Citation Nr: 21028311 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 18-42 062 DATE: May 11, 2021 ORDER Service connection for a left shoulder disorder, other than left trapezius strain, is denied. Prior to May 31, 2018, a rating higher than 10 percent for cervical strain is denied. From May 31, 2018, a 30 percent rating, but no higher, for cervical strain is granted. An earlier effective date of February 25, 2019, for the grant of service connection left upper extremity cervical radiculopathy is granted. A rating higher than 20 percent for left upper extremity cervical radiculopathy is denied. An earlier effective date of December 28, 2016, for the grant of service connection for scar, status post cervical fusion, is granted. A compensable rating for scar, status-post cervical fusion, is denied. A rating higher than 20 percent for left trapezius strain is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. The Veteran does not have a left shoulder disability other than his already service-connected left trapezius strain disability. 2. Prior to May 31, 2018, the evidence shows that the Veteran's cervical spine disability manifested by, at worst, forward flexion limited to 40 degrees. From May 31, 2018, it is factually ascertainable that, when considering flare-ups, the Veteran's disability picture more closely approximated forward flexion of the cervical spine limited to 15 degrees or less. At no point during the appeal period has ankylosis or functional ankylosis been demonstrated. 3. As of February 25, 2019, it is factually ascertainable that the Veteran had a diagnosis of left upper extremity radiculopathy. Such diagnosis was confirmed on VA examination in December 2020. 4. Throughout the appeal period, the Veteran's left upper extremity cervical radiculopathy has manifested by, at worst, mild incomplete paralysis. 5. It is factually ascertainable that the Veteran's cervical spine scar was a result of his 2015 cervical spine surgery. An effective date of December 28, 2016, the date the Veteran filed for service connection for his left trapezius strain/cervical spine disability, is the earliest possible effective date available. 6. For the entire appeal period, the Veteran's cervical spine scar was not painful or unstable, there is no elevation, depression, or adherence to underlying tissue, and it does not have any abnormal pigmentation or texture. 7. For the entire appeal period, the Veteran's left trapezius strain has manifested by, at worst, limitation of motion of the arm at shoulder level with painful motion of the shoulder. 8. The Veteran's service-connected disabilities do not preclude him from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left shoulder disability other than left trapezius strain have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for a rating higher than 10 percent for cervical strain prior to May 31, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5003-5243. 3. From May 31, 2018, the criteria for a 30 percent rating, but no higher, for cervical strain, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5003-5243. 4. The criteria for an earlier effective date of February 25, 2019, but no earlier, for the grant of service connection for left upper extremity radiculopathy have been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 5. The criteria for entitlement to a rating higher than 20 percent for left upper extremity cervical radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 8513. 6. The criteria for an earlier effective date of December 28, 2016, but no earlier, for the grant of service connection for scar, status-post cervical fusion, have been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 7. The criteria for entitlement to a compensable rating for scar, status post cervical fusion, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 7800. 8. The criteria for entitlement to a rating higher than 20 percent for left trapezius strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5201. 9. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service in the United States Army from October 1998 to June 1999. By a January 2019 decision, the Board granted service connection for major depressive disorder. Although the Veteran continues to disagree with the assigned rating, that issue is no longer before the Board. See February 2021 Rating Decision. 1. Entitlement to service connection for a left shoulder disability, other than left trapezius strain. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). In Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018), the Federal Circuit found that the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability." However, Saunders does not eliminate the need for underlying pathology, disease, or injury. In this instance, the Veteran is already service-connected for left trapezius strain (left shoulder). He contends he has a left shoulder disability separate from his left trapezius strain. As previously noted by the Board, when the Veteran filed his claim in June 2017, he specifically stated that he was seeking service connection for a right shoulder disorder. During the appeal period, however, he stated that his claim was supposed to be for his left shoulder. Indeed, on his VA form 9, he clarified "I keep contending that it is not my right shoulder, but my left shoulder that I injured while on active duty." The Veteran's VA treatment records document left shoulder pain but do not indicate a diagnosis separate from left trapezius strain. On several VA examinations, sensory testing revealed a normal shoulder. On VA examination July 2017, the only diagnosis rendered related to the left shoulder was "left trapezius strain." The examiner went on to state that the Veteran injured his "left shoulder area" in service. In January 2019, the Board sought additional VA medical opinion to clarify the Veteran's diagnoses. On VA examination in December 2020, the Veteran was noted to have no diagnosis of the left shoulder other than left trapezius strain. The examiner stated, "no shoulder condition was revealed on examination, the shoulder joint is intact and only has range affected due to spasm in the trapezius due to strain, which is already [service-connected]." Based on the available evidence of record, the Board finds that the Veteran does not have a left shoulder disorder other than his already service-connected left trapezius strain. He is currently being compensated for the functional loss caused by the strain and there is no additional functional loss such that it can be said he has a separate "disability" consistent with Saunders, supra. The Board acknowledges the Veteran's sincere belief that he has a left shoulder disability separate from his left trapezius strain. Although he is competent to state that he has left shoulder pain, he is not competent to state that he has a separate left shoulder diagnosis as that requires specialized medical training. Instead, the Board affords more probative weight to the VA treatment records and examination reports, which have attributed the Veteran's pain to his already service-connected left trapezius strain disability. In the absence of proof of a current disability there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. As such, the Veteran's claim for a left shoulder disability must be denied. 2. Entitlement to a rating higher than 10 percent for cervical strain prior to May 31, 2018. 3. Entitlement to a rating higher than 20 percent prior to December 5, 2020; and a rating higher than 30 percent thereafter. 4. Entitlement to a rating higher than 20 percent for left cervical radiculopathy. 5. Entitlement to a compensable rating for scar, status post cervical fusion. The Veteran contends that higher ratings are warranted for his service-connected cervical spine disability, which is currently rated under hyphenated Diagnostic Code 5003-5243. Schedular ratings for disabilities of the spine are provided by application of the General Rating Formula for Diseases or Injuries of the Spine or by application of the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. 38 C.F.R. § 4.71a. The General Formula specifies that the criteria and ratings apply with or without symptoms such as pain, whether or not it radiates, stiffness, or aching in the area affected by residuals of injury or disease. 38 C.F.R. § 4.71a. Under the General Rating Formula for Diseases or Injuries of the Spine, the diagnostic code criteria pertinent to cervical spine disabilities provides that a 10 percent rating is warranted when there is forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees, or a combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour or, vertebral body fracture with loss of 50 percent or more of height. A 20 percent rating is warranted when there is forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, combined range of motion of the cervical spine not greater than 170 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 30 percent rating is warranted when there is forward flexion of the cervical spine 15 degrees or less, or, favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. 38 C.F.R. § 4.71a. Ankylosis is defined, for VA compensation purposes, as a condition in which all or part of the spine is fixed in flexion or extension. 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine, Note (5). Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent rating is assigned where there are incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. An incapacitating episode is defined 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. 38 C.F.R. § 4.71a; Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1). Effective February 7, 2021, DC 5243, which contemplates IVDS was amended. In pertinent part, the amendment states: Evaluate intervertebral disc syndrome (preoperatively or postoperatively) either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under §4.25. In reviewing the evidence of record, the Board notes that at no point during the appeal period has he demonstrated any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician. As such, further discussion of the IVDS regulations is not necessary. The rating criteria states that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine, Note (1). As noted above, in January 2019, the Board remanded the Veteran's increased rating claim for his cervical spine. As a result of the additional VA examination, the Veteran was separately service-connected for left cervical radiculopathy, rated as 20 percent disabling under Diagnostic Code 8513. In addition, the RO granted service connection and separately rated the Veteran's cervical scar under Diagnostic Code 7800. Because these ratings were borne out of the original increased rating claim, they are part-and-parcel of the claim and the Board will also address the propriety of the ratings assigned. The Veteran's VA examination reports as well as service treatment records confirm that he is right-hand dominant. Therefore, his left extremity is his "minor" extremity. Under Diagnostic Code 8513, for the minor extremity, the rating schedule provides a 20 percent rating for mild incomplete paralysis, a 30 percent rating for moderate incomplete paralysis, and a 40 percent rating for severe incomplete paralysis of all radicular groups. Where there is complete paralysis of the minor extremity, an 80 percent rating is assigned. 38 C.F.R. § 4.124a. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. Id. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The terms "mild," "moderate" and "severe" are not defined in VA regulations, and the Board must arrive at an equitable and just decision after having evaluated the evidence. 