Citation Nr: 21004026 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 11-03 483 DATE: January 25, 2021 ORDER A rating higher than 10 percent for cervical spine degenerative disc disease (DDD) prior to July 29, 2016, and higher than 20 percent thereafter is denied. A rating higher than 20 percent for right shoulder strain prior to July 29, 2016, is denied. A 30 percent rating for right shoulder strain as of July 29, 2016, is granted. A rating higher than 20 percent for left shoulder strain is denied. A rating higher than 10 percent for right knee limitation of flexion is denied. A rating higher than 10 percent for left knee limitation of flexion is denied. FINDINGS OF FACT 1. Prior to July 29, 2016, the Veteran’s cervical spine DDD resulted in limitation of flexion at worst to 45 degrees; no incapacitating episodes were noted. 2. As of July 29, 2016, the Veteran’s cervical spine DDD resulted in limitation of flexion at worst to 20 degrees; no incapacitating episodes were noted. 3. Prior to July 29, 2016, the Veteran’s right shoulder had limitation at worst at shoulder level. 4. As of July 29, 2016, the Veteran’s right shoulder had limitation midway between his side and shoulder level. 5. Throughout the appeal, the Veteran’s left shoulder was not limited to 25 degrees from his side. 6. Throughout the appeal, the Veteran’s right knee had flexion at worst to 110 degrees. 7. Throughout the appeal, the Veteran’s left knee had flexion at worst to 110 degrees. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 10 percent prior to July 29, 2016, and higher than 20 percent thereafter for cervical spine DDD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5243. 2. The criteria for a rating higher than 20 percent for right shoulder strain prior to July 26, 2016, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5201. 3. The criteria for a 30 percent rating for right shoulder strain as of July 26, 2016, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5201. 4. The criteria for a rating higher than 20 percent for left shoulder strain are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5201. 5. The criteria for a rating higher than 10 percent for limitation of flexion of the right knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260. 6. The criteria for a rating higher than 10 percent for limitation of flexion of the left knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1985 to May 1988 and from November 1998 to April 2008. The Veteran testified before the undersigned Veterans’ Law Judge in October 2013. A copy of the transcript is associated with the record. The Board has previously remanded these matters. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 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. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Cervical spine DDD The Veteran’s cervical spine DDD is assigned a 10 percent rating prior to July 29, 2016, and a 20 percent rating thereafter under DC 5243. DC 5243 addresses Intervertebral Disc Syndrome (IVDS) and mandates that the condition is either rated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever merits the higher rating. Pursuant to DC 5243, “incapacitating episodes” are defined as periods of acute signs and symptoms due to IVDS that require bed rest prescribed by a physician and treatment by a physician. DC 5243 Note (1). Under DC 5243, a 20 percent rating is given if the condition has incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is given if the condition has incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating, the highest available rating, is given if the condition has incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. The General Rating Formula for Diseases and Injuries of the Spine provides that, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, unfavorable ankylosis of the entire spine is assigned a 100 percent rating. Unfavorable ankylosis of the entire cervical spine is assigned a 40 percent rating. Forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis is assigned a 20 percent rating. Normal cervical range of motion is from 0 to 45 degrees in all directions (forward flexion, extension, left and right lateral flexion) except for left and right lateral rotation, where it is from 0 to 80 degrees. The combined total thus is 340 degrees. Note (2); Plate V. Note (1) of the General Rating Formula provides that VA should evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate DC. Note (5) indicates that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. When evaluating musculoskeletal disabilities based on limitation of motion, a higher rating must be considered where the evidence demonstrates additional functional loss due to pain, pursuant to 38 C.F.R. §§ 4.40 and 4.45. The diagnostic codes pertaining to range of motion do not subsume sections 4.40 and 4.45, and the rule against pyramiding does not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including use during flare-ups. See DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In determining if a higher rating is warranted on this basis, pain itself does not constitute functional loss. Similarly, painful motion alone does not constitute limited motion for the purposes of rating under diagnostic codes pertaining to limitation of motion. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance, as provided in sections 4.40 and 4.45. