Citation Nr: 21063803 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 09-44 341 DATE: October 18, 2021 ORDER Entitlement to service connection for a lumbar spine disability is denied. Entitlement to service connection for a cervical spine disability is denied. Entitlement to service connection for disability manifested by numbness of the hands is denied. Entitlement to increased ratings for residuals of left shoulder dislocation based on limitation of motion and ankylosis, currently rated 20 percent prior to December 5, 2007, 30 percent from December 5, 2007 to May 25, 2017, 40 percent from May 26, 2017 to December 11, 2019, and 30 percent from December 12, 2019, is denied. Entitlement to a new separate rating of 20 percent, but no higher, for joint instability of the left shoulder is granted from April 30, 2012. Entitlement to initial ratings for left knee sprain in excess of 10 percent prior to December 12, 2019, in excess of 50 percent from December 12, 2019 to March 30, 2021, and in excess of 10 percent from March 31, 2021, is denied. FINDINGS OF FACT 1. The probative evidence does not establish that a lumbar spine disability had onset in service, is causally related to service, or was caused or aggravated by a service-connected disability. 2. The probative evidence does not establish that a cervical spine disability had onset in service, is causally related to service, or was caused or aggravated by a service-connected disability. 3. The probative evidence does not establish that a disability manifested by numbness of the hands had onset in service, is causally related to service, or was caused or aggravated by a service-connected disability. 4. Prior to December 7, 2007, the Veteran's service-connected left shoulder disability was not shown to be manifested by limitation of motion to 25 degrees from the side. 5. From December 5, 2007 to May 25, 2017, the Veteran's service-connected left shoulder disability was manifested by limitation of motion to 25 degrees from the side; no ankylosis was demonstrated. 6. From May 26, 2017 to December 11, 2019 the Veteran's service-connected left shoulder disability was manifested by unfavorable ankylosis. 7. Since December 12, 2019, the Veteran's service-connected left shoulder disability was manifested by limitation of motion to 25 degrees from the side; no ankylosis has been demonstrated. 8. Since April 30, 2012, the Veteran's left (minor) shoulder disability has manifested in recurrent dislocation with at least infrequent episodes, and guarding of movement at least at shoulder level (flexion and/or abduction at 90 degrees); it has not manifested in fibrous union or nonunion of the humerus, nor has it manifested in loss of the humerus head. 9. Prior to December 12, 2019, the Veteran's left knee condition was manifested by painful motion but not by flexion limited to 30 degrees nor as extension limited to 10 degrees. 10. From December 12, 2019 to March 30, 2021, the Veteran's left knee condition was manifested by extension limited to 50 degrees, but not by flexion limited to 45 degrees. 11. From March 31, 2021, the Veteran's left knee condition was manifested by painful motion but not by flexion limited to 30 degrees nor as extension limited to 10 degrees. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a lumbar spine disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for entitlement to service connection for a cervical spine disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 3. The criteria for entitlement to service connection for disability manifested by numbness of the hands have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for entitlement to increased ratings for residuals of left shoulder dislocation, currently rated 20 percent prior to December 5, 2007, 30 percent from December 5, 2007 to May 25, 2017, 40 percent from May 26, 2017 to December 11, 2019, and 30 percent from December 12, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5010-5201 (as in effect prior to February 7, 2021), and 4.71a, Diagnostic Code 5010-5201 (as in effect from February 7, 2021). 5. Since April 30, 2012, the criteria for a new/separate 20 percent rating, but no higher, for joint instability of the left shoulder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5202 (as in effect prior to February 7, 2021), and 4.71a, Diagnostic Code 5202 (as in effect from February 7, 2021). 6. The criteria for entitlement to initial ratings for left knee sprain in excess of 10 percent prior to December 12, 2019, in excess of 50 percent from December 12, 2019 to March 30, 2021, and in excess of 10 percent from March 31, 2021, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5260 and 5256 to 5263 (as in effect prior to February 7, 2021), and 4.71a, Diagnostic Codes 5003-5260 and 5256 to 5263 (as in effect from February 7, 2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1967 to December 1971. These matters come to the Board of Veterans' Appeals (Board) on appeal from April 2009 and September 2009 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In February 2013 the Board remanded the case for further development. In August 2018, the Veteran provided testimony before the undersigned Veterans Law Judge by videoconference hearing. A transcript is of record. In May 2019, the Board remanded the case for further development. The Board's May 2019 remand included the issue of entitlement to a total disability rating based on individual unemployability (TDIU). In an April 2021 rating decision, the RO granted TDIU from May 27, 2013. As the Veteran has reported that he last worked fulltime in May 2013, and he has not disagreed with the effective date of the TDIU award, the Board will not further address the TDIU issue. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be granted for certain diseases based on presumed exposure to certain herbicide agents, even though there is no record of such disease during service. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). The presumptive provisions of 38 C.F.R. § 3.307 are specifically limited to enumerated chronic diseases listed in 38 C.F.R. § 3.309 (e). Service connection for certain chronic diseases may also be established on a presumptive basis by showing that the disease manifested to a compensable degree during service or within one year from the date of separation from active service. 38 C.F.R. §§ 3.307 (a) (3), 3.309 (a). If not shown as chronic during service or if a diagnosis of chronicity is legitimately questioned, continuity of symptomatology after service is required. 38 C.F.R. § § 3.303 (b). Continuity of symptoms may establish service connection only for those diseases listed in 38 C.F.R. § § 3.309 (a). 38 U.S.C. § §§ 1101, 1112; 38 C.F.R. § §§ 3.303 (b), 3.307(a)(3), 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Secondary service connection may be granted for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (a). Secondary service connection includes the concept of aggravation of a nonservice-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of observable symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). 