Citation Nr: 21075313 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 14-00 587 DATE: December 20, 2021 ORDER Entitlement to an increased disability evaluation for severe degenerative disc disease with grade I spondylolisthesis of L5, currently rated as 20 percent disabling, is denied. Entitlement to an increased, 30 percent disability evaluation for gastroesophageal reflux disease (GERD) is granted. Entitlement to an increased disability evaluation for right shoulder, soft tissue calcification, rated as 20 percent disabling for the rating period prior to November 9, 2016, is denied. Entitlement to an increased disability evaluation for right total shoulder joint replacement, rated as 30 percent disabling for the rating period since January 1, 2018, is denied. Entitlement to service connection for obstructive sleep apnea, as secondary to service-connected posttraumatic stress disorder (PTSD), is denied. Entitlement to service connection for arthralgia of the hands is denied. FINDINGS OF FACT 1. The Veteran's degenerative disc disease with grade I spondylolisthesis of L5, is manifested by pain on motion, with functional loss due to pain upon movement. Forward flexion is limited to no worse than 50 degrees; there is no ankylosis; the Veteran does not have intervertebral disc syndrome. 2. The Veteran's GERD causes recurrent epigastric distress with pyrosis and regurgitation, with substernal pain; there are no complaints of weight loss, anemia, hematemesis, melena, or impairment of health. 3. For the rating period prior to November 9, 2016, the Veteran's right shoulder, soft tissue calcification, was productive of pain on motion, with limitation of motion, but is not limited to 25 degrees from the side, with no additional functional loss. 4. For the rating period since January 1, 2018, the Veteran's right total shoulder joint replacement is manifested by pain but is not manifested with chronic residuals consisting of severe painful motion or weakness. 5. The Veteran's obstructive sleep apnea did not manifest during service and is not attributable to service; obstructive sleep apnea was not caused or aggravated by a service-connected PTSD. 6. The Veteran's arthralgia of the hands did not manifest during service and is not attributable to service. CONCLUSIONS OF LAW 1. The criteria for a disability evaluation in excess of 20 percent for severe degenerative disc disease with grade I spondylolisthesis of L5, have not been met. 38 U.S.C. §§ 1155, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5235 5243 (2020). 2. The criteria for a 30 percent disability rating, but no higher, for GERD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.113, 4.114, Diagnostic Codes 7399 7346 (2020). 3. The criteria for a disability evaluation in excess of 20 percent for right shoulder, soft tissue calcification, for the rating period prior to November 9, 2016, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (2020). 4. The criteria for a disability evaluation in excess of 30 percent for right total shoulder joint replacement, for the rating period since January 1, 2018, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5051 (2020). 5. The criteria for entitlement to service connection for obstructive sleep apnea, including as secondary to service-connected PTSD, have not been met. 38 U.S.C. §§ 1101, 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 6. The criteria for service connection for arthralgia of the hands have not been met. 38 U.S.C. §§ 1101, 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from June 1984 to April 1987 and from February 1988 to June 2006. These matters come before the Board of Veterans' Appeals (Board) on appeal from April 2011, June 2011, and October 2011 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The April 2011 rating decision, in pertinent part, granted service connection for GERD and assigned a 10 percent disability evaluation, effective August 10, 2010; this rating decision also awarded an increased, 20 percent disability evaluation for the Veteran's severe degenerative disc disease with grade I spondylolisthesis of L5, effective August 10, 2010. The June 2011 rating decision, in pertinent part, denied the Veteran's claim for an increased disability evaluation for his right shoulder, soft tissue calcification, and his claim of entitlement to service connection for obstructive sleep apnea. The October 2011 rating decision denied the Veteran's claim of entitlement to service connection for arthralgia of the hands. In a December 2019 rating decision, the Veteran was awarded an increased, 20 percent disability evaluation for his right shoulder, soft tissue calcification, effective July 1, 2006. In a September 2021 rating decision, the Veteran was granted a temporary total disability evaluation for his right total shoulder joint arthroplasty for the rating period from November 9, 2016 through December 31, 2017. A 30 percent disability evaluation was assigned, effective January 1, 2018. As the Veteran has not been granted the maximum benefits allowed with regard to his claims for increased disability evaluations, these claims remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board most recently remanded the claims on appeal to the Agency of Original Jurisdiction (AOJ) in November 2020. A supplemental statement of the case was most recently issued in September 2021. The case has since been returned to the Board for appellate review. The Board finds that there was substantial compliance with its remand orders. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). Duties to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board ... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Increased Rating Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In addition, when assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. When evaluating musculoskeletal disabilities, VA must consider whether a higher evaluation is warranted, where the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups. See 38 C.F.R. § § 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Nevertheless, pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Moreover, functional impairment must be supported by adequate pathology. Id.; Johnson v. Brown, 9 Vet. App. 7, 10 (1996) (both citing to 38 C.F.R. § 4.40). Notably, during the appeal period, changes were made to 38 C.F.R. § 4.71a, Diagnostic Codes 5051, 5201, 5242, and 5243. Effective February 7, 2021, VA amended its regulations governing the schedule of rating musculoskeletal disabilities. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5051, 5201, 5242, and 5243). Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). 1. Entitlement to an increased disability evaluation for severe degenerative disc disease with grade I spondylolisthesis of L5, currently rated as 20 percent disabling. Lumbosacral and cervical spine disabilities are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine ("general rating formula"). 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242. Intervertebral disc syndrome (IVDS) is rated under the General Rating Formula for Rating Diseases and Injuries of the Spine or the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Formula for Rating IVDS Based on Incapacitating Episodes provides for ratings from 10 to 60 percent based on the frequency and duration of incapacitating episodes, defined in Note 1 as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. The maximum 60 percent schedular rating is warranted for incapacitating episodes having a total duration of at least 6 weeks during the previous 12 months. The Board notes that effective February 7, 2021, the spine regulations were amended to state that Diagnostic Code 5243 governing intervertebral disc syndrome should only be assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root, and that Diagnostic Code 5242 should apply to all other disc diagnoses. See 85 Fed. Reg. 76462 (Nov. 30, 2020) (effective 2/7/2021). The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note 1 provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. As discussed above, ratings for bowel and bladder impairment are not on appeal. Note 2 provides that, for VA compensation purposes, the combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. Note 4 provides that range of motion measurements are to be rounded to the nearest five degrees. Note 5 defines unfavorable ankylosis as a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note 6 provides that disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. According to the general rating formula, a 20 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is to be assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is to be assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5235 for vertebral fracture or dislocation; 5236 for sacroiliac injury and weakness; 5237 for lumbosacral strain; Diagnostic Code 5238 for spinal stenosis; Diagnostic Code 5239 for spondylolisthesis or segmental instability; Diagnostic Code 5240 for ankylosing spondylitis; Diagnostic Code 5241 for spinal fusion; Diagnostic Code 5242 for degenerative arthritis of the spine; and Diagnostic Code 5243 for intervertebral disc syndrome. The Veteran is assigned a 20 percent disability rating for his severe degenerative disc disease with grade I spondylolisthesis of L5 pursuant to the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5242. The Veteran contends that he is entitled to a higher rating because his current disability evaluations do not property account for the severity of his symptoms. After a review of all the evidence, the Board finds that, for the rating period on appeal, the Veteran's disability picture more nearly approximates the criteria for the currently assigned 20 percent disability evaluation for his service-connected severe degenerative disc disease with grade I spondylolisthesis of L5. At the July 2007 VA examination, the Veteran had flexion to 90 degrees, extension to 20 degrees, lateral flexion to 30 degrees bilaterally, and lateral rotation to 30 degrees bilaterally. The Veteran had pain on movement resulting in functional loss. The Veteran had guarding, and tenderness to palpation, but there was no muscle spasm or atrophy; there was also no evidence of ankylosis. The VA examiner indicated that the Veteran did not have IVDS or experience incapacitating episodes. At the August 2010 VA examination, the Veteran had flexion to 45 degrees, extension to 10 degrees, lateral flexion to 10 degrees bilaterally, and lateral rotation to 15 degrees bilaterally, with pain on motion resulting in functional loss. There was guarding upon sitting and rising, but with normal gait, and tenderness on palpation; however, there was no muscle spasm or atrophy, and there was also no evidence of