accordingly, the Board finds that the Veteran’s left shoulder is non-dominant, or minor, and shall therefore be evaluated as a minor extremity. See 38 C.F.R. § 4.69. In addition, the Board finds that the September 2010 VA examination report confirms that the Veteran suffered recurrent left shoulder dislocation with infrequent episodes, as well as guarding of his left arm movements, as enumerated in Diagnostic Code 5202. However, the subsequent three VA examination reports in August 2011, July 2015, and December 2019 all indicate a lack of recurrent left shoulder dislocation. Regardless, as stated above, a rating of 30 percent for recurrent dislocations under Diagnostic Code 5202 is available only for a major extremity, which in this case is the Veteran’s right arm. Instead, a 20 percent rating is the maximum rating afforded to a minor extremity exhibiting episodes of recurrent dislocations at the scapulohumeral joint, which in this case is the Veteran’s left arm. See 38 C.F.R. § 4.71a, Diagnostic Code 5202. Accordingly, because the Veteran has been consistently found to be right-hand dominant, the Board finds that his left shoulder is properly classified as a minor rather than a major extremity, and therefore, a 20 percent evaluation is the maximum available for the Veteran’s episodes of dislocation and guarding under Diagnostic Code 5202. See 38 C.F.R. § 4.69. In addition, the relevant evidence of record does not indicate that the Veteran’s left shoulder disability manifests any of the symptoms warranting a rating higher than 20 percent under Diagnostic Code 5202 such as loss of head (flail shoulder), nonunion (false flail joint), fibrous union, or malunion of the humerus. See id. Accordingly, the Board concludes that the preponderance of evidence weighs against the Veteran’s claims of entitlement to a disability evaluation under Diagnostic Code 5202 in excess of 20 percent, because 20 percent is the maximum rating afforded to a minor extremity exhibiting frequent or infrequent episodes of recurrent dislocations at the scapulohumeral joint and guarding of either all arm movements or only at the shoulder level. See 38 C.F.R. § 4.71a, Diagnostic Code 5202. In addition, the Board finds that a disability rating in excess of 20 percent is not warranted under Diagnostic Code 5201 as the evidence of record indicates that for the entire period on appeal, the Veteran’s service-connected left shoulder disability did not manifest limitation of motion of the right arm at 25 degrees from his left side, as required for the 30 percent rating for the minor arm. Rather, all four VA examination reports reflect that, accounting for painful motion and repetition, the Veteran’s left shoulder forward flexion and abduction were limited to no less than 35 degrees. Accordingly, the Board concludes that the preponderance of evidence weighs against the Veteran’s claims of entitlement to a disability evaluation under Diagnostic Code 5201 in excess of 20 percent, because 20 percent is the maximum rating afforded to a minor extremity exhibiting range of motion limited to shoulder level absence evidence of limitation to 35 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. Moreover, although the Veteran’s left shoulder disability does cause pain, painful motion does not result in the degree of functional loss required for a rating in excess of 20 percent. Consideration has also been given to the potential application of the other diagnostic codes for disabilities of the shoulder and arm; however, the Board finds no basis upon which to assign increased or additional ratings for the Veteran’s left shoulder disability at any point during the period of appeal. See 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5203. The Veteran has never been found to have ankylosis of the scapulohumeral articulation or impairment of the clavicle or scapula. Thus, Diagnostic Codes 5200 (ankylosis of scapulohumeral articulation) and 5203 (impairment of clavicle or scapula) do not apply in this case. In addition, because the evidence of record includes X-ray evidence establishing that the Veteran’s left shoulder disability manifests degenerative arthritis, the Board has considered whether the Veteran’s left shoulder disability is entitled to a higher rating under Diagnostic Code 5003-5201 for degenerative arthritis. As stated above, degenerative arthritis is evaluated by the criteria enumerated in Diagnostic Code 5201, which provides that in order to warrant a 30 percent rating, a minor arm’s limitation of motion must be restricted to 25 degrees from the Veteran’s side. However, the record in this case does not reflect that the Veteran’s left shoulder disability manifested flexion or abduction limited to 25 degrees at any point during the period on appeal. On the contrary, the limitation of motion of the Veteran’s left arm was at most restricted to 35 degrees. Accordingly, the preponderance of the evidence of record weighs against a finding that the Veteran’s left shoulder disability is entitled to a 30 percent rating under Diagnostic Code 5003-5201. Moreover, as outlined above, evaluation of the same disability or the same manifestations under various diagnoses, or pyramiding, is prohibited. See 38 C.F.R. § 4.14. Compensation may not be awarded more than once for the same symptomatology, as such a result would overcompensate a veteran for the actual impairment of his earning capacity. See Brady v. Brown, 4 Vet. App. 203, 206 (1993). However, separate and distinct manifestations attributable to the same injury may be compensated under different diagnostic codes. See Esteban, 6 Vet. App. at 261-62. In this case, the assignment of separate ratings under Diagnostic Code 5202 and Diagnostic Code 5003-5201 would constitute the sort of pyramiding prohibited by 38 C.F.R. § 4.14. As noted above, Diagnostic Code 5202 rates the dislocation or instability of the shoulder, while Diagnostic Code 5201 rates the flexion and abduction of the arm at shoulder level, or motions to bend or straighten the arm. Thus, the rating criteria under Diagnostic Code 5202 overlaps with the rating criteria of Diagnostic Code 5201 because the Diagnostic Code 5202 rating is partially based on limitation of motion. Accordingly, the Veteran may not be assigned a rating under Diagnostic Code 5202 (impairment of the scapulohumeral joint) and assigned a separate rating under Diagnostic Code 5201 (limitation of flexion and extension) without resulting in unlawful pyramiding. See 38 C.F.R. § 4.14. The Veteran has not specifically raised any other issues, nor have any other issues been reasonably raised by the evidence of record. See Doucette v. Shulkin, 28 Vet. App. 366, 370 (2017). Accordingly, and for the foregoing reasons, the Board finds that, for the entire period on appeal, a preponderance of the evidence of record weighs against a finding that the Veteran’s left shoulder disability is entitled to a disability rating in excess of 20 percent; therefore, the benefit of the doubt doctrine does not apply in this case, and the Veteran’s increased rating claim must be denied. See Gilbert, 1 Vet. App. at 53-54. 