Citation Nr: 21070902 Decision Date: 11/26/21 Archive Date: 11/26/21 DOCKET NO. 12-10 126 DATE: November 26, 2021 ORDER Service connection for a cervical spine disorder is denied. Service connection for numbness of the upper and lower extremities is denied. Service connection for dizziness is denied. A rating higher than 20 percent for a left shoulder disability is denied. FINDINGS OF FACT 1. The most probative evidence is against a finding that the Veteran's current cervical spine/neck disorder had its onset during active duty service or is related to such service; that arthritis in the neck was manifested within one year of the Veteran's discharge from active duty service; or that the current cervical spine/neck disorder was caused or aggravated by the Veteran's service-connected thoracic spine disability. 2. The most probative evidence is against a finding that the Veteran's numbness of the upper and lower extremities onset during active duty service or is related to such service; or that the numbness was caused or aggravated by the Veteran's service-connected thoracic spine disability. 3. The Veteran experienced an episode of vertigo/dizziness during the appeal that was suspected to have been caused by medication taken for a nonservice-connected disability; complaints of dizziness that pre-date the appeal period were also linked to medication taken for a nonservice-connected disability. 4. The Veteran's left shoulder disability has not been manifested by limitation of the minor arm motion to 25 degrees from the side or less. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical spine disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for numbness of the upper and lower extremities have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 3. The criteria for service connection for dizziness have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 4. The criteria for a rating higher than 20 percent for a left shoulder disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5201. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from January 1973 to November 1983. These matters come to the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran presented testimony at a personal hearing before the undersigned Veterans Law Judge in June 2014. A transcript is of record. The claims were denied by the Board in August 2019. The Veteran appealed the Board's August 2019 decision to the United States Court of Appeals for Veterans Claims (Court). In a July 2020 Joint Motion for Partial Remand, the parties requested that the Court vacate the August 2019 Board decision that denied service connection for a cervical spine disorder, numbness of the upper and lower extremities, and dizziness, and entitlement to a rating higher than 20 percent for a left shoulder disorder. In a July 2020 Order, the Court granted the Joint Motion. The claims were remanded by the Board in January 2021. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Where a veteran served continuously for 90 days or more during active service, and arthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. § §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may be established on a secondary basis for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Further, a disability that is aggravated by a service-connected disability may be service connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). 1. Service connection for a cervical spine disorder 2. Service connection for numbness of the upper and lower extremities The Veteran seeks service connection for a cervical spine (neck) disorder. He alleges his neck disorder is the result of an injury that occurred at the same time as his thoracic spine injury, for which he is service connected. The Veteran reports recurrent symptoms since that time. He has also raised service connection for a neck disorder as secondary to his service-connected thoracic spine disability. Since the Veteran has been diagnosed during the appeal with a cervical spine disorder, the first criterion for establishing service connection has been met. The question becomes whether this condition is related to service or to the service-connected thoracic spine disability. The Veteran also seeks service connection for upper and lower extremity numbness. He asserts both that the in-service injury resulting in his thoracic spine disability caused the numbness and that the numbness is secondary to his service-connected thoracic spine disability. For purposes of continuing the service connection analysis, the Board will accept the Veteran's contention that he experiences numbness in his bilateral upper and lower extremities. The question becomes whether this condition is related to service or to the service-connected thoracic spine disability. Service treatment records do reflect complaints related to the neck. In July 1977, the Veteran was seen with left upper trapezius pain with movement of his neck as well as pain in the same area with cough and sneeze. The onset was the day prior after having worked on his car without injury. The Veteran also reported a cervical strain with heavy lifting one and one-half years before. The July 1977 assessment was mild left upper trapezius pain. In August 1977, the Veteran