1. Entitlement to service connection for a lumbar spine disability The Veteran contends that he injured his low back playing football during service in October 1969, at the same time he injured his left shoulder. Alternatively, the Veteran contends that his lumbar spine disability was caused or aggravated by his service-connected left shoulder disability. The service treatment records do not note a low back injury. The October 1969 treatment record notes only a left shoulder separation. On his report of medical history completed in December 1971, the Veteran denied recurrent back pain. The December 1971 separation examination noted normal spine. A VA orthopedic examination in March 1976, conducted to evaluate the Veteran's left shoulder disability, did not note any back complaints or findings. Private treatment records show that the Veteran complained of his back hurting in February 1986. Aching and tightness in the back muscles was noted in July 1986. In January 1987 the Veteran reported pain in his back. In October 1987 degenerative disc disease of L4 and L5 was noted. Degenerative arthritis of the spine was noted in March 1989. In May 1993 he complained of low back pain. X-rays of the lumbar spine in October 1996 showed moderately severe degenerative disc disease of L5-S1. In an April 2009 private treatment record, T.A. Walker, M.D., the Veteran's treating orthopedist, noted that the Veteran "has arthritis in his shoulder and lumbar spine as a result of his career as a military athlete." A VA examination was conducted in September 2009. The Veteran reported having had back pain for "many, many years," but he did not know a "specific entity that caused it." The examiner noted lumbar disc disease and opined that the Veteran's left shoulder condition did not cause or aggravate his lumbar spine condition. "It is my opinion that it is at least as likely as not that his job as a firefighter is related to his... lumbar disk disease." A VA examiner in December 2019 indicated that the Veteran's current low back disability was at least as likely as not incurred in or caused by service. However, the examiner did not provide a rationale for this opinion. Rather, the examiner noted that the Veteran was seen in October 1996 (which was 25 years after separation from service) for low back pain. In March 2021, a VA examiner opined that the Veteran's low back disability was less likely as not incurred in or caused by service. The examiner noted that the service separation examination did not contain evidence to support that degenerative disc disease was incurred in service. The examiner provided no further rationale for this opinion. The same examiner also opined that the Veteran's low back disability was less likely as not proximately due to or the result of his service-connected left shoulder disability. The examiner noted that medical literature did not support residual left shoulder dislocation as a cause or risk factor for lumbar degenerative disc disease. In April 2021 the Veteran was again provided with a VA examination. The Veteran reported a history of back pain beginning in service. The examiner opined that it was not at least as likely as not (50 percent probability or greater) that any current back disability, to include degenerative disc disease and degenerative joint disease of the lumbosacral spine, had onset during, or is otherwise related to, service, to include as a result of an injury while playing basketball and/or football. The examiner noted the service treatment records were silent for any lumbar complaints or conditions, including the separation exam report. The post-service medical records were also silent for low back complaints for many years after service and the first evidence was found in 1987 which was over 15 years after discharge. The examiner also indicated that the Veteran's post-discharge occupation included working as a firefighter (per many notes in private medical and VA medical) which he noted, by nature, can cause low back disease. Concerning the remand statement conceding an injury while in service /playing basketball/football/hardcore activities, the examiner noted that the "definition of an injury is very broad and ALL injuries do not lead to chronic problems in fact the vast majority are muscular in origin and heal completely. I discussed with a radiologist the timeline in which an x-ray could show [degenerative disc disease] from an injury. He stated there was no repeated reviews he was aware of that has determined this." With respect to whether it was at least as likely as not that any current low back disability was proximately caused by the Veteran's service-connected residuals of left shoulder dislocation, the examiner stated that it was "less likely as not. Biomechanically there is no relationship between his shoulder and the low back area. The medical record was silent for any injury or accident caused by his shoulder that ended in a low back injury." With respect to whether it was at least as likely as not that any current low back disability was aggravated by the Veteran's service-connected residuals of left shoulder dislocation, the examiner stated that it was "less likely as not. Medical record review was silent for any accidents or treatment for an occurrence involving his shoulder condition causing an aggravation of his low back condition. As stated above there is no biomechanical relationship where a shoulder condition would directly aggravate the low back." The examiner noted that he had reviewed the record and had considered the prior medical opinions and reconciled all conflicting/inadequate opinions. Dr. Walker's opinion concerning the etiology of his back and neck conditions was reviewed. The examiner noted that Dr. Walker did not mention anything concerning the Veteran's post-service occupation and its contribution to his conditions or give any clarifications on how he came to his opinion. Taken together, the Board finds the VA opinions provided in September 2009, March 2021 and April 2021 are probative and persuasive as the VA examiners explained the reasons for their conclusions and the opinions were based on an accurate characterization of the evidence. Thus, these opinions are entitled to substantial probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The statement from Dr. Walker does not contain any rationale nor does it acknowledge the Veteran's post-service work history as a firefighter. The available medical evidence does not include competent and supported findings of a nexus between the Veteran's military service, to include playing sports, and the Veteran's degenerative disc disease and arthritis of the lumbar spine. Thus, service connection is not warranted on a direct basis under 38 C.F.R. § 3.303. There is no other medical evidence of record, VA or private showing that the Veteran's currently diagnosed lumbar spine disability is related to service or a service-connected disability. With regard to the years-long evidentiary gap in this case between active service and the earliest notation of back pain complaints in 1986, the Board notes that this passage of time is a factor that weighs against a finding of direct service connection for a back disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Veteran is not entitled to service connection on the basis of continuity of symptomatology as symptoms of lumbar spine arthritis were not noted in service or with continuity after service discharge. The presumption of service connection for chronic diseases diagnosed within one year following discharge from active duty is also not applicable to this case because the evidence demonstrates that arthritis was initially shown more than one year after the Veteran's discharge from service. The Board acknowledges the Veteran's assertion that his back disability is due to sports injuries in service or his service-connected left shoulder disability. However, while the Veteran is competent to report the observable symptoms of a disability, and in certain situations a lay person may be competent to establish the etiology of a disability; in the present case, the Veteran is not competent to provide a nexus between his currently diagnosed arthritis and degenerative disc disease of the lumbar spine and his active service or a service-connected disability. Such an opinion would require medical expertise. Thus, the Board finds that the Veteran, as a layperson, is not qualified to render an opinion concerning the cause of his current back disability. 38 C.F.R. § 3.159 (a)(1), (2). Further, while the Veteran is competent to report that he injured his back in service, as pointed out by the April 2021 VA examiner, not all injuries result in chronic conditions. In this case, the probative medical evidence is against a finding that the Veteran's current lumbar spine condition is related to an inservice injury. For the reasons and basis stated above, the Board finds that service connection for a lumbar spine disability on a direct, presumptive or secondary basis is not warranted. In reaching this decision, the Board has considered benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is the against the claim, that doctrine is not applicable. 