Citation Nr: 21000964 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 18-18 984A DATE: January 6, 2021 ORDER An initial rating in excess of 10 percent for degenerative arthritis of the left knee with limitation of flexion is denied. An initial rating in excess of 10 percent for degenerative arthritis of the right knee with limitation of flexion is denied. A rating in excess of 30 percent for right shoulder osteoarthritis, status post (SP) right shoulder replacement, prior to March 2, 2018, is denied. A rating in excess of 60 percent for right shoulder osteoarthritis, SP right shoulder replacement, since March 2, 2018, is denied. FINDINGS OF FACT 1. The Veteran’s degenerative arthritis of the left knee has been manifested by painful motion with full extension and no instability or subluxation, meniscectomy residuals, locking, and flexion is limited to no more than 90 degrees. 2. The Veteran’s degenerative arthritis of the right knee has been manifested by painful motion with full extension and no instability or subluxation, meniscectomy residuals, locking, and flexion is limited to no more than 90 degrees. 3. Prior to March 2, 2018, the Veteran’s right shoulder disability was manifested by no more than intermediate degrees of residual weakness, pain and/or limitation of motion. 4. Since March 2, 2018, the Veteran’s right shoulder disability has been manifested by severe painful motion but no flail or false flail joint. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for degenerative arthritis of the left knee with limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 2. The criteria for an initial rating in excess of 10 percent for degenerative arthritis of the right knee with limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 3. The criteria for a rating in excess of 30 percent for right shoulder osteoarthritis, SP right shoulder replacement, prior to March 2, 2018, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5051. 4. The criteria for a rating in excess of 60 percent for right shoulder osteoarthritis, SP right shoulder replacement, since March 2, 2018, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5051. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 1962 to November 1965. The matter comes before the Board of Veterans’ Appeal (Board) from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in September 2014 which, in pertinent part, granted service connection for right shoulder osteoarthritis (the major extremity), status post right shoulder replacement, which was assigned an initial 30 percent disability rating under Diagnostic Code (DC) 5051. That rating also granted service connection for degenerative arthritis of each knee, with each being assigned an initial 10 percent rating based on limited flexion. That rating denied service connection for bilateral hearing loss, a left shoulder disability, a left hip disability, a right hip disability, residuals of a right hip replacement, and bilateral varicose veins. In pertinent part, in the Veteran’s VA Form 21-0958, Notice of Disagreement (NOD), in September 2015 he purported to disagree with an evaluation for left shoulder arthritis. However, the September 2014 rating denied service connection for left shoulder arthritis and, so, no disability evaluation had been assigned for that disability at that time (although service connection is now in effect for left shoulder osteoarthritis which is rated 20 percent disabling). Subsequently, a VA Form 21-0958, NOD, was received on April 30, 2018 as to denials of service connection for each hip and each shoulder. By RO letters of March 15 and 18, 2019, the Veteran was informed that this NOD was not timely as to his claims on the issues of his left hip and right hip. Each letter informed him that he could reopen his claim and he was provided with the appropriate form to do so. A March 2018 rating decision granted service connection for a post operative (PO) scar of the right shoulder, SP total right shoulder replacement, which was assigned an initial noncompensable evaluation. In May 2019 the Board remanded claims service connection for a left shoulder disorder (osteoarthritis), service connection for bilateral varicose veins, ratings in excess of 10 percent for degenerative arthritis of each knee with limited flexion of each knee, and a rating in excess of 30 percent for right shoulder osteoarthritis, status post (SP) right shoulder replacement. A May 2020 rating decision granted service connection for osteoarthritis of the left shoulder, which was assigned an initial 20 percent raring; granted service connection for varicose veins of the left lower extremity, which was assigned an initial 10 percent rating; granted service connection for varicose veins of the right lower extremity, which was assigned an initial 10 percent rating; and also granted a separate 20 percent rating for limited right shoulder motion under DC 5201 (while maintaining a 30 percent rating for right shoulder osteoarthritis SP right shoulder replacement under Diagnostic Code (DC) 5051). A July 2020 rating decision found clear and unmistakable error (CUE) in a prior denial of service connection for right hip degenerative arthritis, SP total right hip replacement, and granted service connection with a 30 percent disability rating effective October 29, 2013. The 30 percent rating for