Citation Nr: 22010772 Decision Date: 02/24/22 Archive Date: 02/24/22 DOCKET NO. 10-37 018 DATE: February 24, 2022 ORDER Entitlement to an initial evaluation in excess of 10 percent for right knee patellofemoral syndrome with degenerative joint disease (previously evaluated as right knee patellofemoral syndrome) is denied. Entitlement to a separate 10 percent evaluation, but no higher, for right knee recurrent patellar subluxation or dislocation is granted under the pre-amendment criteria for Diagnostic Code 5257, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an initial evaluation in excess of 20 percent for left shoulder acromioclavicular joint osteoarthritis with subacromial/subdeltoid bursitis (previously evaluated as status post left shoulder arthroscopic surgery with scars) is denied. FINDINGS OF FACT 1. The Veteran's right knee patellofemoral syndrome with degenerative joint disease has not been productive of flexion limited to 30 degrees; extension limited to 10 degrees; ankylosis; recurrent subluxation or lateral instability other than recurrent patellar subluxation or dislocation; dislocated semilunar cartilage; removal of semilunar cartilage; impairment of the tibia and fibula; or, genu recurvatum. 2. The Veteran's right knee patellofemoral syndrome has progressed to include degenerative joint disease (arthritis) established by x-ray findings. The disability has been productive of slight recurrent patellar subluxation or dislocation, but not recurrent instability after surgical repair. 3. The Veteran's left shoulder acromioclavicular joint osteoarthritis with subacromial/subdeltoid bursitis has not been productive of limitation of motion of the major arm to midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees). CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 10 percent for right knee patellofemoral syndrome with degenerative joint disease have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.59, 4.71a, Diagnostic Codes 5299-5260. 2. Resolving reasonable doubt in favor of the Veteran, the criteria for a separate 10 percent evaluation, but no higher, for right knee recurrent patellar subluxation or dislocation under the pre-amendment criteria for Diagnostic Code 5257 have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.59, 4.71a, Diagnostic Code 5257. 3. The criteria for an initial evaluation in excess of 20 percent for left shoulder acromioclavicular joint osteoarthritis with subacromial/subdeltoid bursitis have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.71a, Diagnostic Code 5201. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1987 to May 2007. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision issued by the Department of Veterans Affairs (VA). In a March 2010 rating decision, the agency of original jurisdiction (AOJ) increased the evaluations for the right knee and left shoulder disabilities to 10 percent effective from June 1, 2007, which was the day after the Veteran's discharge from service. While the case was in remand status, the AOJ increased the evaluation for the left shoulder disability to 20 percent (changing the diagnostic code to more accurately reflect the Veteran's overall disability picture for that disability) effective from November 13, 2015, and then later granted the 20 percent evaluation effective from June 1, 2007. See February 2017 and July 2018 rating decisions. Because these evaluations do not represent the highest possible benefit, the issues remain in appellate status as stated above. AB v. Brown, 6 Vet. App. 35 (1993). The Board also notes that, in the September 2010 substantive appeal, the Veteran limited his appeal to the above issues and the other increased evaluation claims adjudicated in the August 2017 Board decision, as well as claims for service connection for head pain and neck pain that were also denied in the July 2008 rating decision. In a June 2013 rating decision, the AOJ granted those service connection claims. The Veteran expressed disagreement with the initial evaluations assigned for those disabilities; however, he did not subsequently perfect an appeal. See July 2013 notice of disagreement; October 2013 statement of the case (SOC). The Veteran was scheduled for a hearing before a Decision Review Officer (DRO) of the AOJ in May 2010, but he failed to appear for that hearing. He requested that the hearing be rescheduled; however, the AOJ determined that good cause had not been shown and declined to reschedule the hearing. See August 2010 supplemental SOC (SSOC) (notified Veteran of decision regarding rescheduling hearing). Moreover, the Board finds that any question as to whether the Veteran was afforded due process in regard to the DRO hearing was also addressed when he was provided the opportunity to testify at a Board hearing. See Bowen v. Shinseki, 25 Vet. App. 250, 253-54 (2012) (holding that there is no due process violation when VA denies the veteran a hearing before the AOJ in error, but veteran maintains the ability to appeal and obtain a de novo hearing before the Board). The Board remanded the case in May 2015 to reschedule the Veteran for a Board hearing. The requested hearing was held before the undersigned Veterans Law Judge in November 2015. A transcript of the