reported neck pain the night before during mobilization. It was also noted that he had had a similar episode the month before and that he had sustained an original injury two years prior when he felt a pop in his neck. The assessment made in August 1977 was related to the thoracic spine, not the cervical spine (neck). There is no indication that the Veteran was seen with complaints involving his neck following the August 1977 treatment, and no mention of neck problems was made during examinations in November 1978 and May 1983. Service treatment records indicate that the Veteran reported a strange feeling in his left arm, like it was going to sleep, in August 1977. No assessment specific to the left arm was made at that time and service treatment records do not document complaints made in reference to the right arm or either lower extremity. The Veteran denied leg cramps and neuritis during a November 1978 examination and there were no references to numbness of any extremity during a May 1983 examination. The Veteran underwent a VA examination in January 1984, approximately two months after his discharge from service. He reported that he threw his neck out during service in 1975 but made no complaint specific to the neck at that time and no diagnosis related to the cervical spine/neck was provided. The Veteran also reported that his arm would go to sleep and was sore at times. Physical examination revealed grossly intact cranial nerves and there were no diagnoses made regarding any extremity. VA medical records indicate that the Veteran underwent lumbar CT scan in September 2002 due to right sacroiliac notch pain with radiation down the back of the leg and mild degenerative joint disease. The pertinent impression was no obvious spinal canal stenosis. Records obtained from the Social Security Administration (SSA) indicate that in October 2002, the Veteran reported that his right lower extremity pain and numbness developed two years prior. Another private record dated in October 2002 indicates that the Veteran reported intermittent right lower extremity pain began last winter; an impression of right lower extremity pain and dysesthesias, etiology unknown, was made. VA medical records indicate the Veteran has reported the numbness in his upper and lower extremities initially began in 2003. During a June 2010 VA examination, the examiner noted that the Veteran had pain, numbness, and tingling down both legs, which would not be related to mild stable compression fractures of thoracic spine. It was noted he had known cervical and lumbar spine conditions and that the thoracic vertebra in areas 7, 8, and 9 do not cause radicular symptoms to the extremities as these dermatome lines do not track in these areas. The examiner indicated that only a severed or severe spinal cord compression at this level would cause lower extremity issues. This opinion is afforded high probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). An April 2011 VA record indicates the Veteran was complaining of numbness in the hand and feet and was assessed with diabetic neuropathy. A May 2015 VA record assessed cervical radiculopathy secondary to herniated disc C4-C6; in October 2015, the Veteran was diagnosed with bilateral claudication after reporting that he experienced needles/pins like feeling in his feet with walking and he also experienced calf cramping with walking along with right hip discomfort. The Veteran underwent a VA thoracolumbar spine examination in February 2016, at which time the examiner noted he had radicular pain/signs or symptoms due to radiculopathy of both lower extremities, specifically mild intermittent pain (usually dull), mild paresthesias and/or dysesthesias, and mild numbness. The nerve roots involved were L4/L5/S1/S2/S3, the sciatic nerves. The examiner noted that all complaints of radiculopathy are not related to the thoracic spine disability. The Veteran underwent a cervical spine conditions VA examination in September 2016. He reported an in-service injury to his neck when a portable hospital fell from a truck onto him, resulting in his inability to move his head the following day. The Veteran indicated that he did not have any problems with his neck until 2003, when he was told he had bulging discs. The Board notes that this is corroborated in the record, since an April 2003 VA examination noted that magnetic resonance imaging of the cervical spine showed protruding disk at the fifth through sixth cervical, foraminal stenosis on the left, spinal canal narrowing at this level, and moderate circumferential disk bulge at the fourth through fifth cervical. The September 2016 VA examiner noted the in-service references made to the Veteran's neck in July and August in 1977 but provided an opinion that the current condition was less likely than not incurred in or caused by the claimed in-service injury or event. The rationale was based on a determination that there were no true problems or chronic problems noted of the cervical spine in service; that no problems were noted until 20 years after service; and that the degenerative changes noted in the cervical spine are related to aging. An addendum opinion on the claim involving the cervical spine was obtained in June 2017 from the same VA