right shoulder osteoarthritis SP right shoulder replacement under DC 5051 was increased to 60 percent, effective March 2, 2018 (date of VA rating examination). Basic eligibility to Dependents’ Educational Assistance was granted effective March 2, 2018. The noncompensable rating for surgical scars of the right shoulder and right hip, SP arthroplasties, were confirmed and continued. Also, CUE was found in the prior assignment of a separate 20 percent rating for limited right shoulder motion under DC 5201, while concurrently maintaining an evaluation based on the right shoulder replacement. The Veteran has had a combined disability rating of 80 percent since October 29, 2013; 90 percent since April 21, 2014; and 100 percent since March 2, 2018. The Veteran did not appeal the ratings or effective dates for the grants of service connection for a left shoulder disability and for bilateral varicose veins, thus those matters are not before the Board. Likewise, he did not appeal the termination of the separate 20 percent rating for limited right shoulder motion, while concurrently maintaining an evaluation based on the right shoulder replacement. Thus, that matter is not before the Board. The Board remanded the claims as to the ratings for the arthritis with limited flexion of each knee and the rating for the right shoulder disability for additional rating examinations. Those examinations were conducted in February 2020. The Veteran and his service representative has not challenged the adequacy of the findings of the February 2020 VA examinations. The 2019 Board remand instructed that an examination of the Veteran’s knees was to attempt to obtain information relative to functional impact during flare-ups. The February 2018 VA examiner explained, as to the knees and the right shoulder, that because the Veteran was not having a flare-up at the time of the examination, an objective, accurate, measurable estimate of the additional loss of motion or other limitations during a flare could not be derived from the Veteran's inputs or other procurable and assembled data and, so, it was not possible to accurately estimate and report any additional limitation of motion or other limitations due to pain during a flare-up. This followed the Board’s instructions in the remand and caselaw. See generally Sharp v. Shulkin, 29 Vet. App. 26 (2017), and Stegall v. West, 11 Vet. App. 268, 271 (1998); D’Aries v. Peake, 22 Vet. App. 97, 105 (2008) (citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999)). The Board has thoroughly reviewed all the evidence and while obligated to provide supporting reasons and bases, it does not have to discuss, in detail, all of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380 – 81 (Fed. Cir. 2000). This analysis focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show. The Veteran must not assume that any evidence not explicitly discussed has been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000); and Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed.Cir. 2007) (“There is a presumption that [VA] considered all of the evidence of record,” and the mere failure by the board to discuss a particular piece of evidence is insufficient to rebut that presumption). Rating Principles Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When a question arises as to which of two ratings apply under a specific diagnostic code, the higher is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. A higher rating may not be denied on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria and the ameliorative effects of medication must be discounted when assigning an evaluation. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012) and McCarroll v. McDonald, 28 Vet. App. 267, 271 (2016) (en banc). Ratings for a joint based on limitation of motion require consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. In other words, ratings based on limited motion do not ipso facto include or subsume the other rating factors in §§ 4.40 and 4.45, e.g., pain, functional loss, fatigability, and weakness. Thus, a higher rating may be assigned if there is additional limitation of motion from pain or limited motion on repeated use of the joint. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Also with any form of arthritis, painful motion is factor to be considered. Painful motion of a joint with periarticular pathology is to be at rated at least at the minimum compensable rating for the joint. 38 C.F.R. § 4.59. See DeLuca v. Brown, 8 Vet. App. 202 (1995); Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); Mitchell v. Shinseki, 25 Vet. App. 32 (2011); and Burton v. Shinseki, 25 Vet. App. 1, 5-6 (2011). However, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance.” Id., quoting 38 C.F.R. § 4.40. 