2. Entitlement to service connection for a cervical spine disability The Veteran contends that he injured his neck while playing basketball during service in January 1970. Alternatively, the Veteran contends that his cervical spine disability was caused or aggravated by his service-connected left shoulder disability. The service treatment records document a dental fracture following a blow to the mouth in the basketball game in January 1970. No neck or cervical spine injury or pathology was noted at that time. The December 1971 separation examination noted normal spine, head, and neck. A VA orthopedic examination in March 1976, conducted to evaluate the Veteran's left shoulder disability, did not note any neck or cervical spine complaints or findings. Private treatment records show that the Veteran complained of a "crick in his neck" in January 1987. An April 2009 cervical spine X-ray showed moderate degenerative disc disease at C5/6, and borderline spinal stenosis. Chronic neck pain was noted in May 2009. A VA examination was conducted in September 2009. The Veteran reported having "had, since 2007, neck pain daily in the middle part of his neck... He denies any specific trauma to his neck." MRI revealed disk bulge, C3-C4, C4- C5, and C5-C6 with facet hypertrophy and moderate neuroforaminal narrowing on the right. The examiner opined that the Veteran's "left shoulder condition did not cause or aggravate his cervical...spine condition. It is my opinion that it is at least as likely as not that his job as a firefighter is related to his cervical disk disease.... Again, I believe his cervical disk disease...[is] not related to his left shoulder condition that occurred in the service." A VA examiner in December 2019 indicated that "pathophysiologically, the trauma to the shoulder joint does not cause neck pain; it's quite the opposite, neck trauma first often causes shoulder pain. Therefore, it less likely than not proximately due to or the result of the Veteran's service-connected condition." In March 2021, a VA examiner opined that the Veteran's neck disability was less likely as not incurred in or caused by service. The examiner noted that the service separation examination did not contain evidence to support that a neck condition was incurred in service. The examiner provided no further rationale for this opinion. In April 2021 the Veteran was again provided with a VA examination. The examiner opined that it was not at least as likely as not (50 percent probability or greater) that any current neck disability, to include degenerative disc disease and degenerative joint disease of the cervical spine had onset during, or is otherwise related to, service, to include as a result of an injury while playing basketball and/or football. The examiner noted that: STR's did not show any evidence of a neck injury. The teeth condition was reviewed. There was no evidence of a blow serious enough to cause neck trauma. There was no evidence of loss of consciousness. Separation exam was silent for neck complaints. There was no evidence of a chronic neck condition for many years post service. The first evidence I could locate was in 1987. This was many years post service. Post service occupation included working as a firefighter per multiple reports in private and VA medical records. Obviously this job is quite strenuous on all joints. The comment in the remand about conceding an injury during the activities in service was reviewed. The definition of an injury is very broad and ALL injuries do not lead to chronic problems in fact the vast majority are muscular in origin and heal completely. I discussed with a radiologist the time line in which an x-ray could show DDD from an injury. He stated there was no repeated reviews he was aware of that has determined this. With respect to whether it was at least as likely as not that any current cervical spine disability was proximately caused by the Veteran's service-connected residuals of left shoulder dislocation, the examiner stated that it was "less likely as not. There was no evidence in the STR's reporting a neck injury with the shoulder dislocations. Review of the biomechanics of the neck and shoulder does not lean itself to a causation of a chronic neck condition such as DDD from a recurrent shoulder dislocation or surgical treatment of. The formation of the structures of the neck are a significant distance for the shoulder to cause any relationship for this causation." With respect to whether it was at least as likely as not that any current cervical spine disability was aggravated by the Veteran's service-connected residuals of left shoulder dislocation, the examiner stated that it was "less likely as not. There was no evidence in the STR's consistent with aggravation of a neck condition. There was no evidence in the post service medical record of any event or occurrence causing his neck condition to become acutely worse in relation to his service-connected shoulder." Taken together, the Board finds the VA opinions provided in September 2009, December 2019, March 2021 and April 2021 are probative and persuasive as the VA examiners explained the reasons for their conclusions and the opinions were based on an accurate characterization of the evidence. Thus, these opinions are entitled to substantial probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The available medical evidence does not include competent and supported findings of a nexus between the Veteran's military service, to include playing sports, and the Veteran's degenerative disc disease and arthritis of the cervical spine. Thus, service connection is not warranted on a direct basis under 38 C.F.R. § 3.303. There is no other medical evidence of record, VA or private showing that the Veteran's currently diagnosed cervical spine disability is related to service or a service-connected disability. With regard to the years-long evidentiary gap in this case between active service and the earliest notation of neck pain complaints in 1987, the Board notes that this passage of time is a factor that weighs against a finding of direct service connection for a neck disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Veteran is not entitled to service connection on the basis of continuity of symptomatology as symptoms of cervical spine arthritis were not noted in service or with continuity after service discharge. The presumption of service connection for chronic diseases diagnosed within one year following discharge from active duty is also not applicable to this case because the evidence demonstrates that arthritis was initially shown more than one year after the Veteran's discharge from service. The Board acknowledges the Veteran's assertion that his neck/cervical spine disability is due to sports injuries in service or his service-connected left shoulder disability. However, while the Veteran is competent to report the observable symptoms of a disability, and in certain situations a lay person may be competent to establish the etiology of a disability; in the present case, the Veteran is not competent to provide a nexus between his currently diagnosed arthritis and degenerative disc disease of the cervical spine and his active service or a service-connected disability. Such an opinion would require medical expertise. Thus, the Board finds that the Veteran, as a layperson, is not qualified to render an opinion concerning the cause of his current neck disability. 