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion. See Mitchell, 25 Vet. App. 32. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis).   (a) Prior to July 29, 2016 X-rays of the Veteran’s cervical spine in 2010, 2011, and 2012 showed degenerative changes of the cervical spine. A January 2010 private medical record showed the Veteran’s neck had full and normal range of motion. A March 2010 VA examination reported the Veteran’s cervical spine pain was at the base of his neck without any radiculopathy. He reported his neck pain was moderate and he did not report any incapacitating episodes for the 12 months prior. He denied flare-ups. He reported being able to perform his activities of daily living, including work, operating a motor vehicle, dressing, undressing, and attending his needs of nature. His forward flexion was to 45 degrees with extension to 0 degrees. His lateral flexion/extension was 45 degrees to 0 degrees bilaterally, with a “pop” on right lateral flexion with sharp, momentary pain. His lateral rotation was 0 to 80 degrees bilaterally. He had no evidence of spasm, weakness, tenderness, atrophy, or guarding. No additional limitations were noted with repetitions. A September 2012 private medical record showed the Veteran’s neck had normal and full range of motion with no crepitus. He denied pain, weakness, and numbness. A November 2012 private medical record noted the Veteran’s cervical spine was normal upon examination. A March 2013 VA medical record noted the Veteran’s cervical spine had normal range of motion. Pain was noted, but there were no radicular symptoms. A September 2013 private medical record showed the Veteran reported chronic neck pain. His range of motion in extension and bilateral lateral flexion was limited 25 percent. His cervical flexion and lateral rotation were within normal limits. In October 2013, the Veteran testified that his neck will lock up on him and he would not be able to turn his head and would have to turn his whole body. He stated his pain was in the crook of his neck or in the curvature of his neck. He stated he had popping and cracking in his neck and that his pain was an 8. He stated in bothered his daily activities when he has to look above his head. May and September 2015 private medical records reported the Veteran’s neck had full range of motion and was non-tender. An April 2016 MRI of the Veteran’s cervical spine showed the Veteran had reported worsening pain with numbness and tingling intermittently into his left arm and hand. No significant weakness was noted at that time. C4-5, C5-6, and C6-7 foraminal narrowing was found which was noted to be consistent with the Veteran’s reported radiculopathy. A May 2016 VA medical record showed the Veteran reported neck pain which radiated down into his shoulders. Pursuant to the rating criteria, the Veteran’s eligibility for a rating higher than 10 percent for his cervical spine would necessitate findings of limitation of flexion of 30 degrees or less or incapacitating episodes of more than 2 weeks. Based on the foregoing, the Board does not find that any evidence of record supports either finding. Throughout this period of time, there are no records or statements by the Veteran which indicate that his cervical spine pain limited his functional ability to range of motion limits consistent with flexion limited to 15 to 30 degrees or that he suffered any incapacitating episodes of more than a 2 week duration. There are numerous records throughout this period which indicate that the Veteran had normal range of motion of the cervical spine and that his cervical spine was non-tender. His at worst reported flexion limitation was to 45 degrees. No incapacitating episodes or ankylosis were reported. Neither criterion for higher ratings were met. The Board considered the Veteran’s statements and the doctrines of benefit of the doubt and reasonable doubt. While the Veteran is competent to report his symptoms, whether a disability meets the schedular criteria for the assignment of an evaluation is a factual determination by the Board based on the Veteran’s complaints coupled with the medical evidence. Here, although the Veteran may believe that he meets the criteria for higher ratings, the medical findings show that he does not meet the schedular requirements for such ratings, as explained and discussed above. The Board has concluded that the medical evidence, prepared by skilled professionals, is more probative regarding the Veteran’s degree of disability. Furthermore, there is no doubt or reasonable doubt to resolve to the Veteran’s benefit or in his favor as the evidence of record does not support a higher rating. (b) Beginning July 29, 2016 In July 2016, a VA examination found that the Veteran’s cervical spine caused intermittent, sharp lower neck pain with stiffness. His pain extended into his scapular region. The Veteran denied flare-ups. His pain caused functional loss reported as pain on turning his head, pain disrupting his sleep and limiting his driving visibility; he stated lifting his arms produced pain and pressure at the base of his neck and limited his ability to lift greater than 30 pounds. His at worst range of motion was recorded as: flexion to 30 degrees, extension to 25 degrees, right lateral flexion to 15 degrees, left lateral flexion to 20 degrees, right lateral rotation to 25 degrees, and left lateral rotation