38 C.F.R. § 4.71a, Diagnostic Code 5003, degenerative arthritis, provides that degenerative arthritis is rated on the basis of limitation of motion under appropriate diagnostic codes for the specific joint or joints involved, but that when limitation of motion of the specific joint is noncompensable, a 10 percent rating is warranted for limitation of motion of a major joint or group of minor joints. With X-ray evidence of arthritis of two or more joint groups without compensable limitation of motion a single disability evaluation of 10 percent may be assigned. Where, however, the limitation of motion of a specific joint or joints involved is noncompensable under the code for rating based on limited motion, a rating of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Knee Ratings Under DC 5257, which rates impairment of the knee due to recurrent subluxation or lateral instability, a 10 percent rating is assigned with evidence of slight recurrent subluxation or lateral instability of a knee; 20 percent rating is assigned with evidence of moderate recurrent subluxation or lateral instability; and 30 percent rating is assigned with evidence of severe recurrent subluxation or lateral instability. Pursuant to 38 C.F.R. §§ 4.40 and 4.45, pain is inapplicable to ratings under DC 5257, because it is not predicated on loss of range of motion. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). “DC 5257 is unambiguous; by its plain language, it provides compensation [] from impairments of the knee, other than those enumerated elsewhere in the relevant regulations, that cause the symptoms of recurrent subluxation or lateral instability.” Delisle v. McDonald, 789 F.3d 1372 (Fed. Cir. 2015) (explaining that this interpretation is consistent with the language of DC 5257 and the remainder of the relevant regulations, and thus DC 5257 is limited to establishing compensation for disabilities causing symptoms specifically enumerated in that DC). DC 5258 provides for a 20 percent rating for a dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the knee joint. DC 5259 provides for a 10 percent rating for symptomatic residuals of removal of a semilunar cartilage. Ratings under DC 5259 require consideration of 38 C.F.R. §§ 4.40 and 4.45, because removal of a semilunar cartilage may result in complications producing loss of motion. VAOGCPREC 9-98. Under DC 5260, a noncompensable rating is assigned for flexion limited to 60 degrees. A rating of 10 percent requires limitation of flexion to 45 degrees. A rating of 20 percent requires limitation of flexion to 30 degrees, and a rating of 30 percent requires limitation of flexion to 15 degrees. Under DC 5261, extension limited to 5 degrees warrants a noncompensable rating. A rating of 10 percent requires limitation of extension to 10 degrees; 20 percent requires limitation of extension to 15 degrees; 30 percent requires limitation of extension to 20 degrees; 40 percent requires limitation of extension to 30 degrees; and a rating of 50 percent requires limitation of extension to 45 degrees. In this case, and as will be discussed below, the record evidence reflects that the Veteran has not had ankylosis of either knee, instability of either knee, dislocated semilunar cartilage of a knee, removal of semilunar knee cartilage, impairment of the tibia or fibula with malunion or nonunion, or genu recurvatum of either knee. Thus, the diagnostic criteria for evaluating these disabilities are not applicable. See 38 C.F.R. § 4.71a, DCs 5256, 5257, 5258, 5259, 5262, 5263. Shoulder Ratings Following shoulder replacement (prothesis) of the major extremity, a 100 percent rating is warranted for a period of one year. 38 C.F.R. § 4.71a, DC 5051. Thereafter, a 30 percent rating is warranted for intermediate degrees of residual weakness, pain or limitation of motion, rated analogously to DCs 5200 and 5203. A 60 percent rating is warranted for chronic residuals consisting of severe, painful motion or weakness of the affected extremity. DC 5200 provides for a minimum 30 percent rating for ankylosis of the scapulohumeral articulation of the major extremity with ankylosis in a favorable position and abduction to 60 degrees, such that the hand can reach the mouth and head; a 40 percent rating is warranted if ankylosis is in in intermediate position, between favorable and unfavorable; and a maximum 50 percent rating is warranted if ankylosis is in an unfavorable position with abduction limited to 25 degrees from the side. DC 5203 provides that with impairment of the scapula or clavicle, of the major extremity, with malunion a 10 percent rating is warranted; with nonunion without loose movement a 10 percent rating is warranted; with nonunion with loose movement a 20 percent rating is warranted; with dislocation, a 20 percent rating is warranted. Under DC 5201, limitation of motion of the major extremity at the shoulder level warrants a 20 percent rating; with movement limited to midway between the side and shoulder a 30 percent rating is warranted; and with movement limited to 25 degrees from the side a 40 percent rating is warranted. The Board must determine whether the weight of the evidence supports each claim or is in relative equipoise, with the appellant prevailing in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Background Private clinical records show that on June 14, 2006, the Veteran underwent a total right shoulder replacement. Private clinical records show that in 2010 the Veteran had cortisone injections in each knee. A January 2012 record from Fairfax Orthopaedics shows that the Veteran had a history of arthritic right knee pain which was worse on weight-bearing and ambulation. He denied locking or giving way. On examination he had mild right knee swelling but full range of motion. The patella tracked normally. There was a positive patellofemoral compression test and positive medial joint line tenderness. There was