ankylosis. The VA examiner indicated that the Veteran did not experience incapacitating episodes. The April 2019 VA examination report reflects that the Veteran had forward flexion to 40 degrees, extension to 25 degrees, lateral flexion to 25 degrees bilaterally, and lateral rotation to 20 degrees on the right and 25 degrees on the left. He did not have additional loss of motion on repetitive use testing. He had pain on motion resulting in functional loss, but he did not have pain on weightbearing. The Veteran had localized tenderness and guarding, without muscle spasm, which did not result in abnormal gait or abnormal spinal contour. Muscle strength and reflexes were normal and there was no evidence of muscle atrophy or ankylosis. The VA examiner stated that the Veteran did not have intervertebral disc syndrome or experience incapacitating episodes. The VA examiner noted that there were no signs of weakness, fatigability, incoordination, or instability on examination, but acknowledged that pain could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. The VA examiner also noted that the Veteran does not require use of an assistive device. At the January 2021 VA examination, the Veteran had forward flexion to 55 degrees, extension to 15 degrees, right and left lateral flexion to 15 degrees bilaterally, and lateral rotation to 25 degrees bilaterally. The examination report reflects that that the Veteran experienced pain on all planes of motion, with flexion reduced by 5 degrees upon repetitive use testing; forward flexion was estimated as reduced to 45 degrees during flare-ups, but all other planes of motion remained unaffected. There was pain on weight-bearing, but there was no tenderness to palpation; there was muscle spasm without abnormal gait or spinal contour, but there was no guarding or muscle atrophy. The VA examination report indicates that there was pain on motion, without incoordination or weakness; strength and reflex testing was normal. The VA examiner found that the Veteran does not have IVDS, and that he does not experience incapacitating episodes. The VA examiner noted that the Veteran uses a cane to aid ambulation. VA treatment records dated throughout the rating period on appeal reflect that the Veteran was treated for back pain. The lay and medical evidence demonstrates that the Veteran's symptoms do not result in additional functional limitation to a degree that would support a rating in excess of a 20 percent disability rating at any time during the appeal period. The evidence shows that the Veteran experiences forward flexion of the thoracolumbar spine which is better than 30 degrees which is required for a higher rating based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 5242. Here, the lay evidence has been considered; however, that evidence when accepted as correct does not establish that he is functionally limited to 30 degrees or less forward flexion. Further, the evidence does not show favorable or unfavorable ankylosis of the entire thoracolumbar spine during the rating period on appeal. Additionally, the Veteran does not experience incontinence or bowel complaints as a result of his service-connected severe degenerative disc disease with grade I spondylolisthesis of L5. The Board has considered whether additional functional impairment due to factors such as pain, weakness and fatigability demonstrate additional limitation of motion or function to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca at 206-07. The evidence shows no atrophy or decrease in strength. To the extent that the Veteran claims that his pain upon motion is the equivalent of limited motion, the Board finds that the Veteran's subjective complaints of pain have been contemplated in the current rating assignment, as the current rating is based on the objectively demonstrated reduced motion and impairment, including during a flare-up. See Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). See also Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017). Moreover, the available medical findings do not show that painful motion, limitation of motion on repetitive use testing, or pain or limitation of motion on active motion/passive motion/in weight-bearing/nonweight-bearing resulted in functional loss warranting the assignment of any higher evaluation for the thoracolumbar spine during the entire appeal period. See Correia v. McDonald, 28 Vet. App. 158 (2016). To the extent that the Veteran reports flare-ups limiting his ability to bend and lift objects, as well as complaints of difficulty with prolonged activity, the Board finds that the Veteran's flare-ups, especially in light of their frequency, do not show that the evidence more nearly approximates a disability picture with forward flexion of the spine limited to 30 degrees or less. 38 C.F.R. §§ 4.7, 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Therefore, the lay and medical evidence demonstrates that the Veteran's symptoms do not result in additional functional limitation to a degree that would support a rating in excess of a 20 percent disability rating at any point during the rating period on appeal. With respect to a higher evaluation based on incapacitating episodes under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, the Veteran has not been diagnosed with intervertebral disc syndrome. Moreover, review of the Veteran's VA examination reports and