hearing is of record. The Veterans Law Judge held the record open for a 60-day period following the hearing to allow for the submission of additional evidence. Thereafter, the Veteran submitted additional evidence without a waiver of initial AOJ consideration. But see February 2017 SSOC (AOJ noted review of all evidence of record). The Board remanded the case for further development in April 2016. In an August 2017 decision, the Board denied the other increased evaluation claims that were on appeal and remanded the above claims for further development. The Board again remanded the case for further development in September 2018. While the case was in remand status, the AOJ granted a separate compensable evaluation for a left shoulder surgical scar. See June 2020 rating decision. The Veteran did not express disagreement with that determination. Most recently, the Board remanded the case for further development in September 2020. That development was completed to the extent possible, as discussed below, and the case has returned to the Board for appellate review. Law and Analysis Initially, the Board finds that VA's duty to assist has been met as to obtaining VA examinations or medical opinions. The Board requested new VA examinations in the April 2016 remand based on the Veteran's testimony suggesting that the disabilities had increased in severity since the most recent VA examinations. The resulting VA examinations were provided in August 2016. The Board requested additional VA examinations in the August 2017 remand (providing the Veteran another opportunity to appear for the examinations in the 2018 remand) to obtain findings required under Correia v. McDonald, 28 Vet. App. 158 (2016) and to obtain a retrospective medical opinion for the other VA examinations conducted during the appeal period. The resulting August 2019 VA examination report contains the necessary contemporaneous Correia findings. The Board attempted to obtain an additional VA medical opinion in the September 2020 remand, as the August 2019 VA examiner's retrospective opinion was inadequate. The September 2020 VA examiner determined that, in order to provide a fair, accurate, and objective medical opinion, face-to-face orthopedic examinations were necessary. The record shows that the Veteran declined the opportunity for an additional VA examination. See December 2020 contact history printout and July 2021 report of general information. Because of this, a remand to schedule a new VA examination to consider the revised rating criteria for the right knee, discussed in detail below, is unnecessary. See Wood v. Derwinski, 1 Vet. App. 190 (1991) (duty to assist is not a one-way street). Moreover, the 2019 VA examination reports, considered along with other evidence of record, otherwise fully address the rating criteria that are relevant to rating the disabilities in this case. There is also no objective evidence indicating that there has been a material change in the severity of the disabilities since he was last examined. Neither the Veteran nor his representative has raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where the question for consideration is the propriety of the initial rating assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Fenderson v. West, 12 Vet. App. 119, 125-27 (1999). In this case, the now-assigned evaluations, but no higher, for the right knee disability and continuation of the current evaluation for the left shoulder disability are warranted based on the evidence. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. The rating criteria for the musculoskeletal system were amended effective February 7, 2021. See 85 Fed. Reg. 76453 (Nov. 30, 2020). When a law or regulation changes during the pendency of an appeal, the version most favorable to the claimant applies, absent congressional intent to the contrary. The amended rating criteria can only be applied for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See 38 U.S.C. § 5110(g) and 38 C.F.R. § 3.114; VAOPGCPREC 3-2000, 65 Fed. Reg. 33422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The Board is allowed to consider these changes even though the AOJ has not yet done so. 38 C.F.R. § 20.904(d)(2) (remand to the AOJ is not necessary for consideration of law not already considered by the AOJ, including regulations). For the right knee, there were changes to a relevant diagnostic code; however, the changes do not result in a different outcome in this case, as discussed in detail below. For the left shoulder, the relevant diagnostic codes remained unchanged, or the changes served to clarify the language of the old rating criteria (rather than resulting in a material change). See, e.g., Yonek v. Shinseki, 722 F.3d 1355, 1358-59 (Fed. Cir. 2013) (pre-amendment case noting that 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"). The post-amendment clarifying language for Diagnostic Code 5201 is provided in parentheses. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307, 37312 (Fed. Cir. Dec. 17, 2021) (benefit-of-the-doubt rule not for application when evidence persuasively favors one side or the other). Right Knee The Veteran seeks a higher evaluation for his right knee disability. He has contended that his knee has caused difficulties including pain, giving out, popping, and locking, as well as with motions such as prolonged walking, using stairs, and squatting. See, e.g., VA examination reports from 2008 to 2019; November 2015 Bd. Hrg. Tr.; August 2012 private treatment record and April 2018 VA treatment record. He is currently assigned a 10 percent evaluation pursuant to Diagnostic Codes 5299-5260 for disability productive of painful motion under 38 C.F.R. § 4.59. Hyphenated diagnostic codes including a diagnostic code ending in the digits "99" are used when there is no specifically applicable diagnostic code and the disability is rated by analogy; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Under Diagnostic Code 5260, limitation of flexion of the leg warrants a noncompensable evaluation when flexion is limited to 60 degrees; a 10 percent evaluation when limited to 45 degrees; a 20 percent evaluation when limited to 30 degrees; and a 30 percent evaluation when limited to 15 degrees. Under Diagnostic Code 5261, limitation of extension of the leg warrants a noncompensable evaluation when extension is limited to 5 degrees; a 10 percent evaluation when limited to 10 degrees; a 20 percent evaluation when limited to 15 degrees; a 30 percent evaluation when limited to 20 degrees; a 40 percent evaluation when limited to 30 degrees; and a 50 percent evaluation when limited to 45 degrees. For VA compensation purposes, the normal range of motion of the knee is 140 degrees of flexion and 0 degrees of extension. 38 C.F.R. § 4.71, Plate II. Under the pre-amendment version of Diagnostic Code 5003, the severity of 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. When limitation of motion of the specific joint(s) is present, but noncompensable under the appropriate diagnostic code(s), a 10 percent evaluation is for application for each affected major joint or group of minor joints. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is warranted with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, and a 20 percent evaluation is warranted with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. For the purpose of rating disability from arthritis, the knee is a major joint. 38 C.F.R. § 4.45(f). The post-amendment version of Diagnostic Code 5003 remains the same, except that these rating criteria apply only to degenerative arthritis other than posttraumatic arthritis. Under Diagnostic Code 5256, a 30 percent evaluation is warranted for ankylosis of the knee at a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. A 40 percent evaluation is warranted for ankylosis of the knee in flexion between 10 and 20 degrees. A 50 percent evaluation is warranted for ankylosis of the knee in flexion between 20 and 45 degrees. A 60 percent evaluation is warranted for extremely unfavorable ankylosis, in flexion at an angle of 45 degrees or more. Under the pre-amendment version of Diagnostic Code 5257, recurrent subluxation or lateral instability warrants a 10 percent evaluation when slight; a 20 percent evaluation when moderate; and a 30 percent evaluation when severe. Subluxation is an incomplete or partial dislocation. See Dorland's Illustrated Medical Dictionary, 1791 (32nd 2012). The words "slight, "moderate," "marked," and "severe" as used in the various diagnostic codes are not defined in the VA rating schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. Under the post-amendment version of Diagnostic Code 5257, there are separate rating criteria for patellar instability and recurrent subluxation or instability. For patellar instability, a 10 percent evaluation is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent evaluation is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 30 percent evaluation is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Note (1) provides that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) provides that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). For recurrent subluxation or instability, a 10 percent evaluation is warranted for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent evaluation is warranted for one of the following: (a) a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or, (b) unrepaired or failed repair of a complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 30 percent evaluation is warranted for unrepaired or failed repair of a complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. Under Diagnostic Code 5258, a 20 percent evaluation is warranted for dislocated semilunar cartilage, with frequent episodes of locking, pain, and effusion into the joint. Semilunar cartilage is the meniscus lateralis articulationis genus (lateral meniscus) and the meniscus medialis articulationis genus (medial meniscus). See Dorland's at 299. Under Diagnostic Code 5259, a 10 percent evaluation is warranted for symptomatic removal of semilunar cartilage. Under the pre-amendment version of Diagnostic Code 5262 for impairment of the tibia and fibula, malunion of the tibia and fibula warrants a 10 percent evaluation with slight knee or ankle disability; a 20 percent evaluation with moderate knee or ankle disability; and a 30 percent evaluation with marked knee or ankle disability. A 40 percent evaluation is warranted for