Citation Nr: 21025272 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 17-44 174 DATE: April 27, 2021 ORDER Entitlement to an evaluation in excess of 30 percent for residuals, status post scapula resection, scapula and rotator cuff syndrome of left shoulder is denied Entitlement to an increased evaluation in excess of 20 percent for degenerative joint disease of the right shoulder is denied. REMANDED Entitlement to service connection for dystonia musculorum deformans, to include as secondary to service-connected left and right shoulder disabilities, is remanded. Entitlement to service connection for cervical spine disorder, to include as secondary to service-connected left and right shoulder disabilities, is remanded. Entitlement to a total disability rating based upon individual unemployability based on service-connected disabilities (TDIU) is remanded. Entitlement to special monthly compensation based on the need for regular aid and attendance or by reason of being housebound is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran’s residuals, status post scapula resection, scapula and rotator cuff syndrome of left shoulder, were manifested, at worst, by flexion to 70 degrees and abduction to 70 degrees of the major extremity. 2. Throughout the appeal period, the most probative evidence of record reflects, the Veteran’s degenerative joint disease of the right shoulder, was manifested by impairment of the humerus with recurrent dislocation of the scapulohumeral joint of the minor extremity. There was no factually ascertainable increase within a year prior to the date of the claim on appeal. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for residuals, status post scapula resection, scapula and rotator cuff syndrome of left shoulder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5202-5201. 2. The criteria for a rating in excess of 20 percent for degenerative joint disease of the right shoulder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003-5202. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1983 to March 1987. These matters come before the Board of Veterans’ Appeals (Board) on appeal of a May 2013 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). The May 2013 rating decision, in pertinent part, continued a 30 percent evaluation for the Veteran’s left shoulder disability and a 20 percent evaluation for her right shoulder disability. However, a prior February 2012 rating decision, in pertinent part, continued a 30 percent evaluation for the Veteran’s left shoulder disability and granted a 20 percent evaluation for her right shoulder disability, based on a claim for increased rating received by VA on April 14, 2011. The Veteran did not appeal these evaluations. However, as best the Board can discern, the Agency of Original Jurisdiction found VA received new and material evidence specific to the Veteran’s bilateral shoulder disability within the appeal period following issuance of the February 2012 rating decision. 38 C.F.R. § 3.156 (b). The right and left shoulder claims were readjudicated in the May 2013 rating decision, which the Veteran expressly appealed and perfected an appeal 60 days after the issuance of a June 2017 statement of the case, issued, in part, for these claims. Thus, resolving reasonable doubt in the Veteran’s favor, the rating period for consideration on appeal as to the Veteran’s right shoulder disability and left shoulder disability, is based on the April 14, 2011 informal claims for increase. These issues were remanded by the Board in April 2019. They now return for appellate review. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA must consider whether to “stage” the rating, meaning assign different ratings at different times during the rating period to compensate the Veteran for times when the disability may have been more severe than at others. Consideration of the appropriateness of a staged rating is required for increased rating claims, irrespective of whether it is an initial rating at issue or instead an established rating. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. 1. Entitlement to an evaluation in excess of 30 percent for residuals, status post scapula resection, scapula and rotator cuff syndrome of left shoulder The Veteran contends that she is entitled to a higher rating for her left shoulder disability. Specifically, in her April 2011 informal claim for increase, the Veteran reported the use of medication for her bilateral shoulder. Additionally, in a January 2012 statement, the Veteran reported, in part, that she could not walk very far because her shoulder started hurting. An October 2012 record from the Social Security Administration reported the Veteran had bilateral shoulder pain with reaching over head or lifting/carrying more than 10 lbs. In an August 2017 substantive appeal, VA Form 9, the Veteran generally reported chronic and constant pain. Most recently, during the December 2019 examination, the Veteran reported worsening bilateral shoulder pain requiring more rest and medication with minimal relief. Additionally, in a statement signed in March 2013, the Veteran’s friend reported, in part, that the Veteran needed help with normal life situations such as shopping, because she could not lift or reach due to her shoulder and thumb conditions. As discussed above, the current claim for increase for the Veteran’s left shoulder disability stems from an April 14, 2011 informal claim for increase. Thus, the period for consideration on appeal is from one year prior to the date of receipt of the claim for increase, if it is factually ascertainable that an increase occurred during that period. Throughout the appeal period, the Veteran’s service-connected left shoulder disability is rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5202-5201. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. Here, Diagnostic Code 5202, the rating code for other impairment of the humerus is listed first, followed by a hyphen and then Diagnostic Code 5201, the rating code for limitation of motion of the arm. The Veteran’s left shoulder disability is thus ultimately rated by application of the provisions Diagnostic Code 5201. The Board notes that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, were amended effective February 7, 2021. 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). Prior to February 7, 2021, the Board will consider the old version of the diagnostic codes only; however, for the period beginning February 7, 2021 the Board will consider both the old and amended version of the diagnostic code and rate based on whichever is most favorable to the Veteran. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Under the prior version of Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Diagnostic Code 5201 “does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm.” Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). The revised VA regulations, effective February 7, 2021, clarify that limitation of motion of the arm under Diagnostic Code 5201 includes either flexion or abduction. The revised regulations also clarify that “shoulder level” equates to flexion and/or abduction limited to 90 degrees, “midway between side and shoulder level” equates to flexion and/or abduction limited to 45 degrees, and “[t]o 25 degrees from side” equates to flexion and/or abduction limited to 25 degrees from side. The Board finds that the preponderance of the evidence is against a rating in excess of 30 percent for the Veteran’s left shoulder disability. The evidence of record, to include May 2013, June 2018, December 2019 shoulder and arm conditions disability benefits questionnaires (DBQs), demonstrates that the Veteran’s left hand is dominant. Additionally, the May 2013 VA examiner found, as to the Veteran’s left shoulder, for both active range of motion and passive range of motion, she had abduction, flexion, external rotation and internal rotation, all to 90 degrees, with pain and with repetitive testing. In March 2016, the Veteran annotated the May 2013 DBQ and indicated, in part, no post test range of motion was performed and that she had pain before 90 degrees as to all range of motion findings. In another March 2016 statement, the Veteran expressed concern with the DBQ because the original examiner had a family emergency, and her examination was reassigned to an examiner with a full work load, that there possible bias as the examiner read the prior examination while doing the current examination, that key questions were unanswered in critical testing and/or not performed, that most answers were in notes rather that in the questionnaire itself, and that findings were contradictory. However, the question of whether an examiner is competent and whether he or she has rendered an adequate opinion are two separate inquiries. See Francway v. Wilkie, 930 F.3d 1377, 1381 (Fed. Cir. 2019). Absent some challenge to the expertise of a VA expert, there is no requirement that VA present affirmative evidence of a medical professional’s qualifications in every case as a precondition for the Board’s reliance upon that person’s opinion, and the Board is entitled to assume the competence of a VA examiner unless the competence is challenged. Sickels v. Shinseki, 643 F.3d 1362, 1365-66 (Fed. Cir. 2011); Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009). This presumption is rebutted when the Veteran raises the issue of competency. See Francway, 930 F.3d at 1380. After the Veteran challenges the competency of a medical examiner, the Board must then make factual findings regarding the qualifications and provide reasons and bases for concluding whether or not the medical examiner was competent to provide the opinion. Id. at 1381. Rather than challenging the competency of the May 2013 VA examiner in this case, the Veteran’s objections are generally based on how the examiner conducted the examination, reviewed the evidence, and provided the findings within the report itself. However, there is no evidence to support the Veteran’s contentions of any material irregularity nor is the Board able to discern any material irregularities in the May 2013 DBQ, thus this DBQ is adequate. Additionally, a June 2018 VA examiner found, as to the Veteran’s left shoulder, she had abduction and flexion to 80 degrees each, and she had external rotation and internal rotation, to 30 degrees each, with pain and with repetitive testing. Most recently, a December 2019 VA examiner found, as to the Veteran’s left shoulder, she had flexion to 90 degrees, abduction to 85 degrees, external rotation to 70 degree, and internal rotation to 30 degrees, all with pain and repetitive testing. The June 2018 and December 2019 VA examiners also found there was objective evidence of pain on passive range of motion testing and when the joint was used in non-weight bearing but did not provide findings in degrees. However, generally, active