treatment records do not reveal any periods of physician prescribed bed rest as a result of his severe degenerative disc disease with grade I spondylolisthesis of L5. With consideration of the provisions of Note (1) of the General Rating Formula for Diseases and Injuries of the Spine, the Veteran was granted service connection for radiculopathy of the right and left lower extremities and assigned separate disability evaluations for each lower extremity. As the Veteran is separately evaluated for his lower extremity neurological deficits, it is not for consideration here. As such, the Board finds that the evidence of record reveals manifestations consistent with a 20 percent evaluation, but no higher, for the entire rating period on appeal for service-connected severe degenerative disc disease with grade I spondylolisthesis of L5. 2. Entitlement to an increased disability evaluation for GERD, currently rated as 10 percent disabling. The Veteran's GERD is currently evaluated as 10 percent disabling pursuant to 38 C.F.R. § 4.114, Diagnostic Codes 7399 7346. See 38 C.F.R. § 4.27 (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; disabilities requiring rating by analogy will be coded first the numbers of the most closely related body part and "99"). This hyphenated diagnostic code may be read to indicate that an unlisted digestive system disorder is the service-connected disorder, and it is rated as if the residual condition is hiatal hernia under Diagnostic Code 7346. Under Diagnostic Code 7346, a 10 percent disability evaluation is warranted for hiatal hernia where there are two or more of the symptoms for a 30 percent disability evaluation, of less severity. A 30 percent disability evaluation is warranted for hiatal hernia where there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, which is productive of considerable impairment of health. A 60 percent disability evaluation requires pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severely impaired health. See 38 C.F.R. § 4.114, Diagnostic Code 7346. For purposes of evaluating conditions in 38 C.F.R. § 4.114, the term "substantial weight loss" means a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer; and the term "minor weight loss" means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. 38 C.F.R. § 4.112. The term "inability to gain weight" means that there has been substantial weight loss with inability to regain it despite appropriate therapy. "Baseline weight" means the average weight for the two-year-period preceding onset of the disease. After review of the evidence of record, the Board finds that a 30 percent disability rating, but no higher, is warranted for the Veteran's service-connected GERD for the entire rating period on appeal. The January 2021 VA esophageal examination report reflects that the Veteran experienced persistent, recurring epigastric distress with pyrosis, dysphagia, nausea, and regurgitation, but without vomiting, material weight loss, hematemesis or melena with moderate anemia, or other symptom combinations symptoms productive of severe impairment of health; the Veteran also reported experiencing substernal pain. At the April 2019 VA examination, the Veteran reported that his symptoms were controlled with medication. At the August 2010 VA esophageal examination report noted that the Veteran experienced recurrent epigastric distress with daily reflux and weekly regurgitation, even with medication. However, the August 2010, April 2019, and January 2021 VA esophageal examiners found that the Veteran did not have esophageal stricture, spasm or acquired diverticulum of the esophagus, and his abdomen had no rigidity, rebound or guarding. As the Veteran has substernal pain, the Board finds that the Veteran has met the rating criteria for a 30 percent disability evaluation for the entire rating period on appeal. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). However, neither the medical evidence of record, nor the Veteran's statements support a disability rating in excess of 30 percent during the rating period on appeal, as there was no evidence of material weight loss, hematemesis, or melena with moderate anemia; or other symptom combinations productive of severely impaired health. Specifically, none of the VA examination reports or available treatment records reflect that the Veteran had weight loss encompassing over 10 percent of his baseline weight for three months or longer. The August 2010 and January 2021 VA examiners noted that the Veteran's GERD does not impact his ability to work. As such, a 60 percent rating under Diagnostic Code 7346 is not warranted. The Board has considered other applicable rating criteria. See 38 C.F.R. § 4.114 (which stipulates that ratings under DCs 7301 to 7329 inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other). However, there is no basis for an additional separate rating. Based on the Veteran's disability picture, Diagnostic Codes 7200 to 7205, and 7330, 7332 to 7340, 7343, 7344, 7351, and 7354 are not applicable here. There is no evidence of injuries of the mouth, tongue, or esophagus, fistula of the intestines, impairment or other disability of the rectum or anus, inguinal or ventral hernia, or liver transplant or hepatitis. As such, the Board finds that the Veteran's service-connected GERD is entitled to a disability evaluation of 30 percent, but no higher, for the entire rating period on appeal. 