38 C.F.R. § 4.6. The Veteran was afforded an in-person VA examination for his cervical spine in July 2017. At that time, the examiner noted diagnoses of cervical strain and degenerative arthritis of the spine and noted that in 2015, the Veteran required a cervical fusion due to spondylosis. On examination, he endorsed flare-ups that were "daily, lasting hours" which caused loss of driving tolerance as well as ability to perform overhead activities. On range of motion testing, he demonstrated forward flexion to 40 degrees; extension to 25 degrees; bilateral lateral flexion to 35 degree; right lateral rotation to 40 degrees; and left lateral rotation to 35 degrees. Pain was noted on forward flexion and bilateral lateral rotation. There was evidence of pain with weight bearing as well as localized tenderness/plan on palpation at "paravertebrals at right side of spine." The Veteran performed repetitive use testing with no additional loss of motion. The examiner noted guarding/muscle spasms of the cervical spine not resulting in abnormal gait or abnormal spinal contour. Muscle strength testing was completely normal with no muscle atrophy found. Reflex examination was also normal, and the examiner stated that the Veteran did not have any radicular pain or any other signs or symptoms due to radiculopathy. No ankylosis was found. No neurological abnormalities were demonstrated. The examiner noted a scar of the cervical area measuring 6 cm x. 0.5 cm that was not unstable or painful. The Veteran was afforded additional VA examination for his cervical spine in May 2018. He again endorsed flare-ups and stated during flares, he experienced loss of overhead activities, poor tolerance for driving, dressing uppers, and working with a computer. On range of motion testing, he had forward flexion to 20 degrees; extension to 20 degrees; right lateral flexion to 25 degrees; left lateral flexion to 20 degrees; right lateral rotation to 25 degrees; and left lateral rotation to 30 degrees. Severe muscle spasms were noted. Pain was noted during forward flexion and extension. There was also objective evidence of localized tenderness. The Veteran performed repetitive use testing without additional loss of function. There was no pain on non-weight bearing but pain was noted on passive range of motion testing and during weight-bearing. The pain did not result in/cause functional loss. The examiner again noted that the Veteran had muscle spasms and guarding, however, such did not result in abnormal gait or abnormal spinal contour. Muscle strength testing was completely normal, and no muscle atrophy was found. Reflex examination was also normal, and the examiner noted that the Veteran did not have any radicular pain or any other symptoms or signs due to radiculopathy. No ankylosis of other neurologic abnormalities were demonstrated. The examiner stated that the Veteran did not have IVDS and did not have any incapacitating episodes. Constant use of a cane was noted. VA treatment records document the Veteran's pain related to his cervical spine disorder. In addition, they indicate that the Veteran was diagnosed with cervical radiculopathy on February 25, 2019. The Veteran was afforded additional VA examination for his cervical spine in December 2020. On examination, he reported symptoms of neck pain, trapezius pain, stiffness, numbness, and weakness in the left upper extremity. On examination, he denied experiencing flare-ups of the cervical spine. Instead, he reported that he cannot move his neck at all without pain, so he wears a brace all the time when out of the house. When in the house, he is careful with his motions. On range of motion testing, the Veteran had forward flexion to 10 degrees; extension to 5 degrees; bilateral lateral flexion to 10 degrees; and bilateral lateral rotation to 10 degrees. The examiner noted that the Veteran has difficulty in driving due to limited range of motion of the neck because he cannot check his blind spots. Pain was noted on examination on rest/non-movement. All ranges of motion exhibited pain. The examiner noted moderate diffuse muscular pain and pain on all cervical paraspinals. There was evidence of pain with weight-bearing. The Veteran was able to perform repetitive use testing without any additional loss of motion. The examiner opined that the Veteran's ranges of motion would be the same on repeated use over a period of time as well as during any flare-up. The examiner noted that the Veteran had decreased sensation in the inner/outer left forearm and hand/fingers. The rest of his sensory examination was normal. The examiner indicated that the Veteran had left upper extremity radiculopathy (impacting upper radicular group) that was mild in nature. The right extremity was not impacted. The Veteran experienced symptoms of mild intermittent pain, numbness, and paresthesias without any constant pain. Regular use of a brace, cane, and walker was noted. The Veteran's treatment records support that he has a lumbar spine disability with radiculopathy unrelated to service (not service-connected). There is objective evidence of pain when the neck is used in non-weight bearing. Passive and active range of motion were the same on examination. The examiner also noted the Veteran's cervical scar and separately afforded him a VA examination for such. The examiner noted the scar was from the Veteran's 2015 ACFR surgery and the course of the condition has stayed the same. The scar was not tender to palpation, painful, or unstable. There was no underlying soft tissue damage. No gross distortion or asymmetry of facial features was noted. The scar was noted to be on the anterior neck and to be 5 cm x 0.1 cm in size. After having considered all of the evidence of record, the Board finds that prior to May 31, 2018, a rating higher than 10 percent for the Veteran's cervical spine disability is not warranted. However, as of May 31, 2018, it is factually ascertainable that the Veteran's disability picture more nearly approximated forward flexion limited to 15 degrees such that a 30 percent rating, but no higher, is warranted as of that date. It is factually ascertainable that the Veteran's scar has been present since his 2015 cervical spine surgery such that an earlier effective date of June 7, 2017, is warranted. However, because the scar is essentially asymptomatic, a compensable rating is not warranted at any time during the appeal period. As of February 25, 2019, it is factually ascertainable that the Veteran had left upper extremity radiculopathy. At worst, throughout the appeal period, the Veteran's left upper extremity cervical radiculopathy has manifested by mild incomplete paralysis. Regarding the Veteran's cervical spine disability, the Board notes that prior to May 31, 2018, notwithstanding the Veteran's reports of a painful neck, he had forward flexion in the cervical spine to 40 degrees. On examination in July 2017, he endorsed flare-ups in the form of loss of