to 30 degrees. Pain was noted on examination and caused functional loss found to be an inability to fully rotate his cervical spine without pain and a limitation of visibility while driving. Pain was noted on flexion and right/left lateral rotation. There was evidence of localized tenderness or pain on palpation found at the base of the cervical spine. There was evidence of pain with weight bearing. He had guarding and muscle spasm, but it did not result in abnormal gait or spinal contour. He had no radicular pain or other signs or symptoms due to radiculopathy. There was no ankylosis. In September 2017, a VA examination reported the Veteran stated his neck pain was progressive and was brought on by movements from side to side. He denied flare-ups and functional loss/impairment. Pain was noted upon examination with all ranges of motion. His at worst range of motion was noted to be: forward flexion to 30 degrees, extension to 25 degrees, right and left lateral flexion to 25 degrees, and right and left lateral rotation to 75 degrees after three repetitions. Pain, fatigue, and weakness caused functional loss. There was moderate localized tenderness or pain on palpitation at the C3/C4 area. There was pain with weight bearing. The Veteran did not report signs or symptoms of radiculopathy. There was no ankylosis. The Veteran’s functional impact was noted to be pain when turning side to side or up/down quickly, pain after driving for long periods of time, and carrying weight over 25 pounds. A June 2018 VA medical record showed the Veteran’s cervical spine had normal range of motion and no tenderness. He denied radiation or numbness into his arms. In September 2020, a VA examination of the Veteran’s cervical spine noted the Veteran’s condition had progressed and that the Veteran reported pain and stiffness of his neck. He reported his pain was 7 out of 10. He reported flare-ups of his neck as increased pain when he is at his computer for over 15 minutes which occurred 2-3 times per week. He reported his functional loss as not being able to exercise as he would like. His at worst range of motion was recorded as: flexion to 20 degrees, extension to 30 degrees, right/left lateral flexion to 30 degrees, right lateral rotation to 60 degrees, and left lateral rotation to 65 degrees. His range of motion limitation was found to limit his dexterity and his ability to participate in general physical work. Pain was noted on all ranges of motion and localized tenderness or pain on palpation was located at the mid-line of the neck. He had no loss of function or range of motion after three repetitions. Repetitive use over time and flare-ups caused functional loss due to pain, fatigue, and weakness. The Veteran did not report any signs or symptoms of radiculopathy. He had no ankylosis or other neurological abnormality related to his cervical spine. Pursuant to the rating criteria, the Veteran’s eligibility for a rating higher than 20 percent for his cervical spine would necessitate findings of limitation of flexion of 15 degrees or less or incapacitating episodes of more than 4 weeks. Review of the records, as highlighted above, does not show that the Veteran’s cervical spine disability caused such limitations. His flexion was, at worst, found to be 20 degrees. This measurement took into consideration the Veteran’s limitation during a flare-up. Thus, there is no basis upon which to find that his cervical spine was limited in function to those standards set forth in a 30 percent rating (i.e. flexion to 15 degrees or less). Also, there were no incapacitating episodes reported by the Veteran and no ankylosis was present at any time. The record simply does not contain any evidence, including any statements by the Veteran, which support a conclusion that his functional limitations were commiserate with a 15 degree or more flexion limitation. The basis for a higher rating, then, is not found in the record. The Board has again considered the Veteran’s statements and the doctrines of benefit of the doubt and reasonable doubt. While the Veteran is competent to report his symptoms, whether a disability meets the schedular criteria for the assignment of an evaluation is a factual determination by the Board based on the Veteran’s complaints coupled with the medical evidence. As discussed above, there is no evidence in the record, or identified by the Veteran or his representative, which indicated the Veteran’s limitation met those mandated necessary for higher ratings. There is no doubt or reasonable doubt to resolve to the Veteran’s benefit or in his favor as the evidence of record does not support a higher rating. Shoulders The Veteran’s right and left shoulder are rated under DC 5201 which provides that limitation of motion of the arm at shoulder level warrants 20 percent. Limitation of motion of the arm from midway between the side and shoulder level warrants a 30 percent rating for a major extremity, and 20 percent rating for a minor extremity. Limitation of motion to 25 degrees from the side warrants a 40 percent rating for a major extremity, and 30 percent rating for a minor extremity. 38 C.F.R. § 4.71a The Veteran’s right shoulder is his major extremity. Normal range of motion of the shoulder is flexion and abduction from 0 to 180 degrees, and internal and external rotation each to 90 degrees. 