Citation Nr: 21061503 Decision Date: 10/04/21 Archive Date: 10/04/21 DOCKET NO. 15-09 668 DATE: October 4, 2021 ORDER An initial rating in excess of 10 percent prior to August 10, 2018, in excess of 20 percent prior to March 19, 2021, and in excess of 40 percent for lumbar spine degenerative arthritis, degenerative joint disease with spondylolisthesis and thoracic spine strain (hereinafter, back disability) is denied. An initial rating in excess of 10 percent for right knee strain is denied. An initial rating in excess of 10 percent for left knee strain is denied. The separate rating for left knee instability associated with left knee strain, evaluated as 10 percent disabling as of March 19, 2021, is proper; the appeal is denied. An initial rating in excess of 20 percent for left shoulder degenerative joint disease and rotator cuff tendinopathy (hereinafter, left shoulder disability) is denied. FINDINGS OF FACT 1. Prior to August 10, 2018, the Veteran's back disability was manifested by forward flexion limited to, at most, 80 degrees and a total combined range of motion of the thoracolumbar spine limited to, at most, 210 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without muscle spasm or guarding resulting in abnormal gait or abnormal spinal contour, ankylosis, or intervertebral disc syndrome (IVDS) with incapacitating episodes having a total duration of at least two weeks but less than four weeks. 2. From August 10, 2018, to March 19, 2021, the Veteran's back disability was manifested by forward flexion limited to, at most, 40 degrees, without favorable ankylosis of the entire thoracolumbar spine, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without IVDS with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past twelve months. 3. As of March 19, 2021, the Veteran's back disability is not manifested by unfavorable ankylosis of the entire thoracolumbar spine or the entire spine, without IVDS with incapacitating episodes having a total duration of at least six weeks during the past twelve months. 4. For the entire appeal period, the Veteran's right knee strain was manifested by flexion limited to, at most, 75 degrees and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis, lateral instability, recurrent subluxation, dislocation or removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. 5. For the entire appeal period, the Veteran's left knee strain was manifested by flexion limited to, at most, 65 degrees and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis, dislocation or removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. 6. Prior to March 19, 2021, the Veteran's left knee strain did not result in recurrent subluxation or lateral instability and, as of such date, resulted in no more than recurrent patellar instability without the need for surgical repair or a prescribed assistive device. 7. The Veteran is right hand dominant. 8. For the entire appeal period, the Veteran's left shoulder disability is manifested by symptoms of pain with arm motion limited to, at most, midway between the arm and shoulder level, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without malunion of the humerus, recurrent dislocation of the humerus at the scapulohumeral joint, or ankylosis of the scapulohumeral articulation. CONCLUSIONS OF LAW 1. The criteria for initial ratings in excess of 10 percent prior to August 10, 2018, in excess of 20 percent from August 10, 2018, to March 19, 2021, and in excess of 40 percent thereafter for back disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5237, 5242. 2. The criteria for an initial rating in excess of 10 percent for right knee strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 3. The criteria for an initial rating in excess of 10 percent for left knee strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 4. The separate rating for left knee instability associated with left knee strain, evaluated as 10 percent disabling as of March 19, 2021, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 5. The criteria for an initial rating in excess of 20 percent for left shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5201. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the Air Force from February 1969 to October 1976 and March 1984 to February 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in January 2013 by a Department of Veterans Affairs (VA) Regional Office, which granted service connection for the Veteran's left knee disability, right knee disability, back disability, and left shoulder disability. The Veteran timely filed an appeal of this decision. A rating decision issued in September 2018 awarded an increased evaluation of 20 percent for the Veteran's left shoulder disability effective November 18, 2011, and an increased evaluation of 20 percent for the Veteran's back disability effective August 10, 2018. In May 2020, the Board remanded the issues for further development. An April 2021 rating decision increased the rating assigned for the Veteran's back disability to 40 percent effective March 19, 2021, and awarded a separate 10 percent rating for left knee instability effective March 19, 2021. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71A were amended effective February 7, 2021. 83 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021, applying the criteria that is more favorable to the Veteran. 1. Back Disability The Veteran contends that he is entitled to higher ratings for his back disability due to decreased range of motion and recurring muscle spasms. See Veteran Correspondence dated March 16, 2015. The Veteran's back disability is currently rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5242-5237. Hyphenated DCs are used when a rating under one code requires use of an additional DC to identify the basis for the rating. 38 C.F.R. § 4.27. Here, the hyphenated DC indicates that the Veteran's back disability is currently rated, by analogy, under DC 5237 for a lumbosacral or cervical strain. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 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. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. Unfavorable ankylosis is defined as "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." Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is "always" considered favorable ankylosis. Id. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The Formula for Rating IVDS Based on Incapacitating Episodes provides that a 10 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted for IVDS with 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 warranted for IVDS with 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 is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. Note 1 to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note 1. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, the assignments of ratings under these Diagnostic Codes were not changed. However, under the revised regulation effective February 2021, Diagnostic Code 5243 applies to IVDS when there is disc herniation with compression and/or irritation of the adjacent nerve root. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Prior to August 10, 2018 Prior to August 10, 2018, the Veteran was assigned an initial rating of 10 percent for his back disability. At this time, he was rated under DC 5243 for IVDS. Diagnostic Code 5243 provides that IVDS is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. In September 2012, the Veteran was afforded a VA examination where he was diagnosed with bilateral pars interarticularis defect at L5-S1 with spondylolisthesis and degenerative disk disease (DDD). The Veteran reported that since service, pain and stiffness in his lower back has progressively worsened. He reported that he did not have flare-ups. On examination, the Veteran demonstrated forward flexion to 80 degrees with pain and extension to 10 degrees with pain. Repetitive use testing was performed with no additional loss of range of motion (ROM). The examiner noted tenderness to palpation of the lower lumbar spine/lumbosacral junction. No guarding or muscle spasms were found. Muscle strength testing showed full strength of 5/5 and no muscle atrophy was observed. The examiner indicated a diagnosis of intervertebral disc syndrome (IVDS) with no incapacitating episodes. VA treatment records from this time do not indicate more severe symptoms than those exhibited at the September 2012 VA examination. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the Veteran's back disability. While the September 2012 examiner indicated a diagnosis of IVDS, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. The preponderance of the evidence is also against a rating in excess of 10 percent for the Veteran's back disability under the General Rating Criteria. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, stiffness, and decreased range of motion. The Veteran did not report having flare-ups and did not exhibit any additional range of motion limitation after repetitive use. As a result, there is insufficient evidence to show that the Veteran had limitation of motion more nearly approximating forward flexion greater than 30 degrees but not greater than 60 degrees or the combined range of motion of the thoracolumbar spine not greater than 120 degrees. Additionally, the Veteran did not have muscle spasm or guarding to warrant an increased rating due to these conditions prior to August 10, 2018. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for an initial rating in excess of 10 percent for his back disability prior to August 10, 2018. From August 10, 2018, to March 19, 2021 For the period from August 10, 2018, to March 19, 2021, the Veteran's back disability is rated as 20 percent disabling pursuant to Diagnostic Code 5237. The Veteran was afforded another VA examination in August 2018 where he was diagnosed with degenerative arthritis of the spine, spondylolisthesis, bilateral pars interarticularis defect at L5-S1 with spondylolisthesis and DDD. The Veteran did not report any flare-ups. On examination, the Veteran demonstrated forward flexion to 40 degrees and extension to 20 degrees. No radiculopathy, ankylosis, other neurological abnormalities, IVDS, or muscle atrophy were noted. The Veteran reported using a cane regularly due to hip pain. Based on the above, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for a back disability for the period from August 10, 2018, to March 19, 2021. Here, the evidence of record does not show that pain or other symptoms functionally limited forward flexion of the lumbar spine to 30 degrees or less, as required for a 40 percent rating. In particular, the August 2018 examination showed forward flexion to 40 degrees. As such, a higher rating for this period based on additional functional loss under 38 C.F.R. §§ 4.40 and 4.45 is not warranted. Consideration has also been given to assigning a rating under the Formula for Rating IVDS. The September 2012 VA examination is the only indication that the Veteran had a diagnosis of IVDS, and the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician (a foundational requirement for an IVDS rating) for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. As such, a rating in excess of 20 percent for IVDS is not appropriate for the period from August 10, 2018, to March 19, 2021. As of March 19, 2021 As of March 19, 2021, the Veteran's back disability is currently rated as 40 percent disabling. A March 2021 VA examination diagnosed the Veteran with lumbar spine degenerative arthritis, degenerative joint disease with spondylolisthesis, thoracic spine strain and bilateral lumbar lower extremity radiculopathy. The Veteran reported symptoms of constant aching mostly in his low back and in the middle and down both hips. He reported that the pain is worse in the morning when he wakes up, causing his walk to be very unstable. The Veteran indicated that he has fallen a few times as a result of this weakness. The Veteran reported severe, daily flare-ups resulting in increased pain in his lower back which are alleviated by rest. These flare-ups are precipitated by laying down, walking any distance, and standing any length of time. On examination, the Veteran demonstrated forward flexion to 30 degrees and extension to 0 degrees with pain. Pain was evident during weight-bearing, non-weight-bearing, active and passive motion and on rest/non movement causing functional loss. The Veteran was unable to perform repetitive use testing due to pain after initial ROM testing. The examiner estimated that after repetitive use testing and during flare-ups, the Veteran would demonstrate forward flexion to 25 degrees and extension to 0 degrees. The Veteran showed localized tenderness of the thoracic and lumbar spine and bilateral musculature which did not result in abnormal gait or abnormal spinal contour. Muscle strength testing showed abnormal strength findings (4/5) in all categories, indicative of active movement against some resistance. The Veteran had mild paresthesias and/or dysesthesias and mild numbness in the right and left lower extremities. The Veteran did not have muscle atrophy, ankylosis, other neurological abnormalities, or IVDS. The Veteran reported constant use of a cane. Based on this evidence, the Board finds the current assignment of a 40 percent rating, but no higher, is appropriate in this case as the March 2021 VA examination reflects the estimation of flexion limited to 25 degrees after repeated use over time and during flare-ups. However, a higher rating is not warranted as the evidence does not demonstrate unfavorable ankylosis of the entire thoracolumbar spine or the entire spine or functional impairment equivalent thereof. Here, the medical evidence specifically indicates that the Veteran does not have ankylosis in his thoracolumbar spine. Consideration has also been given to assigning a rating under the Formula for Rating IVDS. However, during this period, the evidence does not show that the Veteran has IVDS, and the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. Other Considerations Regarding neurological impairment, the Veteran has already been granted service connection for bilateral upper and lower extremity radiculopathy for the entire appeal period, the Veteran has not yet appealed the disability ratings assigned for such, and the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. 2. Right Knee Strain 3. Left Knee Strain The Veteran contends that he is entitled to higher ratings for his service-connected knee disabilities because of increased pain. The Veteran also indicated that he felt that his disabilities were not rated properly as a result of the VA examiner forcing his knees to produce flexion and that the actual severity of his condition thus was not considered. See Veteran Correspondence dated March 16, 2015. For the entire appeal period, the Veteran's right and left knee strains are each currently rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5260, which pertains to limitation of flexion. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Diagnostic Code 5261 provides for a zero percent rating where extension of the leg is limited to five degrees. A 10 percent rating requires extension limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent rating, extension must be limited to 30 degrees. Finally, where extension is limited to 45 degrees a 50 percent rating may be assigned. VA's General Counsel has also stated that separate ratings under Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 (2004). As noted above, VA amended the rating criteria for evaluating the musculoskeletal disabilities under 38 C.F.R. § 4.71A, effective February 7, 2021. See 85 Fed. Reg. 230 (Nov. 30, 2020). However, DCs 5260 and 5261 were not changed by the new regulations. Normal ROM of the knee is to zero (0) degrees (full extension ROM) to 140 degrees (full flexion ROM). 38 C.F.R. § 4.71a, Plate II. In September 2012, the Veteran was afforded a VA examination where he was diagnosed with bilateral knee strains. The Veteran reported worse pain in his right knee that occurs daily when he walks. The Veteran indicated that his left knee locks on him once every two weeks. No flare-ups were reported. On examination, the Veteran demonstrated right knee flexion to 140 degrees or greater and extension to 0 degrees with no evidence of painful motion. The Veteran demonstrated left knee flexion to 140 degrees or greater and extension to 0 degrees with no evidence of painful motion. The Veteran was able to perform repetitive-use testing and there was no additional loss of range of motion for either knee. Muscle strength testing showed full strength of 5/5 and joint stability testing showed no instability in either knee. The examiner did not find any muscle atrophy, meniscus condition, or recurrent patellar subluxation/dislocation in either knee. In August 2018, the Veteran was afforded a VA examination where the diagnosis of bilateral knee strain was confirmed. He reported that his knees locked up, causing soreness and bilateral hip pain. He indicated that he uses a cane to ambulate due to weakness and instability when attempting to mobilize. The Veteran described the pain as a dull, achy pain (7/10). The Veteran did not report flare-ups. The Veteran reported that he is unstable with walking and that his knee locks and rolls out to the right. He also reported hearing popping noise like two bones popping together. The Veteran indicated that he was unable to sit or stand for long periods of time. On examination, the Veteran demonstrated flexion to 130 degrees and extension to 0 degrees on the right knee, with pain on flexion. On examination, the Veteran demonstrated flexion to 100 degrees and extension to 0 degrees on the left knee. The Veteran was able to perform repetitive use testing with at least three repetitions without functional loss in either knee. Muscle strength testing showed full strength of 5/5, except for flexion of the right knee which showed active movement against some resistance (4/5). Joint stability testing showed no instability in either knee. The examiner did not find any muscle atrophy, meniscus condition, ankylosis, or patellar/fibular impairment in either knee. The Veteran regularly used a cane for stability of the hip and knee. In March 2021, the Veteran was afforded a VA examination where he was diagnosed with bilateral knee strains, bilateral degenerative arthritis, and left knee instability. The Veteran indicated that his left knee moved from side to side and his right knee locked up. He reported pain in both knees and that his left knee hurt if he walked or stood for a long time. The Veteran reported daily severe flare-ups characterized by worsening pain, weakness, and fatigue. These flare-ups occurred after laying down, walking any distance, or standing any length of time. Flare-ups were alleviated by rest and leg elevation. The Veteran reported instability or recurrent subluxation of the knee. He stated that his left knee felt loose and that his right knee locked. The Veteran also reported intermittent swelling of the knees. Physical examination showed right knee flexion to 80 degrees and extension to 0 degrees. There was pain noted on examination of the right knee. On examination, left knee flexion was limited to 70 degrees and extension to 0 degrees. There was pain noted on examination of the left knee. The Veteran was unable to perform repetitive use testing for both knees due to pain and weakness. The examiner indicated that pain, fatigability, weakness, lack of endurance, and incoordination would significantly limit functional ability with repeated use over time. For the right knee, the examiner estimated that after repetitive use the Veteran's right knee flexion would be limited to 75 degrees and extension to 0 degrees. For the left knee, the examiner estimated that after repetitive use flexion would be limited to 65 degrees and extension to 0 degrees. Joint stability testing showed recurrent patellar instability in the left knee. The examiner did not find any muscle atrophy, meniscus conditions, ankylosis, or use of assistive devices for either knee. VA treatment records do not show knee symptoms that are more severe than those reflected in the VA