driving tolerance as well as ability to perform overhead activities. The loss of overhead function has been attributed to his left trapezius disability. Although the Veteran reported not being able to turn to see his blind spots as a result of his cervical spine, the evidence does not show that his cervical spine disability manifested by flexion greater than 15 degrees but not greater than 30 degrees, which is required for the next higher rating. Indeed, on VA examination, the Veteran was noted to have painful motion in forward flexion and despite this, he still had flexion to 40 degrees. His VA treatment records do not show flexion limited to less than 40 degrees prior to May 31, 2018. However, as of May 31, 2018, the Board finds that the Veteran's disability picture has more nearly approximated forward flexion of the cervical spine limited to 15 degrees or less. It is worth noting that on his May 2018 VA examination, the Veteran himself reported that his cervical spine disability had become worse than when he was previously examined in June 2017. Indeed, on VA examination in May 2018, his forward flexion was limited to 20 degrees. This range of motion, alone, would warrant a 20 percent rating. However, the examiner did not attempt to quantify the loss of function in the Veteran's cervical spine during flare-ups. Further, the examiner noted the Veteran experienced severe muscle spasms but did not qualify the additional loss of motion as a result of these spasms. Therefore, the Board resolves doubt in favor of the Veteran in finding that flare-ups likely caused additional loss of motion, such that his disability picture more nearly approximated forward flexion limited to 15 degrees or less. However, at no point during the appeal period has the Veteran demonstrated any level of ankylosis. The Court has recently held that when evaluating a disability under VA's General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), the criteria for a rating based on ankylosis may be met by evidence demonstrating the functional equivalent of ankylosisi.e., functional loss consistent with that contemplated by ankylosis. See Chavis v. McDonough, No. 18-2928 (April 2021); 38 C.F.R. §§ 4.40, 4.45; Mitchell v. Shinseki, 25 Vet. App. 32 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995). As noted above, ankylosis is defined, for VA compensation purposes, as a condition in which all or part of the spine is fixed in flexion or extension. Although on VA examination in December 2020, the Veteran reported being unable to move his neck at all without pain, the Board does not find this to be the "functional equivalent" of ankylosis. Specifically, he reported retaining enough function to complete activities such as driving a car, light cleaning, eating/feeding, grooming, and toileting. It is reasonable to assume that these activities require him to move his head. Further, although the Veteran reported pain in all motions, he did not describe the level of pain being so severe that he essentially could not move his neck at all. As such, the Board finds that at no point during the appeal period as the Veteran demonstrated ankylosis or functional ankylosis. The Board acknowledges the Veteran's lay reports regarding his cervical spine and his sincere belief that higher ratings are warranted. The Board has considered the Veteran's lay reports in rendering a decision on appeal. The Board concludes that the medical findings on examinations are of greater probative value than the Veteran's allegations regarding the severity of his disability. The symptomatology noted in the medical and lay evidence has been adequately addressed by the evaluation assigned and do not more nearly approximate the criteria for a higher rating for the Veteran's cervical spine disability. Next, the Board will address the propriety of the Veteran's rating as well as the effective date assigned for the grant of service connection for his left upper extremity cervical radiculopathy. Except as otherwise provided, the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be on the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. §§ 3.400, 3.400(b)(2). As noted above, on VA examination in May 2018, the Veteran was found not to have any signs or symptoms of radiculopathy. However, on VA examination in December 2020, the examiner found that the Veteran did in fact have left upper extremity radiculopathy and such was mild in severity. The RO granted the Veteran service connection for left upper extremity radiculopathy from December 5, 2020, the date of the Veteran's VA examination which confirmed his diagnosis. However, the Board finds that an earlier effective date of February 25, 2019, for the grant of service connection for left upper extremity cervical radiculopathy is warranted. As of February 25, 2019, it is factually ascertainable that the Veteran had a diagnosis of left upper extremity cervical radiculopathy as the Veteran's VA treatment records state as much. The diagnosis was confirmed on VA examination in December 5, 2020. There is no evidence included in any of the private or VA treatment records confirming a diagnosis of left upper extremity radiculopathy prior to that time. As such, February 25, 2019, is the earliest possible effective date. As to the propriety of the currently assigned rating, the Board finds that after having considered all of the evidence of record, a rating higher than 20 percent for left upper extremity cervical radiculopathy is not warranted. On VA examination in December 2020, the Veteran endorsed only mild symptoms. Specifically, he stated he experienced mild intermittent pain, mild paresthesias, and mild numbness. The Board finds the December 2020 VA examiner's finding that the Veteran's radiculopathy is mild in severity probative as it was based on examination of the Veteran as well as the Veteran's own report of his symptoms. The evidence establishes that the Veteran's radiculopathy is wholly sensory with only mild symptoms reported. As such, a higher rating is not warranted. As noted above, the RO granted a separate noncompensable rating for the Veteran's cervical spine scar by a December 2020 rating decision and assigned an effective date of December 18, 