38 C.F.R. § 4.71, Plate I. Abduction is the motion of lifting the arm from the side, with 0 degrees representing the arm at the side and 90 degrees representing the arm at the shoulder level. 38 C.F.R. § 4.71a, Plate I. Diagnostic Code 5201 “does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm.” Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). Right Shoulder The Veteran’s right shoulder is assigned a 20 percent rating, excepting for the period of time after surgery from October 18, 2018, to February 1, 2019, in which he was assigned a 100 percent rating for convalescence. As this period provides the Veteran the maximum percentage allowed, it is not on appeal to the Board. In a September 2012 private medical record, the Veteran denied shoulder pain, weakness, and numbness. A March 2013 private physical therapy report showed the Veteran’s range of motion to be: flexion at worst to 160 degrees, abduction at worst to 160 degrees, external rotation to 80 degrees, and internal rotation 30 degrees. A September 2013 private medical record showed the Veteran’s right shoulder range of motion was within normal limits in active and passive range of motion, including flexion, extension, abduction, internal rotation, and external rotation. The Veteran’s October 2013 hearing testimony reported that the Veteran’s shoulder pain occurred when he reached over his head to reach something. He reported pain when he put up a ceiling fan in his home. A May 2016 VA medical record showed the Veteran reported shoulder pain. Upon examination, his right shoulder was noted to be normal. There was no swelling, erythema, warmth, or misalignment. Motion was normal and there was no pain elicited upon examination. No instability was noted. A July 2016 VA examination showed the Veteran’s right shoulder had symptoms of constant dull pain in his shoulder joints, pain with weight bearing, pain with raising his arms above his shoulders, and pain that disrupts his sleep. The Veteran denied flare-ups. He stated his functional loss was inability to lift his arms above level of his shoulders, inability to reach objects overhead, pain with weightbearing, pain with driving greater than 30 minutes, pain that disrupts sleep, and inability to lie on his right shoulder. The Veteran’s range of motion was noted to be: flexion at worst to 90 degrees, abduction at worst to 80 degrees, external rotation to 30 degrees, and internal rotation 20 degrees. The Veteran’s range of motion caused him to be unable to lift his arms above shoulder level to reach objects and have limited weight bearing. Pain was noted with all ranges of motion and there was pain at the superior AC joint with a severity of 6 out of 10. There was objective evidence of pain with weightbearing, but no objective evidence of crepitus. There was no ankylosis. No clavicle, scapula, AC joint or sternoclavicular joint condition was suspected. There was no condition of the humerus noted. A November 2017 X-ray of the right shoulder showed no fractures or dislocations; it was determined to be within normal limits for age. A March 2018 X-ray showed the Veteran had arthritic changes of his AC joint. There was no evidence of fracture of dislocation. In April 2018, the Veteran reported some pain in a neutral position and increased pain in all planes of motion. Upon examination, his right shoulder had active flexion to 115 degrees, active abduction to 90 degrees, active external rotation to 75 degrees, and active internal rotation to 35 degrees. He was diagnosed with shoulder impingement syndrome and had a steroid injection of his right shoulder. In June 2018, a VA medical record recorded the Veteran’s right shoulder range of motion as: flexion to 180 degrees, abduction to 180 degrees, extension to 45 degrees, external rotation with arm at side to 40 degrees, and external/internal rotation with arm abducted to 90 degrees. In October 2018, the Veteran underwent surgery on his right shoulder. In December 2018, a VA examination of the Veteran’s right shoulder showed the Veteran reported flare-ups and functional loss of his right shoulder. He stated that his flare-up could be stated as stiffness and pain. His range of motion, at worst, was flexion to 90 degrees, abduction to 90 degrees, external rotation to 45 degrees, and internal rotation to 45 degrees after repeated use over time. He had pain on all ranges of motion and pain was found to contribute to functional loss. There was no objective evidence of tenderness or pain on palpation, pain with weight bearing, or objective evidence of crepitus. The Veteran reported less movement than normal due to pain, stiffness, limited range of motion, and difficulty with heavy lifting. No ankylosis or instability was present. No clavicle, scapula, AC joint or sternoclavicular joint condition was suspected. There was no condition of the humerus noted. A September 2020 VA examination showed the Veteran reported flare-ups of right shoulder pain while working overhead which could happen 1-2 times per week. He reported functional loss as not being able to play softball anymore. His at worst range of motion was reported as: flexion to 140 degrees, abduction to 135 degrees, external/internal rotation to 80 degrees. His limited flexion and abduction of his shoulder limited his ability to participate in activities that require repetitive use of his shoulder for general physical work. Pain was noted on flexion and abduction. There was moderate pain noted