Citation Nr: 22013145 Decision Date: 03/08/22 Archive Date: 03/08/22 DOCKET NO. 16-49 350 DATE: March 8, 2022 ORDER Entitlement to a rating in excess of 20 percent prior to November 8, 2021, for right shoulder disability, is denied. Entitlement to a separate rating of 20 percent, but no more, from August 30, 2019, for right shoulder limitation of motion, is granted. Entitlement to a rating in excess of 30 percent from November 8, 2021, for right shoulder disability, is denied. FINDINGS OF FACT 1. Prior to November 8, 2021, the Veteran experienced recurrent dislocation of the humerus at scapulohumeral joint with infrequent episodes and guarding of movement; however, he did not experience recurrent dislocation of the humerus at scapulohumeral joint with frequent episodes and guarding of all arm movements nor did he experience malunion of the humerus with marked deformity. 2. From August 30, 2019, the Veteran's right shoulder exhibited limited range of motion (ROM) at shoulder level (flexion and/or abduction limited to 90 degrees). 3. From November 8, 2021, the Veteran's right shoulder disability is productive of frequent recurrent dislocation at the scapulohumeral joint, with guarding of all arm movements; however, it is not affected by fibrous union, nonunion of the humerus, or loss of head of the humerus. CONCLUSIONS OF LAW 1. Prior to November 8, 2021, the criteria for a rating in excess of 20 percent for right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DCs) 5010-5202. 2. From August 30, 2019, the criteria for a separate rating of 20 percent, but no more, for right shoulder disability based on limitation of motion, have been met. 38 U.S.C. §§ 1155, 5107; 38C.F.R. §§3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5201. 3. From November 8, 2021, the criteria for a rating in excess of 30 percent for right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DCs 5010-5202. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 2004 to February 2008. In November 2018 and July 2021, the Board remanded the claim for further development. Increase Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Additionally, it is possible for a veteran to be awarded separate percentage evaluations for separate periods (staged ratings), based on the facts. See Fenderson v. West, 12 Vet. App. 119, 12627 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. 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; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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). Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the relevant overall temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under several diagnostic codes, known as "pyramiding," must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14 (2019). When evaluating musculoskeletal disabilities, VA may, in addition to applying the schedular criteria, assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Nonetheless, a disability rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,'" as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that while "pain may cause a functional loss, pain itself does not constitute a functional loss," and, is therefore, not grounds for entitlement to a higher disability rating). Additionally, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, actually painful, unstable or malaligned joints, due to a healed injury, are recognized as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see also Burton v. Shinseki at 5 (holding that the provisions of 38 C.F.R. § 4.59 are not limited to disabilities involving arthritis). The Veteran's right shoulder disability has been rated under 38 C.F.R. § 4.71a, DC 5010-5202. Hyphenated DCs are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. The evidence of record shows that the Veteran is right-handed, therefore his right arm is the major extremity. See 38 C.F.R. § 4.69. The Board notes that the rating criteria for musculoskeletal disorders were revised on February 7, 2021. The amended regulations became effective on February 7, 2021 and claims that were pending on this date must be considered under the former and revised criteria with the most favorable version applied to the claim. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DCs 5003, 5200, 5201, 5202). Effective February 7, 2021, DC 5010 was amended to provide that post-traumatic arthritis is to be rated based on limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. Under the pre-amended criteria, DC 5010 provides that traumatic arthritis as shown by x-ray studies is rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a, DC 5010. When, however, the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. A rating of 20 percent may be applied where there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DCs 5003, 2010. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Diagnostic Code 5200 did not change under the new regulation. Diagnostic Code 5200, which pertains to ankylosis of the scapulohumeral articulation, provides a 30 percent rating for favorable abduction to 60 degrees, can reach the mouth and head. A 40 percent rating is warranted where there is unfavorable ankylosis that is intermediate between favorable and unfavorable. A 50 percent rating is warranted where there is unfavorable ankylosis with abduction limited to 25 degrees from the side. 38 C.F.R. § 4.71a, DC 5200. Under the old criteria, DC 5201, which pertains to limitation of motion of the arm, provides a 30 percent rating is assigned for limitation of the major arm to midway between side and shoulder level. A 40 percent evaluation is assigned for limitation of the major arm to 25 degrees from the side. 38 C.F.R. § 4.71a, DC 5201. The new criteria for 5201 is essentially unchanged but now indicates the ROM in degrees for flexion and abduction associated with each disability evaluation. A 20 percent rating is warranted for limitation of flexion and/or abduction limited to 90 degrees. A 30 percent rating is warranted for limitation of motion of the major arm limited to midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees). A 40 percent rating is warranted for limitation of motion of the major arm flexion and/or abduction limited to 25 degrees from side. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020). A veteran is only entitled to a single disability rating under DC 5201 as that DC does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm. Yonek v. Shinseki, 722 F.3d 1355 (Fed. Cir. 2013). For VA purposes, normal range of arm motion is flexion 0 to 180 degrees; abduction 0 to 180 degrees; external rotation 0 to 90 degrees; and internal rotation 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. Under the old and new regulation, DC 5202, which pertains to, humerus, other impairments, notes that when there is malunion of the humerus in the major arm, a 30 percent rating is assigned with marked deformity. A 30 percent rating is also assigned when there is recurrent dislocation of the humerus at the scapulohumeral joint in the major arm, with frequent episodes and guarding of all arm movements. A 50 percent rating is assigned when there is fibrous union of the arm; a 60 percent rating is assigned when there is nonunion of (false flail joint) the humerus in the arm; and an 80 percent rating is assigned when there is loss of head of (flail shoulder) the humerus in the arm. Diagnostic Code 5203 did not change under the new regulation and provides a maximum of 20 percent evaluation for impairment of the clavicle or scapula. Analysis The Veteran contends that his disability is more severe than the ratings depict. In July 2012, the Veteran was seen at the Lake Baldwin CBOC for right shoulder pain. The Veteran reported flare-ups of the shoulder. He had chronic pain that was intermittent. The aggravating factors included using ball cutters at work, reaching above his head, and reaching back. He was "ok" with lifting from the ground but not lifting above his head. The Veteran stated that he began swimming in the summer; however, his shoulder ached with swimming. He stated that push-ups helped with the shoulder pain, and he was able to perform 100 push-ups with no shoulder pain. Upon examination, there was no swelling, joint line tenderness, deformity, or redness. The examiner noted Nl ROM and motor 5/5 compared to his left. On August 21, 2012, the Veteran saw an orthopedic surgeon. The examiner diagnosed the Veteran with anterior instability, right shoulder. The Veteran complained of dislocating right shoulder, ongoing pain, and feeling of instability during abduction and external rotation. However, he stated that he had not had an actual shoulder dislocation since basic training. The examiner noted full ROM and a well-muscled right shoulder with no weakness, swelling, or tenderness. The examiner stated that extremes of abduction and external rotation caused anxiety and feelings of subluxation anteriorly. X-rays were within normal limits. In February 2014, the Veteran was afforded a VA examination to determine the severity of his disability. The Veteran injured his shoulder in service. Since onset, his right shoulder had progressed, and he experienced increased pain with movement. He reported experiencing loss of rotation and overhead lifting. He also stated when he slept, his shoulder slipped. An MRI noted Hill-Sachs lesion consistent with anterior dislocation of the right shoulder. The examiner confirmed the Veteran's right shoulder dislocation and surgery diagnosis. The Veteran is right hand dominant. He reported flare-ups, to include limited ROM and movement, that impacted the function of his shoulder. Right shoulder flexion was to 130 degrees, and abduction was to 140 degrees with objective evidence of painful motion beginning at 140 degrees. Left shoulder flexion and abduction were to 160 degrees with objective evidence of painful motion beginning at 160 degrees. The Veteran was able to perform repetitive-use testing with 3 repetitions. After three repetitions, right shoulder flexion was to 130 degrees and abduction was to 140 degrees, and left shoulder flexion and abduction were to 160 degrees. The Veteran did not have additional limitation in ROM of the shoulder following repetitive-use testing, and there was no functional loss