nonunion of the tibia and fibula with loose motion requiring a brace. Under the post-amendment version of Diagnostic Code 5262 for impairment of the tibia and fibula, medial tibial stress syndrome (MTSS), or shin splints, warrants a noncompensable evaluation with required treatment of less than 12 consecutive months of one or both lower extremities; a 10 percent evaluation with required treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment of one or both lower extremities; a 20 percent evaluation with required treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment of one lower extremity; and a 30 percent evaluation with required treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment of both lower extremities. In addition, malunion of the tibia and fibula is evaluated under Diagnostic Codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. A 40 percent evaluation is warranted for nonunion of the tibia and fibula with loose motion requiring a brace. Under Diagnostic Code 5263, a 10 percent evaluation is warranted for acquired, traumatic genu recurvatum with weakness and insecurity in weight-bearing objectively demonstrated. The VA Office of General Counsel has provided guidance concerning increased rating claims for knee disorders. Separate evaluations may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. VA General Counsel has stated that compensating a claimant for separate functional impairment under Diagnostic Codes 5257 and 5003 does not constitute pyramiding. See VAOPGCPREC 23-97 (July 1, 1997). VA General Counsel held in VAOPGCPREC 23-97 that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate evaluation must be based upon additional disability. When a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion under Diagnostic Code 5260 or 5261 in order to obtain a separate evaluation for arthritis. If the veteran does not at least meet the criteria for a zero percent evaluation under either of those diagnostic codes, there is no additional disability for which an evaluation may be assigned. In VAOPGCPREC 9-98, VA General Counsel also held that if a veteran has an evaluation under Diagnostic Code 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate evaluation for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. In addition, VA General Counsel considered a hypothetical situation in which a knee disability was evaluated under Diagnostic Code 5259 that was productive of pain, tenderness, friction, osteoarthritis established by x-rays, and a slight loss of motion. For the purposes of the hypothetical, it was assumed that Diagnostic Code 5259 did not involve limitation of motion. Given the findings of osteoarthritis, the VA General Counsel stated that the availability of a separate evaluation under Diagnostic Code 5003 in light of 38 C.F.R. §§ 4.40, 4.45, and 4.59 must be considered. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Absent x-ray findings of arthritis, limitation of motion should be considered under Diagnostic Codes 5260 and 5261. The claimant's painful motion may add to the actual limitation of motion so as to warrant an evaluation under Diagnostic Codes 5260 or 5261. VA General Counsel further noted that the removal of the semilunar cartilage may involve restriction of movement caused by tears and displacements of the menisci, but that the procedure may result in complications such as reflex sympathetic dystrophy, which can produce loss of motion. Therefore, limitation of motion is a relevant consideration under Diagnostic Code 5259, and the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 must be considered. See VAOPGCPREC 9-98 (Aug. 14, 1998). In addition, evaluation of a knee disability under Diagnostic Code 5257 and/or Diagnostic Code 5261 does not preclude separate evaluation of a meniscal disability of the same knee under Diagnostic Code 5258 or 5259. Entitlement to a separate evaluation in a given case depends on whether the manifestations have already been compensated by an assigned evaluation under a different diagnostic code. Lyles v. Shulkin, 29 Vet. App. 107 (2017). In addition, VA General Counsel has held that separate evaluations may be assigned under Diagnostic Codes 5260 and 5261 for disability of the same joint. VAOPGCPREC 9-2004 (Sept. 17, 2004). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that an increased evaluation is warranted for right knee patellofemoral syndrome with degenerative joint disease. The Veteran has not been shown to have flexion limited to 30 degrees to warrant a higher evaluation under Diagnostic Code 5260. The January 2008, February 2013, and August 2016 VA examination reports show flexion to 140 degrees (with no pain on the first two examinations). The August 2019 VA examination report documented flexion to 90 degrees (with pain at 90 degrees on active and passive motion and on weight-bearing and non-weight bearing motions). In addition, the Veteran has not been shown to have extension limited to 10 degrees to warrant a separate evaluation under Diagnostic Code 5261. The January 2008, February 2013, and August 2016 examination reports show full extension to 0 degrees (with no pain on the first two examinations). The August 2019 VA examination report similarly shows full extension (with pain at the beginning of active and passive motion and on weight-bearing and non-weight bearing motions). See also, e.g., October 2013 VA treatment record (noted full range of motion). The August 2019 VA examiner's opinion is inadequate as to retrospective Correia findings for the earlier VA examinations performed during the appeal period; however, as noted above, the Veteran declined an additional examination deemed necessary to provide such an opinion. Moreover, the 2019 VA examination findings consistent with the Correia requirements reflect the greatest limitation of flexion of record (with full extension remaining), but that limitation of flexion remains greater than the level required for a compensable evaluation under the rating criteria without application of 38 C.F.R. § 4.59. The Board has also considered other potentially applicable diagnostic codes. Regarding Diagnostic Code 5003, the record shows that the Veteran's right knee patellofemoral syndrome has progressed to include degenerative joint disease (arthritis) established by x-ray findings. See February 2013 VA examination report (shows right knee x-ray results with finding of degenerative spur involving patella, impression of minor degenerative changes as mentioned above; examiner determined that findings represented progression of previous service-connected diagnosis because x-rays show DJD (degenerative joint disease). The disability has been recharacterized to reflect this diagnosis. Nevertheless, the currently assigned evaluation under Diagnostic Code 5260 contemplates the Veteran's painful and limited motion. The assignment of a separate 10 percent evaluation under Diagnostic Code 5003 would constitute pyramiding and is accordingly not warranted. Regarding Diagnostic Code 5257, the Board finds that there is a reasonable doubt as to whether the right knee disability has been productive of recurrent patellar subluxation or dislocation. In this regard, the record shows that the Veteran has reported throughout the appeal period that his knee gives out and occasionally locks. He has been prescribed a hinged knee brace for medial/lateral knee support and a knee sleeve to wear as needed in VA treatment based on his reported symptoms. See, e.g., VA examination reports from 2008 to 2019; August 2012 private treatment record; VA treatment records from October 2013, April 2018, and June 2018; November 2015 Bd. Hrg. Tr. The February 2013 VA examiner considered the Veteran's reported symptomatology and determined on examination that there was evidence or history of slight recurrent patellar subluxation or dislocation of the right knee. Although the remaining examiners did not identify this impairment, the Veteran's reported symptoms during the examinations and outside of the examination setting appear to be consistent with such a determination. See also, e.g., Cleveland Clinic, "Patellar Dislocations" (noting patella subluxation may feel uncomfortable or unsteady with a popping noise as kneecap moves; patella dislocation symptoms include popping, buckling, and locking of knee), https://my.clevelandclinic.org/health/diseases/21633-patellar-dislocations (reviewed February 2022). Based on the foregoing, and resolving reasonable doubt in favor of the Veteran, the Board concludes that the right knee disability has been productive of slight recurrent patellar subluxation or dislocation to warrant a separate 10 percent evaluation under the pre-amendment rating criteria for Diagnostic Code 5257. See also VAOPGCPREC 9-98. Nevertheless, the Veteran has not been shown to have patellar subluxation or dislocation productive of recurrent instability after surgical repair or other recurrent subluxation or lateral instability to warrant a higher or separate evaluation under the pre- or post-amendment versions of Diagnostic Code 5257. The record does not reflect that the Veteran has had surgical repair for his right knee as contemplated in the post-amendment rating criteria for patellar instability. The January 2008 VA examination report shows that examination of the anterior and posterior cruciate ligaments and medial and lateral collateral ligaments was normal. The February 2013, August 2016, and August 2019 VA examination reports show anterior, posterior, medial, and lateral stability test results were normal. It was noted that there was no subluxation on the January 2008 VA examination report, and it was also noted that there was no history of recurrent subluxation or lateral instability on the 2016 and 2019 examination reports. The examiners did not diagnose a right knee sprain or ligament tear, including on the August 2019 VA examination report specifically providing boxes for strains and ligament tears. The August 2019 VA examination report indicates that the subluxation and lateral instability question referred to the tibiofemoral knee joint itself and not to the patellofemoral portion of the joint. The findings in the VA and private treatment records are consistent with this determination as well. Regarding Diagnostic Codes 5258 and 5259, the Veteran has not been shown to have dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint or symptomatic removal of semilunar cartilage to warrant a separate evaluation under