Citation Nr: 21076057 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 17-17 629 DATE: December 22, 2021 ORDER Entitlement to an initial disability rating of 30 percent, but no higher, for right upper extremity ulnar neuropathy is granted. Prior to July 21, 2021, entitlement to an initial 10 percent disability rating, but no higher, for left knee strain, status post anterior cruciate ligament tear surgical repair is granted. From July 21, 2021, entitlement to disability rating in excess of 10 percent for left knee strain, status post anterior cruciate ligament tear surgical repair is denied. Entitlement to an initial disability rating of 10 percent, but no higher, for left knee instability under Diagnostic Code 5257 is granted. Entitlement to an initial disability rating in excess of 20 percent for right shoulder impingement syndrome status post-surgical repair is denied. FINDINGS OF FACT 1. The Veteran's right upper extremity ulnar neuropathy is manifested by moderate incomplete paralysis of the major extremity; severe incomplete paralysis and complete paralysis of the right upper extremity are not approximated. 2. Prior to July 21, 2021, the Veteran's left knee strain, status post anterior cruciate ligament tear surgical repair manifested with degenerative changes that resulted in limitation of flexion to 120 degrees with painful motion at that point; the Veteran's left knee strain did not manifest in limitation of flexion to 30 degrees or less, including due to painful motion and during flare-ups. 3. From July 21, 2021, the Veteran's left knee strain, status post anterior cruciate ligament tear surgical repair did not manifest in limitation of flexion to 30 degrees or less, including due to painful motion and during flare-ups. 4. The Veteran's left knee strain status post anterior cruciate ligament tear surgical repair manifests with "slight" lateral instability; moderate instability of the left knee is not approximated. 5. The Veteran's right shoulder impingement syndrome status post-surgical repair does not more nearly approximate limitation of motion to midway between side and shoulder level or ankylosis of the major extremity. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 30 percent, and no higher, for right upper extremity ulnar neuropathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8516. 2. Prior to July 21, 2021, the criteria for a disability rating of 10 percent, but no higher, for left knee strain, status post anterior cruciate ligament tear surgical repair were met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, DCs 5010, 5260. 3. From July 21, 2021, the criteria for a disability rating in excess of 10 percent for left knee strain, status post anterior cruciate ligament tear surgical repair have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, DCs 5010, 5260. 4. The criteria for a separate 10 percent rating, but no higher, under DC 5257 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, DC 5257. 5. The criteria for a rating in excess of 20 percent for right shoulder impingement syndrome status post-surgical repair have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, DC 5201. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1995 to January 2016. The Veteran testified during a virtual hearing before the undersigned Veterans Law Judge in April 2021. A transcript of the hearing is associated with the record. In May 2021, the Veteran's claim was by the Board for additional development. Review of the completed development reveals that, at the very least, substantial compliance with the remand directives was obtained. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Increased Ratings, Generally Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the entire record to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 38 C.F.R. §§ 4.1, 4.2, 4.10. When evaluating a musculoskeletal disability based upon a range of motion, consideration is given to the degree of any additional limitation upon motion due to functional loss. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). This includes the analysis of additional functional impairment above and beyond the limitation of motion objectively demonstrated involving such factors as painful motion, weakness, incoordination, and fatigability, etc., particularly during times when these symptoms "flare up," such as during prolonged use, and assuming these factors are not already contemplated in the governing rating criteria. Id. See also 38 C.F.R. §§ 4.40, 4.45 and 4.59 (2018). 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. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. Staged ratings are appropriate when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). 1. Entitlement to an initial disability rating of 30 percent, but no higher, for right upper extremity ulnar neuropathy In a May 2016 rating decision, the Veteran was granted entitlement to service connection for right upper extremity ulnar neuropathy. A 10 percent disability rating was assigned, effective February 1, 2016. The Veteran appealed this rating decision contending that a higher rating was warranted. Upon review of the evidence of record, the Board finds that a 30 percent rating, but no higher, is warranted for the Veteran's right upper extremity ulnar neuropathy throughout the period on appeal. Paralysis of the ulnar is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8516. Under these criteria, mild incomplete paralysis is rated as 10 percent for both the major and minor extremity. Moderate incomplete paralysis is rated as 30 percent for the major extremity and 20 percent for the minor extremity. Severe incomplete paralysis is rated as 40 percent for the major extremity and 30 percent for the minor extremity. 