of the anterior shoulder. There was no pain with weight bearing or objective evidence of crepitus. Pain and weakness contributed to his functional loss. No ankylosis was present. No clavicle, scapula, AC joint or sternoclavicular joint condition was suspected. There was no condition of the humerus noted. In order for the Veteran to merit a rating higher than 20 percent, his right shoulder must show limitation of motion of the arm from midway between the side and shoulder level or limitation of motion to 25 degrees from the side. After review of the records, highlighted above, the Board does not find that the evidence of record prior to July 29, 2016, VA examination supports a rating higher than 20 percent for the Veteran’s right shoulder disability. The Veteran’s documented range of motion prior to the July 2016 VA examination showed that he had range of motion above his shoulder. Indeed, his range of motion was noted to normal on more than one clinic visit. However, as of his July 29, 2016, VA examination, the Veteran’s right shoulder documented movement restricted at shoulder level, which warrants a 30 percent rating under DC 5201. It is clear from the Veteran’s VA examination findings that his functional ability during flare-ups and after repeated motion prevented him from lifting his right arm above shoulder level. His examination findings do not show, however, that his shoulder was restricted to 25 degrees from his side. As such, a rating higher than 30 percent is not supported by the record. The Board notes that the Veteran and his representative have not identified or introduced any medical record in evidence which shows that the Veteran’s range of motion was restricted to the criteria set forth by a rating higher than 20 percent. The Board has again considered the Veteran’s statements and the doctrines of benefit of the doubt and reasonable doubt. As discussed above, there is no evidence in the record, or identified by the Veteran or his representative, which indicated the Veteran’s limitation met those mandated necessary for higher ratings. There is no doubt or reasonable doubt to resolve to the Veteran’s benefit or in his favor as the evidence of record does not support a higher rating. Increased evaluations under other potentially applicable diagnostic codes have been considered. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The evidence of record does not show that the Veteran has other such impairments that additional ratings pursuant to DCs 5208-5213 are warranted. 38 C.F.R. §§ 4.7, 4.71a. Left Shoulder A March 2010 VA examination reported that the Veteran’s had no acute pain in his shoulders at rest. He had no signs of heat, redness, swelling, or tenderness. He did not report flare-ups. He had flexion to 180 degrees, abduction to 180 degrees, internal and external rotation to 90 degrees. There was no evidence of pain at rest or during motion. In a September 2012 private medical record, the Veteran denied shoulder pain, weakness, and numbness. A November 2012 VA medical record showed the Veteran had pain in his left shoulder and decreased range of motion for the past month and a half. His strength was noted to be 4 out of 5 (good) and an X-ray of the left shoulder was unremarkable. His functional limitation was noted to be discomfort during activities of daily living. His range of motion was found to be flexion to 130 degrees, abduction to 140 degrees, extension to 80 degrees, external rotation to 65 degrees, and internal rotation to 75 degrees. He was given a list of shoulder range of motion and strengthening exercises. November 2012 private medical records show the Veteran complained of left shoulder pain. He had no redness, swelling, ecchymosis, or tenderness. His range of motion was internal rotation to 90 degrees, external rotation to 70 degrees, forward flexion to 150 degrees, abduction to 90 degrees, and extension to 90 degrees. Abduction and forward flexion with internal rotation failed to cause pain. Stress testing failed to cause pain or weakness. He was diagnosed with impingement syndrome and rotator cuff tendonitis and was given a steroid injection. A December 2012 VA medical record reported the Veteran’s range of motion to be flexion to 135 degrees, abduction to 95 degrees, extension to 75 degrees, external rotation to 65 degrees, and internal rotation to 30 degrees. He reported his pain as 7 out of 10. January 2013 private medical records show the Veteran complained of left shoulder pain. He had no redness, swelling, or ecchymosis. He had tenderness at the scapular boarder. His range of motion was, at worst, internal rotation to 80 degrees, external rotation to 70 degrees, forward flexion to 145 degrees, abduction to 90 degrees, and extension to 90 degrees. Abduction and forward flexion with internal rotation failed to cause pain. Stress testing failed to cause pain or weakness. He was diagnosed with impingement syndrome and rotator cuff tendonitis and was given a steroid injection. A March 2013 VA medical records showed the Veteran treated for left shoulder pain. There was no obvious edema, ecchymosis, or joint effusion. His range of motion was noted to be full with very minimally increased pain at the extremes. Impingement signs were negative. He had no increased pain in the in the AC joint area, but limited ability to reach to the other scapula. March 2013 private physical therapy records