negative varus/valgus instability, and negative Lachman’s, Drawer’s, and pivot shift tests as well as negative McMurray’s test. Sensation and motor function of the lower extremity was intact and symmetric with the contralateral side. He was given a cortisone injection in the right knee. An X-ray revealed moderately advanced arthritis. On VA examination on May 30, 2014, the Veteran’s claim file was reviewed. It was noted that he had had a total right hip replacement in December 2005. On examination of his right shoulder he reported having had pain and limited right shoulder motion since military service. There had been no complications from his June 2006 right shoulder replacement. He now had occasional right shoulder pain, aggravated by lifting. He denied taking medication for shoulder pain. He was right handed. He did not report that flare-ups impacted the function of the shoulder and/or arm. On examination right shoulder flexion and abduction (which were normally to 180 degrees) was to 170 degrees, with pain beginning at that point. Even after 3 repetitions of motion, flexion and abduction were to 170 degrees, with no additional limitation in either plane of motion following repetitive-use testing. It was reported that he had functional loss or impairment of the right shoulder due to pain and limited motion. He had localized tenderness or pain on palpation of joints/soft tissue/biceps tendon of right shoulder but no guarding of that shoulder. Strength was normal in right shoulder flexion and abduction, at 5/5. There was no ankylosis of the glenohumeral articulation. All testing for rotator cuff impairment were negative. He had no history of mechanical symptoms, e.g., clicking, catching, or recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joints. There was no acromioclavicular (AC) joint condition or any other impairment of the clavicle or scapula, and no tenderness on palpation of the AC joint. It was reported that his residual symptoms of the right shoulder replacement were limited motion and pain. Imaging studies had previously revealed arthritis. It was reported that his right shoulder condition impacted his ability to work but a work position should allow for light duty regarding use of right upper extremity. Because he did not have a flare-up at the time of the examination, it would be only speculation to report the additional limitation of motion due to pain during a flare-up. On VA examination on May 30, 2014, of the Veteran’s knees his claim file was reviewed. He complained of occasional bilateral knee pain, aggravated by walking or standing more than 30 minutes. In the past he had had physical therapy and steroid injections. He did not report that flare-ups impacted function of the knees. On examination the Veteran had full extension but flexion to 120 degrees in each knee (normal flexion being to 140 degrees), with no additional limitation of motion in either plane after three repetitions of motion. It was reported that he had functional loss or impairment of each knee due to limited and painful motion. He had tenderness or pain to palpation for joint line or soft tissues of each knee but normal strength in flexion and extension of each knee. Testing of ligamentous stability was normal in each knee and he had no history of recurrent patellar subluxation/dislocation or menisceal condition. He did not use an assistive device for ambulation. Imaging studies revealed arthritis but no patellar subluxation. His knee conditions impacted his ability to work but a proper work position should allow for regular breaks from prolonged standing or walking. Because he did not have a flare-up at the time of the examination, it would be only speculation to report the additional limitation of motion due to pain during a flare-up. In an August 2015 statement Dr. Lovallo reported that the based upon a review of records and a July 2015 examination the Veteran’s loss of flexion in each shoulder had increased since his last VA rating examination. In an August 2015 statement Dr. Stinger reported that the Veteran had had a right hip replacement in December 2015. When seen in July 2015 he had left hip and bilateral knee pain. X-rays revealed advanced degenerative arthritis in both knees. Right knee flexion was to 125 degrees and extension was to 8 degrees, with a total arc of motion of 115 degrees. Left knee flexion was to 130 degrees and extension was to 5 degrees, with a total arc of motion of 125 degrees. X-rays revealed a varus positioning of the right knee of 8 degrees and 6 degrees in the left knee. He ambulated with an antalgic gait due ot dysfunction of the left hip and both knees. He had a 2 cms. leg length discrepancy of the right leg due to his right hip replacement. He had joint space narrowing of the right knee of 1 mm. and of 2 mms. in the left knee. On VA examination on March 2, 2018, of the Veteran’s right shoulder his claim file was reviewed. His complaints included difficulty with overhead activities, including donning a shirt, reaching behind his back, etc. Pain impacted the quality of his sleep. He stated he had been told he should have a total left shoulder replacement, however due to other medical conditions (cardiac) he was unable to have this done. His baseline pain was 3/10, with functional impact during his baseline of difficulty with overhead activities and