and/or functional impairment of the shoulder. He did not have localized tenderness or pain on palpation of joints/soft tissue/biceps tendon of either shoulder. He had guarding of the right shoulder. Muscle strength testing was normal. He did not have ankylosis. Hawkins' impingement, empty can, external rotation/infraspinatus strength, and lift-off subscapularis tests were negative. The Veteran did not have a history of mechanical symptoms (clicking, catching, etc.). However, he had a history of infrequent episodes of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint of the right shoulder. Right shoulder crank apprehension and relocation test was positive. The Veteran did not have an acromioclavicular (AC) joint condition or any other impairment of the clavicle or scapula. There was no tenderness on palpation of the AC joint. Cross-body adduction test was negative. The Veteran had not had a total shoulder joint replacement. He had left shoulder arthroscopic or other shoulder surgery. The Veteran did not have any residual signs and/or symptoms due to arthroscopic or other shoulder surgery. There were no other pertinent physical findings, complications, conditions, signs, symptoms, and/or scars related to his condition. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The Veteran's shoulder condition did not have an impact on his ability to work. In August 2016, the Veteran was seen at the Lake Baldwin CBOC complaining of shoulder pain. The Veteran wondered if his right shoulder pain contributed to him not tolerating CPAP well, i.e., his mask came off once or twice at night due to movement. In his October 2016 Substantive Appeal, VA Form 9, the Veteran disagreed with VA's decision to deny increasing his disability rating to 30 percent. He stated that his right shoulder had further deteriorated by evidence of his chronic dislocating and guarding of the right shoulder since his February 2014 exam. He also stated that he made continuous complaints regarding pain and discomfort during sleep which aggravated the proper use of his CPAP machine mask. In November 2017, the Veteran was seen at Fyzical Therapy and Balance Center for physical therapy for shoulder pain. The Veteran demonstrated symptoms of shoulder impingement associated with chronic shoulder subluxation, shoulder pain, and musculature imbalance of right shoulder. The Veteran stated that he experienced bilateral shoulder pain and limited ROM. He also reported chronic instability and dislocation. The examiner noted hypertrophied anterior deltoid of the right shoulder. Bilaterally, ROM was from zero to 140 degrees. Left external rotation was from zero to 30 degrees and right was from zero to 40 degrees. Bilaterally, internal rotation was from zero to 80 degrees. Bilateral anterior apprehension and right shoulder relocation tests were positive. The Veteran's VA treatment records document complaints and treatments for shoulder pain. In December 2017, the Veteran demonstrated limited ROM with bilateral shoulders and symptoms of shoulder impingement associated with chronic shoulder subluxation, pain, and musculature imbalance of right shoulder. In August 2019, the Veteran was afforded a VA examination to determine the severity of his right shoulder disability. The Veteran's disability began in service. Since onset, his right shoulder had progressed, and he experienced increased pain with movement and loss of rotation and overhead lifting. He reported slipping of the shoulder when he slept. He reported aching and throbbing pain. The Veteran treated his disability topically and with Flexeril and meloxicam. The examiner confirmed the Veteran's rotator cuff tear and residuals of right shoulder dislocation diagnoses. The Veteran is right hand dominant. He reported flare-ups, to include, limited ROM and movement that impacted the function of the shoulder or arm. He reported functional loss or functional impairment, to include, limited ROM and being unable to raise/lift his arm above his head. Right shoulder flexion and abduction were from zero to 90 degrees and external and internal rotation were from zero to 60 degrees. The ROM itself contributed to functional loss, to include limited ROM due to pain. Pain was noted on flexion and abduction and caused functional loss. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue or evidence of pain with weight bearing. The examiner noted objective evidence of crepitus. Left shoulder flexion was from zero to 115 degrees, abduction was from zero to 110 degrees, and internal and external rotation were from zero to 75 degrees. The ROM itself did not contribute to functional loss. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, evidence of pain with weight bearing, or objective evidence of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions, bilaterally. There was no additional loss of function or ROM after three repetitions. The Veteran's right shoulder disability was not examined immediately after repetitive use over time; as such, the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. Pain and weakness significantly limited functional ability with repeated use over a period of time. The examiner was able to describe in terms of ROM, i.e., flexion and abduction were from zero to 90 degrees and internal and external rotation were from zero to 60 degrees. The Veteran's left shoulder was not examined immediately after repetitive use over time; as such, the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Weakness significantly limited functional ability with repeated use over a period of time. The examiner was able to describe in terms of ROM, i.e., flexion and abduction were from zero to 110 degrees and internal and external rotation were from zero to 75 degrees. Bilaterally, the examination was not conducted during a flare up; as such, the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss during flare ups. Regarding the right shoulder, pain and weakness significantly limited functional ability during flare-ups. The examiner was able to describe in terms of ROM, i.e., flexion and abduction were from zero to 90 degrees and internal and external rotation were from zero to 60 degrees. Regarding the left shoulder, weakness significantly limited functional ability during flare-ups. The examiner was able to describe in terms of ROM, i.e., flexion and abduction were from zero to 110 degrees and internal and external rotation were from zero to 75 degrees. The examiner noted additional contributing factors of the disability, i.e., bilateral shoulder rotator cuff tears caused less movement than normal of the shoulders. Bilateral shoulder muscle strength testing was normal, and there was no reduction in muscle strength and no muscle atrophy. The Veteran did not have ankylosis. A right shoulder rotator cuff condition was suspected, i.e., Hawkins' impingement and external rotation/infraspinatus strength, and lift off subscapularis tests were positive. Empty can test was negative. The examiner did not suspect left shoulder rotator cuff condition. Shoulder instability, dislocation or labral pathology was not suspected. Additionally, a clavicle, scapula, AC joint or sternoclavicular joint condition was not suspected, and the Veteran did not have an AC joint condition or any other impairment of the clavicle or scapula. Additionally, the clavicle or scapula condition did not affect the Veteran's ROM of the shoulder (glenohumeral joint). There was no tenderness on palpation of the AC joint. Right shoulder cross-body adduction test was positive. The Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus or malunion of the humerus with moderate or marked deformity. In 2007, the Veteran had left shoulder arthroscopic surgery. The Veteran did not have any other pertinent physical findings, complications, conditions, signs, symptoms, and/or scars related to his shoulder condition. He did not use any assistive devices. There was no functional impairment of an extremity such that no effective functions remained other than that which would be equally well served by an amputation with prosthesis. Diagnostic testing revealed posterior-superior humeral impaction fracture compatible with Hill-Sachs defo and anterior-inferior bony labral glenoid disruption. The Veteran's disability impacted his ability to perform any type of occupational task, i.e., he was unable to push, pull, or lift heavy objects. Bilaterally, there was no objective evidence of pain on non-weight bearing. In July 2020, the Veteran submitted a statement regarding his right shoulder disability. The Veteran stated that his rotation and movement were less than 40 percent which was consistent with the August 2019 VA examination. He further stated that the pain had increased over the years making him dependent on pain and arthritis medications, muscle relaxers, and daily creams for hot/cold therapy. In his January 2020 Appellate Brief, the Veteran, through is representative, stated that the Veteran experienced limitation of motion in almost all ROM. Based on that information, the Veteran requested consideration be given to VAOPGCPREC 9-2004. "Specifically, this decision found that the loss of flexion and extension must be addressed as separate disabilities. Separate ratings under DC 5260 (leg, limitation of flexion) and DC 5261 (leg, limitation of extension), both currently codified at 38 C.F.R. § 4.71a, may be assigned for disability of the same joint." In November 2021, the Veteran was afforded a VA examination to determine the severity of his right shoulder disability. The Veteran stated, since onset, his disability has gotten worse. The examiner confirmed the Veteran's recurrent right shoulder dislocation and right shoulder instability diagnoses. The Veteran is right hand dominant. He reported flare-ups of the shoulder. The flare-ups occurred three to four times a week and lasted six to eight hours. During flare-ups, the pain was worse. He stated, due to his shoulder pain, he slept in an awkward position. He further stated that cold weather and reaching a lot precipitated the pain. The pain was severe. Ice alleviated the pain. The extent of functional impairment the Veteran experienced during a flare-up of symptoms included limitation with lifting, and the Veteran was unable to jog or walk. He reported functional