Citation Nr: 22016732 Decision Date: 03/23/22 Archive Date: 03/23/22 DOCKET NO. 17-22 265A DATE: March 23, 2022 ORDER Entitlement to an initial disability evaluation in excess of 20 percent for the Veteran's cervical spine disability is denied. Entitlement to an increased disability evaluation in excess of 20 percent for the Veteran's left shoulder disability is denied. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's cervical spine disability has not more closely approximated forward flexion of the cervical spine to 15 degrees or less, favorable ankylosis of the entire cervical spine, unfavorable ankylosis of the entire cervical spine or of the entire spine; nor did it more closely approximate intervertebral disc syndrome (IVDS), with any incapacitating episodes over the past 12 months. 2. Throughout the appeal period, the Veteran's left (minor) shoulder disability has not more closely approximated a limitation of motion of 25 degrees or less from the side, nor did it exhibit ankylosis, loss of head, nonunion or fibrous union of the humerus, or any malunion of the humerus with marked deformity. CONCLUSIONS OF LAW 1. The criteria for an initial disability evaluation in excess of 20 percent for the Veteran's cervical spine disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.25 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5242, 5243 (2020). 2. The criteria for an increased disability evaluation in excess of 20 percent for the Veteran's left shoulder disability have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5201, 5200, 5202, 5203 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from November 1992 to October 1999, March 2002 to July 2002, November 2003 to April 2004, November 2004 to June 2005, February 2007 to April 2007, November 2008 to January 2009, and May 2010 to October 2010. Schedular Ratings 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 (2019). 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 (2012); 38 C.F.R. § 4.1 (2020). 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. 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). 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(b). Evidence is not in approximate balance or nearly equal, and therefore the benefit-of-the-doubt rule does not apply, when the evidence persuasively favors one side or the other. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). 1. Entitlement to an initial disability evaluation in excess of 20 percent for cervical-spine disorder. The Veteran submitted an informal claim for service connection for cervical-spine disorder, received by VA on July 29, 2014. A March 2015 rating decision granted service connection for the claim at a 20 percent rating, effective July 29, 2014. The Veteran filed a claim for a higher initial disability rating on May 3, 2016. A July 2016 denied that claim. The Veteran initiated a timely appeal of that decision by submission of a Notice of Disagreement (NOD), received by VA on May 24, 2017. The appeal period for this claim commenced on May 3, 2016, the date of claim for a higher initial rating. The Veteran's cervical spine disability has been evaluated under Diagnostic Code 5242 for degenerative disease of the spine, which, in turn, defers to the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), which provides a 20 percent disability rating for forward flexion of the cervical spine greater than 15 degrees, but not greater than 30 degrees; or, the 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 disability rating is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent disability rating is available for unfavorable ankylosis of the entire cervical spine. A 100 percent rating would be warranted if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. The Board will briefly note here that ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY, 94 (32nd ed. 2012). See also Villareal v. Principi, 18 Vet. App. 13 (2001) (defining ankylosis to mean "a joint is fixed, or 'frozen' in one position"). Note (2) of the General Rating Formula provides that, for VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. The combined range of motion refers to the sum of the range of motion of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. Although Note 4 of the General Rating Formula offers the choice of alternatively rating lumbar spine disorder under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula), the latter rating formula must be based on incapacitating episodes in the last 12 months, defined as a period of acute signs and symptoms due to intervertebral disc syndrome (IVDS) which requires bed rest prescribed by a physician and treatment by a physician (Note (1)). IVDS can be rated either under the General Rating Formula or under the IVDS Formula, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. It is the Board's duty to acknowledge and consider all regulations which are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Under the IVDS Formula, a 20 percent rating is available when there are incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks during the past 12 months. The IVDS Formula provides a 40 percent rating when there are incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks during the past 12 months. A 60 percent rating would be assigned when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Turning to the record, in June 2016, the Veteran underwent a VA examination for cervical-spine disorder conditions, in which the examiner diagnosed degenerative disc disease of the cervical spine, status post cervical fusion. He noted the Veteran's report of July 2015 C4-C7 fusion surgery, resulting in pain being "75 % better." He further reported current symptoms as constant neck pain, aggravated by bending over and lying in bed at night. Range of motion measurements show cervical-spine forward flexion from 0 to 30 degrees (45 degrees, normal) and extension at 0 to 25 degrees (45 degrees, normal). The Veteran was able to perform repetitive-use testing with at least 3 repetitions, but showing no additional loss of function or range of motion. The examiner offered no findings for repeated use over time or during a flare-up. The Veteran reported the effects of a flare-up as difficulty bending and sleeping, but the examiner made no findings. He