38 C.F.R. § 3.159 (a)(1), (2). Further, while the Veteran is competent to report that he injured his neck in service, as pointed out by the April 2021 VA examiner, not all injuries result in chronic conditions. In this case, the probative medical evidence is against a finding that the Veteran's current cervical spine condition is related to an inservice injury. For the reasons and basis stated above, the Board finds that service connection for a neck/cervical spine disability on a direct, presumptive or secondary basis is not warranted. In reaching this decision, the Board has considered benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is the against the claim, that doctrine is not applicable. 3. Entitlement to service connection for disability manifested by numbness of the hands The service treatment records do not note any complaints of numbness of the hands. On his report of medical history completed in December 1971, the Veteran denied neuritis. The December 1971 separation examination noted normal neurologic findings. Private treatment record dated in August 1985 noted that the Veteran reported getting numbness in the arms and left index finger at times. The Veteran was noted to play a lot of racquetball and to jog. Generalized mild inflammation mainly involving the upper arms probably from sports activity was noted. In July 1986 he complained of numbness to the tips of the second, third, and fourth digits. This was noted to be likely secondary to occupational involvement; the Veteran used the fingers to flip a toggle switch on the firetruck he drove. In February 2001 the Veteran was seen with complaint of bilateral numbness and tingling sensation of the hands. Probable bilateral carpal tunnel syndrome was noted. Bilateral upper extremity nerve conduction studies in March 2001 were noted as within normal limits. A VA examination was conducted in September 2009. The examiner noted that the Veteran "states he has some discomfort that will radiate in both arms. His left arm will be a sleeve-like distribution at night, described as numbness only. He denies any weakness. Concerning his right, he will have a tingling in his right thumb and index finger. This can occur throughout the day... He says that his left arm is somewhat 'weak'; however, this has been an issue since his left shoulder was operated on while in the Service. He recently had nerve conduction studies performed on his upper extremities. These were performed on May 19, 2009, and showed minimal findings of median neuropathy of the right motor and sensory, most likely carpal tunnel. There was no abnormality on the left at all, and there was no cervical radiculopathy on the right." On neurological examination, sensory examination noted gross touch was normal in the upper extremities, which will place it at 2/2, except for the right thumb and index finger which was slightly decreased at 1/2. Deep tendon reflexes, right over left. Biceps and triceps were 0/0. Brachioradialis was 2/2. Strength examination was difficult since, due to his left shoulder injury, the Veteran would not use his left upper extremity at all. "Due to this fact, I could not get an objective examination of the strength in his left upper extremity. His right upper extremity strength was normal at 5/5. Pulses in the radial dorsalis pedis arteries were normal bilaterally." The examiner diagnosed carpal tunnel syndrome of the right upper extremity, and noted nerve conduction velocities revealing no radiculopathy in the cervical area objectively. The examiner noted: The nerve conduction velocities did not reveal any cervical radiculopathy at this time. I believe his right upper extremity discomfort is secondary to his carpal tunnel syndrome. Concerning his left upper extremity, at this time, he had a normal sensory examination. I believe his discomfort in his left upper extremity was secondary to his service-connected left shoulder disorder at this time. An April 2014 VA examiner opined that the Veteran's bilateral upper extremity numbness complaints were likely related to carpal tunnel syndrome. The examiner noted that while the numbness condition was bilateral, the service-connected shoulder disability was on the left only. The examiner opined that it was less likely that the bilateral numbness condition was caused by or made worse by the service-connected left shoulder disability. A VA examination in December 2019 diagnosed neuropathy of both hands. The examiner opined that trauma to the shoulder joint does not cause numbness to the hands. The same examiner noted that it was at least as likely as not that the Veteran's numbness of the hands was incurred in or caused by service. However, the examiner did not provide a rationale for this opinion. In April 2021 the Veteran was again provided with a VA examination. The examiner opined that it was not at least as likely as not (50 percent probability or greater) that any current disability manifested by numbness of the hands had onset during, or is otherwise related to, service: Review revealed symptoms are consistent with PCP's diagnosis of carpal tunnel syndrome. STR's were silent for symptoms consistent with carpal tunnel syndrome. It was many years post discharge before symptoms of carpal tunnel syndrome were mentioned. Carpal tunnel syndrome is by definition the entrapment of the median nerve. His post service occupation including working as a firefighter requires repetitive use of the hands and wrists which is a major risk factor for carpal tunnel syndrome. The medical record from his private M.D. lists his carpal tunnel as occupational in nature (July 1986 notes). The remand directive conceding injury in service from hardcore training or participating in sports was considered. Again there was no documented event in service that would cause carpal tunnel syndrome. As stated before the vast majority of injuries occurring in sports resolve completely. With respect to whether it was at least as likely as not that any current disability manifested by numbness of the hands was proximately caused by or aggravated by the Veteran's service-connected residuals of left shoulder dislocation, the examiner stated that it was less likely as not. "Carpal tunnel is caused by the entrapment of the median nerve in the wrist area. Biomechanically the shoulder is a considerable distance from the wrist and there is not any feasible way it could cause an entrapment of the median nerve in the wrist area." Taken together, the Board finds the VA opinions provided in April 2014 and April 2021 are probative and persuasive as the VA examiners explained the reasons for their conclusions and the opinions were based on an accurate characterization of the evidence. Thus, these opinions are entitled to substantial probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). These examiners determined that the Veteran's numbness complaints of the bilateral hands are related to carpal tunnel syndrome that had its onset decades after service and was likely the result of occupational factors. The examiners found no basis for a finding of causation or aggravation of the carpal tunnel syndrome by the Veteran's service-connected left shoulder disability. The available medical evidence does not include competent and supported findings of a nexus between the Veteran's military service, to include playing sports, and the Veteran's carpal tunnel syndrome. Thus, service connection is not warranted on a direct basis under 38 C.F.R. § 3.303. There is no other medical evidence of record, VA or private showing that the Veteran's currently diagnosed bilateral carpal tunnel syndrome is related to service or a service-connected disability. With regard to the years-long evidentiary gap in this case between active service and the earliest notation of hand numbness complaints in 1985, the Board notes that this passage of time is a factor that weighs against a finding of direct service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board acknowledges the Veteran's assertion that his hand numbness disability is due to sports injuries in service or his service-connected left shoulder disability. However, while the Veteran is competent to report the observable symptoms of a disability, and in certain situations a lay person may be competent to establish the etiology of a disability; in the present case, the Veteran is not competent to provide a nexus between his currently diagnosed carpal tunnel syndrome and his active service or a service-connected disability. Such an opinion would require medical expertise. Thus, the Board finds that the Veteran, as a layperson, is not qualified to render an opinion concerning the cause of his current carpal tunnel syndrome. 