range of motion testing produces more restrictive results than passive range of motion testing, in that passive range of motion testing requires the physician to force the joint through its motions. There is also no indication that the range of motion testing in these DBQs was performed other than on weight-bearing. Therefore, there is no prejudice to the Veteran in relying on the June 2018 and December 2019 DBQs that involved active range of motion testing with weight bearing because such results tend to produce the “worst case scenario” of impairment and thus would tend to support the highest possible rating. Additionally, the Veteran’s clinical treatment records throughout the rating period noted the existence of left shoulder disability. For example, June 2015 and July 2016 VA treatment records documented, as to the Veteran’s left shoulder, she had forward flexion to 90 degrees and abduction to 80 degrees. Also, a May 2018 VA treatment record documented, in part, that Veteran was unable to actively abduct either her right or left upper extremity. The May 2018 VA treatment record also noted she was able to passively abduct both shoulders but only to about 100 degrees. However, the May 2018 VA treatment record’s finding that the Veteran was unable to actively abduct either shoulder is isolated and not consistent with the clinical record, including proximate to such reported finding. In this regard, an October 2017 VA treatment record documented, in part, the Veteran had four out of five muscle strength with right shoulder abductors, and more generally, five out of five muscle strength with shoulder abduction. As such, the Board does not find that the criteria for a higher rating is warranted based the May 2018 VA treatment record’s isolated finding. Further, a June 2013 VA treatment record documented, in part, secondary to dystonia, the Veteran demonstrated maximum 90 degrees of flexion of the bilateral shoulder. Thus, to the extent the Veteran may have had other diagnoses related to her left shoulder at any point during the appeal period, such as dystonia, the Board will consider all findings of non-distinct symptomology as attributed to the Veteran’s service-connected residuals, status post scapula resection, scapula and rotator cuff syndrome of left shoulder. Mittleider v. West, 11 Vet. App. 181, 182 (1998). The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to weakness and pain, to include pain with walking and lifting, chronic and constant pain, pain requiring more rest and medication with minimal relief, pain during flare-ups, and pain during repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by her statements would not result in symptoms more nearly approximating limitation of motion of the arm to 25 degrees from the side (including flexion and/or abduction since February 7, 2021). In this regard, the May 2013 VA examiner also found the Veteran did not have any functional loss or functional impairment of the shoulder or arm, and also documented that no pain, fatigue, weakness or incoordination were noted. The June 2018 VA examiner also documented the Veteran did not report having any functional loss or having any functional impairment of the shoulder joint. A December 2019 VA examiner also noted the Veteran reported function loss or functional impairment of the shoulder described as an inability to work overhead. Additionally, the May 2013 and December 2019 VA examiners each documented the Veteran did not report flare-ups of the shoulder. A June 2018 VA examiner found the Veteran reported flare-ups of the left shoulder described as spasms. The June 2018 VA examiner also documented pain and weakness significantly limited functional ability with flare-ups and with repeated use over a period of time resulting in flexion to 70 degrees, abduction to 70 degrees, external rotation to 20 degrees and internal rotation to 20 degrees. A December 2019 VA examiner found pain significantly limit functional ability with repeated use over a period of time resulting in flexion to 85 degrees, abduction to 75 degrees, external rotation to 45 degrees and internal rotation to 35 degrees. These findings do not more nearly approximate limitation of motion of the arm to 25 degrees from the side (including flexion and/or abduction since February 7, 2021). The Board has considered whether higher or separate ratings are warranted under alternate diagnostic codes pertaining to the left shoulder. However, there is no indication of ankylosis or functional loss consistent with ankylosis of the scapulohumeral articulation. Thus, a rating under Diagnostic Codes 5200 is not available. VA treatment records, including dated in March 2015, July 2015, October 2015, April 2016, October 2016, and April 2017, also reflected the Veteran experienced left shoulder dislocations. Also, VA imaging reflected that, as to the Veteran’s left shoulder, there were changes compatible with old resection of the distal left clavicle at the acromioclavicular articulation and an irregular contour to the inferior scapula medially suggesting old posttraumatic change. Furthermore, the December 2019 VA examiner found the Veteran did have an acromioclavicular joint condition or other impairment of the clavicle or scapula, specifically dislocation (acromioclavicular separation or sternoclavicular dislocation) of the left shoulder, which affected the range of motion of the shoulder. Thus, the evidence tends to reflect the Veteran’s