examinations. The Board finds that the preponderance of the evidence is against the assignment of ratings in excess of 10 percent for the Veteran's right and left knee disabilities. Here, the Veteran has already received the minimum compensable rating (10 percent) for each knee based on painful motion. To qualify for a higher rating, the evidence must show the Veteran's symptomatology functionally limited extension to 10 degrees or flexion to 30 degrees. At worst, the Veteran demonstrated right knee flexion to 75 degrees and left knee flexion to 65 degrees, with full extension of both knees throughout the appeal. See March 2021 VA Examination. The Board has also considered other Diagnostic Codes pertaining to the knee and leg. The Veteran's left knee instability has been compensated is discussed in greater detail below. See April 20, 2021 Rating Decision. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). As the evidence of record does not demonstrate ankylosis, dislocated or removal of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum at any time during the pendency of the appeal, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 are not for application. 4. Left Knee Instability As of March 19, 2021, the Veteran is in receipt of a separate 10 percent rating for left knee instability associated with his left knee strain under 38 C.F.R. § 4.71a, Diagnostic Code 5257, for other impairment of the knee. Preliminarily, although the Veteran did not specifically appeal the assignment of this separate rating, the Board has assumed jurisdiction over the matter as part and parcel of the issues on appeal - specifically, his request for an increased rating for his left knee disability. The Board initially notes that Diagnostic Code 5257 does not require objective medical evidence of lateral instability for a rating to be assigned. English v. Wilkie, 30 Vet. App. 347 (2018). However, while the Veteran is competent to describe feelings of giving way, he is not competent as a lay person to diagnose lateral instability or recurrent subluxation as such requires the administration and interpretation of specialized testing of the ligaments and patella, respectively. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Prior to February 7, 2021, Diagnostic Code 5257 provides for the assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability, a 20 percent rating when there is moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. As of February 7, 2021, Diagnostic Code 5257 provides ratings for patellar instability and recurrent subluxation or lateral instability. For the former, a 10 percent rating for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is provided for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 30 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. With regard to recurrent subluxation or lateral instability under the amended Diagnostic Code 5257, a 10 percent rating is warranted for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistance device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is assigned for one of the following: (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation, or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. Note (1) provides that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) states that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). During the September 2012 VA examination, the Veteran did not report any knee instability, and joint stability testing was normal. However, he indicated that he experienced pain and that his knee sometimes locked on him. The VA examiner, nevertheless, found no evidence of recurrent patellar subluxation or dislocation. At the August 2018 VA examination, the Veteran indicated that he experienced weakness and instability causing him to use a cane to ambulate. However, physical examination did not reveal any joint instability, and the VA examiner reported that the Veteran did not have a history of recurrent subluxation, lateral instability, or recurrent effusion. At the March 2021 VA examination, the Veteran reported that his left knee moved from side to side. The Veteran was diagnosed with recurrent patellar instability in the left knee. VA treatment records indicate that the Veteran uses a cane, however, no assistive devices have been prescribed by a medical provider. For example, a June 2019 VA treatment note indicates that the Veteran normally uses a cane. There is no indication from this note or the Veteran's other VA medical records that this cane was prescribed by a medical provider. Upon review, the Board finds the criteria for a higher rating for left knee instability under either the old or amended Diagnostic Code 5257 have not been met at any time during the appeal period. VA examiners in September 2012 and August 2018 determined that, despite the Veteran's subjective reports, he did not have instability, subluxation, or dislocation on physical examination. However, VA examination on March 19, 2021, revealed recurrent patellar instability of the left knee. Here, the evidence of record