38 C.F.R. § 4.124a. The words "mild," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Veteran was afforded a VA Peripheral Nerves Conditions examination in January 2016. A diagnosis of ulnar neuropathy of the right upper extremity was noted, as was the Veteran's right-hand dominance. The Veteran reported loss of grip in the mornings and constant pain from the ulnar notch distal to the fingers. Veteran also reported numbness on the palmar surface worse in the index and middle fingers. Upon examination, the examiner reported that the Veteran had mild incomplete paralysis of the ulnar nerve with symptoms of mild constant pain, mild paresthesias and dysesthesias, and mild numbness. In October 2020, the Veteran was seen for a neurosurgery evaluation through the Iowa City VA Medical Center. The physician noted that on examination that the Veteran had a positive Tinel sign at the right elbow and "a hint" of some interosseous weakness was noted in the right hand compared to the left. Additionally, some finger extension and finger flexion weakness of the ulnar digits was reported. In July 2021, the Veteran was afforded another VA examination of regarding the impairment of his ulnar nerve. The Veteran reported symptoms of weakness of the right arm and right hand, numbness and tingling sensation in the right hand, especially the right 3rd and 4th fingers. He also reported difficulty in holding objects in his right hand for prolonged periods of time, trouble with using hand tools and writing with right hand. The examiner opined that the Veteran suffered from "moderate" incomplete paralysis of the ulnar nerve with symptoms of mild intermittent pain; moderate paresthesias and dysesthesias, and moderate numbness. The examiner noted that muscle strength testing indicated 4/5 muscle strength for right elbow flexion and extension, right wrist flexion and extension, and right grip and pinch strength. Based on the above, the Board finds that the Veteran's level of impairment of the ulnar nerve throughout the period on appeal warrants a 30 percent rating, but no higher, is warranted for "moderate" incomplete paralysis of the ulnar nerve of the Veteran's right (major) upper extremity. The Board finds probative the finding of the 2021 VA examiner that opined that the Veteran's ulnar nerve impairment was moderate. This is supported by findings of "moderate" numbness and paresthesias/dysesthesias and reduced (4/5) muscle strength in the Veteran's right upper extremity. While the Board notes the opinion of the 2016 VA examiner that the Veteran's paralysis of the ulnar nerve was "mild" in nature, the Board finds this opinion less probative as the findings of the examination did not address the Veteran's reports of symptoms of reduced grip strength in his right hand. Both the 2020 VA physician and the 2021 VA examiner indicated objective signs of reduced grip strength, which supports the Veteran's lay statements of reduced grip strength from his 2016 examination. Further, the 2016 examination did not discuss whether additional limitations would be present during period of flare-ups of the Veteran's condition. As such, the Board will resolve the benefit of the doubt in favor of the Veteran and finds that "moderate" incomplete paralysis of the ulnar nerve has been present throughout the period on appeal. See Swain v. McDonald, 27 Vet. App. 219, 224 (2015). The Board, however, finds that a rating in excess of 30 percent due to severe incomplete paralysis of the ulnar nerve or complete paralysis of the ulnar nerve has not been present during the period on appeal. The Board finds probative that neither the 2016 nor the 2021 VA examiner reported evidence of muscle atrophy of the right upper extremity. Further, the evidence does not suggest that the Veteran has complete loss of use of the right wrist or elbow. As such, the Board finds that a rating in excess of 30 percent is not warranted for severe incomplete paralysis or complete paralysis of the ulnar nerve of the Veteran's right upper extremity. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that a 30 percent rating, and no higher, throughout the entire period on appeal, is warranted for "moderate" incomplete paralysis of the ulnar nerve of the Veteran's right (major) upper extremity. 38 C.F.R. §§ 4.3, 4.7, 4.124a, DC 8516. 2. Entitlement to an initial 10 percent disability rating, but no higher, for left knee strain status post anterior cruciate ligament tear surgical repair The Veteran's left knee strain, status post anterior cruciate ligament tear surgical repair (left knee disability) is rated under hyphenated diagnostic code DC 5019-5260. 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 assigned rating; the additional code is shown after the hyphen. Here, the hyphenated diagnostic code indicates that bursitis of the left knee (5019) has been rated under the criteria for limitation of leg flexion (DC 5260). See 38 C.F.R. § 4.27. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). The Veteran was originally assigned a noncompensable rating for left knee instability (DC 5257), effective February 1, 2016 in a May 2016 rating decision. In an August 2021 rating decision, the Veteran's diagnostic code for his condition was changed to DC 5019-5260 and a 10 percent rating was assigned from July 21, 2021. Multiple diagnostic codes are potentially applicable to evaluation of a knee disability. Simultaneous compensation under several diagnostic codes is permissible so long as differing symptomatology is being compensated by each DC. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology or manifestations of the conditions is not duplicative or overlapping. 38 C.F.R. § 4.14; Amberman v. Shinseki, 570 F.3d 1377 (Fed. Cir. 2009). Normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. DC 5019 is rated under the criteria of DC 5003 (degenerative arthritis). DC 5003 provides that degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5003. Under DC 5003, when limitation of motion would be noncompensable, i.e., zero percent, under a limitation-of-motion code, but there is at least some limitation of motion, VA assigns a 10 percent disability rating for each major joint so affected, to be combined, not added. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of any limitation of motion, involvement of 2 or more major joints or 2 or more minor joint groups warrants a 10 percent evaluation, and the same with occasional incapacitating exacerbations warrants a 20 percent evaluation. Id. The knee is considered a major joint. 38 C.F.R. § 4.45. DC 5260 provides for the assignment of a noncompensable rating when flexion is limited to 60 degrees. 38 C.F.R. § 4.71a, DC 5260. A 10 percent rating is warranted when flexion of the leg is limited to 45 degrees. Id. A rating of 20 percent is appropriate when leg flexion is limited to 30 degrees, and a rating of 30 percent is warranted when flexion is limited to 15 degrees. Id. DC 5261 provides the rating criteria for limitation of extension of the leg. Under this diagnostic code provision, extension that is limited to 5 degrees is noncompensable; extension that is limited to 10 degrees warrants a 10 percent disability rating; and extension limited to 15 degrees warrants a 20 percent disability rating. Extension limited to 20 degrees warrants a 30 percent disability rating; extension limited to 30 degrees warrants a 40 percent disability rating; and extension limited to 45 degrees warrants a 50 percent disability rating. 38 C.F.R. § 4.71a, DC 5261. A veteran may receive separate ratings for compensable limitations in both flexion and extension. See VAOPGCPREC 9-2004. DC 5258 provides a 20 percent evaluation is assigned for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a. DC 5259 provides a 10 percent evaluation is assigned for removal of semilunar cartilage which is symptomatic. 38 C.F.R. § 4.71a. The Veteran's left knee disability was initially assigned a noncompensable evaluation, effective As an initial point, the United States Court of Appeals of Veterans' Claims has held that the intent of the Rating Schedule (and specifically 38 C.F.R. § 4.59) is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. In Burton v. Shinseki, 25 Vet. App. 1 (2011), the Court found that the Board failed to address painful motion and the applicability of 38 C.F.R. § 4.59 in a case involving an initial disability rating for residuals of a left shoulder injury with surgical repair. As such, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board must address its applicability. Here, the January 2016 VA examiner noted the Veteran's reports of pain with use of his left knee (kneeling, using stairs, jumping, and running). The Board finds that this evidence of pain upon knee flexion is sufficient to support a compensable rating under 38 C.F.R. § 4.59. Therefore, a 10 percent rating (the minimum compensable rating) is assigned for the left knee prior to July 21, 2021 based upon painful motion of the left knee. The Board will now turn to whether a rating in excess of 10 percent is warranted for left knee any time during the appeal period at issue. Under 38 C.F.R. § 4.71a, Diagnostic Code 5260, a noncompensable rating is assigned when flexion of the leg is limited to 60 degrees; a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. 38 C.F.R. § 4.71, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is assigned when extension of the leg is limited to 5 degrees; a 10 percent rating is assigned when extension of the leg is limited to 10 degrees; and a 20 percent rating is assigned when extension is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. In this case, left knee flexion was not limited to 30 degrees or less at any point during the appeal period, including considering limitations due to painful motion, during flare-ups, or after repetitive use. The Board finds probative that the Veteran's left knee flexion was reported to be limited to 130 degrees after repetitive use and to 120 degrees during flare-ups by the July 2021 VA examiner. The Veteran was not reported to have limitation of extension of the left knee to less than 0 degrees during the period on appeal, including considering limitations due to painful motion, during flare-ups, or after repetitive use. Therefore, a rating in excess of 10 percent is not warranted based on the demonstrated ranges of motion. 38 C.F.R. § 4.71a, DCs 5260, 5261. In reaching this conclusion, the Board has considered whether higher ratings are warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. In this case, while the Veteran reported experiencing pain with range of motion testing on occasion, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011) (emphasis added). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 43; see 38 C.F.R. § 4.40. Here, any additional functional loss or reduced range of motion has been considered in the Veteran's range of motion testing reported by the 2016 and 2021 VA examiners including additional limitations due to repetitive use and during flare-ups. Consequently, pain was not found to cause functional limitation to the point that a higher rating would be warranted. The Board has also considered whether higher ratings are warranted under any other relevant Diagnostic Codes. Under 38 C.F.R. § 4.71a, Diagnostic Code 5258, a 20 percent rating is assigned for dislocated semilunar cartilage with frequent episodes of "locking", pain and effusion into the joint. Under 38 C.F.R. § 4.71a, Diagnostic Code 5259, a 10 percent rating is assigned for symptomatic removal of symptomatic semilunar cartilage. Semilunar cartilage is synonymous with the meniscus. The 2016 and 2021 VA examiners of record specifically found that there is no evidence of any meniscal conditions. Consequently, a separate compensable rating is not warranted for the left knee under either Diagnostic Codes 5258 or 5259. DC 5256 (ankylosis of the knee), 5262 (impairment of the tibia and fibula), and 5263 (genu recurvatum). The Veteran does not warrant compensable ratings under any of these DCs as none of these conditions have been shown. As described, a 10 percent rating, but no more, is warranted for the Veteran's left knee disability prior to July 21, 2021; and a rating in excess of 10 percent for the Veteran's left knee conditions is not warranted, thereafter. 38 C.F.R. §§ 4.3, 4.7, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, DCs 5010, 5260, 5261, 5258, 5259. 3. Entitlement to an initial disability rating of 10 percent, but no higher, for left knee instability The Board, however, finds that a separate 10 percent disability rating for left knee instability is warranted throughout the period on appeal. Instability of the knee is rated under DC 5257, which provides ratings for impairment of the knee that includes recurrent subluxation or lateral instability. The schedular criteria for rating knee instability was amended effective February 7, 2021. The amendments apply to claims, such as the Veteran's, that were pending before VA as of that date, with the provision that the more favorable of the old and new criteria are to be applied. If application of the revised regulation results in a higher rating, the effective date for the higher disability rating can be no earlier than the effective date of the change in the regulation.38U.S.C. §5110 (g). Prior to the effective date of the change in the regulation, the Board can apply only the original version of the regulation. Prior to February 7, 2021, DC 5257 provided a 10 percent rating for slight recurrent subluxation or lateral instability of the knee, a 20 percent rating for moderate recurrent subluxation or lateral instability of the knee, and a 30 percent rating for severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, DC 5257 (2020). The words "slight," "moderate" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all the evidence to the end that its decisions are "equitable and just," under 38 C.F.R. § 4.6. Under the amended criteria, DC 5257 provides for recurrent subluxation or instability with a 30 percent rating that is unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation, a 20 percent rating that is(a) a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation(b) an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation, and a 10 percent rating for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. DC 5257 also provide for patellar instability with a 30 percent rating for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker, a 20 percent rating for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker, and a 10 percent rating for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. Note (1) of the rating provides that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon, and Note 2 states that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). The evidence of record reflects that the schedular criteria of DC 5257 in effect prior to February 7, 2021 are more favorable to the Veteran and are for application here. The Board finds that the Veteran left knee instability resulted in "slight" impairment throughout the period on appeal. The Board notes that the Veteran's initial noncompensable rating was assigned under DC 5257 based upon the Veteran's reports of instability. While the January 2016 and July 2021 examiners stated that the Veteran's left knee did not demonstrate instability during any testing on examination, the Board notes the Veteran's lay reports of instability during his April 2021 Board hearing and reports of his knee occasionally feeling like it will give out while going down steps by his primary care physician in June 2019 to be competent and credible. Based upon this evidence, the Board finds that a separate 10 percent rating for "slight" left knee instability is warranted for the period on appeal. 38 C.F.R. §§ 4.3, 4.71a, DC 5257. A rating in excess of 10 percent, however, is not warranted for symptoms that more nearly approximate "moderate" or "severe" left knee instability during the period on appeal under either the old or new rating criteria. In making this finding, the Board finds probative the findings of the 2016 and 2021 VA examiners. The VA examiners did not find objective evidence of instability during either examination, which is indicative of less severe instability. While the 2016 examiner indicated that the Veteran "occasionally" used a knee brace, the Veteran was not reported to use any assistive devices by the 2021 VA examiner. The Board also finds probative that the Veteran's medical records do not report a frequent history of falls due to his left knee disability. Rather, while the Veteran reported "occasional" feelings that his knee was going to "give out" while using stairs, the Veteran's primary care physician indicated that the Veteran denied any falls. Accordingly, the Board finds that the Veteran's left knee disability has not more nearly approximated "moderate" recurrent subluxation or lateral instability during the period on appeal. Id. In sum, the Board finds that a separate 10 percent rating, and no higher, throughout the entire period on appeal, is warranted for instability of the left knee. 38 C.F.R. §§ 4.3, 4.7, 4.71a, DC 5257. 