loss or functional impairment of the right shoulder, to include difficulty driving, i.e., limited rotation impaired driving; difficulty writing and typing; and he was unable to lift children in and out of cars or up and down. The Veteran's ROM itself did not contribute to functional loss. Active and passive right shoulder flexion and abduction were from zero to 90 degrees and external and internal rotation were from zero to 45 degrees. Pain was noted on flexion, abduction, and internal and external rotation. The examiner noted evidence of pain on weight bearing and active and passive motion. The pain caused functional loss. Flexion and abduction were limited due to pain. There was no objective evidence of crepitus. There was objective evidence of localized tenderness or pain on palpation of the shoulder joint or associated soft tissue, i.e., due to recurrent dislocation and instability, there was moderate pain in the right shoulder upon palpation. The examiner was unable to test the left shoulder because the unclaimed joint was injured/damaged. The examiner was instructed to provide ROM for the unclaimed joint if it was undamaged. The Veteran was able to perform repetitive-use testing with at least three repetitions. There was no additional loss of function or ROM after three repetitions. The Veteran was not examined immediately after repeated use over time. Pain and fatigability caused this functional loss. After repetitive use over time, flexion and abduction were from zero to 85 degrees and internal and external rotation were from zero to 40 degrees. The examination was not conducted during a flare-up. After flare-ups, flexion and abduction were from zero to 80 degrees and internal and external rotation were from zero to 35 degrees. The examiner noted additional contributing factors of the disability, to include disturbance of locomotion and less movement than normal. Additionally, due to recurrent dislocations and instability, the Veteran was unable to move his shoulder well, and he experienced pain with locomotion. The Veteran did not have muscle atrophy or ankylosis. Hawkins' impingement, empty can, external rotation/infraspinatus strength, and lift-off subscapularis tests were negative. Crank apprehension and relocation test was positive. The examiner noted shoulder instability, dislocation, or labral pathology. The Veteran also had mechanical symptoms and residuals of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint, to include frequent episodes and guarding of all arm movements. The residuals affected the Veteran's ROM. Crossbody abduction test was negative. The Veteran did not have a clavicle, scapula, AC joint, sternoclavicular joint condition or other impairment; tenderness on palpation of the AC joint; loss of head, nonunion, or fibrous union of the humerus; or malunion of the humerus with moderate or marked deformity. The humerus condition did not affect ROM of the shoulder (glenohumeral joint). He had not had surgery on his right shoulder. There were no other pertinent physical findings, complications, signs, symptoms, and/or scars related to his right shoulder conditions. The Veteran did not use any assistive devices. There was no functional impairment of an extremity such that no effective functions remain other than that which would be equally well-served by an amputation with prosthesis. A 2012 x-ray/MRI revealed Hill-Sachs lesion evident consistent with anterior dislocation right shoulder. The Veteran's disability impacted his ability to perform any type of occupational task, i.e., his disability limited his ability to lift, write, and type, and rotate which impaired his driving ability. Additionally, due to the pain, he was unable to jog or walk. The examiner stated that the Veteran had frequent episodes of dislocation and guarding movements. The Veteran subjectively reported this, and the physical exam revealed guarding. His apprehension test was positive, significant for instability, a consequence of frequent dislocation. Based on the evidence of record, the Board finds that, prior to November 8, 2021, a rating in excess of 20 percent for right shoulder disability is not warranted. Under DC 5202, a 30 percent requires malunion of the humerus with marked deformity OR recurrent dislocation of the humerus at scapulohumeral joint with frequent episodes and guarding of all arm movements. Prior to November 2021, the evidence does not demonstrate malunion of the humerus with marked deformity. The Board notes that, prior to November 8, 2021, the Veteran experienced guarding of all arm movements with infrequent episodes; but, the record does not demonstrate guarding of all arm movements with frequent episodes until November 2021. As such, the Board finds that prior to November 8, 2021, a rating in excess of 20 percent is not warranted under DC 5202. However, the Board finds that, from August 30, 2019, a separate rating of 20 percent under DC 5201 is warranted. In this case, from August 30, 2019, the Veteran exhibited abduction and flexion limited to 90 degrees, i.e., to shoulder level. Based on these findings, the Board finds that a rating of 20 percent for