38 C.F.R. § 3.159 (a)(1), (2). In this case, the probative medical evidence is against a finding that the Veteran's current carpal tunnel syndrome is related to an in-service injury. For the reasons and basis stated above, the Board finds that service connection for numbness of the hands, diagnosed as bilateral carpal tunnel syndrome, on a direct or secondary basis is not warranted. In reaching this decision, the Board has considered benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is the against the claim, that doctrine is not applicable. Increased Ratings Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Rating a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). 4. Entitlement to increased ratings for residuals of left shoulder dislocation, currently rated 20 percent prior to December 5, 2007, 30 percent from December 5, 2007 to May 25, 2017, 40 percent from May 26, 2017 to December 11, 2019, and 30 percent from December 12, 2019 The Veteran's current claim for increased rating was received December 5, 2007. The April 2009 rating decision on appeal continued a 20 percent rating for the left shoulder disability that had been in effect since May 1999. The Veteran filed a notice of disagreement. An August 2009 rating decision increased the rating for the Veteran's left shoulder disability to 30 percent from December 5, 2007. A subsequent April 2021 rating action increased the rating to 40 percent from May 26, 2017, and assigned a 30 percent rating from December 12, 2019. The appeal period begins on December 5, 2007, the date of the increased rating claim, with a one-year look back period. See Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). The Veteran's left shoulder disability, characterized as left shoulder impingement syndrome, degenerative arthritis, post-operative Bristow, recurrent dislocations, adhesive capsulitis, and Hill Sachs deformity of humeral head, has been rated at various times under Diagnostic Codes 5200, 5201, and 5010. The record shows that the Veteran is right-handed, thus his left shoulder is the non-dominant one. The Board notes that 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. 85 Fed. Reg. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board will consider the old version of the diagnostic codes only; however, for the period beginning February 7, 2021 the Board will consider both the old and amended version (amended code) of the diagnostic code and rate based on whichever is most favorable to the Veteran. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). 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. The amendment to Diagnostic Code 5010, effective February 7, 2021, for post-traumatic arthritis was clarified that it can be rated as limitation of motion, dislocation, or instability. 38 C.F.R. § 4.71a, 85 Fed. Reg. 76453 (Nov. 30, 2020). Under the amendment, Diagnostic Code 5002 also was renamed from rheumatoid arthritis to multi-joint arthritis to take into account all systemic arthritis (except post-traumatic and gout). Id. Under Diagnostic Code 5200, for favorable ankylosis with abduction to 60 degrees and ability to reach mouth and head, a 20 percent rating is warranted for the minor side. For intermediate ankylosis between favorable and unfavorable, a 30 percent rating is warranted for the minor side. For unfavorable ankylosis and abduction limited to 25 degrees from the side, a 40 percent rating is warranted for the minor side. Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. As noted, the Veteran's right shoulder is considered his minor side. As applicable to the Veteran's shoulder disability, the amendments to the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, clarify that Diagnostic Code 5201 addressing limitation of motion of arm includes either flexion or abduction. 38 C.F.R. § 4.71a, 85 Fed. Reg. 76453 (Nov. 30, 2020). The amendments further clarify that Diagnostic Codes 5201 and 5202 provide that shoulder level is 90 degrees and midway is 45 degrees. 38 C.F.R. § 4.71a, 85 Fed. Reg. 76453 (Nov. 30, 2020). Id. 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). 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 factors listed in section 4.40 or section 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."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board finds that aspects of the Veteran's left shoulder disability can be rated under 38 C.F.R. § 4.71a, Diagnostic Code 5202, for other impairment of the humerus. The provisions of Diagnostic Code 5202 pertaining to the minor arm specify that malunion warrants a 20 percent rating, recurrent dislocation is rated at 20 percent with frequent episodes and guarding (the amended regulations also included infrequent episodes and guarding of movement at shoulder level (flexion and/or abduction at 90 degrees)); fibrous union of the humerus is rated at 40 percent; nonunion of the humerus is rated 50 percent; and a loss of the humerus head is rated 70 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5202. Evidence A February 2008 private treatment record noted range of motion of the left shoulder was limited secondary to pain. Forward elevation was 120 degrees. Passively, the Veteran could not go much further than that due to pain. External rotation was limited to 15 degrees. Internal rotation with the arm abducted was 80 degrees. External rotation with the arm abducted was 50 degrees. There was pain on passive stretch of the anterior capsule. There was significant weakness with resisted external rotation with the arm at the side and the arm abducted to 90 degrees. Distal pulses were intact. A VA examination was conducted in February 2008. The Veteran reported that he had not had further left shoulder surgery since the 1990s. He had also not had any dislocation since then, but he reported having chronic pain that was getting progressively worse. He rated his pain as 9/10 on a scale of zero to 10. He reported that he received intermittent cortisone injections in his shoulder. The Veteran described his symptoms as pretty much present 24/7 and that he usually did not have flare-ups. From a functional standpoint he reported he could not lift anything heavy with the left arm and could not work overhead. The Veteran stated that he could not even raise his arm as high as his shoulder. He could not do chores around the house to keep up his yard and had to hire someone to do this. On examination, abduction of the shoulder caused pain at 30 degrees and the Veteran could then go to 45 degrees. He had pain on forward elevation at 35 degrees and can then go to 50 degrees. External rotation was limited by pain to 45 degrees. Internal rotation was limited by pain to 20 degrees. With repetition there was no additional loss in range of motion due to pain, fatigue, weakness or incoordination. The examiner noted there was no additional limitation following three repetitions, but there was an increase in pain. On VA examination in April 2009, the examiner noted that the Veteran had rather huge deltoid muscles of the left shoulder, which had not atrophied. There was no tenderness. Abduction of the left shoulder caused pain at 30 degrees and with help he could go to 45 degrees. Flexion of the shoulder caused pain at 35 degrees, but he could go all the way to 60 degrees. External rotation was limited to 45 degrees, but with internal rotation he could go to 90 degrees with assistance. "These were all on three repeats. All motion was complicated by pain, but no weakness, fatigability, or loss of endurance." On VA examination in January 2011, the Veteran reported, his pain to be anterior and lateral, generalized, 10 on a scale of 10 with any attempt at use. With hydrocodone and ibuprofen, which did not