showed the Veteran had compliant of left shoulder pain. His ranges of motion were noted as: flexion, at worst, to 145 degrees, abduction at worst to 130 degrees, external rotation to 70 degrees, and internal rotation to 60 degrees. A September 2013 private medical record showed the Veteran’s right shoulder range of motion was within normal limits in active and passive range of motion, including flexion, extension, abduction, internal rotation, and external rotation. An April 2016 X-ray of the Veteran’s left shoulder showed mild degenerative changes in his AC joint. The Veteran’s October 2013 hearing testimony reported that the Veteran’s shoulder pain occurred when he reached over his head to reach something. He reported pain when he put up a ceiling fan in his home. A May 2016 VA medical record showed the Veteran reported shoulder pain. Upon examination, he had tenderness on palpation and pain on motion. Motion was normal. He did not have swelling, warmth, edema, or misalignment. No instability was noted. At a July 2016 VA examination the Veteran had symptoms of constant dull pain in his shoulder joints, pain with weight bearing, pain with raising his arms above his shoulders, and pain that disrupts his sleep. The Veteran denied flare-ups. He stated his functional loss was inability to lift his arms above level of his shoulders, inability to reach objects overhead, pain with weightbearing, pain with driving greater than 30 minutes, pain that disrupts sleep, and inability to lie on his left side for more than an hour. His range of motion was noted to be: flexion at worst to 95 degrees, abduction at worst to 90 degrees, external rotation to 30 degrees, and internal rotation 30 degrees. The Veteran’s range of motion caused him to be unable to lift his arms above shoulder level to reach objects and have limited weight bearing. Pain was noted with all ranges of motion and there was pain at the superior AC joint with a severity of 6 out of 10. There was objective evidence of pain with weightbearing, but no objective evidence of crepitus. There was objective evidence of pain with weightbearing, but no objective evidence of crepitus. There was no ankylosis. No clavicle, scapula, AC joint or sternoclavicular joint condition was suspected. There was no condition of the humerus noted. In a December 2018 VA examination, the Veteran denied flare-ups of his left shoulder. His range of motion, at worst, was flexion to 180 degrees, abduction to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. No pain was noted upon examination. There was no objective evidence of crepitus. No ankylosis or instability was present. No clavicle, scapula, AC joint or sternoclavicular joint condition was suspected. There was no condition of the humerus noted. A September 2020 VA examination reported the Veteran’s at worst range of motion as: flexion to 160 degrees, abduction to 170 degrees, external/internal rotation to 90 degrees. His limited flexion and abduction of his shoulder limited his ability to participate in activities that require repetitive use of his shoulder for general physical work. Pain was noted on flexion and abduction. There was mild pain noted of the anterior shoulder. There was no pain with weight bearing or objective evidence of crepitus. No ankylosis was present. No clavicle, scapula, AC joint or sternoclavicular joint condition was suspected. There was no condition of the humerus noted. As the Veteran’s left arm is his minor arm, a rating higher than 20 percent is only available under DC 5201 if the Veteran’s arm was restricted to limitation of motion to 25 degrees from the side. The evidence of record does not show that such a limitation of motion was present at any time. The Board notes that the Veteran’s left shoulder has restricted motion above his shoulder level. However, the rating for that level of disability is 20 percent – his current rating. There is no indication the Veteran was restricted from moving his left arm more than 25 degrees from his side. Simply put, there is no evidence of record which supports a rating higher than 20 percent for the Veteran’s left shoulder disability and the Board notes that the Veteran and his representative have not identified or introduced any medical record in evidence which shows that the Veteran’s range of motion was restricted to the criteria set forth by a rating higher than 20 percent. The Board has again considered the Veteran’s statements and the doctrines of benefit of the doubt and reasonable doubt. As discussed above, there is no evidence in the record, or identified by the Veteran or his representative, which indicated the Veteran’s limitation met those mandated necessary for higher ratings. There is no doubt or reasonable doubt to resolve to the Veteran’s benefit or in his favor as the evidence of record does not support a higher rating. Separate evaluations under other potentially applicable diagnostic codes have been considered. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The evidence of record does not show that the Veteran has other such impairments that additional ratings pursuant to DCs 5208-5213 are warranted. 38 C.F.R. §§ 4.7, 4.71a. Knees The Veteran’s right and left knee are assigned 10 percent ratings under DC 5260 which provides for a 10 percent with flexion limited to 45 degrees; a 20 percent rating with flexion limited to 30 degrees; and the highest available 30 percent rating with flexion limited to 15 degrees. Normal extension of the knee is to 0 degrees and normal flexion of the knee is to 140 degrees. 