examiner, who provided an opinion that the compression fracture and all symptoms from the Veteran's thoracic spine disability do not etiologically cause a cervical spine problem. The examiner explained that individuals with compression fractures do not typically suffer extension of problems to the rest of the spine unless the trauma is very significant at which point the rest of the spine would have suffered immediately at the time with further fractures etc. and would be apparent at the time of trauma. The examiner reiterated that the Veteran's cervical spine problems many years after service would not be secondary to his complaints during service or from his thoracic spine problems. During the September 2016 VA cervical spine conditions examination, the examiner noted complaint of left arm numbness during service in August 1977 and that an October 1983 service record documents that the Veteran reported awakening with numbness in his arms and tingling in his hands that resolved quickly with movement. The examiner indicated that no true nerve problem was noted at that time. The examiner also noted that a private chiropractor reported arm numbness but did not conduct medical or radiological workup since it was suspected to be secondary to the cervical spine. This is corroborated by a June 2014 letter from chiropractor W.L.W., who reports that the Veteran's hand numbness and elbow pain involve the brachial plexus, which comes off of the cervical region. The September 2016 VA examiner also provided an opinion that the Veteran's problems with paresthesias and numbness of the arms are not the same problem as in service and occurred much later. In October 2016, a nerve conduction study revealed mild left S1 radiculopathy. In a letter faxed in January 2018, private physician M.A.B. reported that the Veteran's in-service injury could have been the initial injury leading to his current condition. While not specific as to what current condition Dr. B. was referring, the cervical spine findings on imaging reports were referenced. This opinion is not afforded high probative value since it is conclusory and speculative in nature. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (noting that the use of the term "could," without other rationale or supporting data, is speculative). The Veteran underwent another VA cervical spine conditions examination in November 2018. He reported injuring his neck in 1975 when a portable hospital fell on him and being told he had a cervical strain. The examiner noted that no x-rays were taken at that time, that the Veteran was placed in a cervical collar, and that his symptoms had gotten progressively worse since that time. It was the examiner's opinion that the arthritis in the Veteran's cervical spine was aggravated by the service-connected thoracic spine disability because the injury had progressed from cervical strain to cervical arthritis. This opinion is not afforded high probative value because it is based on an inaccurate factual premise, namely that the Veteran was placed in a cervical collar during service following a diagnosis of cervical strain, which is not corroborated by service treatment records. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative); see also Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely") (citing Reonal)). The Veteran also underwent a VA peripheral nerves examination in November 2018. In the diagnosis section, the examiner wrote "Has neuropathy due to the diabetes and a peripheral nerve condition due to injury when Mobil hospital fell on him. Both upper and lower neuropathy." The examiner provided an opinion that the claimed conditions are at least as likely as not proximately due to or the result of the Veteran's service-connected condition. The rationale was that the "current severity of the service connected peripheral nerve condition warrants by proximity, association of the claimed secondary CONDITION. The disorder began subsequent to the service connected condition and is the direct result of the antecedent condition. The medical literature supports this. A nexus is established." In the remarks section, the examiner indicated that the peripheral nerve condition is related to the compression fracture of the back of T7-8-9 residuals. The November 2018 VA examiner also provided an opinion addressing whether the numbness of upper and lower extremities is at least as likely as not aggravated beyond its natural progression by the Veteran's service-connected thoracic spine condition. In answering this question, the examiner reported that after the in-service injury, the Veteran had progressive pain and limited movement of his back, and pain to the point in 2003 he was contemplating suicide; that the fractures in his thoracic back have led to numbness in his feet and legs; and that the numbness had progressed beyond its natural progression. These opinions are not afforded high probative value because they are based on an inaccurate factual premise, namely that the numbness in the upper and lower extremities began subsequent to the in-service injury that resulted in a service-connected condition. See Reonal, 5 Vet. App. at 461; see also Monzingo, 26 Vet. App. at 107. It appears that the examiner relied upon the Veteran's history