2020, the date of the Veteran's VA examination confirming his scar. However, the Board finds that an earlier effective date of December 28, 2016, the date the Veteran filed for service connection for his left trapezius strain/cervical spine disability, is warranted. The evidence of record establishes that the scar was caused by his 2015 surgery for his cervical spine and has been present the entire appeal period. Thus, an earlier effective date of December 28, 2016, is warranted. As to the Veteran's currently assigned rating, the Board notes that his scar has been rated under DC 7800. During the appeal period, the criteria for rating scars have been amended. During the appeal period, changes were made to certain Diagnostic Codes under 38 C.F.R. § 4.118. Effective August 13, 2018, VA amended its regulations governing skin disabilities. VA's intent is that the 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. As the Veteran filed his claim before the August 13, 2018 effective date, the Board will consider whether either the old or new rating criteria is more favorable to the Veteran. Under the old rating criteria, Diagnostic Code 7805 provided that other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804 require the evaluation of any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-7804 under an appropriate Diagnostic Code. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2017). The Board notes that this diagnostic code is largely unchanged under the new amendments apart from the replacement of the phrase "(including linear scars)" with "and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, or 7804." 38 C.F.R. § 4.118, Diagnostic Code 7805 (August 13, 2018). Diagnostic Code 7800 (which was unchanged by the 2018 amendments), contemplates scars of the head, face, or neck. 38 C.F.R. § 4.118, Diagnostic Code 7800. Under Diagnostic Code 7800, for disfigurement of the head, face, or neck, a 10 percent disability rating is warranted for scarring with one characteristic of disfigurement. A 30 percent disability rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or two or three of the characteristics of disfigurement. A 50 percent disability rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or four or five characteristics of disfigurement. An 80 percent disability rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or six or more characteristics of disfigurement. 38 C.F.R. § 4.118. The eight characteristics of disfigurement for the purposes of rating under 38 C.F.R. § 4.118 are: scar of 5 in. or more (13 or more centimeters (cm.)) in length; scar at least 1/4 in. (0.6 cm.) wide at its widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding 6 sq. in. (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 sq. in. (39 sq. cm.); underlying soft tissue missing in an area exceeding 6 sq. in. (39 sq. cm.); and skin indurated and inflexible in an area exceeding 6 sq. in. (39 sq. cm.). Id., Note (1). The pre-amended Diagnostic Code 7801 provided disability ratings for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2017). In contrast, the amended Diagnostic Code 7801 contemplates burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801 (August 13, 2018). Prior to August 13, 2018, Diagnostic Code 7802 provided rating criteria for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear. 38 C.F.R. § 4.118, Diagnostic 7802 (2017). The amended version is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802 (August 13, 2018). Under both the old and new rating criteria, Diagnostic Code 7804 provides disability ratings for scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic 7804. In every instance where the schedule does not provide a 0 percent rating for a diagnostic code, a 0 percent rating will be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. In this instance, the Veteran's scar is not painful, not unstable, and is not due to a burn. It does not cover at least five inches. It is not elevated or depressed on palpation and does not adhere to underlying tissue. The skin is not hypo or hyper-pigmented, the underlying soft tissue is not missing, and the scar is not indurated or inflexible. The scar is on the Veteran's neck but is otherwise asymptomatic. The Veteran himself has not alleged any characteristics of disfigurement. The December 2020 VA examination report, VA treatment records, and private treatment records also do not support as much. Thus, under both the old and new regulations, a compensable rating is not warranted at any time during the appeal period for the Veteran's cervical spine scar. As such, entitlement to a compensable rating for scar of the cervical spine must be denied. 6. Entitlement to a rating higher than 20 percent for left trapezius strain. The Veteran's left trapezius strain is currently rated as 20 percent disabling under Diagnostic Code 5201. As noted above, he is separately rated for his cervical spine symptomatology under a different Diagnostic Code. As such, the Board may only consider the impairment caused by the Veteran's left trapezius strain alone in determining the appropriate rating. The normal range of motion of the shoulder is 0 to 180 degrees of flexion (forward elevation), 0 degrees to 180 degrees of abduction, 0 degrees to 90 degrees of external rotation, and 0 degrees to 90 degrees of internal rotation. 