reaching behind his back. He had daily flare-ups, which he rated as 9 – 10/10, for the duration of activity or positioning. The functional impact during flare-ups was difficulty with overhead activities and reaching behind his back. As to activities of daily living, he was able to self dress/bathe/feed and toilet without assistance but stated he had to modify how he donned/doffed pants and shirts due to both knee and shoulder conditions, respectively. Had to have assistance trimming his toenails. As to exercise and sports, he no longer played golf, having stopped about 10 years ago, and he limited his walking. He no longer did any running. He had retired at age 54. On examination right shoulder flexion was to 90 degrees (normal being to 180 degrees), abduction was to 80 degrees (normal being to 180 degress), external rotation was to 60 degrees and internal rotation was normal to 90 degrees with both having a normal range of 90 degrees). He had pain in flexion, abduction, and external rotation but not internal rotation. He could perform repetitive use testing with no additional functional loss or decreased motion. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. There was evidence of pain on passive range of motion testing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue but there was objective evidence of crepitus. The examiner was unable to state whether the Veteran had pain, weakness, fatigability or incoordination which significantly limit functional ability with flare-ups without resorting to speculation because the Veteran was not experiencing a flare at the time of examination. However, the Veteran had normal strength of the right shoulder in flexion and abduction, at 5/5/, and no muscle atrophy. All testing for rotator cuff disability were positive but no shoulder instability, dislocation or labral pathology was suspected. No clavicle, scapula, AC joint or sternoclavicular joint condition was suspected. The diagnostic impression was residuals of a right shoulder replacement with intermediate degrees of residual weakness, pain and/or limitation of motion. It was reported that the right shoulder disorder did not impact the Veteran’s ability to perform any type of occupational task (such as standing, walking, lifting, sitting). On VA examination on March 2, 2018, of the Veteran’s knees his claim file was reviewed. The diagnosis was arthritis of both knees. He complained of constant pain, worse with certain activities including walking, ascending and descending stairs. He described his baseline pain of being 5/10, with being able to stand for no more than 30 minutes and being able to walk for no more than 1/4 mile but he was not limited as to sitting. During flare-ups, his pain was 9/10 daily for the duration of any activity, with the functional impact at such times being that he usually rested during a flare-up. As to activities of daily living, the Veteran was able to self dress/bathe/feed and toilet without assistance but he had to modify how he donned/doffed pants and shirts due to both knee and shoulder conditions, respectively. Had to have assistance trimming his toenails. As to exercise and sports, he no longer played golf, having stopped about 10 years ago, and limited his walking. He no longer did any running. He had retired at age 54. On examination the Veteran had full extension of each knee, but flexion was to only 110 degrees in the right knee and to only 100 degrees in the left knee. He had pain in each knee in flexion and extension, but it did not result in or cause functional loss. He did not have pain with weight bearing in either knee but had crepitus in each knee. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue in the left knee but not the right knee. On three repetitions of motion and after repetitive use testing, the Veteran had full extension in each knee, but flexion was to only 90 degrees in the right knee and to only 80 degrees in the left knee, with pain causing the additional loss of motion. As to each knee, additional contributing factors of disability were disturbance of locomotion and interference with standing. There was no evidence of pain on passive range of motion testing or when the joints were used in non-weight bearing. The examiner was unable to state whether pain, weakness, fatigability or incoordination significantly limited functional ability with flare-ups without speculation because there was no flare-up during the examination. Muscle strength was normal in each knee in flexion and extension and there was no muscle atrophy. There was no history of recurrent subluxation or lateral instability or effusion of either knee. The ligaments of both knees were stable, and he had never had a meniscus condition. He occasionally used a cane as an ambulatory aid. The examiner opined that the Veteran’s knee conditions did not impact his ability to perform any type of occupational task (such as standing, walking, lifting, or sitting. On VA examination of February 18, 2020 of the Veteran’s shoulders his claim file was reviewed. It was reported that he took medication for pain, which was partially effective and without side effects. The pertinent diagnoses were glenohumeral joint arthritis of both shoulders and total right shoulder replacement. He reported having flare-ups about weekly with weather changes and which lasted about