in providing these opinions rather than by reviewing the medical evidence specific to this case, which shows that when receiving private and VA treatment, the Veteran reported that the onset of his upper and lower extremity numbness began between 2000 and 2003. Another addendum opinion was obtained in February 2019 from the VA examiner who conducted the September 2016 examination to address whether the cervical spine/neck disorder was aggravated by the service-connected thoracic spine disability. The examiner provided an opinion against the claim. The rationale was based in part on a determination that numerous radiological studies confirm that the thoracic spine disability did not aggravate the cervical spine/neck disorder. The examiner also noted that the compression fractures of the thoracic spine are mild and healed with some mild kyphosis noted on radiological study only; that the medical record did not indicate there was any residual sequelae; that the cervical spine problems were due to the inherent development of his cervical spine with aging only; and that the problems and symptoms of the thoracic spine during service were of an acute and resolved nature as noted in the service treatment records and would not cause the problems of his cervical spine some 20-30 years later. An addendum opinion was also obtained from this VA examiner to address the claim for service connection for upper and lower extremity numbness. The examiner determined that the numbness in the upper and lower extremities is less likely than not proximately due to or the result of the Veteran's service-connected thoracic spine disability. The rationale was that the symptoms as described and the radiological studies do not show the upper extremity numbness to be due to diabetes, but rather consistent with his cervical spine condition as noted on MRI in 2017. The examiner further stated that the upper extremity numbness would not be the result of or aggravated by the healed thoracic spine compression fracture. Regarding the lower extremity numbness, the examiner indicated that it was secondary to S1 radiculopathy and peripheral vascular disease of the lower extremities. The examiner explained that the compression fractures of the thoracic spine are healed with no objective sequelae and that the service-connected disability would not cause or aggravate the numbness as verified by the results of all the radiological studies reviewed and symptoms identified. The opinions provided by the September 2016 VA examiner are afforded high probative value because they consider the Veteran's lay assertions as well as his service and post-service medical records, to include imaging reports associated with his spine. See Nieves-Rodriguez, 22 Vet. App. at 302-04. The claims for service connection for a cervical spine disorder and numbness of the upper and lower extremities were remanded by the Board in January 2021 to comply with the Joint Motion and to obtain an opinion to better address the question of whether the Veteran's service-connected thoracic spine condition had aggravated the cervical spine/neck disorder and/or numbness of the upper and lower extremities. The requested opinion was provided in January 2021. The examiner concluded that the condition claimed is less likely than not proximately due to or the result of the Veteran's service-connected condition. In the rationale section, the examiner stated that the thoracic spine disability did not aggravate the cervical spine or nerves from the cervical spine; that the thoracic spine disability does not affect the cervical spine and/or any disability manifested by upper or lower extremity numbness above the thoracic spine and there is no medical evidence or research to suggest that a thoracic spine condition can aggravate a cervical spine condition and/or any disability manifested by upper or lower extremity numbness; and that the cervical spine does not affect the lower extremities nor does the thoracic spine affect the upper or lower extremity nerve innervation. The Veteran's attorney asserts that the opinion obtained on remand regarding the cervical spine disorder and numbness of the upper and lower extremities is inadequate because it merely states, without any support, that there is no connection between thoracic and cervical spine disabilities generally and failed to consider whether an alteration of the Veteran's gait or weightbearing could cause or aggravate a cervical spine disability. The attorney further asserts that although the examiner vaguely and broadly stated that no medical research suggests a connection between thoracic and cervical spine disabilities, the examiner did not describe any research conducted in this case or relate any current research to the Veteran's particular conditions. The Board disagrees and finds that the January 2021 opinion is adequate. The Veteran and his attorney have not submitted any medical research or literature to refute the examiner's determination that there is no connection between the service-connected thoracic spine disability and the cervical spine/neck disability and/or numbness of the upper and lower extremities. Nor have the Veteran and his attorney submitted any medical evidence to show that the Veteran's gait and