right arm limitation at the shoulder level is warranted under DC 5201. The Board notes that in his January 2020 Appellate Brief, the Veteran, through is representative, stated that the Veteran experienced limitation of motion in almost all ROM and insinuated that the Veteran should be awarded separate ratings for these limitations. However, as noted above, a veteran is only entitled to a single disability rating under DC 5201 as that DC does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm. Yonek v. Shinseki, 722 F.3d 1355 (Fed. Cir. 2013). Therefore, the Board finds that the Veteran is not entitled to multiple disability ratings under DC 5201. From November 8, 2021, the Board finds that a rating in excess of 30 percent is not warranted under DC 5202. As noted above, a 50 percent rating is warranted for fibrous union of the humerus. However, during his November 2021 examination, the examiner noted that the Veteran did not have fibrous union of the humerus. As such, a rating in excess of 30 percent is not warranted under DC 5202. The Board recognizes that, under DeLuca v. Brown, 8 Vet. App. 202 (1995), VA must consider "functional loss" of a musculoskeletal disability separately from consideration under the DCs. "Functional loss" may occur because of pain, weakness, excess fatigability, incoordination, and flare-ups, pursuant to 38 C.F.R. §§ 4.40, 4.45 and 4.59 and the Court's holding in DeLuca v. Brown, supra. In this case, the Veteran experienced impairment of the right shoulder, to include less movement than normal; pain on movement; difficulty driving, writing, and typing; and he was unable to raise/lift his arm above his head. However, the weight of the evidence does not show that the ROM of the Veteran's right shoulder was so functionally limited as to meet the criteria for a disability rating in excess of 20 percent. The Veteran's symptoms were considered and assessed by the VA examiners. He is able to move the right arm beyond 25 degrees on flexion and abduction including when functional loss during flare-ups, repeated use, and pain are considered. Therefore, the Board finds that a higher rating is not warranted. Further, the Board has considered the potential application of the other provisions of 38 C.F.R., Parts 3 and 4. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The Board notes that other criteria for rating shoulder disabilities are provided under DCs 5051 for shoulder replacement (prosthesis), 5200 for ankylosis, and 5203 for impairment of the clavicle or scapula. However, the record does not reflect, and the Veteran has not claimed, that he has undergone total shoulder joint replacement, nor does it reflect ankylosis of the scapulohumeral articulation or a clavicle or scapula impairment. As such, DCs 5051, 5200, and 5203 are not applicable. The Board notes in his Appellate Brief, the Veteran and his representative asserted that an extraschedular rating is warranted for the Veteran's right shoulder disability. In this case, considering the lay and medical evidence, the right shoulder disability has been manifested by pain, painful motion, chronic dislocation and guarding, and instability; these findings and symptoms are contemplated by the schedular rating criteria, to include as due to DeLuca and 38 C.F.R. §§ 4.40, 4.45, 4.59 factors such as weakness or weakened movement, incoordination, and fatigability, which are incorporated into the schedular rating criteria as applied to the particular diagnostic code. The Veteran has also asserted that, due to his right shoulder disability, he experienced sleeping issues, i.e., continuous complaints regarding pain and discomfort during sleep which aggravated the proper use of his CPAP machine mask. However, the Board notes that the Veteran has already been awarded a separate rating for his sleep disorder, to include as secondary to his service-connected right shoulder disability. Additionally, the Board notes that aggravation of the proper use of a CPAP machine mask is not a disability for which service connection can be granted. Therefore, the Board finds the preponderance of the evidence is against finding an extraschedular rating is warranted, as the Veteran's symptoms are contemplated under the assigned diagnostic codes. Extraschedular ratings are reserved for exceptional cases. See 38 C.F.R. § 3.321. The Board acknowledges the Veteran and his representative's statements regarding the severity of the Veteran's right shoulder disability to be both competent and credible. However, as lay persons, they do not have the training or expertise to render a competent opinion which is more probative than the VA examiners' opinions and the other medical evidence of record, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the Board finds that the lay opinions by themselves are outweighed by the medical evidence. The Board finds that the current ratings reasonably describe the Veteran's disability level and symptomatology associated with the right shoulder disability. Therefore, the benefit of the doubt doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Moore, T. 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.