a day, during which time he avoided using his shoulders. He related having functional impairment consisting of avoiding overhead motion or lifting. He had to keep his hands lower on a steering wheel when driving, and he avoided any pushing, or pulling with his arms, all due to each of his shoulder disabilities. On examination the Veteran had right shoulder flexion to 90 degrees (normal being to 180), abduction to 100 degrees (normal being to 180), external rotation to 20 degrees (normal being to 90), and internal rotation to 20 degrees (normal being to 90). His limited right shoulder motion contributed to functional loss because he had to avoid overhead reaching or lifting, had to keep his hands lower on a steering wheel, avoid any pushing /pulling with arms. Also, he had pain in all planes of right shoulder motion which caused functional loss. He had generalized tenderness of each shoulder. He was able to perform repetitive use testing with at least three repetitions without any additional functional loss or limitation of motion. On repetitive use testing over time there was also no additional loss of motion but it was reported that pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time. As to flare-ups, the examination was not conducted during a flare-up but it was reported that pain significantly limited functional ability with flare-ups. However, in terms of range of motion, because he was not having a flare-up at the time of the examination, an objective, accurate, measurable estimate of the additional loss of motion or other limitations during a flare could not be derived from the Veteran's inputs or other procurable and assembled data and, so, it was not possible to accurately estimate and report any additional limitation of motion or other limitation due to pain during a flare-up. In addition to the matters addressed above, there were no additional contributing factors of disability. Right shoulder strength was normal at 5/5, in flexion and abduction, and there was no muscle atrophy. All tests of the rotator cuff of the right shoulder were positive; however, there was no shoulder instability, dislocation or labral pathology. There was no clavicle, scapula, AC joint or sternoclavicular joint condition. He did not have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus and did not have malunion of the humerus with moderate or marked deformity. The examiner reported that as to the Veteran’s total right shoulder replacement he had intermediate degrees of residual weakness, pain and/or limitation of motion. His right shoulder disorder impacted his ability to perform occupational tasks because, as stated by the Veteran, he had to avoid overhead reaching or lifting, keep his hands lower on a steering wheel, and avoid any pushing/pulling with arms, all due to each of his shoulders independently limiting these activities; however, this did not preclude limited duty or sedentary employment. On VA examination of February 18, 2020, of the Veteran’s knees his claim file was reviewed. It was noted that he had not had surgery on either knee but took pain medication three times daily which provided partial relief without adverse side effects. The Veteran reported having weekly flare-ups with weather changes which lasted for a day, during which time he had to stay off his feet. He also reported having functional impairment due to avoiding standing or walking more than 30 minutes, as well as kneeling or squatting, which independently limited his activities. On examination the Veteran had full extension of each knee and flexion of each knee to 90 degrees, even with three repetitions of motion and repetitive use over time, with pain throughout these motions. This limitation of motion and pain contributed to functional loss, as described above. He had pain in each knee with weight bearing, bilateral crepitus, and general knee tenderness. He also had daily swelling and effusion of each knee. The examiner reported that because the Veteran was not having a flare-up at the time of the examination and an objective, accurate, measurable estimate of the additional loss of motion or other limitations during a flare could be derived from the Veteran's inputs or other procurable and assembled data and, so, it was not possible to accurately estimate and report any additional limitation of motion or other limitations due to pain during a flare-up. Strength was normal in each knee in flexion and extension, and there was no muscle atrophy. Joint stability tests revealed no recurrent subluxation or instability. He had a meniscus (semilunar cartilage) condition. He regularly used a cane as an ambulatory aid due to disability of both knees, which was partially effective. His disabilities of his knees impacted his ability to perform any type of occupational tasks because he had to avoid standing or walking more than 30 minutes, and kneeling or squatting. Passive ranges of motion and nonweight-bearing ranges of motion and pain were unchanged from active and weight-bearing ranges of motion and on repetitive testing, range of motion values were unchanged from the baseline values reported and no pain, fatigue, weakness or incoordination was noted. 