cause side effects, he had 5 on a scale of 10 discomfort. He does not use a sling or a brace or other external support on the left shoulder. On examination, left shoulder active motion initially was 20 degrees forward flexion, 25 degrees abduction. External rotation was 20 degrees, and internal rotation was 35 degrees. On repeated testing of forward flexion and abduction, initially he did not move his arm at all, and after some coaxing he was able to get the shoulder into the 20 to 25 degree range on forward flexion and abduction. Passive motion was to about 45 degrees in forward flexion and abduction, and then the Veteran complained of pain and resisted further motion. The shoulder was not definitely unstable. The Veteran complained of tenderness over the anterior glenohumeral region. The examiner noted a very slight amount of atrophy posteriorly on the infraspinatus. Otherwise, the Veteran's musculature was symmetrical. The examiner noted: He does not have ankylosis. He does have an ununited coracoid, which would not prevent movement in the same manner than if the joint were ankylosed. The explanation is that the intent of the Bristow procedure is to block inferior and anterior dislocation of the humeral head on the glenoid. Even though the union did not take place from a bony standpoint, he has sufficient scarring in that region which does prevent and has prevented in the almost 40 years since his operation further dislocation. He does not have malunion or nonunion of the humerus or clavicle. He does have nonunion of the attempted coracoid transfer to the inferior glenoid as explained above. He has had no recurrent dislocation of the scapulohumeral, clavicle, or scapula. He does not have "loose movement of the shoulder." He described pain at the extremes and throughout the course of motion, basically with any motion of the left shoulder. He resisted further motion past about 45 degrees of abduction and forward flexion. He did have subjective tenderness. There was no edema, effusion, instability, redness, heat, abnormal movement. He did have guarding. He had no deformity, malalignment, drainage, or weakness. He did describe pain, fatigue, weakness, and lack of endurance and incoordination on testing times three initially. Later he was able to repeat his range of motion as described the first time... [T]his gentleman had a dislocation. He had a Bristow procedure later after a total of three dislocations on the left shoulder. Since that time, he has developed a chronic pain syndrome where he does not use this extremity and limb except in very limited fashion. His lack of use and complaints are not supported by objective physical examination, imaging studies, and measurements of his muscle mass, et cetera. A February 2012 private treatment record noted the Veteran's report of persistent pain in his left shoulder for several years. The Veteran reported that he treated his left shoulder with rest, anti-inflammatories, and activity modification. He reported recent aggravation of his symptoms, especially with activity. Examination showed active abduction of approximately 90 degrees. Active forward elevation was to 100 degrees. With the arm in abduction, external rotation was 45 degrees and internal rotation was 80 degrees. Passively, the treating physician could elevate the Veteran's arm to 120-140 degrees; abduction was limited to 120 degrees. Internal rotation with the arm at the side was to the posterior superior iliac spine (PSIS). External rotation was approximately 30 degrees, compared with 60 degrees on the contralateral extremity. The Veteran had no tenderness over the AC joint. There was some crepitus in the acromiohumeral articulation with ROM of his shoulder. His strength was approximately 3/5 in his rotator cuff with good reserve strength distally. On VA examination conducted April 30, 2012, flexion was to 25 degrees. Painful motion began at zero degrees. Left shoulder abduction was to 15 degrees, with painful motion beginning at zero degrees. After repetitive testing, the ranges were unchanged. The examiner noted that all ranges of motion were passive-only, due to the request of the Veteran not to actively perform range of motion due to discomfort it would cause. Muscle strength was 3/5 for flexion and abduction. There was no ankylosis of the glenohumeral articulation (shoulder joint). There was guarding of all movements and a history of recurrent shoulder dislocation. There was no impairment of the clavicle or scapula. There was tenderness on palpation of the AC joint. A VA examination in April 2014, flexion was to 25 degrees. Painful motion began at zero degrees. Left shoulder abduction was to 15 degrees, with painful motion beginning at zero degrees. The Veteran was not able to do repetitive motion testing. There was functional loss in the form of less movement than normal, painful motion, and weakened movement. There was pain on palpation and guarding. Muscle strength testing was 3/5 for flexion and abduction. The examiner noted ankylosis, with abduction limited to 25 degrees from the side. There was guarding of all movements and a history of recurrent shoulder dislocation. There was no AC joint condition or any other impairment of the clavicle or scapula. The examiner stated that the Veteran did not have a fibrous union of humerus, nonunion of humerus, or loss of humeral head. In a July 2016 addendum to the examination report, the examiner stated that "ankylosis was erroneously checked; correction, there is no ankylosis, see [range of motion]." On VA examination conducted May 26, 2017, the Veteran reported that his shoulder condition had progressed. The Veteran reported chronic shoulder pain rated five out of ten. He described flares with weather changes and activities rating pain eight and lasting varied periods. He had stiffness with the shoulder. There was crepitus. The Veteran reported frequent subjective subluxations, every two months. No E.R. visits were required. The Veteran reported functional loss; he had no sedentary restrictions, but the shoulder limited gripping (weight and duration) and he avoided overhead work. On examination, flexion was to 15 degrees; abduction was to 20 degrees; external rotation was to 40 degrees; and internal rotation was to 70 degrees. There was no additional functional loss or range of motion after three repetitions. There was evidence of pain with weightbearing. There was mild tenderness of the anterior shoulder. The examiner stated that pain, fatigue, weakness, and lack of endurance would significantly limit functional ability with repeated use over a period of time or during flare-ups, however the examiner was unable to describe this in terms of range of motion. Muscle strength testing was 3/5 for flexion and abduction. There was no muscle atrophy. The examiner noted ankylosis in abduction at 25 degrees or less from side (unfavorable ankylosis). There was guarding of all movements and a history of recurrent shoulder dislocation. No clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition was suspected. The Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus. He did not have malunion of the humerus with moderate or marked deformity. The Veteran used a sling. The examiner noted: Arthrogram 2009 showed failed coracoid bone graft fusion to glenoid (failed Bristow procedure) bone. He has degenerative joint disease of the shoulder which is a progression of [service-connected] shoulder. He has history of adhesive capsulitis shoulder diagnosed in the past as well which is a progression of [service-connected] shoulder. Injury in [service] demonstrated humeral head deformity (Hill Sachs deformity). On VA examination conducted December 12, 2019, the Veteran reported flare-ups of the left shoulder that occur daily and were moderate/severe. The left shoulder flare-ups lasted all day and were alleviated by medications and rest. The examiner was unable to test the ranges of left shoulder motion but noted pain that caused functional loss. There was pain with weight bearing and crepitus. Muscle