does not reflect findings of left knee instability at any time during the appeal or findings of recurrent subluxation prior to March 19, 2021. Additionally, the evidence does not demonstrate moderate recurrent subluxation, a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair, or persistent instability requiring the prescription of an assistive device for ambulation by a medical provider. Thus, the separate rating for left knee instability associated with left knee strain, evaluated as 10 percent disabling as of March 19, 2021, is proper, the benefit of the doubt doctrine is not applicable, and the appeal is denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 5. Left Shoulder Disability The Veteran contends that he is entitled to a higher rating because he is unable to lift his left arm with full range of motion and has difficulty doing simple tasks of lifting, reaching, and putting on a seat belt due to this limitation and associated pain. See Veteran Correspondence dated March 16, 2015. Throughout the appeal, the Veteran's left shoulder disability is rated as 20 percent disabling under 38 C.F.R. § 4.71A, Diagnostic Code (DC) 5021-5010. Here, the hyphenated DC indicates that the Veteran's left shoulder disability is rated, by analogy, under DC 5010, for post-traumatic arthritis. Both DC 5201 and DC 5010 require the Veteran's shoulder condition to be rated based on limitation of motion of the arm. The Veteran is right hand dominant and, thus, the appeal concerns his minor extremity. Prior to the regulatory change, DC 5201 indicated that limitation of motion of the minor extremity at the shoulder level warrants a 20 percent rating. Limitation of motion midway between the side and shoulder level warrants a 20 percent rating for the minor extremity. Where motion is limited to 25 degrees from the side, a 30 percent rating is warranted for the minority extremity. 38 C.F.R. § 4.71a, DC 5201. As of February 7, 2021, under the amended criteria, DC 5201, in pertinent part, provides that limitation of motion of the shoulder should be rated as follows: Flexion and/or abduction limited to 25 degrees from the side warrants a 30 percent rating in the minor extremity; midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) warrants a 20 percent rating in the minor extremity; at shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent rating in the minor extremity. Thus, to warrant a higher rating under either the old or revised rating criteria, the evidence must demonstrate motion limited to 25 degrees from the side. The normal range of motion of the shoulder is forward elevation (flexion) from 0 to 180 degrees; abduction from 0 to 180 degrees; external rotation from 0 to 90 degrees; and internal rotation from 0 to 90 degrees. When the arm is held at the shoulder level, the shoulder is in 90 degrees of either forward elevation (flexion) or abduction. 38 C.F.R. § 4.71, Plate 1. In September 2012, the Veteran was afforded a VA examination where he was diagnosed with mild degenerative joint disease (DJD) of the shoulder AC joint with rotator cuff tendinopathy. The Veteran reported that his left shoulder pain has progressively worsened since service. The Veteran indicated that once every two weeks he gets a sharp pain (4-5/10) that lasts one minute, which resolves with changing position. The Veteran reported that he will get left shoulder pain if he lifts more than 40 to 50 pounds. The Veteran did not report having any flare-ups. On examination, the Veteran demonstrated flexion to 180 degrees with painful motion beginning at 175 degrees and abduction to 180 degrees with pain at 180 degrees. Repetitive-use testing was performed and there was no additional ROM lost. Functional loss was noted as pain on movement. Muscle strength testing was normal (5/5). There were no findings of muscle atrophy, ankylosis, or an AC joint condition or any other impairment of the clavicle or scapula. In August 2018, the Veteran underwent an additional VA examination where the prior diagnosis of left shoulder DJD and rotator cuff tendinopathy was confirmed. The Veteran reported that he was unable to ambulate his arm above his head without extreme pain and that he can lift, at most, 20 pounds. He denied flare-ups. On examination, the Veteran demonstrated flexion to 110 degrees and abduction to 110 degrees. Pain was noted on flexion and abduction, but that pain did not cause additional functional loss. Muscle strength testing was normal (5/5). There were no findings of muscle atrophy, ankylosis, or an AC joint condition or any other impairment of the clavicle or scapula. In March 2021, the Veteran underwent a VA examination where he reported that he was unable to raise his left shoulder very high, has limited ROM, and increased pain. The Veteran reported daily, severe flare-ups resulting in constant and intermittent achy pain. On examination, the Veteran demonstrated flexion to 70 degrees with pain and abduction to 70 degrees with pain. The Veteran was unable to perform repetitive use testing due to pain. The examiner estimated that after