38 C.F.R. § 4.3, 4.7. 3. Entitlement to an increased disability evaluation for right shoulder, soft tissue calcification, rated as 20 percent disabling for the rating period prior to November 9, 2016. The Veteran is currently assigned a 20 percent disability evaluation for his service-connected right shoulder, soft tissue calcification, for the rating period prior to November 9, 2016 pursuant to the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5201. See 38 C.F.R. § 4.20. Diagnostic Code 5201 provides that limitation of motion of the arm at the shoulder level is rated 20 percent for either the major or the minor shoulder; limitation of motion of the arm midway between the side and shoulder level is rated as 30 percent for the major shoulder and 20 percent for the minor shoulder; and limitation of motion of the arm to 25 degrees from the side is rated as 40 percent for the major shoulder and 30 percent for the minor shoulder. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The Board notes that effective February 7, 2021, the regulations pertaining to shoulders and arms were amended to state that Diagnostic Code 5201, governing limitation of the motion of the arm, includes flexion or abduction and to provide specific range of motion measurements; midway between side and shoulder level is defined as 45 degrees and at shoulder level is defined as 90 degrees. See 85 Fed. Reg. 76462 (Nov. 30, 2020) (effective 2/7/2021). The Board notes that this change does not impact the evaluation in this case. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 degrees to 180 degrees, abduction from 0 degrees to 180 degrees, external rotation from 0 degrees to 90 degrees, and internal rotation from 0 degrees to 90 degrees. See 38 C.F.R. § 4.71, Plate I (2020). In this case, documents of record establish that the Veteran is right-handed; the Veteran reported that his dominant hand is his right hand at the August 2011 and January 2021 VA examinations. See 38 C.F.R. § 4.69. The current evaluation contemplates pain on motion. In order to warrant a higher evaluation, there must be the functional equivalent of limitation of motion to shoulder level. See DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The Board finds that the Veteran's disability picture for the rating period prior to November 9, 2016 more nearly approximates the criteria for the currently assigned 20 percent disability rating for right shoulder, soft tissue calcification (major). According to the August 2011 VA examination report, the Veteran had active range of motion to 30 degrees flexion and 30 degrees abduction. At the earlier, July 2007 VA examination, he had full range of motion on flexion and abduction; external and internal rotation were each to 90 degrees. There was reduced strength of the right shoulder upon examination, as well as tenderness to palpation. More recently, a June 2016 VA treatment note indicated that the Veteran had range of motion to 100 degrees flexion, 80 degrees abduction, and to 30 degrees external rotation. VA and private treatment records also reflect treatment for right shoulder pain. The Board has considered whether additional functional impairment due to factors such as pain, weakness and fatigability demonstrate additional limitation of motion or function to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca at 206-07. The Board acknowledges that the Veteran reported at his VA examinations that he had difficulty lifting objects above his shoulder and pain with motion due to his right shoulder, soft tissue calcification; however, to the extent that the Veteran claims that his pain upon motion is the equivalent of limited motion, the Board finds that the Veteran's subjective complaints of pain have been contemplated in the current rating assignment, as the current rating is based on the objectively demonstrated reduced motion and impairment. See Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). The July 2007 VA examination report indicates that physical examination showed pain, with pain on motion, but without additional limitations upon repetitive use testing and flare-ups. The Board acknowledges that the August 2011 VA examination report reflects additional pain and limitation of motion on repetitive use testing, which resulted in functional loss; however, this finding is inconsistent with the Veteran's treatment records during the rating period prior to November 9, 2016, which do not indicate that the Veteran's right shoulder, soft tissue calcification, warranted the assignment of any higher evaluation for the right shoulder during the appeal period. See Correia v. McDonald, 28 Vet. App. 158 (2016). The Board finds that the criteria for a disability rating greater than 20 percent for the right shoulder have not been met or more nearly approximated for any part of the rating period prior to November 9, 2016. Although there is evidence of tenderness to palpation, there is no evidence of ankylosis, muscle atrophy, malunion of the humerus with deformity, or loss of head, nonunion, or fibrous union of the humerus during the rating period on appeal. Thus, a higher rating for the left shoulder, based on Diagnostic Codes 5200 and 5202, are not warranted. For the foregoing reasons, the preponderance of the evidence is against a disability rating in excess of 20 percent for the Veteran's right shoulder, soft tissue calcification, for the rating period prior to November 9, 2016. Accordingly, the Veteran's claim for an increased disability evaluation is denied. 