dislocation of the left shoulder is related to impairment of the clavicle or scapula. Nonetheless, a separate rating under Diagnostic 5202 for impairment of the humerus, or under Diagnostic 5203 for impairment of the clavicle or scapula, are not warranted, despite the evidence of dislocation in either case, because it would result in impermissible pyramiding, as the Veteran’s symptoms, including pain, limitation of motion due to pain, and functional impairment are contemplated in the currently assigned rating under Diagnostic Code 5201. See 38 C.F.R. § 4.14. Moreover, a 30 percent rating is the maximum rating for recurrent dislocation of the scapulohumeral joint under Diagnostic Code 5202 and a 20 percent rating is the maximum rating available for dislocation under Diagnostic Code 5203. Thus, to rate the left shoulder disability under Diagnostic Code 5202 or Diagnostic Code 5203 would not benefit the Veteran. Also, the June 2018 and December 2019 VA examiners endorsed a left rotator cuff tear in 1991, which is not proximate to the claim, but also noted a left rotator cuff condition was suspected. Prior to February 7, 2021 tendinopathy is rated under Diagnostic Code 5024 (recharacterized tenosynovitis, tendinitis, tendinosis or tendinopathy on and after February 7, 2021) and is rated on based on limitation of motion, degenerative arthritis, of the affected part As such, any left shoulder tendinopathy in this case would be rated under the currently assigned Diagnostic Code 5201. Accordingly, the Board concludes that a separate rating or a rating greater than 30 percent for the left shoulder disability is not warranted. Additionally, neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record with her respect to her left shoulder disability. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s appeal for a rating in excess of 30 percent for residuals, status post scapula resection, scapula and rotator cuff syndrome of left shoulder. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to an increased evaluation in excess of 20 percent for degenerative joint disease of the right shoulder The Veteran contends that she is entitled to a higher rating for her right shoulder disability. As discussed above, during the pendency of the claim, she has reported the use of medication for her bilateral shoulder, that she could not walk very far because her shoulder started hurting, bilateral shoulder pain with reaching over head or lifting/carrying, chronic and constant pain, and worsening bilateral shoulder pain requiring more rest and medication with minimal relief. Additionally, in a statement signed in March 2013, the Veteran’s sister, reported, in part, that the Veteran had functional impairment of her shoulder. As discussed above, the current claim for increase for the Veteran’s right shoulder disability stems from an April 14, 2011 informal claim for increase. Thus, the rating period for consideration on appeal is from one year prior to the date of receipt of the claim for increase, if it is factually ascertainable that an increase occurred during that period. Throughout the appeal period, the Veteran’s service-connected right shoulder disability is rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5003-5202. 38 C.F.R. § 4.27. Here, Diagnostic Code 5003, the rating code for the rating code for degenerative arthritis is listed first, followed by a hyphen and then Diagnostic Code 5202, for other impairment of the humerus. The Veteran’s right shoulder disability is thus ultimately rated by application of the provisions of Diagnostic Code 5202. As discussed above, during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, were amended effective February 7, 2021. 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). Prior to February 7, 2021, the Board will consider the old version of the diagnostic codes only; however, for the period beginning February 7, 2021 the Board will consider both the old and amended version of the diagnostic code and rate based on whichever is most favorable to the Veteran. See Kuzma, 341 F.3d at 1329. Under the prior version of Diagnostic Code 5202, malunion of the humerus with moderate deformity warrants a 20 percent rating for both the major and minor extremity. Malunion of the humerus with marked deformity warrants a 20 percent rating for the minor extremity. Recurrent dislocation of the humerus at scapulohumeral joint with infrequent episodes and guarding of movement only at shoulder level warrants a 20 percent rating for both the major and minor extremity. Recurrent dislocation of the humerus at scapulohumeral joint with frequent episodes and guarding of all arm movements warrants a 20 percent rating in the minor extremity. Fibrous union of the humerus warrants a 40 percent rating in the minor extremity. Nonunion of the humerus (false fail joint) warrants a 50 percent rating in the minor extremity. Loss of head of the humerus (flail shoulder) warrants a maximum 70 percent rating for the minor extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5202. The revised VA regulations, effective February 7, 2021, clarify “shoulder level” equates to flexion and/or abduction limited to 90 degrees. According to MERRIAM WEBSTER, “moderate” means “tending toward the mean or average amount or dimension”. See www.merriam-webster.com/dictionary/moderate. “Marked” means “having a distinctive or emphasized character”. See www.merriam-webster.com/dictionary/marked. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for the Veteran’s right shoulder disability. As discussed above, the evidence of record, to include May 2013, June 2018, December 2019 DBQs, shows that the Veteran’s left hand is dominant, thus her right shoulder is her minor extremity. In this regard, the May 2013 VA examiner found, in part, there was no history of recurrent dislocation of the glenohumeral (scapulohumeral) joint. June 2018 and December 2019 VA examiners found shoulder instability, dislocation or labral pathology was not suspected. The June 2018 and December 2019 VA examiners also found that the Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus. The June 2018 and December 2019 VA examiners further found the Veteran did not have malunion of the humerus with moderate or marked deformity. However, VA treatment records, including dated in March 2014, March 2015, October 2015, April 2016, October 2016, and April 2017, also reflected the Veteran experienced right shoulder dislocation. Also, VA imaging reflected, as to the Veteran’s right shoulder, documented there were mild degenerative changes developing at the acromioclavicular and glenohumeral articulations, sclerotic irregularity on the right involving the humeral head adjacent to the tuberosity and such a finding could be seen with repeated anterior dislocations of the shoulder and/or some developing rotator cuff pathology at the insertion of the supraspinatus tendon. Thus, the evidence reflects the Veteran’s dislocation of the right shoulder is related to impairment of the humerus. However, impairment of the humerus with recurrent dislocation of the scapulohumeral joint of the minor extremity is rated as 20 percent whether with frequent or infrequent episodes and guarding of movement only at the shoulder level or guarding of all arm movements. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due weakness and pain, to include pain with walking and lifting, chronic and constant pain, pain requiring more rest and medication with minimal relief, and pain during repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by her statements that would not result in symptoms more nearly approximating fibrous union of the humerus, nonunion of the humerus, or loss of head of the humerus. In this regard, the May 2013 VA examiner also found the Veteran did not have any functional loss or functional impairment of the shoulder or arm, and also documented that no pain, fatigue, weakness or incoordination were noted. The June 2018 VA examiner also documented the Veteran did not report having any functional loss or having any functional impairment of the shoulder joint. A December 2019 VA examiner also noted the Veteran reported function loss or functional impairment of the shoulder described as an inability to work overhead. However, these do not approximate fibrous union of the humerus, nonunion of the humerus, or loss of head of the humerus. The Board has considered whether higher or separate ratings are warranted under alternate diagnostic codes pertaining to the right shoulder. However, there is no indication of ankylosis of the scapulohumeral articulation or impairment of the clavicle or scapula at any point during the period on appeal. Thus, ratings under Diagnostic Code 5200 and 5203 are not available. Also, the June 2018 VA examiner noted a right rotator cuff condition was suspected but did not endorse a diagnosis. As noted above, tendinopathy is rated under Diagnostic Code 5024 characterized as tenosynovitis prior to February 7, 2021, and as tenosynovitis, tendinitis, tendinosis or tendinopathy on and after February 7, 2021, and which is rated on limitation of motion, as degenerative arthritis, of the affected part. As such, any right shoulder tendinopathy in this appeal would be rated under Diagnostic Code 5201, which is discussed in more detail below. 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, which here is Diagnostic Code 5201. 38 C.F.R. § 4.71a, Diagnostic Code 5003. These provisions are substantially unchanged by the new regulations effective February 7, 2021. As discussed above, under the prior version of Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating, limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity, and limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The revised VA regulations, effective February 7, 2021, clarify that limitation of motion of the arm under Diagnostic Code 5201 includes either flexion or abduction. In this regard, the May 2013 VA examiner found, as to the Veteran’s right shoulder, for both active range of motion and passive range of motion, she had abduction, flexion, external rotation, and internal rotation, all to 90 degrees, with pain and with repetitive testing. As noted above, in March 2016, the Veteran annotated the May 2013 DBQ and indicated, in part, no post test range of motion was performed and that she had pain before 90 degrees as to all range of motion findings. However, as discussed above, the May 2013 DBQ is adequate. The June 2018 VA examiner also documented, as to the Veteran’s right shoulder, at worst, pain and weakness significantly limited functional ability with repeated use over a period of time resulting in flexion to 90 degrees, abduction to 90 degrees, external rotation to 30 degrees and internal rotation to 30 degrees. Most recently, a December 2019 VA examiner also documented, as to the Veteran’s right shoulder, at worst, pain significantly