strength testing noted 0/5 strength for flexion and abduction. There was no muscle atrophy. The examiner noted ankylosis in abduction between favorable and unfavorable (intermediate ankylosis). A rotator cuff condition was not suspected. No clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition was suspected. The Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus. He did not have malunion of the humerus with moderate or marked deformity. On VA examination in March 2021, the Veteran reported constantly dislocating his shoulder just trying to get on the bed. He had pain constantly and used a sling every day. On examination, flexion was to 120 degrees; abduction was to 120 degrees; external rotation was to 75 degrees; and internal rotation was to 75 degrees. There was no additional functional loss or range of motion after three repetitions. There was evidence of pain with weightbearing and with active and passive motion. The Veteran was not examined immediately after repeated use over time; the examiner stated the procured evidence (statements from the Veteran) did not suggest that pain, fatigability, weakness, lack of endurance, or incoordination significantly limited functional ability with repeated use over time. The examiner was not conducted during a flare-up. The examiner estimated that ranges of motion during flare-ups based on information procured from relevant sources including the lay statements of the Veteran would be flexion to 120 degrees; abduction to 120 degrees; external rotation to 75 degrees; and internal rotation to 75 degrees. The examiner noted that the Veteran's left shoulder disability interfered with his ability to lift and carry. There was no muscle atrophy and no ankylosis. Rotator cuff tests were negative. Shoulder instability was present. No clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition was present. The Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus. He did not have malunion of the humerus with moderate or marked deformity. Analysis For the one-year look back period prior to December 5, 2007, the record does not contain relevant medical evidence addressing the left shoulder disability. Thus, a rating in excess of 20 percent prior to December 5, 2007 is not warranted. For the period from December 5, 2007 to May 25, 2017, the Veteran has been assigned a 30 percent rating, the maximum available under Diagnostic Code 5201 based on limitation of motion of the minor shoulder. A higher rating would require evidence of unfavorable ankylosis of the scapulohumeral articulation, with abduction limited to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5200. The relevant evidence during this time period does not demonstrate such unfavorable ankylosis. The February 2008 and April 2009 VA examiners noted ranges of motion of the left shoulder; they did not describe any ankylosis. The January 2011 VA examiner specifically noted that the Veteran did not have ankylosis. The April 2012 VA examiner also stated that there was no ankylosis. The April 2014 examiner noted ankylosis, with abduction limited to 25 degrees from the side; this examiner subsequently provided an addendum in July 2016 noting that the earlier statement was in error and that there had been no ankylosis found on the April 2014 examination. For the period from May 26, 2017 to December 11, 2019, the Veteran has been assigned a 40 percent rating under Diagnostic Code 5200. This was based on the finding on the May 26, 2017 VA examination that the Veteran had ankylosis in abduction at 25 degrees or less from side (unfavorable ankylosis). This is the maximum rating available for the minor shoulder under this Diagnostic Code. From December 12, 2019, the Veteran has again been assigned a 30 percent rating, the maximum available under Diagnostic Code 5201 based on limitation of motion of the minor shoulder. A higher rating would require evidence of unfavorable ankylosis of the scapulohumeral articulation, with abduction limited to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5200. The December 2019 VA examiner described ankylosis in abduction between favorable and unfavorable (intermediate ankylosis). This warrants a 30 percent rating under DC 5200. The March 2021 VA examiner found no ankylosis. As the Veteran's symptoms involve pain and limitation of motion, an assignment of a rating under both 5200 and 5201 would involve impermissible pyramiding. See 38 C.F.R. § 4.14. However, the Board finds that for the period on appeal since April 30, 2012, it is reasonable to conclude that the evidence shows instability of the Veteran's left (minor) shoulder joint as part of the impairment associated with his service-connected left shoulder disability. No such instability is demonstrated prior to April 30, 2012. The February 2008 VA examiner noted that the Veteran reported no dislocations of the shoulder for many years. The January 2011 VA examiner noted that the Veteran's left shoulder was not definitely unstable and that he had no recurrent dislocation of the scapulohumeral joint. The April 30, 2012 VA examination report noted guarding of all movements and a history of recurrent shoulder dislocations. The April 2014 VA examiner noted the same. The May 2017 VA examination noted that the Veteran reported frequent subjective subluxation, every two months. The examiner also noted guarding of all movements and a history of recurrent dislocations. On the March 2021 VA examination, the Veteran reported "constantly" dislocating his shoulder, and the examiner noted evidence of instability. Diagnostic Code 5202 provides that a 20 percent rating is warranted for the minor shoulder when there is recurrent dislocation with either (a) frequent episodes and guarding of all arm movements, or (b) infrequent episodes and guarding of movement only at shoulder level. Resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for a new separate 20 percent rating under Diagnostic Code 5202 have been met for the Veteran's left shoulder disability since April 30, 2012. To this extent, the appeal is granted. The Board notes that no rating in excess of 20 percent is available on the basis of the shown joint instability for the minor shoulder. There is no indication in this case showing fibrous union, nonunion (false flail joint), or loss of head (flail shoulder) of the humerus. Accordingly, no rating in excess of 20 percent is warranted under Diagnostic Code 5202. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. In summary, the Board finds that no rating in excess of 30 percent prior to May 26, 2017 or since December 12, 2019 is warranted for the left shoulder disability under Diagnostic Code 5200 or 5201 concerning ankylosis or limitation of motion; no rating in excess of 40 percent from May 26, 2017 to December 11, 2019 is warranted for the left shoulder disability under Diagnostic Code 5200 or 5201 concerning ankylosis or limitation of motion; but a new separate/additional 20 percent rating is warranted for the left shoulder disability under Diagnostic Code 5202 for instability of the joint since April 30, 2012. Finally, under Diagnostic Code 5203, 20 percent is the highest schedular rating available; there also is no evidence of impairment of the clavicle or scapula. 