Citation Nr: 21073481 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 04-05 493 DATE: December 8, 2021 ORDER A 30 percent evaluation, and no more, for tear of the infraspinatus tendon of the left shoulder with A/C joint arthritis; glenohumeral joint arthritis; rotator cuff tear status post arthroscopy left shoulder from November 30, 2001, is granted. FINDING OF FACT Throughout the appeal period, the Veteran has been shown to have less than 25 degrees of flexion with objective evidence of pain with range of motion testing; there has been no demonstration of ankylosis, malunion, non-union, or dislocation of the humerus or clavicle. CONCLUSION OF LAW The criteria for a disability evaluation for a 30 percent evaluation, and no more, for tear of the infraspinatus tendon of the left shoulder with A/C joint arthritis; glenohumeral joint arthritis; rotator cuff tear status post arthroscopy left shoulder, have been met throughout the appeal period. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5200-5203 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had service from March 1982 to July 1982 and from October 2001 to November 2001. He also had training periods in the Texas Army National Guard. In a June 2019 decision, the Board denied for the Veteran's left shoulder disability ratings higher than 20 percent before November 25, 2011, and higher than 30 percent from November 25, 2011. The Veteran appealed those denials to the United State Court of Appeals for Veterans Claims (Court). In a December 2020 memorandum decision, the Court set aside the June 2019 Board decision and remanded the matters for further development and readjudication. In July 2021, the Board remanded this matter for further development, to include a VA examination. The requested development has been performed and the matter is now ready for appellate review. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the 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 evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In Fenderson, the Court noted an important distinction between an appeal involving a Veteran's disagreement with the initial rating assigned at the time a disability is service connected. Where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection to consider the appropriateness of "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, 12 Vet. App. at 126; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Diagnostic Code 5003 (5010) 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 (DC 5200 etc.). When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Diagnostic Code 5200 rates ankylosis of the scapulohumeral joint. Where arm limitation of motion is limited to 25 degrees from the side, a 30 percent evaluation is assigned for the minor side. Limitation of motion midway between the side and shoulder level contemplates a 20 percent evaluation; while limitation of motion at shoulder level contemplates a 20 percent evaluation. Diagnostic Code 5201. Under Diagnostic Code 5202, for impairment of the humerus in the minor arm, a 20 percent rating is granted when there is malunion, with moderate deformity. Also under Diagnostic Code 5202, for recurrent dislocations at the scapulohumeral joint, a 20 percent rating is granted with infrequent episodes, and guarding of movement only at shoulder level; a 20 percent rating is granted when there are frequent episodes and guarding of all arm movements. A 40 percent rating is granted for fibrous union; a 50 percent rating is granted for nonunion (false flail joint); and a 70 percent rating is granted for loss of head of (flail shoulder). Under Diagnostic Code 5203, for impairment of the clavicle or scapula, a 10 percent rating is granted for malunion or nonunion without loose movement; a 20 percent rating is granted for nonunion with loose movement or for dislocation. The rating criteria for musculoskeletal disorders changed effective February 7, 2021. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453 (Nov. 30, 2020) (to be codified at 38 C.F.R. §§ 4.71a, 4.73). Where the rating criteria affecting a disability have changed, VA will apply the earlier version before February 7, 2021, the effective date for the change. From February 7, 2021, VA will apply either the earlier version or the revised version, whichever is more favorable to the claimant. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The rating schedule changes include some changes in the criteria for rating shoulder disabilities, including at 38 C.F.R. § 4.71a, Diagnostic Codes 5201 and 5202. As to DC 5202, a 20 percent disability evaluation is assigned for limitation of arm motion between sides and shoulder level (flexion and/or abduction limited to 45 degrees for the minor arm) and a 20 percent disability evaluation is warranted for limitation of motion at the shoulder level (flexion and/or abduction limited to 90 degrees. As to DC 5202, a 20 percent disability evaluation is warranted for other impairment of the humerus with infrequent episodes and guarding of movement only at the shoulder level (flexion and/or abduction at 90 degrees). Disability of the musculoskeletal system is the inability to perform normal working movement with normal excursion, strength, speed, coordination, and endurance. Weakness is as important as limitation of motion, and a part which becomes disabled on use must be regarded as seriously disabled. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is to be considered in evaluating the degree of disability, but a little-used part of the musculoskeletal system may be expected to show evidence of disuse, through atrophy, the condition of the skin, absence of normal callosity, or the like. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. § 4.45 contemplate inquiry into whether there is crepitation, limitation of motion, weakness, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing are also related considerations. It is the intention of the rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as at least minimally compensable. See also DeLuca v. Brown, 8 Vet. App. 202 (1995) (indicates that pursuant to 38 C.F.R. §§ 4.40 and 4.45, pain may be the basis for a rating for a disability rated based on limitation of motion, regardless of whether or not the limitation of motion specified in the Diagnostic Code criteria is shown). 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 VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-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 provide opinions regarding flare-ups based upon estimates derived from information procured from relevant sources, including lay statements, when a flare-up is not observable at the time of examination. The evidence of record, to include VA examinations, are sufficient for rating purposes. Treatment records associated with the file reveal that at the time of a March 2005 Arizona Dept. of Economic Security examination, the Veteran was noted to have abduction to 120 degrees, adduction to 50 degrees, flexion to 120 degrees, extension to 30 degrees, internal rotation to 90 degrees, and external rotation to 45 degrees. Inspection revealed a slight asymmetry with his left deltoid being less prominent than the right. His left upper extremity had normal bulk tone and strength except beyond abduction of the shoulder. There was notable crepitance in the glenohumeral joint of the left with passive range and the empty can test on the left revealed palpable stress and pain over the SITS muscle and rotator cuff. Grip strength testing revealed 80 pounds on the right and 40 pounds on the left. A diagnosis of osteoarthritis in the left glenohumeral joint of the shoulder was rendered. In conjunction with his claim, the Veteran was afforded a VA examination in August 2005. At the time of the examination, the examiner stated that the Veteran's descriptions of pain were initially very vivid and somewhat beyond reasonable medical probability. The examiner noted that when asked how his pain scale was on a constant basis, the Veteran initially stated it was 10/10 and when he was asked whether or not his shoulder pain increased with activity, he said yes. The examiner indicated that after again explaining the analog scale, the Veteran stated that his constant pain was 5/10 but it went to 10/10 on a daily basis whenever he went to work. When asked specifically about what activities in particular exacerbated his left shoulder pain, he stated everything did. The examiner noted that the Veteran claimed to be unable to work a buffer, repair equipment, or work on maintenance for the nursing home without causing severe pain in his left shoulder. He indicated that he tried not to use his left arm and, in fact, stated that he kept his left hand in his pocket on a regular basis and did not move his left arm very much during the course of the day. Recumbency seemed to help the shoulder pain. He slept on his right side. He took four Tylenol in the morning and four Tylenol in the evening to also help relieve his pain. He did not use any other local measures, such as heat, ice, or analgesic balms. The Veteran also stated that his left rib pain was constant and that whenever his left rib pain was exacerbated, the left shoulder increased as well, even if he was not using his left upper extremity. Physical examination revealed no evidence of atrophy in the deltoid. There was no evidence of atrophy in the supraspinatus or infraspinatus spots of the left shoulder joint of the left scapula and there was no evidence of atrophy in the biceps or triceps muscle. Motor testing of the left upper extremity with wrist dorsiflexion and wrist palmar flexion increased shoulder pain. This was specifically asked of the Veteran during the course of the examination and he said that anytime he bent his wrist his left shoulder hurt. Finger abduction testing also caused left shoulder pain. Sensory examination was normal. Deep tendon reflexes were brisk and equal in the brachial radialis, biceps, and triceps in both upper extremities. Range of motion in the shoulders with right to left testing showed forward elevation 0-170 degrees/0-120 degrees with pain over the entire arc on the left shoulder. Abduction was 0-170 degrees/0-150 degrees, with pain over the entire arc of motion in the left shoulder. External rotation was 0-80 degrees/0-80 degrees, with pain over the entire arc of motion in the left shoulder. Internal rotation was 0-80 degrees/0-80 degrees with pain over the entire arc of motion in the left shoulder. When the Veteran complained of the pain, the examiner attempted to elicit exactly at what point the pain began with movement of his left shoulder, but the Veteran continued to state that it started as soon as he started moving his left shoulder. Range of motion in the elbow and wrist was normal. Muscle strength testing in the deltoid showed some breakaway weakness which appeared volitional. X-rays of the left shoulder were essentially normal without evidence of osteoarthritis of the acromioclavicular or glenohumeral joint. A February 2007 MRI of the left shoulder revealed rotator cuff impingement due to AC joint hypertrophy with resultant tendonitis but no evidence of rotator cuff or labral tear. A March 2008 MRI of the left shoulder revealed an infraspinatus tendon undersurface partial thickness tear. At the time of a January 2009 VA examination, the