38 C.F.R. § 4.71, Plate I (2015). The regulations regarding limitation of motion of the shoulder has been amended effective February 7, 2021. Prior to February 7, 2021, limitation of motion of the arm at the shoulder rated under Diagnostic Code 5201, provided for a 20 percent rating when the range of motion of the minor arm was limited to shoulder level or midway between the side and shoulder level and a maximum 30 percent evaluation when the range of motion of the minor arm was limited to 25 degrees from the side. 38 C.F.R. § 4.71a. For the minor arm, the amended regulations provide for a 20 percent rating when range of motion is limited to shoulder level (flexion and/or abduction limited to 90 degrees) or midway between side and shoulder level (flexion and/or abduction limited to 45 degrees); and a maximum 30 percent evaluation is warranted when flexion and/or abduction is limited to 25 degrees from side. Essentially, the new regulations clarify, in degrees, what "shoulder level" is and what "midway between side and shoulder level" is. As noted above, the Veteran is right-hand dominant and as such, his left arm is his "minor" arm. The Veteran was afforded a VA examination for his left shoulder in July 2017. At that time, he endorsed flare-ups in the form of loss of overhead activities. On range of motion testing, he had flexion in the right to 140 degrees; abduction to 130 degrees; external rotation to 70 degrees; and internal rotation to 70 degrees. On the left, the shoulder on appeal, the Veteran had flexion to 90 degrees; abduction to 80 degrees; external rotation to 60 degrees; and internal rotation to 50 degrees. Severe pain at trapezius area was noted. The Veteran was able to perform repetitive use testing without any additional loss of motion in both shoulders. Muscle strength testing was slightly reduced in the left shoulder but no muscle atrophy or ankylosis was found. No rotator cuff, clavicle, scapula, or acromioclavicular (AC) joint condition was suspected. There was no malunion of the humerus. On VA examination in December 2020, the Veteran again endorsed flare-ups of the left trapezius in the form of increased pain. On range of motion testing, in the right shoulder he had flexion to 90 degrees; abduction to 90 degrees; external rotation to 80 degrees; and internal rotation to 80 degrees. In the left shoulder, he had flexion to 90 degrees; abduction to 90 degrees; external rotation to 80 degrees; and internal rotation to 80 degrees. He reported needing assistance with activities of daily living, especially involving those above head. Pain was noted in flexion and external rotation of the shoulder. There was severe tenderness/pain on palpation of the joint. There was no evidence of pain with weight-bearing or crepitus. The Veteran was able to perform repetitive use testing without any additional loss of motion. The examiner opined that the Veteran's range of motion would remain the same during flare-ups and on repeated use over time. Hawkins' impingement test, empty-can test, external rotation/infraspinatus strength test, and left-off subscapularis test were all negative. The examiner noted that the Veteran uses a neck brace to limit motion which also reduces pain in the trapezius. There was no objective evidence of pain on non-weight bearing and his active and passive motion were the same. The Veteran's VA and private treatment records do not show limitation of motion of the left trapezius more severe than indicated on VA examination. Having considered all of the evidence of record, the Board finds that after applying the old and new rating criteria, a rating higher than 20 percent is not warranted at any point during the appeal period for the Veteran's left trapezius strain. At worst, the Veteran's flexion has been limited to 90 degrees and abduction has been limited to 80 degrees. The examiners found that the Veteran's motion would not change during a flare-up. Although he experiences pain during flare-ups, such pain does not result in additional functional loss. At no point during the appeal period does the evidence show that the Veteran's left shoulder range of motion has been limited to 25 degrees from the side. Nor has his disability more nearly approximated as much. The Board acknowledges the Veteran's sincere belief that a higher rating is warranted. The Board finds his reports regarding pain in his left trapezius (shoulder) both competent and credible. However, pain alone is not a disability. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). 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. The evidence demonstrates that the Veteran has movement, albeit painful movement, beyond the range required for a higher rating under Diagnostic Code 5201. Although some functional loss and/or functional impairment of the shoulder with less movement than normal and pain on movement was shown during the VA examinations, the evidence does not demonstrate that these symptoms result in increased functional limitation. Specifically, range of motion testing conducted during the VA examinations revealed that the Veteran was able to achieve the same range of motion after repetitive use. As such, the weight of the lay and medical evidence demonstrates that the Veteran does not have such disabling pain or functional impairment resulting from his service-connected left trapezius disability to warrant a higher rating. For these reasons, the Board finds that a rating higher than 20 percent is not warranted for the Veteran's left trapezius strain at any point during the appeal period. Thus, the claim must be denied. 7. Entitlement to a TDIU. The Veteran contends that he is unable to secure and follow substantially gainful employment as a result of his service-connected disabilities. It is worth noting that by a November 2020 decision, the Board denied TDIU. However, the TDIU claim is part and parcel of the increased rating claim on appeal and therefore the Board will again address this issue. A total rating based on unemployability due to service-connected disabilities may be granted if the service-connected disabilities preclude the Veteran from obtaining or maintaining substantially gainful employment consistent with his or her education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16(a). In this instance, prior to June 7, 2017, the Veteran was service-connected for a cervical spine disability, rated as 10 percent disabling; left trapezius strain, rated as 20 percent disabling; and scar, rated as noncompensable. His combined rating was 30 percent. Therefore, he does not meet the schedular criteria for a TDIU for that time period. From June 7, 2017 to May 30, 2018, the Veteran was service-connected for major depressive disorder, rated as 30 percent disabling; a cervical spine disability, rated as 10 percent disabling; left trapezius strain, rated as 20 percent disabling; a scar, rated as noncompensable. His combined rating was 50 percent. Therefore, he does not meet the schedular criteria for a TDIU for that time period. From May 31, 2018 to February 25, 2019, the Veteran was service-connected