4. Entitlement to an increased disability evaluation for right total shoulder joint replacement, rated as 30 percent disabling for the rating period since January 1, 2018. The Veteran's right total shoulder joint replacement is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5051. As previously noted, the Veteran received a 100 percent disability evaluation under this Code from November 9, 2016 to December 31, 2017. Diagnostic Code 5051 assigns a 100 percent disability rating for one year following implantation of a prosthetic replacement of the shoulder joint. A 60 percent disability rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. For intermediate degrees of residual weakness, pain or limitation of motion, the knee should be rated by analogy to Diagnostic Codes 5200 and 5203. The minimum rating is 30 percent. The Board notes that Diagnostic Code 5051 was amended effective February 7, 2021. However, the only changes to the provision were the addition of a noncompensable disability evaluation for resurfacing of the joint and additional notes to the existing rating criteria. In pertinent part, the additional notes indicate that when an evaluation is assigned for joint resurfacing or the prosthetic replacement of a joint under diagnostic codes 5051-5056, an additional rating under §4.71a may not also be assigned for that joint, unless otherwise directed; a revision procedure should only be evaluated in the same manner as the original procedure under diagnostic codes 5051-5056 if all the original components are replaced; the 100 percent rating for 1 year following implantation of prosthesis will commence after initial grant of the 1-month total rating assigned under §4.30 following hospital discharge. Since none of these amendments affect the evaluation of the Veteran's shoulder replacement, no further discussion of the amendments will be made. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5055). Diagnostic Code 5200 applies to ankylosis (total loss of joint mobility) of the shoulder, specifically scapulohumeral articulation. Diagnostic Code 5203, for impairment of the clavicle or scapula, does not provide for a disability evaluation in excess of 30 percent, and thus, will not be considered here. For the time period from January 1, 2018, a rating in excess of 30 percent is not warranted for the Veteran's service-connected right total shoulder joint replacement under 38 C.F.R. § 4.71a, Diagnostic Codes 5051 and 5200. The Board has considered entitlement to higher ratings under Diagnostic Code 5200, as directed by Diagnostic Code 5051. The Veteran does not contend, and the medical evidence of record does not demonstrate, that the Veteran has ankylosis of scapulohumeral articulation. The Board also finds that the assignment of a higher (60 percent) rating is not warranted under Diagnostic Code 5051 for severe, chronic residuals of shoulder replacement consisting of severe painful motion or weakness in the right shoulder. VA treatment records, as well as the January 2021 and May 2021 VA examination reports, reflect that the Veteran does not experience instability, deformity, atrophy, or swelling. Treatment records during the appeal period show that the Veteran experiences pain, but not that it was severe or that any weakness was consistent or of such severity that a 60 percent under Diagnostic Code 5051 was warranted. Moreover, although the Veteran reported experiencing pain, fatigability, and lack of endurance which results in limitation of functional ability, the VA examiner at the May 2021 VA examiner clearly indicated that the Veteran's limits were no more than intermediate, and expressly indicated that the Veteran's residuals were not chronic or severe. In short, there were no objective manifestations warranting the assignment of a rating in excess of 30 percent under Diagnostic Codes 5051, 5200. The Board further finds that there is no basis for the assignment of any higher rating based on consideration of functional loss of the right knee. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2018); Deluca, 8 Vet. App. at 204-06; Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). The Board has considered the Veteran's reports of pain, reduced range of motion, and flare-ups. However, upon physical examination, the Veteran has not demonstrated limitation of extension or flexion of the shoulder sufficient to warrant the assignment of a higher evaluation. The evidence reflects that the currently assigned 30 percent disability rating properly compensates the Veteran for the extent of functional loss resulting from pain and reduced range of motion of the right shoulder. Here, the available medical findings do not show that painful motion, limitation of motion on repetitive use testing, or pain or limitation of motion on active motion/passive motion/in weight-bearing/nonweight-bearing resulted in functional loss sufficient to warrant the assignment of any higher evaluation during the appeal period. See Correia v. McDonald, 28 Vet. App. 158 (2016). The Veteran's May 2021 VA examination report indicated that the Veteran's VA examination was not conducted during a flare-up but indicated that the Veteran's range of motion could be estimated as 45 degrees flexion. See Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017). As a result, the evidence of record reveals manifestations consistent with the currently assigned 30 percent disability rating for right total shoulder joint replacement. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 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, 1131; 38 C.F.R. § 3.303(a) (2020). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during servicethe so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. For chronic diseases, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § § 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). At the outset, the Board notes that the Veteran was exposed to combat during service. As such, the provisions of 38 U.S.C. § 1154 are potentially applicable in this case. However, the Veteran does not allege that his obstructive sleep apnea or arthralgia of the hands are related to combat. 5. Entitlement to service connection for obstructive sleep apnea, including as secondary to service-connected PTSD. The Veteran is seeking to establish service connection for obstructive sleep apnea. As an initial matter, the Board notes that the Veteran does not allege, nor does the record reflect, that he first manifested obstructive sleep apnea during service or within one year of his discharge from service, or that such is otherwise related to his active duty service on a direct or presumptive basis. Rather, the Veteran has claimed that his obstructive sleep apnea is secondary to his service-connected PTSD. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (2008) (claims which have no support in the record need not be considered by the Board as the Board is not obligated to consider "all possible" substantive theories of recovery. Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory). In this regard, his service treatment records are negative for any complaints, treatment, or diagnosis of a sleep disorder and a sleep disorder was not diagnosed for many years after his separation from service. The Veteran was diagnosed with sleep apnea in July 2010, approximately 4 years after separation. Therefore, the evidence is against a finding that sleep apnea had its onset during service or is otherwise related to service, and service connection on a direct basis is not warranted. Turning to secondary service connection, the Veteran is service-connected for PTSD, and the Veteran has been diagnosed with and treated for obstructive sleep apnea. Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection may not be established on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310 (b). Review of the record shows that the Veteran's treating providers, as well as the March 2016 VA examiner have not related the Veteran's obstructive sleep apnea to his service-connected PTSD. To the contrary, the Veteran's VA treatment records attribute the Veteran's obstructive sleep apnea to his nonservice-connected obesity. There is also no indication that the Veteran's obstructive sleep apnea was caused or aggravated by his service-connected PTSD. In particular, the March 2016 VA examiner noted that the Veteran was diagnosed with obstructive sleep apnea in 2010, and that obstructive sleep apnea is an abnormal physical condition characterized by recurrent collapse of the airway during sleep which results in severely reduced, or complete cessation of airflow during continued breathing efforts. The VA examiner noted that risk factors for obstructive sleep apnea include advancing age, obesity, male gender, and craniofacial or upper airway soft tissue abnormalities; of these risk factors, the VA examiner found that the most likely factor is obesity. The VA examiner concluded that, given that obstructive sleep apnea is a physical condition caused by an obstructed airway, it is by definition, not a mental health condition, and thus cannot be due to, or aggravated by a mental health condition such as PTSD. The Board acknowledges the argument of the Veteran's representative that the Veteran's PTSD caused the Veteran's obesity, and his obesity, in turn, caused the Veteran's obstructive sleep apnea. (see November 2021 response to the September 2021 supplemental statement of the case). The Board notes that obesity is not a disease or disability for which service connection may be granted. See VAOPGCPREC 1-2017 (holding the "longstanding policy of [VA], that obesity per se is not a disease or injury for purposes of 38 U.S.C. §§ 1110 and 1131 and therefore may not be service connected on a direct basis, is consistent with title 38, United States Code" and "[o]besity per se is not a 'disability' for purposes of 38 C.F.R. § 3.310"). However, service connection may be granted under 38 C.F.R. § 3.310(a) if obesity was an "intermediate step" between a service-connected disability and a current disorder. See VAOPGCPREC 1-2017. The Board finds this argument without merit. The Board observes that none of the Veteran's treating physicians or VA examiners attributed the Veteran's obesity to his PTSD; there is also no evidence that the Veteran's obesity is related to any of his service-connected disabilities. To this point, the Veteran's VA treatment records are replete with notations that the Veteran was counseled to lose weight through a low calorie diet and exercise, so as to improve his obstructive sleep apnea, as well as to counseled to discontinue tobacco use; in both instances, the Veteran declined. Moreover, the Veteran's treatment records indicate that the Veteran did not report that his service-connected disabilities interfered with his ability to exercise. While the Veteran is service-connected for PTSD, there is no evidence of record to support a nexus between his PTSD and his obstructive sleep apnea. Nor is there any indication of a nexus or aggravation of his obstructive sleep apnea by his service-connected PTSD. As a result, entitlement to service connection for obstructive sleep apnea is denied. 