Veteran's chief complaint was pain in his left shoulder. He stated that he was unable to carry heavy objects, unable to push with his left arm, and unable to pull with his left arm because of the pain in his left shoulder. He stated that the pain was constant. He reported having had extensive physical therapy which helped only temporarily. He also had had some steroid injections which had helped only minimally and only for a short period of time. He was taking Ibuprofen 800 mg three times a day which helped to alleviate the more severe pain. He reported having weakness and stiffness because of the pain. There was no swelling, heat, or redness detected. There was no history of locking or fatigability or lack of endurance. There were no joint flareups. Grip in the right hand was 40kg versus 15kg on the left. Range of motion testing revealed external rotation 0 to 60, internal rotation 0 to 50; forward flexion 0 to160, and abduction 0 to 60 degrees with repetition. At the time of a December 2011 VA examination, the Veteran was diagnosed as having left shoulder flare-ups, which he described as severe. Left shoulder flexion was from 0 to 15 degrees, with pain beginning at 10 degrees. Left shoulder abduction was also from 0 to 15 degrees, with pain beginning at 10 degrees. After repetitive motion, flexion and abduction were limited to 5 degrees. The Veteran was noted to have less movement than normal, weakened movement, excess fatigability, and swelling. There was localized tenderness/pain on palpation of the joints, soft tissue, and biceps tendon. Muscle strength was 4/5. There was no history of recurrent dislocation of the glenohumeral/scapulohumeral joint. There was no malunion of the clavicle or scapula, nonunion of the clavicle or scapula without loose movement, or nonunion of the clavicle or scapula with loose movement. A past history of dislocation was noted. X-rays of the shoulder revealed that the visualized soft tissues and bony structures were radiographically within normal limits. At the time of an October 2013 VA examination, the Veteran was noted to have left shoulder flexion to 60 degrees, with pain beginning at 50 degrees. Abduction was to 60 degrees with pain beginning at 50 degrees. Left shoulder external and internal rotation ended at 45 degrees, with pain at 45 degrees. Following repetitive motion, flexion was to 50 degrees as was abduction. The Veteran was noted to have less movement than normal and pain on movement. The Veteran did not have localized tenderness or guarding of the shoulder. Muscle strength was 5/5 for abduction and 4/5 for flexion. There was no ankylosis. There was no history of mechanical symptoms. There was also no history of recurrent dislocation of the glenohumeral/scapulohumeral joint. There was no malunion of the clavicle or scapula, nonunion of the clavicle or scapula without loose movement, or nonunion of the clavicle or scapula with loose movement. There was no tenderness of palpation on the A/C joint. At the time of a November 2015 VA examination, the Veteran reported having an increase in pain and decrease in function with prolonged use of his arm. The Veteran noted having a functional loss with a flare-up of his arm. Range of motion revealed flexion from 0 to 50 degrees, abduction 0 to 90 degrees, external rotation 0 to 40 degrees, and internal rotation 0 to 80 degrees. There was no additional loss with repetitive motion. Pain was noted on examination and caused functional loss. There was pain with weightbearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was also no objective evidence of crepitus. Weakness and pain caused functional loss. Muscle strength was 4/5 for forward flexion and abduction. There was no muscle atrophy. There was no ankylosis. A rotator cuff condition was suspected as the Veteran had a positive external rotation/infraspinatus strength test. Hawkins impingement test, empty can test, and lift-off subscapularis tests were all negative. There was no shoulder instability, dislocation, or labral pathology suspected. There was no involvement of the clavicle, scapular, acromioclavicular, or sternoclavicular joint. The Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder) or fibrous union of the humerus. There was no malunion of the humerus with moderate or marked deformity. As to functional limitation, the Veteran indicated that he had had difficulty performing tasks such as holding heavy items, lifting items overhead, and pushing and pulling. At the time of a November 2017 VA examination, the Veteran reported a burning sensation with overuse, especially pulling/pushing. The Veteran stated that he could not lift or carry as much or as often and that he could not use it as much. Range of motion revealed flexion from 0 to 80 degrees, abduction 0 to 65 degrees, external rotation 0 to 50 degrees, and internal rotation 0 to 90 degrees. The Veteran did not perform repetitive motion due to pain. Pain was noted on examination and caused functional loss. The disorder limited use to below shoulder height. There was pain with weightbearing. There was evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The location was the rotator cuff, infra and supraspinatus, biceps head, and A/C Joint. It was noted to be severe. There was objective evidence of crepitus. Weakness and pain caused functional loss. Muscle strength was 4/5 for forward flexion and abduction. Muscle atrophy was present, 39.5 cm vs. 41 cm on the right. There was no ankylosis. A rotator cuff condition was suspected as the Veteran had positive Hawkins impingement test, empty can test, and external rotation/infraspinatus strength test. The left shoulder condition caused less movement than normal, weakened