for major depressive disorder, rated as 30 percent disabling; a cervical spine disability, rated as 30 percent disabling; left trapezius strain, rated as 20 percent disabling; a scar, rated as noncompensable. His combined rating was 60 percent. Therefore, he does not meet the schedular criteria for a TDIU for that time period. Provision 38 C.F.R. § 4.16(a) establishes that the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Since February 25, 2019, the Veteran has been service-connected for major depressive disorder, rated as 30 percent disabling; a cervical spine disability, rated as 30 percent disabling; left trapezius strain, rated as 20 percent disabling; left upper extremity cervical radiculopathy, rated as 20 percent disabling; and a scar, rated as noncompensable. His combined rating is 70 percent. The Veteran's cervical spine disability, left trapezius disability, and cervical radiculopathy all arise from the same body system, and therefore, the Board finds he meets the schedular criteria for a TDIU under 38 C.F.R. § 4.16(a) as of February 25, 2019. Regarding the period prior to February 25, 2019, the Board notes that for those Veterans who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a), total disability ratings for compensation may nevertheless be assigned when it is found that the service-connected disabilities are sufficient to produce unemployability. Such cases should be referred to the Director, Compensation Service, for extraschedular consideration. 38 C.F.R. § 4.16(b). In reaching a determination of a TDIU, it is necessary that the record reflect some factor which takes the Veteran's case outside the norm with respect to a similar level of disability under the rating schedule. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993); 38 C.F.R. §§ 4.1, 4.15. The fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The question is whether or not the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. The central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to a veteran's level of education, special training, and previous work experience, but advancing age and the impairment caused by nonservice-connected disabilities are not for consideration in determining whether such a total disability rating is warranted. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose, 4 Vet. App. at 363. The United States Court of Appeals for Veterans Claims (Court) has held that the term unable to secure and follow a substantially gainful occupation in 38 C.F.R. § 4.16 has two components. First, there is an economic component which essentially contemplates an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Second, there is a non-economic component dealing with the individual veteran's ability to follow and secure employment. For the second component, attention must be given to: (a) the veteran's history, education, skill and training, (b) the veteran's physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy or very heavy) required by the occupation at issue, with relevant factors such as lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory and visual, and (c) whether the Veteran has the mental ability to perform the type of activities required by the occupation at issue, with relevant factors such as memory, concentration, and ability to adapt to change, handle work place stress, get along with coworkers and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 72-73 (2019). Although the Veteran does not meet the schedular criteria for a TDIU prior to February 25, 2019, the Board must still address whether the evidence establishes that the Veteran was unable to secure and maintain gainful employment and thus whether referral for extraschedular consideration is necessary. After having considered all of the evidence of record, the Board finds that prior to February 25, 2019, referral for extraschedular consideration is not warranted. Further, since February 25, 2019, the greater weight of the probative evidence is against finding that the Veteran is unable to secure and follow substantially gainful employment as a result of his service-connected disabilities alone. The evidence shows that the Veteran completed high school. His Social Security Records indicate that he has occupational experience, among other jobs, as a machine operator, refrigeration technician, security guard, armored truck driver, and messenger. See also May 2018 TDIU Application. Essentially, he has experience in both largely sedentary and also physical labor. In Withers v. Wilkie, the Court held that the meaning and relevance of the term sedentary work will have to be discerned on a case-by-case basis from the medical and lay evidence presented and considering each Veteran's education, training, and work history. 30 Vet. App. 139 (2018). Merriam-Webster online dictionary defines "sedentary" as (a) "doing or requiring much sitting" or (b) "not physically active." https://www.merriam-webster.com/dictionary/sedentary. The Board employs this definition in the current analysis. Id. (before the Board can rely on an examiner's finding that a veteran is capable of sedentary work to deny TDIU, it must also ensure that the finding is consistent with the medical evidence as a whole). The Social Security records indicate three occupations with a significant number of jobs that exist in the National Economy of which the Veteran's work experience and education level would be consistent. These included order clerk, call out operator, and surveillance system monitor. All of the listed positions are sedentary in nature. As an order clerk, the Veteran would be required to obtain information from costumers, prepare invoices and shipping documents, and receive and respond to customer complaints. As a call out operator, he would be required to speak on the phone and provide call assistance to customers. As a surveillance system monitor, he would be required to provide observation and surveillance for clients and review and investigate alerts generated by surveillance systems and properly escalate as necessary. The Board finds it reasonable to assume that most sedentary positions would require the Veteran to be able to interact with others on a professional level. On VA