4. Entitlement to an initial disability rating in excess of 20 percent for right shoulder impingement syndrome status post-surgical repair As noted above, the Veteran is right-handed. Under Diagnostic Code 5201, limitation of arm motion in the major extremity is as follows: limitation of motion to 25 degrees from the side warrants a rating of 40 percent; limitation to midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) warrants a rating of 30 percent; and limitation to shoulder level (flexion and/or abduction limited to 90 degrees) warrants a rating of 20 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5201. 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. 38 C.F.R. § 4.71, Plate I. The shoulder level is 90 degrees on either forward elevation or abduction. Id. The Veteran contends that his right shoulder impingement syndrome status post-surgical repair (right shoulder disability) warrants a higher rating than his currently assigned rating. The Veteran was initially a 10 percent rating for his right shoulder disability in a May 2016 rating decision, effective February 1, 2016. The Veteran appealed the initial rating assigned. In March 2017, the Veteran was assigned a 20 percent rating, effective February 1, 2016. During the Veteran's April 2021 hearing, the Veteran reported limitation of motion of his shoulder. He stated that there "certain motions" that he "cannot do with his arm. Anything with weight and the hand straight out, things behind my back." See Hearing Testimony, p.3. In January 2016, the Veteran was afforded a shoulder and arm examination by VA. The examiner noted right arm flexion to 170 degrees and right arm abduction to 175 degrees. With regard to flare-ups, the Veteran reported pain with overhead reaching or lifting 20 pounds or more. The Veteran was afforded another shoulder examination in July 2021. The Veteran reported symptoms of a constant dull pain and more frequent flare-ups. The examiner noted right arm flexion to 150 degrees and right arm abduction to 100 degrees. Additional limitations of flexion to 140 degrees and abduction to 95 degrees were reported with repetitive use over time, and flexion to 130 degrees and abduction to 90 degrees with flare-ups. After a review of the evidence discussed above, the Board finds that limitation of motion to midway between the side and shoulder level (flexion or abduction to 45 degrees or less), ankylosis, or impairment of the humerus is not shown or more nearly approximated in the Veteran's right shoulder during the period on appeal. Such findings were not shown, even when considering the Veteran's reported symptomatology including limitations due to painful motion, repetitive use, and during flare-ups. The Veteran's reported symptomatology did not, when viewed in conjunction with the medical evidence, tend to establish or rise to the severity of additional limitations of motion to the degree that would warrant an initial rating in excess of 20 percent for the service-connected right shoulder disability under 38 C.F.R. §§ 4.40, 4.45, 4.59 and the holdings in DeLuca and Mitchell. The Board considered the Veteran's reported history of symptomatology related to the service-connected right shoulder disability, to include as noted in the 2016 and 2021 VA examination reports. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through one's senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, although the descriptions of his symptoms are competent and credible, they do not show that the criteria for a higher initial rating for his right shoulder disability have been met. Kahana v. Shinseki, 24 Vet. App. 428 (2011). Rather the Board finds probative the limitations of the Veteran's impairment of the right shoulder reported by the VA examiners and the medical evidence of record. The Board notes that the competent evidence of record has not established that the Veteran's right shoulder disability results in limitation of flexion or abduction to midway between side and shoulder level. Rather, each evaluation of record has demonstrated range of motion to at least approximately shoulder level including additional limitations during flare-ups. As such, the Board finds these records to be more probative than the Veteran's subjective reports of worsened symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board has considered the possibility of staged ratings and the above evidence reflects that a uniform rating is appropriate; therefore, staged ratings are not warranted. See Fenderson, 21 Vet. App at 505. As the preponderance of the evidence of record is against the Veteran's claim, the Board finds that the Veteran's claim for a rating in excess of 20 percent for his right shoulder disability must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.71a, DC 5201. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P.M. Johnson, 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.