weightbearing caused or aggravated his cervical spine disability. In fact, the Board has reviewed the medical evidence of record specific to the Veteran and finds that while he underwent physical therapy for gait training, his altered gait was due to a knee amputation that resulted from peripheral vascular disease and subsequent prosthesis; it was not due to the service-connected thoracic spine disability. In addition, while the medical evidence specific to the Veteran indicates that he has complained of right shoulder pain when weight bearing through the right upper extremity on walker or forearm crutches when walking with prosthesis, his complaints do not include the cervical spine/neck. Since the Board finds the January 2021 VA opinion to be adequate, it is afforded high probative value. Id. The preponderance of the evidence is against the claim for service connection for a cervical spine/neck disorder. Service connection is not warranted on a presumptive basis because there is no evidence of arthritis involving the cervical spine/neck within one year of the Veteran's November 1983 discharge from service. Service connection is not warranted on direct or secondary bases because the most probative opinions of record, namely those provided by the September 2016 VA examiner during that examination and in addendum opinions in June 2017 and February 2019, and by the January 2021 VA examiner, do not establish a link between the current cervical spine/neck disorder and the in-service references to the neck or to the service-connected thoracic spine disability. The opinions provided by the September 2016 VA examiner, considered together, are afforded high probative value because they consider the Veteran's lay assertions as well as his service and post-service medical records, to include imaging reports associated with his cervical spine. See Nieves-Rodriguez, 22 Vet. App. at 302-04. While the Veteran believes that his cervical spine/neck disorder is related to service or his service-connected thoracic spine disability, as a lay person, he has not shown that he has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnosis and etiology of a neck disorder are matters not capable of lay observation and require medical expertise to determine. Accordingly, the Veteran's opinion as to the diagnosis or etiology of any neck disorder, to include the assertion that his post-service problems are related to the in-service injury that resulted in a grant of service connection for a thoracic spine disability, is not competent medical evidence. Moreover, whether the symptoms the Veteran experienced in service or following service are in any way related to his current disability is also a matter that also requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Thus, the Veteran's own opinion regarding the etiology of his current neck disorder is not competent medical evidence. The Board finds the opinions provided by the September 2016 and January 2021 VA examiners to be significantly more probative than the Veteran's lay assertions and the other medical opinions of record. The preponderance of the evidence is also against the claim for service connection for numbness of the upper and lower extremities. Service treatment records do not show the Veteran experienced numbness in the right upper extremity or either lower extremity; although there are complaints associated with the left upper extremity/arm, the September 2016 VA examiner provided a probative opinion that no true nerve problem was noted at that time. Moreover, the probative opinions of record link the upper extremity numbness to the Veteran's cervical spine disability, a determination also made by the Veteran's private chiropractor, and the probative opinions of record have linked the lower extremity numbness to S1 radiculopathy due to the lumbar spine disability and peripheral vascular disease. The sciatic nerve involvement noted during the February 2016 VA examination was specific to two lumbar segments and three sacral segments (L4/L5/S1/S2/S3). In the absence of probative evidence establishing a link between the upper and lower extremity numbness and service, service connection is not warranted on a direct basis. Service connection is also not warranted for the upper and lower extremity numbness as secondary to the service-connected thoracic spine disability since the probative opinions of record do not support a finding that the thoracic spine disability caused or aggravated the numbness. As noted above, the June 2010 VA examiner explained that the thoracic vertebra in areas 7, 8, and 9 do not cause radicular symptoms to the lower extremities as these dermatome lines do not track in these areas; the September 2016 VA examiner explained that symptoms as described and radiological studies establish that the numbness in the upper and lower extremities was not caused by or aggravated by the thoracic spine disability; and the January 2021 VA examiner explained that the thoracic spine does not affect the upper or lower extremity nerve innervation. To the extent the upper extremity numbness has been attributed to the cervical spine disorder, the lower extremity numbness has been attributed to the lumbar spine disorder, and the right sciatic nerve