2. For the entire period of appeal, a disability rating in excess of 20 percent for diabetes mellitus is denied. As stated above, a May 2004 rating decision awarded service connection for the Veteran’s diabetes mellitus with an evaluation of 20 percent under Diagnostic Code 7913, effective June 23, 2003. The Veteran contends that his service-connected diabetes mellitus has progressively worsened and warrants an increased evaluation in excess of 20 percent; however, for the reasons set forth below, the Board finds that a disability rating in excess of 20 percent for the Veteran’s service-connected diabetes mellitus is not warranted in this case. Diagnostic Code 7913 provides that a 20 percent evaluation for diabetes mellitus is warranted where the record contains competent evidence that the medical management of diabetes requires a restricted diet, along with either one or more daily injections of insulin or an oral hypoglycemic agent. See 38 C.F.R. § 4.119, Diagnostic Code 7913. A 40 percent rating is warranted where there is evidence that the medical management of diabetes requires one or more daily injections of insulin, a restricted diet, and the regulation of activities. See id. In order to establish that the medical management of a veteran’s diabetes requires the regulation of activities, the record must contain competent medical evidence of a qualified medical assessment of the veteran’s individual circumstances and symptoms that includes medical advice to avoid strenuous occupational and recreational activities. See Camacho v. Nicholson, 21 Vet. App. 360, 364-66 (2007); 38 C.F.R. § 4.119. A 60 percent rating unde Diagnostic Code 7913 is warranted where the record contains competent evidence that the medical management of diabetes requires one or more daily injections of insulin, a restricted diet, and the regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year, or twice a month visits to a diabetic care provider, in addition to complications that would not be compensable if separately evaluated. See 38 C.F.R. § 4.119. A total schedular (100 percent) rating is warranted where the record contains competent evidence that the medical management of diabetes requires more than one daily injection of insulin, a restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, in addition to a either progressive loss of weight and strength or complications that would be compensable if separately evaluated. See id. Compensable diabetic complications must be rated separately unless included in the criteria supporting a 100 percent evaluation, but noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. See 38 C.F.R. § 4.119, Note (1) to Diagnostic Code 7913. Due to the successive nature of the rating criteria for diabetes, each of the three criteria listed in the 40 percent rating, a restricted diet, the regulation of activities, and either one or more daily injections of insulin or an oral hypoglycemic agent, must be established by competent medical evidence in order to warrant the award of a 40 percent rating for diabetes mellitus. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). During the period on appeal, the Veteran has been afforded three VA examinations to evaluate his diabetes mellitus: August 2011, July 2015, and December 2019. All three VA examination reports conclude that the Veteran’s medical management of his diabetes mellitus involves a prescription oral hypoglycemic agent and restricted diet but does not require him to regulate his activities. In addition, all three VA examination reports also indicate that the Veteran has had no episodes of ketoacidosis or hypoglycemia requiring hospitalization during the prior twelve months and no progressive unintentional weight loss or loss of strength attributable to diabetes mellitus. The July 2015 and September 2019 VA examination reports further indicate that the Veteran had visits to a diabetic care provider for episodes of hypoglycemia fewer than two times per month. Accordingly, in light of the foregoing, the Board finds that the preponderance of evidence weighs against the Veteran’s claim for a disability evaluation in excess of 20 percent for his service-connected diabetes mellitus, because the competent medical evidence of record does not reflect that, at any time during the period on appeal, medical management of the Veteran’s diabetes mellitus has required the regulation of his activities, or that he has been advised by a qualified medical professional to avoid strenuous occupational and recreational activities. Therefore, because a 20 percent evaluation is the maximum rating afforded to diabetes mellitus manifesting the requirements of an oral hypoglycemic agent and a restricted diet, an increased evaluation in excess of 20 percent is not warranted by the facts of this case. See 38 C.F.R. § 4.119. The Board notes that the Veteran has already been separately awarded separate evaluations for peripheral neuropathy of the bilateral lower extremities and the left upper extremity, erectile dysfunction and hypertension in connection with his diabetes. The Veteran did not contend that higher ratings were warranted for those disabilities. Consideration has also been given to the potential application of the other diagnostic codes governing disabilities of the endocrine system; however, the Board finds no basis upon which to assign increased or additional ratings for the Veteran’s diabetes mellitus at any point during the period of appeal, as the record contains no evidence that the Veteran suffers from any other endocrinological disease subject to the provisions of the Rating Schedule. See id; Schafrath, 1 Vet. App. at 595. Accordingly, the Board finds that no additional evaluations under separate disability ratings are warranted in this case. The Veteran has not specifically raised any other issues, nor have any other issues been reasonably raised by the evidence of record. See Doucette, 28 Vet. App. at 370. (Continued on the next page)   Accordingly, and in light of the foregoing, the Board finds that for the entire period on appeal, a preponderance of the evidence of record weighs against a finding that the Veteran’s diabetes mellitus is entitled to a rating in excess of 20 percent; therefore, the benefit of the doubt doctrine does not apply in this case, and the Veteran’s increased rating claim for his service-connected diabetes mellitus must be denied. See Gilbert, 1 Vet. App. at 53-54. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Marsdale 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.