limited functional ability with repeated use over a period of time resulting in flexion to 85 degrees, abduction to 75 degrees, external rotation to 45 degrees and internal rotation to 35 degrees. These findings do not support a higher rating under the old or new criteria for Diagnostic Code 5201. Additionally, the Veteran’s clinical treatment records throughout the rating period noted the existence of right shoulder disability but do not demonstrate a higher rating is warranted under the old or new criteria for Diagnostic Code 5201. In this regard, as discussed above, a May 2018 VA treatment record documented, in part, that Veteran was unable to actively abduct either her right or left upper extremity, without right sided having greater deficit. The May 2018 VA treatment record also noted she was able to passively abduction both shoulders but to only about 100 degrees. However, the May 2018 VA treatment record’s finding that the Veteran was unable to actively abduct either shoulder is isolated and not consistent with the clinical record, including proximate to such reported finding. In this regard, an October 2017 VA treatment record documented, in part, the Veteran had four out of five muscle strength with right shoulder abductors, and more generally, five out of five muscle strength with shoulder abduction. As such, the Board does not find that the criteria for a higher rating is warranted based the May 2018 VA treatment record’s isolated finding. Further, a June 2013 VA treatment record documented, in part, secondary to dystonia, the Veteran demonstrated maximum 90 degrees of flexion of the bilateral shoulder. Thus, to the extent the Veteran may have had other diagnoses related to her right shoulder at any point during the appeal period, such as dystonia, the Board will consider all findings of non-distinct symptomology as attributed to the Veteran’s service-connected degenerative joint disease of the right shoulder. Mittleider, 11 Vet. App. at 182. Additionally, neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record with her respect to her right shoulder disability. See Doucette, 28 Vet. App. at 369-70. Finally, in this case, the AOJ awarded a 20 percent rating (increased from a 10 percent rating previously in effect) for the Veteran’s right shoulder disability effective from the April 14, 2011, date of the claim on appeal. The Board has now considered whether any worsening of the disability within one-year prior to the claim warranted an increased rating. However, the Board finds no evidence making it factually ascertainable that the Veteran’s right shoulder disability underwent an increase in severity to meet the criteria for an increased rating on any identifiable date within a year prior to the April 14, 2011, date of claim. None of the evidence of record shows a factually ascertainable increase in the Veteran’s right shoulder disability impairments causing the criteria for an increased rating to have been met on a factually ascertainable date within the year prior to April 14, 2011. Accordingly, the Board finds no factually ascertainable date of increase in the severity of right shoulder disability impairment during the one-year period prior to the claim dated April 14, 2011, to serve as a basis for awarding an increased rating effective from prior to that date of the claim. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s appeal for a rating in excess of 20 percent for degenerative joint disease of the right shoulder. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7; Gilbert, 1 Vet. App. at 55-57. REASONS FOR REMAND 1. Entitlement to service connection for dystonia musculorum deformans, to include as secondary to service-connected left and right shoulder disabilities is remanded. A December 2019 VA examiner explained that an amputation DBQ was ordered to address a genetic condition but there were no amputations for this Veteran and the claimed condition of dystonia musculorum deformans was not appropriately addressed within this DBQ. The December 2019 VA examiner also found the claimed condition was less likely than incurred in or caused by the claimed in-service injury, event, or illness, as dystonia musculorum deformans was a genetic hereditary condition. However, the December 2019 VA examiner did not address a June 2017 private medical record which, in part, documented the provided panel of tests did not identify mutations associated with isolated dystonia but also noted this diagnosis could not be completely ruled out due to mutations not detected by this assay or mutations in another gene, or the July 2017 DBQ, authored by Dr. J. Ben Renfroe, which stated, in part, the Veteran’s dystonia was not genetic. Thus, another examination, on the proper DBQ form, is required, as well as a medical opinion to determine whether the Veteran’s dystonia musculorum deformans is genetic, and, if so, whether it is a congenital or developmental defect or a congenital disease. If it is a disease, findings must be made as to whether it was aggravated by her period of active service beyond its natural progression, and if it is a defect, findings must be made as to whether there are any superimposed diseases or injuries in connection with the congenital defect, and if so, whether the superimposed disease or injury is related to the Veteran’s active service.   