involvement has been attributed to the lumbosacral spinal segments, since service connection has been denied for the cervical spine/neck and lumbar spine/low back disorders, service connection for numbness involving the upper and lower extremities is not warranted on a secondary basis. While the Veteran believes that his upper and lower extremity numbness is related to service or his service-connected thoracic spine disability, as a lay person, he has not shown that he has specialized training sufficient to render such an opinion. See Jandreau, 492 F.3d at 1376-77. In this regard, the diagnosis and etiology of upper and lower extremity numbness are matters not capable of lay observation and require medical expertise to determine. Accordingly, the Veteran's opinion as to the diagnosis or etiology of any upper and lower extremity numbness, to include the assertion that his post-service problems are related to the in-service injury that resulted in a grant of service connection for a thoracic spine disability, is not competent medical evidence. Moreover, whether the symptoms the Veteran experienced in service or following service are in any way related to his current disabilities is also a matter that also requires medical expertise to determine. See Clyburn, 12 Vet. App. at 301. Thus, the Veteran's own opinion regarding the etiology of his current upper and lower extremity numbness is not competent medical evidence. The Board finds the opinions provided by the June 2010, September 2016, and January 2021 VA examiners to be significantly more probative than the Veteran's lay assertions and the other medical opinion of record. 3. Service connection for dizziness The Veteran seeks service connection for dizziness. He asserts it is the result of the in-service injury resulting in his thoracic spine disability and that it is secondary to his neck condition. Service treatment records do not document any complaints related to dizziness and the Veteran denied dizziness or fainting spells at the time of a November 1978 examination. VA treatment records dated since the claim was filed indicate that the Veteran consistently denied dizziness prior to April 2013, when he was seen at a VA emergency room with a complaint of vertigo, reporting that he had weekly episodes that come on suddenly at rest and last 10-15 seconds. These started in the 1980s. He reported that popping his neck resolved the vertigo completely, but it returned and his wife brought him to the emergency room. A subsequent April 2013 record includes a diagnosis of dizziness, suspect due to Gabapentin. VA treatment records indicate that the Veteran was prescribed this medication for diabetic neuropathy and complaint of numbness in his hands and feet. The Joint Motion determined that the Board failed to address two VA treatment records containing complaints of dizziness, one dated May 3, 2004, and the other dated the following day. The Board notes that these records pre-date the timeframe on appeal. The May 3, 2004, record is a VA primary care telephone encounter note, which indicated that the Veteran "states he also feels dizzy with a spinning sensation with new med Plavix." The May 4, 2004, record is a VA outpatient note, which indicates that the Veteran "said he is doing okay on Plavix except last week, he had one brief episode of dizziness but has been doing okay since then." These complaints of dizziness are also tied to medication use rather than to any incident in service or a service-connected disability, since the VA records indicate that Plavix was prescribed for coronary artery disease and service connection has not been established for that disability. The preponderance of the evidence is against the claim for service connection for dizziness on a direct basis. Service treatment records do not show the Veteran experienced dizziness during service and the medical evidence does not establish that the post-service complaints of vertigo/dizziness are related to any incident in service. In that vein, the May 2004 references to dizziness were related to the administration of Plavix and the Veteran's April 2013 vertigo/dizziness was suspected to be due to Gabapentin. Service connection is also not warranted on a secondary basis because the neck disorder is not service-connected, and the medication suspected to have caused the Veteran's dizziness is not being taken for a service-connected disability. Increased Rating 4. Entitlement to a rating higher than 20 percent for a left shoulder disability Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part or all the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40; see also 38 C.F.R. §§ 4.45, 4.59. Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Service connection was originally granted for the left shoulder disability in a May 1984 rating decision, which assigned a noncompensable rating by analogy pursuant to 38 C.F.R. § 4.73, Diagnostic Code 5301, effective November 2, 1983. The rating was increased to 20 percent, effective April 2, 2010, pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5201, in a February 2017 rating decision issued during this appeal. The Board must determine whether the Veteran is entitled to a rating higher than 20 percent under the currently applied rating criteria. Diagnostic Code 5003 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. The Veteran's left shoulder disability has been rated under Diagnostic Code 5201 based upon limitation of arm motion. The record shows that the Veteran is right-handed, and thus, his left arm/shoulder is considered his minor arm for rating purposes. Under Diagnostic Code 5201, a maximum 30 percent rating is warranted for limitation of the minor arm motion to 25 degrees from the side. Normal shoulder forward elevation (flexion) and abduction is from zero to 180 degrees, with 90 degrees representing shoulder level; normal shoulder external and internal rotation is from zero to 90 degrees. See 38 C.F.R. § 4.71a, Plate I. The Veteran seeks a rating higher than that currently assigned to his left shoulder disability and complains that it pops and grinds with pain. During VA examination in June 2010, he reported left shoulder pain, stiffness, weakness, grinding and popping, and tenderness. The Veteran also described moderate flare-ups occurring weekly and lasting hours; overhead motions and reaching far out precipitated them and rest and medication alleviated them. He denied functional impairment as he was able to do activities of daily living. During a February 2016 VA examination, the Veteran reported grinding, a catching type pain worse with movement, and limited range of motion. He described flare-ups in the form of increased pain and decreased range of motion but denied any functional loss or functional impairment. The Joint Motion determined that a VA medical examination of the Veteran's left shoulder that complies with Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017), was needed. That examination was conducted in July 2021. The Veteran reported pain as his current left shoulder symptom and flare-ups that occurred one to two times a week lasting 12 hours that were precipitated by overuse that resulted in inability to work overhead and at times being unable to comb his hair. The preponderance of the evidence is against the assignment of a rating higher than 20 percent for the left shoulder disability at any time during the course of the appeal. The Board acknowledges the Veteran's assertions concerning the symptoms he experiences as a result of his left shoulder disability during the course of the claim. To merit the assignment of the next highest (30 percent) rating provided under Diagnostic Code 5201, the evidence must show that the Veteran had limitation of the minor arm motion to 25 degrees from the side. The evidence in this case does not show that. Rather, the Veteran's left shoulder exhibited flexion limited, at worst, to 140 degrees and abduction limited, at worse, to 65 degrees. See VA examination reports; VA and private treatment records. Consideration has been given to any functional impairment and any effects of pain on functional abilities due to the Veteran's service-connected left shoulder disability. The Board acknowledges the Veteran's subjective complaints made in written statements, during testimony, and during VA examination. The Board also acknowledges the objective evidence on VA examinations of pain with active and passive motion, on rest/non-movement, and with weight bearing; crepitus; and tenderness or pain to palpation of the joint or associated soft tissue. Finally, the Board acknowledges that the July 2021 VA examiner determined that left shoulder pain with active and passive motion causes functional loss because the Veteran is unable to work overhead and has pain using a wheelchair. In this case, however, the Board does not find any additional functional loss that is not contemplated by the currently assigned 20 percent rating. The Veteran has described functional limitations which are contemplated in the rating criteria, and the Veteran himself has not described additional motion loss or functional impairments during flare- ups that meets or more nearly approximates the criteria for the next higher (30 percent) rating. The Veteran was able to perform repetitive use testing without additional functional loss or loss of motion during that testing during all three VA examinations. Moreover, flexion was, at worst, limited to 140 degrees, and abduction was, at worst, limited to 65 degrees, which are 115 and 40 degrees more, respectively, than the amount needed to support the assignment of a 30 percent rating. The July 2021 VA examiner also clearly stated that the procured evidence (statements from the Veteran) suggest pain significantly limits functional ability with repeated use over time and flare-ups, but flexion and abduction were both estimated to be 160 degrees during repeated use over time and with flare-ups, which signifies a loss of only 20 degrees from normal and represents movement that is 135 degrees more than the amount needed to support a 30 percent rating. Considering the foregoing, the Board finds that a rating higher than the 20 percent assigned for the Veteran's left shoulder disability is not warranted based on functional impairment at any time during the appeal period. 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 204-06. K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Van Wambeke, 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.