5. Entitlement to initial ratings for left knee sprain in excess of 10 percent prior to December 12, 2019, in excess of 50 percent from December 12, 2019 to March 30, 2021, and in excess of 10 percent from March 31, 2021 The September 2009 rating decision on appeal granted service connection for left knee sprain. An initial 10 percent rating was assigned from June 4, 2008. The Veteran disagreed with the initial rating. A July 2016 rating decision assigned an effective date of March 3, 2008 for the award of service connection. A subsequent April 2021 rating action increased the rating to 50 percent from December 12, 2019, and assigned a 10 percent rating from March 31, 2021. The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Evidence A February 2008 private treatment record noted left knee range of motion from zero to 135 degrees. The knee was stable and there was no effusion. X-rays showed mild medial compartment joint space narrowing. The impression was mild left knee arthritis. On a VA examination in April 2009 the Veteran reported daily pain in the knee with standing and walking. He had not had any surgery. He wore no brace and did not rely on any assistive devices to ambulate. The Veteran reported no instability, only pain. On examination, there was full extension of the left knee to zero degrees and flexion to 140 degrees on three repeats without pain, weakness, fatigability, or loss of endurance. There was no measurable valgus or varus deformity. The kneecap was not lax. There was no laxity of the knee joint. There was no joint heat, effusion, or tenderness. The examiner noted chronic left knee sprain. The examiner did not see any disability with respect to the left knee. On VA examination in September 2009, the Veteran reported continued left knee pain. He denied any operations. The Veteran denied any subluxations, dislocations, or instability. His daily pain was an 8/10 on the lateral aspect of his knee. He described the pain as constant and unchanging. It was worse standing or at night. He denied any locking. The Veteran stated that he could walk 500 feet. He could sit 45 minutes and stand 10 minutes. He tried to avoid squatting. He had no flares. There was no change with repetitive use. The examiner noted in the past, the Veteran had been given a diagnosis of arthritis of his left knee, however, "on x-rays that were performed at our location, the knee was diagnosed as being normal without any arthritic changes." On examination, the left knee had a normal appearance. There was no effusion, redness, or scar. There was minimal lateral tenderness in the joint line. There was no patellar tenderness. Negative Lachman test. Negative collateral ligament test. McMurray test was normal. Extension was to zero degrees and flexion to 130 degrees. There was minimal tenderness in the lateral aspect of the left knee throughout the range of motion exercises. On VA examination in July 2016, range of left knee motion was from zero to 90 degrees. Pain was noted on examination, but the examiner noted it did not result in/cause functional loss. There was pain with weight bearing, and moderate to severe pain to palpation of the knee joint. There was objective evidence of crepitus. There was no additional functional loss or range of motion after three repetitions. The examiner noted that the Veteran was examined immediately after repetitive use over time. Pain and fatigue significantly limited his functional ability with repeated use over a period of time, but the range of motion remained unchanged. The examiner stated that pain, weakness, fatigability or incoordination did not significantly limit functional ability with flare-ups. Left knee muscle strength was 4/5 for flexion and extension. There was no muscle atrophy. There was no ankylosis. There was no joint instability shown on testing. There was no history of meniscal condition. X-rays showed patellar spurring and slight narrowing of the lateral joint compartment. No acute abnormality was present. A VA examination conducted December 12, 2019 diagnosed left knee sprain. The Veteran reported flare-ups. Initial range of motion was extension of 50 degrees and flexion to 75 degrees. Pain was noted on exam (in flexion and extension) and it caused functional loss. There was evidence of pain with weight bearing. The Veteran performed repetitive use testing with at least three repetitions without additional loss of function or range of motion. The examination was not conducted immediately after repetitive use over time or during a flare-up. The examiner stated that pain, weakness, fatigability, or incoordination did not limit functional ability. Muscle strength testing noted 3/5 strength for flexion and 5/5 for extension. There was no muscle atrophy. The knee joint was not ankylosed. There was no history of recurrent subluxation or lateral instability. Joint stability testing was not performed, but no explanation was provided. There was no evidence of recurrent patellar dislocation. The examiner noted objective of pain on passive range of motion testing and on nonweight bearing of the knee. VA examination dated March 31, 2021 diagnosed left knee sprain. The Veteran reported flare-ups. Initial range of motion was noted as extension to zero degrees and flexion to 100 degrees. Pain was noted on exam (in flexion and extension). Passive range of motion and active range of motion were the same. There was evidence of pain with weight bearing, active motion, and passive motion. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of function or range of motion. There was no history of meniscal condition. The examination was not conducted immediately after repetitive use over time; the examiner stated that pain, weakness, fatigability, or incoordination would not limit functional ability after repetitive use. The examination was not conducted during a flare-up; the examiner stated that pain caused functional loss during flare-ups and estimated the range of motion during such as flexion of 100 degrees and extension of zero degrees. The knee joint was not ankylosed. Joint stability tests were normal. Analysis The evidence prior to December 12, 2019 does not provide a basis for a rating in excess of the 10 percent currently in effect for painful motion. For this period, the Board finds the criteria for a higher rating based on limitation of motion are not met. The record does not suggest limitation of extension. Range of motion testing consistently revealed flexion to at least 90 degrees, with flexion measured at 130 degrees, 135 degrees, and 140 degrees on other examinations. The July 2016 examiner specifically noted that pain and fatigue significantly limited the Veteran's functional ability with repeated use over a period of time, but that the range of motion remained unchanged. The examiner stated that pain, weakness, fatigability or incoordination did not significantly limit functional ability with flare-ups. There is no evidence, including history, that the Veteran had limitation of extension or sufficient limitation of flexion to warrant more than the 10 percent rating assigned for limitation of motion including during flares or after repetitive use during this period. For the period from December 12, 2019 to March 30, 2021, the RO has assigned a 50 percent rating based on the extension recorded as 50 degrees on the December 2019 VA examination. That is the highest rating available based on limitation of extension. There is no basis for a compensable rating under DC 5260 based on limitation of flexion as flexion was not shown to be limited to 45 degrees. The evidence since March 31, 2021 does not provide a basis for a rating in excess of the 10 percent currently in effect for painful motion. The March 2021 examiner measured range of motion as zero to 100 degrees and the examiner estimated that this motion would be the same during flare-ups. There is no evidence, including history, that the Veteran had limitation of extension or sufficient limitation of flexion to warrant more than the 10 percent rating assigned for limitation of motion including during flares or after repetitive use during this period. The Board has considered whether a separate or higher rating is warranted based on alternate diagnostic code. The record does not suggest that the Veteran has malunion or nonunion of the tibia and fibula, so a rating is not warranted under Diagnostic Code 5262. Additionally, at no time has the evidence shown any meniscal involvement, history of knee surgery, or instability of the left knee, thus higher ratings are not warranted under Diagnostic Codes 5257, 5258, or 5259. In sum, entitlement to a higher initial ratings for the service-connected left knee sprain is not warranted. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. G. Mazzucchelli, 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.