either diagnostic code. The January 2008 VA examination report shows that examination of the medial and lateral joint lines (menisci) was normal. The February 2013, August 2016, and August 2019 VA examiners indicated that the Veteran did not have any meniscal conditions. The first examiner specifically indicated that the Veteran had not had a surgical procedure for a meniscal condition, and the second two examiners indicated that he had not had any surgical procedures for his right knee. The Veteran has also not been shown to have any ankylosis, impairment of the tibia and fibula, or genu recurvatum to warrant a separate evaluation under Diagnostic Codes 5256, 5262, or 5263. See, e.g., 2008 to 2019 VA examination reports (negative findings as to these impairments; range of motion testing shows joint not immobile or fixed in place). The Board has also considered 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holding in DeLuca. However, an increased evaluation for the Veteran's right knee disability is not warranted on the basis of functional loss due to pain or weakness, as his symptoms are supported by pathology consistent with the assigned evaluations. The Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. For example, even when considering the effects of the Veteran's pain (with none found on the first two examinations) and other reported difficulties, there was no change in the range of motion for flexion or extension or other noted functional loss after repetitive use on all of the VA examinations. The August 2019 VA examiner indicated that the Veteran did have pain with repeated use over time and flare-ups, as well as other functional loss with flare-ups (incoordination, similar to the disturbance of locomotion noted by the August 2016 VA examiner as a contributing factor of disability), but further indicated that he would still have 85 degrees of flexion (repeated use over time, loss of 5 degrees) and 80 degrees of flexion (flare-ups, loss of 10 degrees), with extension remaining full (no loss). The 2013 to 2019 VA examination reports further show that the Veteran had normal muscle strength of the left knee without muscle atrophy. As such, the disability does not more nearly approximate the criteria for a higher or separate evaluation on this basis. Based on the foregoing, the Board finds that the evidence supports the assignment of a separate 10 percent evaluation, but no higher, for the right knee disability under the pre-amendment version of Diagnostic Code 5257, and the claim is granted to this extent. The Board also finds that the evidence persuasively weighs against higher or separate evaluations for the right knee disability under any other pertinent diagnostic code. As such, the benefit-of-the-doubt rule does not apply, and the claim is otherwise denied. Left Shoulder The Veteran seeks a higher evaluation for his left shoulder disability. He has contended that his left shoulder has caused difficulties, including pain, loud popping, and trouble with tasks that require him to lift his arm (causing flare-ups). See, e.g., VA examination reports from 2008 to 2019; November 2015 Bd. Hrg. Tr.; VA treatment records from January 2014 and April 2018. He is currently assigned a 20 percent evaluation pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5201. The record shows that the Veteran is left hand dominant for VA rating purposes, and as such, major shoulder disability ratings are applicable in this case. 38 C.F.R. § 4.69. Under Diagnostic Code 5201, a 20 percent evaluation is warranted for limitation of motion of the major arm at shoulder level (flexion and/or abduction limited to 90 degrees). A 30 percent evaluation is warranted when the major arm is limited to midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees). A 40 percent evaluation is warranted when the major arm is limited to (flexion and/or abduction limited to) 25 degrees from the side. For VA compensation purposes, the normal range of motion of the shoulder is 180 degrees of forward flexion and abduction, and 90 degrees of external and internal rotation. 38 C.F.R. § 4.71, Plate I. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that an evaluation in excess of 20 percent is not warranted for left shoulder acromioclavicular joint osteoarthritis with subacromial/subdeltoid bursitis. Regarding Diagnostic Code 5201, the Veteran has not been shown to have limitation of motion of the major arm to midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees). The January 2008 and February 2013 VA examination reports documents flexion and abduction to 180 degrees, and the August 2016 VA examination report reveals flexion to 150 degrees and abduction to 160 degrees (with no pain on the first two examinations). The August 2019 VA examination report shows flexion to 80 degrees and abduction to 80 degrees (with pain at 80 degrees on active and passive motion and on weight-bearing and non-weight bearing motions). See also, e.g., January 2014 VA treatment record (noted range of motion WFL (within functional limits) but with pain that kept going up as range increased in flexion and abduction). The August 2019 VA examiner's opinion is inadequate as to retrospective Correia findings for the earlier VA