examination in April 2017, a VA examiner opined that the Veteran's neck condition rendered him unable to carry heavy weights due to pain in left trapezius. A VA examiner in July 2017, opined that the Veteran's residuals of a left trapezius strain was productive of no occupational impairment. However, the condition interfered with left shoulder motion upon weightbearing, as well as overhead activities. In May 2018, a VA examiner noted that the neck condition was productive of limitations for overhead activities as well as driving, repetitive motion with his hands, dressing uppers and working with a computer. A VA examiner in October 2019, opined that the Veteran's psychiatric symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. The examination report indicates that there is no history of illegal problems, civil problems, criminal accusations, or any behavioral disturbances. The Veteran's major depressive disorder symptoms include depressed mood, chronic sleep impairment, and disturbances of motivation and mood. The examiner noted that the Veteran came to the interview appropriately dressed with adequate hygiene. He was cooperative, alert, and in contact with reality. His thought process was coherent and logical and there was no looseness of association and no signs of disorganized speech. His affect was broad and appropriate. He was oriented in person, place, and time and his memory for recent, remote, and immediate events was preserved. His judgement was good, and his insight was adequate. The examiner stated: The mental disorder's symptoms are not severe enough to interfere with the Veteran's marital relation, parenting performance, daily activities, family responsibility, financial debts, and social functioning. The Veteran is capable of engaging in regular sedentary occupations, his mental disorder, is not precluding him from any labor sedentary activity. Regarding the Veteran's left shoulder, cervical spine, and upper extremity radiculopathy, on VA examination in December 2020, the examiner stated that these disabilities would limit overhead activities of daily living as well as driving. The evidence shows the Veteran was awarded disability benefits from the Social Security Administration (SSA) due to his back disability and psychiatric disorder, as well as other musculoskeletal disorders, including his neck disability. Reportedly, he became too disabled to work in September 2011. However, an SSA award is not controlling as to his TDIU claim. SSA benefits are based on different criteria than are VA disability benefits. Moreover, although the Veteran has been found to be disabled by the SSA, this finding was not based solely on his service-connected disabilities. Overall, the findings of SSA provides evidence against this claim as it indicates multiple nonservice-connected problems are, in part, the cause of the issue. VA treatment records dated in December 2020 support the SSA findings. Specifically, the examiner noted the Veteran's lumbar stenosis (with chronic low back pain), peripheral vascular disease, thrombosis varicose veins, recent right wrist surgery, unsteady gait, and neuropathy impact his ability to perform activities of daily living. Although the Veteran has complained of pain related to his musculoskeletal disabilities as a whole, these records show that the Veteran's most significant pain (8-9/10 with leg pain) was as a result of his non-service-connected lumbar disability. The SSA records and treatment records clearly indicate significant post-service disabilities that are not related to service. Therefore, the Board finds that although the Veteran's service-connected disabilities are productive of some occupational limitations, the objective medical evidence, to include VA examination reports, do not support a finding that his service-connected disabilities, separately or combined, preclude him from securing and following sedentary employment. The VA examiners addressed the question of employability directly and their opinions are consistent. Moreover, the VA examination opinion reports, as outlined above, fail to show that the Veteran's service-connected disabilities either singularly or jointly, preclude him from gainful employment, and collectively provide evidence against this finding. The evidence of record shows that throughout the appeal period, the Veteran has continued to have the mental capacity to interact with customers, his work history includes sedentary employment, and his musculoskeletal disabilities, although impacting his ability to carry and lift objects, do not inhibit his ability to remain sedentary for a workday. The Board acknowledges lay statements from the Veteran addressing the impact of his service-connected disabilities on his ability to work during the period on appeal. The Board does not dispute that the Veteran's service-connected disabilities impact his ability to work. Indeed, a higher rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Although the Veteran is competent to report symptoms he experiences, an opinion as to the limitations on gainful employment due to his service-connected disabilities (and not his age or nonservice-connected problems) is beyond his medical expertise. See Jandreau, supra. Thus, any such lay statements regarding him being unable to work are not competent or sufficient. Simply stated, both the factual evidence, including occupational history reported by the Veteran, and the medical evidence, in the form of the examinations cited above, provides evidence against this claim. As noted above, the Veteran appears to be attempting to use disabilities not related to service as the basis for why he cannot work (which may, in fact, be true). However, the Board may only consider the impairments caused by the Veteran's service-connected disabilities in determining whether a TDIU is warranted. Accordingly, the Board concludes that referral of this issue for extraschedular consideration of TDIU pursuant to 38 C.F.R. § 4.16(b), is not appropriate prior to February 25, 2019, and that a TDIU is not warranted at any time during the appeal. SONJA S. AN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Martha R. Luboch, 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.