movement, atrophy or disuse, instability of station, and disturbance of locomotion. There was no shoulder instability, dislocation, or labral pathology suspected. The Veteran was noted to have acromioclavicular arthritis. The Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder) or fibrous union of the humerus. There was no malunion of the humerus with moderate or marked deformity. As to functional limitation, the condition limited use at or above shoulder height. Weakness and atrophy secondary to the diagnosed conditions further limited use and contributed to loss of use with overall weakness and discomfort. The conditions collectively contributed to overall loss of range of motion and to pain. The examiner further indicated that the limited use at original range of motion and pain/tenderness on palpation would make practical use extremely painful. The limitations as defined were substantial and use in flare and/or repetitive use would be expected to be extremely painful. At the time of a May 2018 VA examination, the Veteran reported he had recently had about 6 weeks of physical therapy, which didn't really help. He had trouble lifting a gallon of milk. He could not do any overhead movement. He took tramadol 50mg daily, about 3-4 times per day as need for pain (also taken for costochondral pain). He also used a TENS unit several times per day, which did help. He noticed that warmth seemed to relieve the pain, and when he transitioned to a cold environment the pain was much worse. He stated that there was constant throbbing pain at rest and markedly limited movement and that the pain had worsened over time. Range of motion revealed flexion from 0 to 60 degrees, abduction 0 to 60 degrees, external rotation 0 to 20 degrees, and internal rotation 0 to 20 degrees. The Veteran did not perform repetitive motion due to pain. Pain was noted on examination and caused functional loss. The disorder prevented him from reaching overhead. There was pain with weightbearing. There was no evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no objective evidence of crepitus. Weakness and pain caused functional loss. The examiner indicated that this would limit flexion to 50 degrees, abduction to 50 degrees, external rotation to 10 degrees, and internal rotation to 10 degrees. Muscle strength was 5/5 for forward flexion and abduction. There was no muscle atrophy present. There was no ankylosis. A rotator cuff condition was suspected but no tests were performed. Shoulder instability, dislocation, or labral pathology was suspected. The Veteran had a history of mechanical symptoms but there was no history of recurrent dislocation of the glenohumeral/scapulohumeral joint. The Veteran was noted to have A/C arthritis. The Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder) or fibrous union of the humerus. There was no malunion of the humerus with moderate or marked deformity. As to functional limitation, shoulder pain limited reaching, pressing, pushing, and overhead movement. The examiner stated that the Veteran experienced pain in the left shoulder in flexion, abduction, external rotation, and internal rotation, which caused functional loss as well as pain on weight bearing. Due to excessive pain, the Veteran was unable to complete three repetitions of range of motion testing in the left shoulder. In the left shoulder, pain, fatigue and lack of endurance would cause an additional decrease in range of motion after repetitive use over time. There was no left shoulder muscle weakness or lack of coordination upon examination. There was a history of mechanical symptoms such as clicking and catching in the left shoulder; however. no history of recurrent dislocation of the glenohumeral joint. The examiner further noted that the Veteran denied experiencing flare ups in the left shoulder. He reported constant pain. The Veteran's left shoulder was not evaluated after repeated use over time, however, the examiner stated that after repeated use, the Veteran would experience a decrease in motion described above, due to pain, fatigue, and lack of endurance. The Veteran reported that after repeated use over time he had very limited movement, painful lifting, and could not reach overhead. In October 2020, the Veteran underwent left shoulder arthroscopic surgery. The Veteran was afforded a VA examination in August 2021. At that time, diagnoses of left rotator cuff tear, glenohumeral joint arthritis, and acromioclavicular joint osteoarthritis were rendered. A tear of the left shoulder infraspinatus tendon was also diagnosed. The Veteran reported that his symptoms had become worse. He noted having had shoulder surgery in October 2020. He stated that he had constant left shoulder pain. The pain was a constant throbbing which he rated as 8/10. There were no flare-ups reported. The Veteran was noted to have pain with lifting over the head and to have limited movement of the left shoulder. Active range of motion revealed flexion from 0 to 50 degrees, abduction 0 to 50 degrees, external rotation 0 to 20 degrees, and internal rotation 0 to 20 degrees. The Veteran did not perform passive motion due to pain. Pain was noted on examination and caused functional loss. The examiner observed that the Veteran had pain with all movements and that pain caused flexion to be limited to 45 degrees; abduction to be limited to 45 degrees; internal rotation to be limited to 15 degrees; and external rotation to be limited to 15 degrees. There was throbbing shoulder pain with tenderness to the touch, which was severe and along the left shoulder joint. The disorder prevented him from reaching overhead. Range of motion after three reportions resulted in no additional