examinations performed during the appeal period; however, as noted above, the Veteran declined an additional examination deemed necessary to provide such an opinion. Moreover, the 2019 VA examination findings consistent with the Correia requirements reflect the greatest limitation of flexion and abduction of record. The Board has also considered other potentially applicable diagnostic codes. Regarding Diagnostic Code 5003, the record shows that the Veteran has left shoulder acromioclavicular joint osteoarthritis. See, e.g., May 2011 private MRI report and February 2013 VA examination x-ray report. Nevertheless, the currently assigned evaluation under Diagnostic Code 5201 contemplates the Veteran's painful and limited motion. The assignment of a separate 10 percent evaluation under Diagnostic Code 5003 would constitute pyramiding and is accordingly not warranted. 38 C.F.R. § 4.14; Esteban, supra. The Veteran has also not been shown to have any ankylosis, impairment of the humerus (flail shoulder, false flail joint, fibrous union of the humerus, recurrent dislocation of the humerus at the scapulohumeral joint, malunion of the humerus), or impairment of the clavicle or scapula (dislocation, nonunion, or malunion). See, e.g., 2008 to 2019 VA examination reports (negative findings as to these impairments; range of motion testing shows joint not immobile or fixed in place, including external and internal rotation measurements). The August 2016 and August 2019 VA examiners indicated that the Veteran has impairment of the clavicle or scapula of acromioclavicular joint osteoarthritis/DJD; however, the resulting functional impairment noted between those reports (decreased range of motion and tenderness) is contemplated in the current evaluation assigned. The 2019 VA examiner specifically indicated negative findings as to dislocation, nonunion, and malunion, and the Veteran testified that while he had a popping sensation with pain, he had not had a full dislocation. See November 2015 Bd. Hrg. Tr. In addition, to the extent that the August 2016 VA examiner indicated that the Veteran may have shoulder instability related to the service-connected disability given the positive test, the resulting functional impairment is contemplated in the current evaluation assigned. Therefore, a separate or higher evaluation is not warranted under Diagnostic Codes 5200, 5202, or 5203. In addition, the Board acknowledges the Veteran's testimony that he had tingling in his arm and hand and lost grip in his hand on use of his shoulder. See November 2015 Bd. Hrg. Tr. Nevertheless, the August 2019 VA examiner determined that this symptomatology was associated with the Veteran's separately service-connected cervical spine disability rather than the left shoulder disability after examination. The Board has also considered 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holding in DeLuca. However, an increased evaluation for the Veteran's left shoulder disability is not warranted on the basis of functional loss due to pain or weakness, as his symptoms are supported by pathology consistent with the assigned evaluation. His complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. For example, even when considering the effects of the Veteran's pain (with none on the first two examinations) and other reported difficulties, there was no change in the range of motion for flexion or abduction or other noted functional loss after repetitive use on all of the VA examinations. The August 2019 VA examiner indicated that the Veteran did have pain with repeated use over time and flare-ups, as well as other functional loss with flare-ups (incoordination), but that he would still have 75 degrees of flexion and abduction (repeated use over time, loss of 5 degrees for each) and 70 degrees of flexion and abduction (flare-ups, loss of 10 degrees for each). The external and internal rotation measurements were noted to be, at worst, 40 degrees and 50 degrees, respectively, with external rotation to 35 degrees (repeated use over time) and 30 degrees (flare-ups) and internal rotation to 45 degrees (repeated use over time) and 40 degrees (flare-ups). See 2008 to 2019 VA examination reports. The 2013 to 2019 VA examination reports show that the Veteran had normal muscle strength of the shoulder (4/5 or 5/5) without muscle atrophy (specifically noted on the last two examination reports). As such, the disability does not more nearly approximate the criteria for a higher evaluation on this basis. Based on the foregoing, the Board finds that the evidence persuasively weighs against an evaluation in excess of 20 percent for residuals of left shoulder acromioclavicular joint osteoarthritis with subacromial/subdeltoid bursitis. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. Conclusion The Veteran and his representative have not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 368 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). The Board again advises the Veteran to file claims with the AOJ if he wishes to pursue secondary service connection for the opposite shoulder and knee problems raised during the hearing. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Postek, 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.