2. Entitlement to service connection for cervical spine disorder, to include as secondary to service-connected left and right shoulder disabilities is remanded. A December 2019 VA examiner found the Veteran’s cervical condition was from dystonia musculorum deformans (a genetic, hereditary condition) but it was plausible to opine that this was further aggravated by shoulder injuries in service. However, the December 2019 VA examiner was unable to provide further a nexus opinion without a full assessment with the proper DBQ (as discussed above, an amputations DBQ was ordered in error as to the Veteran’s dystonia musculorum deformans). Thus, after a full assessment of dystonia musculorum deformans on the proper DBQ, an opinion addressing the claim as secondary to service-connected left and right shoulder disabilities is warranted. Also, as the issue of entitlement to service connection for cervical spine disorder is intertwined with claim for service connection for dystonia musculorum deformans, a remand is warranted for the claim for a cervical condition. Harris v. Derwinski, 1 Vet. App. 180 (1991). 3. Entitlement to a total disability rating based upon individual unemployability based on service-connected disabilities (TDIU) is remanded. The Veteran’s claim for entitlement to a TDIU, must be remanded as it remains inextricably intertwined with the above issues being remanded herein. Id. 4. Entitlement to special monthly compensation based on the need for regular aid and attendance or by reason of being housebound is remanded. The Veteran’s claim for special monthly compensation based on based on the need for aid and attendance or housebound status, must be remanded as it remains inextricably intertwined with the above issues being remanded herein. Id. The matters are REMANDED for the following actions: 1. Please obtain any updated VA and non-VA treatment records. 2. Schedule the Veteran for a VA examination (with use of the proper DBQ) for her dystonia musculorum deformans. The clinician must review the claims file, and in particular, the December 2019 VA examiner’s finding that dystonia musculorum deformans was a genetic hereditary condition as well as a June 2017 private medical record which, in part, documented the provided panel of tests did not identify mutations associated with isolated dystonia but also noted this diagnosis could not be completely ruled out, and the July 2017 DBQ authored by Dr. J. Ben Renfroe, which stated, in part, the Veteran’s dystonia was not genetic. The clinician is asked to provide a response to the following: (a.) Is the Veteran’s dystonia musculorum deformans is a genetic hereditary condition? (b.) If the answer to (a) is yes, please identify whether it is a congenital “defect,” or a congenital “disease”. The examiner is advised that for purposes of VA compensation, a congenital “defect” is defined as a condition that is more or less stationary in nature, whereas a congenital “disease” is defined as a condition capable of improving or deteriorating. (c.) If the Veteran’s dystonia musculorum deformans is considered a congenital “defect,” the examiner must opine whether it is at least as likely as not that there was a superimposed disease or injury on the congenital defect during active military service. If yes, please identify the superimposed disease or injury, as well as the resultant disability due to such superimposed disease or injury. (d.) If the Veteran’s dystonia musculorum deformans is considered a congenital “disease,” state whether such was aggravated (increased in severity) beyond the normal progress of the disease in service. (e.) If the clinician finds that the Veteran’s dystonia musculorum deformans is not a genetic hereditary condition, the examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. (f.) If the answer to the above questions are negative, address whether the Veteran’s dystonia musculorum deformans is at least as likely as not (1) proximately due to service-connected right shoulder disability and/or left shoulder disability, or (2) aggravated, i.e., any increase in disability, by service-connected right shoulder disability and/or left shoulder disability. A baseline must be provided if the disability is deemed aggravated. Rationale must be provided for each opinion proffered. 3. Obtain a medical opinion from an appropriate clinician addressing the nature and etiology of any identified cervical spine disorder. The clinician is asked to provide a response to the following: (a.) Is it at least as likely as not that any identified cervical spine disorder was proximately due to service-connected right shoulder disability and/or left shoulder disability? (b.) Is it at least as likely as not that identified cervical spine disorder was aggravated, i.e., any increase in disability, by service-connected right shoulder disability and/or left shoulder disability? A baseline must be provided if the disability is deemed aggravated. Rationale must be provided for each opinion proffered. 4. After undertaking any other development deemed appropriate, readjudicate the issues on appeal, to include TDIU and special monthly compensation based on the need for regular aid and attendance or by reason of being housebound. If any benefit sought is not granted, furnish the Veteran and her representative with a supplemental   statement of the case and afford them an opportunity to respond before the record is returned to the Board for further review. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Espinoza, 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.