1. Entitlement to a rating in excess of 10 percent for left knee degenerative arthritis The Board concludes that criteria for an initial rating in excess of 10 percent for degenerative arthritis of the left knee with limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. The Veteran’s degenerative arthritis of the left knee has been manifested by painful motion with full extension and no instability or subluxation, meniscectomy residuals, locking, and flexion is limited to no more than 90 degrees. While the Veteran does have left knee pain, it must be observed that the current 10 percent rating is assigned based on painful motion and not based upon the degree of actual limitation of motion. In fact, he has never had any actual limitation of motion which is compensable under Diagnostic Codes 5260 (limitation of flexion) or 5261 (limitation of extension). Specifically, flexion has never been limited to 45 degrees or less and extension has never been limited to 10 degrees or less. Rather, as stated, the current 10 percent rating is assigned based on the adverse impact that the Veteran’s pain causes with respect to left knee motion and functional impairment. While the Veteran is competent to attest to the subjective symptoms which he experiences, he does not have the clinical training, education or expertise to attest that the symptoms he experiences are the type of actual clinical findings which are required under the rating schedule. For example, while he may have stiffness, this is not the same as actual locking of the left knee joint. It must also be noted that the Veteran does not have ankylosis of the left knee and has never had left knee surgery. Thus, compensable ratings are not warranted for ankylosis or cartilage pathology under DCs 5256, 5258, and 5259. Similarly, the evidence does not show that he has any impairment of either the left tibia or the left fibula which would warrant a rating under DC 5262. While he has reported having had swelling, and has more recently been found to have some effusion, he does not have any instability or recurrent subluxation. The Veteran has used a cane as an ambulatory aid. On the other hand, repeated rating examinations have found not actual decrease in strength in either flexion or extension of the left knee and has never needed any bracing of the knee. While he does undoubtedly have some difficulty squatting or with prolonged ambulation, the overall functional impairment is not shown to be of such severity that, even with consideration being given to the favorable resolution of doubt, as to more closely approximate the criteria for the next higher schedular rating of 20 percent which would require limitation of knee flexion to 30 degrees. Rather, while he has limitation of flexion to 90 degrees, this is three times greater than the amount of limited motion required for the next higher rating of 20 percent. Accordingly, in reaching this determination, the Board finds that the preponderance of the evidence is against awarding a rating in excess of 10 percent based on limitation of motion of the left knee. 2. Entitlement to a rating in excess of 10 percent for right knee degenerative arthritis The Board concludes that criteria for an initial rating in excess of 10 percent for degenerative arthritis of the right knee with limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. The Veteran’s degenerative arthritis of the right knee has been manifested by painful motion with full extension and no instability or subluxation, meniscectomy residuals, locking, and flexion is limited to no more than 90 degrees. While the Veteran does have right knee pain, it must be observed that the current 10 percent rating is assigned based on painful motion and not based upon the actual degree of limitation of motion. In fact, he has never had any actual limitation of motion which is compensable under Diagnostic Codes 5260 (limitation of flexion) or 5261 (limitation of extension). Specifically, flexion has never been limited to 45 degrees or less and extension has never been limited to 10 degrees or less. Rather, as stated, the current 10 percent rating is assigned based on the adverse impact that the Veteran’s pain causes with respect to right knee motion and functional impairment. While the Veteran is competent to attest to the subjective symptoms which he experiences, he does not have the clinical training, education or expertise to attest that the symptoms he experiences are the type of actual clinical findings which are required under the rating schedule. For example, while he may have stiffness, this is not the same as actual locking of the right knee joint. It must also be noted that the Veteran does not have ankylosis of the right knee and has never had left knee surgery. Thus, compensable ratings are not warranted for ankylosis or cartilage pathology under DCs 5256, 5258, and 5259. Similarly, the evidence does not show that he has any impairment of either the right tibia or the right fibula which would warrant a rating under DC 5262. While he has reported having had swelling, and has more recently been found to have some effusion, he does not have any instability or recurrent subluxation. The Veteran has used a cane as an ambulatory aid. On the other hand, repeated rating examinations have found not actual decrease in strength in either flexion or extension of the right knee and has never needed any bracing of the knee. While he does undoubtedly have some difficulty squatting or with prolonged