6. Entitlement to service connection for arthralgia of the hands. The Veteran contends that his arthralgia of the hands is related to his active military service. As an initial matter, the Board notes that the Veteran has a current diagnosis of arthralgia of the hands. The Veteran has been diagnosed with arthralgia of the hands, right thumb base with mild deformity, and left thumb base with old fracture. Thus, the first element of service connection is met. With regard to an in service event, injury or disease, the Board acknowledges that the Veteran has a remote history of left little finger very small avulsion fracture in 1986, which resolved without objective evidence of any residuals; a 2011 x-ray did not show any left little finger abnormalities. However, a review of the Veteran's available service treatment records from the Veteran's second period of service does not reflect complaints, treatment, or diagnoses related to the Veteran's hands. Nevertheless, at the March 2016 VA examination, the Veteran reported that he thought that he dislocated or hurt his thumbs during service, but that he did not think he was treated for hand or thumb pain during service; he described possible injuries as exiting a vehicle while carrying a weapon or falling. As the described injuries are capable of lay report and observation, the Board finds that an in-service event or injury, the second element of service connection has been established. Turning to nexus, the Board notes that the Veteran reported at the March 2016 VA examination that he slipped and fell onto a concrete curb in the winter of late 2006 or early 2007, wherein he hurt his left wrist and hand; he could not recall if he injured his right hand then, or another time after service. The Veteran also reported that this injury was contemporaneous with his chronic alcohol abuse, and that he had a history of a post-service diagnosis of right carpal tunnel syndrome. VA treatment records dated January 2007 reflect that the Veteran was treated for right wrist pain, and that x-rays revealed a healing fracture of the right wrist. At that time, the Veteran reported that he might have injured it during a period when he was drunk in December 2006; VA treatment records show treatment for alcohol abuse in December 2006. The Board observes that none of the post-service treatment records reflect complaints, treatment, or diagnoses of a bilateral hand disorder prior to the Veteran's post-service injury in 2006 2007, and that none of the Veteran's treating providers associate his arthralgia of the hands and related complaints to his service. After examining the Veteran, September 2011 and March 2016 VA examiners concluded that the Veteran's arthralgia of the hands is not related to the Veteran's service. According to the September 2011 and March 2016 VA medical opinions, the Veteran's bilateral hand arthralgia is not likely to be related to his service given the absence of any related complaints or treatment, other than the resolved left little finger fracture, during the Veteran's many years of service. Additionally, the March 2016 VA examiner noted that the Veteran did not have complaints of bilateral hand pain until after the Veteran's post-service injury, which the Veteran himself acknowledged. In short, the evidence of record indicates that the Veteran's arthralgia of the hands is associated with an intercurrent injury following service. See 38 C.F.R. § 3.303(b) (subsequent, isolated manifestations of a chronic disorder are not service connected where they are clearly attributable to intercurrent causes). Accordingly, the Board finds that the evidence fails to establish a nexus between the Veteran's arthralgia of the hands and his active service. The Board finds the VA opinions to be the most probative evidence as to nexus. The opinions are based on the record, an accurate medical history, which does not contain evidence of continuing symptoms or treatment since service to diagnosis, and provide an adequate rationale to support the findings. The Board has considered the Veteran's statements regarding nexus. However, the Veteran's statements are insufficient to establish that the Veteran's arthralgia of the hands is related to his service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran is competent to report observable symptoms such as pain, but he is not competent to determine the cause of his disability. Such determinations require more than mere observation of symptoms, but medical training and knowledge which the Veteran does not have. Thus, his lay assertions of nexus is not competent evidence as to the claim. Given that the preponderance of the evidence is against the claim, entitlement to service connection for right hand arthralgia is denied. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Brokowsky, 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.