loss of motion. As to range of motion with repeated use over time, the examiner indicated that flexion was to 45 degrees, abduction was to 45 degrees, internal rotation to 15 degrees and external rotation to 15 degrees. There were no flare-ups during the examination. There were no additional factors contributing to the disability. There was no muscle atrophy. There was also no ankylosis. A rotator cuff condition was suspected as the Veteran had positive external rotation/infraspinatus strength test; Hawkins impingement test; empty can test; and lift-off subscapularis test. The Veteran had no shoulder instability, dislocation, or labral pathology. There were no residuals of recurrent dislocation of the glenohumeral joint. Cross body adduction testing was positive. The Veteran was noted to have A/C joint arthritis. This did not affect range of motion of the shoulder. The Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder) or fibrous union of the humerus. There was no malunion of the humerus with moderate or marked deformity. A February 2021 MRI of the left shoulder was noted to have shown unchanged partial-thickness tears of the supraspinatus and infraspinatus; a fissure tear of the anterior and anterior-inferior labrum; and osteoarthrosis of the glenohumeral joint and acromioclavicular joint. As to impact on employment, the examiner noted that the Veteran was currently not working (reported previously working as HVAC technician). She stated that the Veteran had lost 0-1 week work time in last 12 months. She observed that symptoms due to tear, intraspinatus tendon, left shoulder, rotator cuff tear, acromioclavicular arthritis, glenohumeral joint arthritis, and status post-arthroscopic surgery impacted lifting overhead. The examiner stated that AC joint arthritis; glenohumeral joint arthritis; rotator cuff tear status post arthroscopy left shoulder were a progression from the previously diagnosis of tear, infraspinatus tendon, left shoulder due to injury to rotator cuff, wear and tear of AC joint and glenohumeral joint and surgery to repair left shoulder. As it relates to the left shoulder, the codes overlap in that some form of movement is contemplated with regard to each applicable code. Thus, the Veteran will be rated under the most appropriate code to determine if an increased disability evaluation is warranted. During the current rating appeal, the evidence does not show nonunion of the clavicle or scapula with loose movement or dislocation of the clavicle or scapula to warrant a rating under Diagnostic Code 5203. See 38 C.F.R. § 4.71a, Diagnostic Code 5203 (2020). VA x-rays do not reflect nonunion or dislocation in the clavicle or scapula, nor was any nonunion or dislocation noted on the Veteran's VA examinations, there was no dislocation or recurrent subluxation noted on examinations. Based on this evidence, the Board finds that a higher evaluation is not warranted under Diagnostic Code 5203 for any period. The Veteran has not been shown to have ankylosis of the scapulohumeral articulation of the left shoulder to warrant a rating under Diagnostic Code 5200. See 38 C.F.R. § 4.71a, Diagnostic Code 5200 (2020). Range of motion testing was completed during the above VA examinations; no ankylosis was shown. There has also been no demonstration of recurrent dislocations at the scapulohumeral joint, with infrequent episodes, and guarding of movement only at shoulder level; frequent episodes and guarding of all arm movements; fibrous union; nonunion (false flail joint); or loss of head of (flail shoulder), to warrant an increased disability evaluation under DC 5202. Pursuant to this decision, the Board increases the Veteran's rating from 20 to 30 percent prior to November 25, 2011, in recognition of the Veteran's complaints of pain and functional loss which had been previously overlooked. However, a rating higher than 30 percent is not warranted. As noted above, there has been no demonstration of fibrous union or other more disabling symptoms. The Veteran's complaints of pain have been noted and addressed at the time of his VA examinations. The most recent VA examination also noted the Veteran's ranges of motion, taking into account limitation of motion due to pain when reporting the findings. In reaching the above conclusions, with respect to the Veteran's increased rating claim, the Board has considered all the evidence, lay and medical, as it bears on the criteria pertinent to rating the disabilities. With respect to the Rating Schedule, the criteria set forth therein generally require medical expertise where the types of findings required are not readily observable by a lay person. In all other instances, the lay evidence has been weighed and considered, along with the medical evidence, to determine the appropriate ratings. The Board has not overlooked the Veteran's statements with regard to the severity of his disability or specific reports of pain or other limiting factors or limitations of function described. In this regard, the Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing pain and weakness. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Veteran has also provided lay evidence with respect to the presence of pain and the severity of such during various VA examinations. He is competent to provide such statements and the Board finds that the Veteran's statements with regard to his current pain are credible. The Veteran's reported symptomatology has been noted above, and the Board has considered the Veteran's reports with respect to pain in determining the assigned rating. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. S. Kelly, 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.