ambulation, the overall functional impairment is not shown to be of such severity that, even with consideration being given to the favorable resolution of doubt, as to more closely approximate the criteria for the next higher schedular rating of 20 percent which would require limitation of knee flexion to 30 degrees. Rather, while he has limitation of flexion to 90 degrees, this is three times greater than the amount of limited motion required for the next higher rating of 20 percent. Accordingly, in reaching this determination, the Board finds that the preponderance of the evidence is against awarding a rating in excess of 10 percent based on limitation of motion of the right knee. 3. Entitlement to a rating in excess of 30 percent for right shoulder osteoarthritis, SP right shoulder replacement, prior to March 2, 2018 The Board concludes that the criteria for a rating in excess of 30 percent for right shoulder osteoarthritis, SP right shoulder replacement, prior to March 2, 2018, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5051. Prior to March 2, 2018, the Veteran’s right shoulder disability was manifested by no more than intermediate degrees of residual weakness, pain and/or limitation of motion. The 30 percent rating for SP right shoulder replacement is the minimum rating following a total shoulder replacement of the major extremity, and here the Veteran is right-handed, and encompasses impairment which is less than that for the next higher rating of 60 percent. Thus, for a 60 percent rating there must be chronic residuals consisting of severe, painful motion or weakness. Here, however, prior to March 2, 2018, the Veteran did not have limitation of flexion or abduction of less than 90 degrees, with the normal range of motion in these plans being to 180 degrees. He also did not have any impairment of the scapula consisting of dislocation, malunion or nonunion, under DC 5203. His right shoulder motion was never limited in abduction such as to equate with ankylosis in an unfavorable position with abduction limited to 25 degree, for a 50 percent rating under DC 5200, or intermediate ankylosis which is between favorable and unfavorable (with favorable allowing for abduction to 60 degrees. Additionally, under DC 5201 a 30 percent rating would encompass limitation of motion of the shoulder such that the arm can be raised to no more than midway between the side and shoulder level, i.e., 45 degrees, or 40 percent if motion is limited to 25 degrees from the side. But here, the Veteran has never had limitation of either abduction or flexion to less than 90 degrees, which is to the shoulder level. Significantly, repeated rating examinations have found not actual decrease in strength in the right shoulder. While the Veteran does undoubtedly have some difficulty, and particularly upon attempting to use his right arm in an activity that requires use above shoulder level, the overall functional impairment is not shown to be of such severity that, even with consideration being given to the favorable resolution of doubt, as to more closely approximate the criteria for the next higher schedular rating. In reaching this determination, the Board has considered the doctrine of the favorable resolution of doubt in favor of the Veteran but finds that the preponderance of the evidence is against awarding a rating in excess of 30 percent prior to the March 2, 2018, VA examination. 4. Entitlement to a rating in excess of 60 percent for right shoulder osteoarthritis, SP right shoulder replacement, since March 2, 2018 The Board concludes that the criteria for a rating in excess of 60 percent for right shoulder osteoarthritis, SP right shoulder replacement, since March 2, 2018, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5051. Since March 2, 2018, the Veteran’s right shoulder disability has been manifested by severe painful motion but no flail or false flail joint. As noted above, the March 2, 2018, VA examination found that the Veteran had an intermediate degree of pain and limitation of motion, which by itself would warrant the assignment of a 30 percent disability evaluation. However, effective that date a 60 percent rating was assigned, based upon severe painful motion. This is the highest schedular rating under DC 5051, except for a 100 percent rating which is assigned only for one year following implantation of the total shoulder replacement. Here, however, the Veteran was never assigned a 100 percent rating because he did not file for service connection for right shoulder disability until more than one year after the total right shoulder replacement. No higher rating is assignable than 60 percent under DCs 5200,5201, 5202, 5203, unless there is loss of the humeral head (flail shoulder) for an 80 percent rating under DC 5202. In fact, a 60 percent rating under DC 5202 is warranted for nonunion of the humerus (false flail joint). However, there is no competent evidence of either a flail shoulder or a false flail shoulder. In reaching this determination, the Board has considered the doctrine of the favorable resolution of doubt in favor of the Veteran but finds that the preponderance of the evidence is against awarding a rating in excess of 60 percent since March 2, 2018. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Fussell, 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.