repeated use over time, flexion and abduction would both be limited to approximately 65 degrees. The examiner indicated that pain, fatigability, weakness, lack of endurance, and incoordination would cause functional loss with repeated use over time. There were no findings of ankylosis. The examiner indicated that the Veteran has an AC joint strain in his left shoulder. There were no findings of ankylosis or muscle atrophy. VA treatment records do not show shoulder symptoms that are more severe than those reflected in the VA examinations. Upon review, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for the Veteran's left shoulder disability. The evidence of record shows that the Veteran is right-handed. See August 2018 and March 2021 VA examinations. At no time during the appeal has the objective evidence demonstrated limitation of motion to 25 degrees from the side as required for a rating in excess of 20 percent. 38 C.F.R. § 4.71a, DC 5201. In this regard, the Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss with repeated use due to pain, fatigability, weakness, lack of endurance, and incoordination and functional loss due to pain. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that the Veteran has limited ROM would not result in symptoms more nearly approximating limitation of motion of the arm to 25 degrees from the side of the minor extremity. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). Here, the evidence of record does not show that pain, weakness, or other symptoms have functionally limited the range of motion in the left shoulder to 25 degrees from the side as required for a 30 percent rating. As such, a rating in excess of 20 percent is not warranted under 38 C.F.R. §§ 4.40 and 4.45. The Board also considered whether a higher rating could be assigned under DC 5003, which provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Both the September 2012 and August 2018 VA examinations indicated that there was degenerative or traumatic arthritis of the left shoulder documented on x-rays. When the limitation of motion of the specific joint or joints involved is noncompensable, a rating of 10 percent is assigned. In the absence of limitation of motion, a maximum of 20 percent rating is assigned under DC 5003 for two or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations. Here, a 20 percent rating has already been assigned under DC 5201 based on limitation of motion, rendering the 10 percent and 20 percent ratings under DC 5003 inapplicable. Additionally, the competent evidence does not demonstrate ankylosis of the scapulohumeral articulation, impairment of the humerus, or impairment of the clavicle or scapula to warrant a higher and/or separate rating under Diagnostic Codes 5200, 5202, or 5203. Id. Accordingly, the Board finds the preponderance of the evidence does not show that the Veteran's left shoulder disability meets the criteria for a rating in excess of 20 percent under any applicable rating criteria at any time during the pendency of the appeal. Other Considerations In making its determinations in this case, the Board has carefully considered the Veteran's contentions with respect to the nature of his service-connected disabilities at issue and notes that his lay testimony is competent to describe certain symptoms associated with these disabilities. The Veteran's history and reported symptoms have been considered, including as presented in the medical evidence discussed above, and has been contemplated by the disability ratings that have been assigned. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence when evaluating the pertinent symptoms of the service-connected disabilities at issue. As such, while the Board accepts the Veteran's testimony concerning matters that he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluations of functional impairment, symptom severity, and details of clinical features of the service-connected conditions at issue. The Board has also considered whether additional staged ratings under Hart, supra, and Fenderson, supra, are appropriate for the Veteran's back disability, knee disabilities, and left shoulder disability; however, the Board finds that his symptomatology has been stable throughout the already-established periods on appeal. Therefore, assigning additional staged ratings for such disabilities is not warranted. Further, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the increased rating claims adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). In reaching the foregoing determinations, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims of entitlement to increased ratings for his back disability, left knee disability, right knee disability, and left shoulder disability. Consequently, the benefit of the doubt doctrine is inapplicable in such regard, and the Veteran's claims for increased ratings must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. M. M. Celli Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jennifer M. Narvaez, Associate 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.