38 C.F.R. § 4.71a, Plate II. Right Knee In a March 2010 VA examination, the Veteran reported pain in his right knee began in 2001 and that he had surgery in 2006. He reported aching and stiffness with pain with squatting. He had no signs of heat, redness, swelling, or tenderness. He did not report flare-ups. He reported he was able to perform his activities of daily living without assistance. His range of motion was flexion to 140 degrees, extension to 0 degrees. There was no evidence of pain at rest or during motion. He was found to have mild crepitus of his knee throughout his range of motion or with squatting. His stability was intact. There was no ankylosis. There were no additional limitations after repetitive movement. The Veteran’s limitations were caused by pain, fatigue, weakness, lack of endurance, and incoordination. A November 2011 private medical record showed the Veteran had right knee pain and he reported the knee giving way. The Veteran’s right knee stress test was normal. A December 2011 private medical record showed the Veteran reported his pain as 5 out of 10. He reported aching, weakness, popping, soreness, giving way and instability. Upon examination of his right knee, no weakness was present. He had tenderness present at the lateral and medial joint line. He had full range of motion and no swelling or ecchymosis. Pain or crepitus on patella femoral compression was absent. His ligament was stable in flexion and extension. Testing did not produce pain. A January 2012 private medical record showed the Veteran had full range of motion of the right knee with no swelling, ecchymosis, or weakness. Tenderness was present at the lateral and medial joint line. Pain upon testing was not noted. The Veteran’s October 2013 hearing testimony indicated that it was hard to bend down or squat. He stated he had knee braces. He reported that prolonged sitting or standing caused an increase in pain. He stated he had a period of swelling of his knees and that his knees popped. A May 2016 VA medical record recorded the Veteran’s complaints of right knee pain. A November 2016 VA medical record showed the Veteran to have had a right knee steroid injection in October 2016. A July 2019 VA examination showed the Veteran reported his symptoms as constant dull achy right knee pain with limited mobility. He denied flare-ups. He stated that he was unable to squat or lunge, unable to climb stairs without pain, was unable to walk a mile before pain and was unable to run or jump. His at worst range of motion was flexion to 110 degrees and extension to 0 degrees. He was unable to perform full flexion for climbing stairs or squatting. Pain was noted on examination in flexion and throughout the entire patella complex with a severity of 8 out of 10. There was evidence of pain with weight bearing. There was no additional functional loss with repetitive use testing. The examiner noted that he was unable to speculate about additional loss of range of motion with repeated use over time or during a flare-up. There was no ankylosis, joint instability, or recurrent effusion. A September 2020 VA examination of the Veteran’s knee showed that he reported flare-ups if standing over 15-20 minutes, which caused increased pain and numbness to his knees. He stated he could not play softball anymore, could not exercise as he would like, which included hiking and walking his dogs. He also reported he could not be active with his daughter such as walking or running with her. His examination showed range of motion, at worst, as: flexion to 120 degrees and extension to 0 degrees. His limited flexion limited the ability to squat or climb stairs for general physical work. He had no evidence of crepitus or pain with weight bearing. He had pain on flexion and moderate localized tenderness or pain on palpitation of the lateral joint line. Pain and weakness limited his functional ability with repeated use over time and flare-ups. He was also found to have disturbance of locomotion and interference with standing. He did not have ankylosis or joint instability. A rating higher than 10 percent is only available to the Veteran if his right knee shows limitation of flexion to 30 degrees or less. There are no records which indicate or show that the Veteran’s right knee impairment reached such a limitation. His at worst range of motion throughout the appeal period was flexion to 110 degrees. See July 2016 VA examination. Even factoring in the Veteran’s pain and functional limitations, the evidence does not support finding that an additional 80 plus degree limitation was manifested by his pain or functional loss. At no point was flexion in his right knee measured at less than 110 degrees. Therefore, a higher rating under DC 5260 for limitation of motion of his right knee is not warranted. Neither the Veteran nor his representative have identified or introduced any evidence which supports a finding that the Veteran’s knee limitation was commiserate with a limitation of flexion to 30 degrees or more. The Board has again considered the Veteran’s statements and the doctrines of benefit of the doubt and reasonable doubt. As discussed above, there is no evidence in the record, or identified by the Veteran or his representative, which indicated the Veteran’s limitation met those mandated necessary for higher ratings. There is no doubt or reasonable doubt to resolve to the Veteran’s benefit or in his favor as the evidence of record does not support a higher rating. Separate evaluations under other potentially applicable diagnostic codes have been considered. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The evidence of record does not show that the Veteran has other such impairments that additional ratings pursuant to DCs 5256-5259 and 5261-5263 are warranted. Left Knee In a March 2010 VA examination, the Veteran reported aching and stiffness with pain with squatting. He had no signs of heat, redness, swelling, or tenderness. He did not report flare-ups. He reported he was able to perform his activities of daily living without assistance. His range of motion was flexion to 140 degrees, extension to 0 degrees. There was no evidence of pain at rest or during motion. He was found to have mild crepitus of his knee throughout his range of motion or with squatting. His stability was intact. There was no ankylosis. There were no additional limitations after repetitive movement. The Veteran’s limitations were caused by pain, fatigue, weakness, lack of endurance, and incoordination. The Veteran’s October 2013 hearing testimony indicated that it was hard to bend down or squat. He stated he had knee braces. He reported that prolonged sitting or standing caused an increase in pain. He stated he had a period of swelling of his knees and that his knees popped. March 2015 VA medical records show that the Veteran had pain and swelling in his left knee. His pain was aching and an 8 out of 10. April 2015 VA medical records show the Veteran had left knee pain and had a steroid injection. April 2016 VA medical records show the Veteran reported left knee swelling and pain. An August 2016 VA medical record showed the Veteran had a steroid injection of his left knee. A March 2016 VA medical record showed the Veteran underwent a steroid injection of his left knee. He reported pain after bicycling, squatting, and walking. In a July 2016 VA examination the Veteran reported his symptoms as constant sharp left knee pain with swelling and fluid. His at worst range of motion was flexion to 110 degrees and extension to 0 degrees. He was unable to perform full flexion for climbing stairs or squatting. Pain was noted on examination in flexion and throughout the entire patella complex with a severity of 8 out of 10. There was evidence of pain with weight bearing. There was no additional functional loss with repetitive use testing or repeated use over time. The examiner noted that he was unable to speculate about additional loss of range of motion. A September 2020 VA examination of the Veteran’s knee showed that he reported flare-ups if standing over 15-20 minutes, which caused increased pain and numbness to his knees. He stated he could not play softball anymore, could not exercise as he would like, which included hiking and walking his dogs. He also reported he could not be active with his daughter such as walking or running with her. His range of motion, at worst, was recorded as: flexion to 120 degrees and extension to 0 degrees. His limited flexion limited the ability to squat or climb stairs for general physical work. He had no evidence of crepitus or pain with weight bearing. He had pain on flexion and moderate localized tenderness or pain on palpitation of the lateral joint line. Pain and weakness limited his functional ability with repeated use over time and flare-ups. He was also found to have disturbance of locomotion and interference with standing. He did not have ankylosis. He did not have ankylosis or joint instability. As with his right knee, a rating higher than 10 percent is only available to the Veteran if his left knee shows limitation of flexion to 30 degrees or less. Again, there are no records which indicate or show that the Veteran’s right knee impairment reached such a limitation. His at worst range of motion throughout the appeal period was flexion to 110 degrees. See July 2016 VA examination. Again, at no point was flexion in his left knee measured at less than 110 degrees. Therefore, a higher rating under DC 5260 for limitation of motion of his left knee is not warranted. Neither the Veteran nor his representative have identified or introduced any evidence which supports a finding that the Veteran’s knee limitation was commiserate with a limitation of flexion to 30 degrees or more. The Board has again considered the Veteran’s statements and the doctrines of benefit of the doubt and reasonable doubt. As discussed above, there is no evidence in the record, or identified by the Veteran or his representative, which indicated the Veteran’s limitation met those mandated necessary for higher ratings. There is no doubt or reasonable doubt to resolve to the Veteran’s benefit or in his favor as the evidence of record does not support a higher rating. Separate evaluations under other potentially applicable diagnostic codes have been considered. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The evidence of record does not show that the Veteran has other such impairments that additional ratings pursuant to DCs 5256-5259 and 5261-5263 are warranted. JOHN Z. JONES Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Parrish, 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.