found the Veteran does not have spinal ankylosis, IVDS and available imaging studies do not document arthritis. Regarding the functional impact of his disorder on the ability to work, the examiner noted the Veteran reported difficulty bending. An August 2017 VA physical medicine rehabilitation note shows findings for a cervical-spine evaluation, in which the treatment provider appears to have made range-of-motion findings based on a visual assessment. He found flexion ended at " 50 %," by which the Board understands this would be approximately 23 degrees in goniometric measurements. He added extension was at 20 percent, indicating approximately 9 degrees. However, such measurements without goniometric findings by regulation are inadequate for VA purposes. See 38 C.F.R. § 4.46 ("The use of a goniometer in the measurement of limitation of motion is indispensable in examinations..."). In an August 2019 VA examination for cervical-spine conditions, the examiner diagnosed cervical-spine degenerative disc disease with intermittent bilateral upper extremity radiculopathy (mildly affecting the middle radicular group). She noted the Veteran's report of currently having nearly constant neck pain. Range of motion measurements show cervical-spine forward flexion at 0 to 25 degrees and extension at 0 to 10 degrees. The Veteran was able to perform repetitive-use testing with at least 3 repetitions, but showing no additional loss of function or range of motion. The examiner estimated findings for repeated use over time and for during a flare-up as reducing range of motion only for the right-lateral rotation and left-lateral rotation maneuvers to 0 to 10 degrees each. The Veteran reported the effects of a flare-up as severe, occurring twice monthly, lasting hours to days and aggravated by walking and stress, with associated functional loss of barely being able to turn his head to the left. The examiner found the Veteran has IVDS, but further found he has not had had any episodes of acute signs and symptoms due to IVDS which required bed rest prescribed by a physician and treatment by a physician in the past 12 months. She noted available imaging studies do not document arthritis. The examiner found functional impact on ability to work as the Veteran cannot turn his neck well and therefore he has difficulty evaluating his environment for sudden dangers, as well as not being able to lift heavy weights due to neck pain. The Board will note here, although the examiner made a finding for an additional factor contributing to disability being less movement than normal "due to ankylosis, adhesions, etc.," she further found later in the examination the Veteran has no spinal ankylosis. As these findings appeared ostensibly contradictory, the Board in its September 2021 Remand determined these findings inadequate and remanded the claim for a new examination for clarification regarding ankylosis, as well as complete findings, to include active and passive motion, in weight bearing and non-weight bearing maneuvers and for estimated range of motion loss for forward flexion and extension due to repeated use over time and during a flare-up. As directed by the Board, the Veteran's was afforded in October 2021 another VA examination for cervical-spine conditions, in which the examiner stated a 2014 diagnosis of degenerative arthritis. She noted the Veteran's reports of a March 2014 onset, when first having pain in his neck when placing his head down to pray at church. The Veteran reported he had herniated discs in neck in May 2014 and he later had surgery. He further reported neck pain is better since neck surgery, but he still has some pain from time to time. He reported current symptoms of aching pain and stiffness. Range of motion measurements show cervical-spine forward flexion ending at 45 degrees and extension ending at 45 degrees. Passive range of motion was not tested. The Veteran was able to perform repetitive-use testing with at least 3 repetitions, but showing no additional loss of function or range of motion. For repeated use over time, the examiner estimated the loss of range of motion due to pain would be at the same endpoints for flexion and extension as above. For flare-ups, she made the same estimation. The Veteran reported flare-ups make it more difficult to turn and move his head. She further found the Veteran has no spinal ankylosis. This examiner found the Veteran in fact does not have IVDS. She noted there were no available imaging studies. Regarding functional impact on the ability to work, the examiner noted the Veteran works occasionally part-time driving for the Mercedes-Benz Corporation as needed. The Veteran state the necessity of turning his head with driving aggravates his neck disorder. As stated at the beginning of this section, the higher rating of 30 percent under the General Rating Formula, as an alternative to flexion ending at 15 degrees, requires favorable ankylosis of the entire thoracolumbar spine and the 40 and 100 percent ratings require findings of unfavorable ankylosis of the entire thoracolumbar spine and unfavorable ankylosis of the entire spine, respectively. The June 2012, August 2019 and the October 2021 VA examiners specifically found there was no spinal ankylosis of any kind. The overall record of treatment contains no findings of ankylosis. However, in a recent decision, the United States Court of Appeals for Veterans Claims (the Court) noted the criteria for a rating based on ankylosis may be met by evidence demonstrating the functional equivalent of ankylosis. See Chavis v. McDonough, 34 Vet. App. 1, 20 (2021). Therefore, ankylosis pertaining to the Veteran's lumbar-spine disorder could be shown by functional loss consistent with that contemplated by ankylosis under the General Rating Formula. As already stated, essentially, ankylosis indicates "immobility and consolidation of a joint due to disease, injury, or surgical procedure." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY, 94 (32nd ed. 2012). Nonetheless, the above VA examinations do not show reports by the Veteran or any findings on examination suggesting a "functional equivalent" to ankylosis. For example, in the June 2016 examination, the examiner found the functional impact on the Veteran's ability to work as difficulty bending. The August 2019 examiner found the effect on work as the Veteran cannot turn his neck adequately to perceive what is around him and he cannot lift heavy weights due to neck pain. The October 2021 examiner noted the Veteran occasionally works part-time driving for the Mercedes-Benz Corporation as needed and reported turning his head when driving aggravates his neck disorder. These past and prospective assessments of the Veteran's capability in the work place implicitly indicate nonetheless he can move. Experiencing "difficulty" or pain is not a reasonable equivalent to the inability to move at all. As a factual deamination by the Board, a plausible "functional equivalent" to ankylosis must very definitely be indicated by a complete lack of movement, resulting from consolidation, fusion or fixedness, that is to say, immobility of the cervical spine as a single joint. This would effectively render the Veteran a quadriplegic and nothing in the Veteran's reports or findings in treatment and on examination reasonably supports such a conclusion. The Board therefore finds ankylosis cannot be established by functional loss consistent with or equivalent to ankylosis as contemplated under the General Rating Formula. See Chavis v. McDonough, 34 Vet. App. at 20. As stated, the Veteran's disorder is rated under Diagnostic Code 5242, which looks to the General Rating Formula for rating criteria. However, among other rating criteria, VA's rating schedule includes diagnostic codes related to arthritis of the musculoskeletal system. See 38 C.F.R. § 4.71a, Diagnostic Codes 5010 and 5003. Additionally, as already stated, during the pendency of the appeal, the criteria for evaluating musculoskeletal disorders were revised, effective February 7, 2021. The Board will briefly note here that, as a general proposition, the February 2021 revisions of Diagnostic Code 5003 and of any other diagnostic codes set forth later in this decision are not applicable in the closed period prior to February 7, 2021. In the later stage of the appeal period, the Board will apply the revised versions. However, if a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g). Therefore, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. However, if the former version is more favorable, VA can apply the earlier version of the regulation for the periods both prior to and from the effective date of the change. 38 U.S.C. § 5110. Consequently, the Board will look to both the old and new rating criteria from February 7, 2021, with the criteria more favorable to the Veteran being applied. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Revised Diagnostic Code 5242 adds the description of degenerative disc disease and specifically states it did not apply to IVDS. Moreover, in addition to Diagnostic Code 5242 refers to degenerative arthritis of the spine and states "also, see DC [Diagnostic Code] 5003 or 5010." As a first matter, Diagnostic Code 5010 directs the rater to evaluate traumatic arthritis as degenerative arthritis under Diagnostic Code 5003. Under revised Diagnostic Code 5010, effective February 7, 2021, traumatic arthritis is now rated as "limitation of motion, dislocation, or other specified instability under the affected joint." The pre-revision and revised versions of Diagnostic Code 5003 are identical, other than the revised version specifying it pertains to degenerative arthritis, "other than post-traumatic." The code states, when established by x-ray findings, degenerative arthritis 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 or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint affected by limitation of motion to be combined, not added under Diagnostic Code 5003. 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 rating of 10 percent will be assigned with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating 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. The above ratings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2020 and revised February 7, 2021). The spine is considered for VA rating purposes as 1 major joint. Briefly, the examiners produced range-of-motion findings for forward flexion and they are well beyond the 15 degrees or less required for a 30 percent rating. As an alternative criterion to ankylosis findings, Diagnostic Code 5003 provides no rating higher than 20 percent. As the Veteran has been assigned 20 percent, there can be no "extra" ratings for arthritis "added on" to the Veteran's ratings, as this would be impermissible "pyramiding" one upon the other of the same, similar or overlapping symptoms or diagnoses regarding limitations of movement. See 38 C.F.R. § 4.14. Diagnostic Code 5243, states to evaluate IVDS (preoperatively or postoperatively) either under the General Rating Formula or under the IVDS Formula, whichever method results in the higher evaluation when all disabilities are combined under §4.25. The August 2019 examiner found IVDS, but further found there were no incapacitating episodes over the past 12 months. However, the revised version of Diagnostic Code 5243 adds that this diagnostic code is applicable only when there is disc herniation with compression and/or irritation of the adjacent nerve root. It appears from her examination report the August 2019 examiner based her finding of IVDS on her finding of radicular pain, with involvement of the C-7 nerve roots (middle radicular group), as well as the Veteran report of July 2014 neck surgery involving microdecompression and fusion, to include at C-6-7. However, once again, based on the Veteran's reports, she could not make a finding of incapacitating episodes over the past 12 months, making the IVDS Formula inapplicable to the findings on examination. The Board notes, based on the Veteran's own reports in the above examinations, symptoms of functional loss due to cervical-spine disorder were noted by the VA examiners, as well as changes affecting normal working movements, which were sufficiently reviewed, included in the examination findings and considered in the assignment of the Veteran's current disability evaluations, but they have not presented a basis for a higher evaluations, as discussed above. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. at 204-07; Mitchell v. Shinseki, 25 Vet. App. at 37; Burton v. Shinseki, 25 Vet. App. at 5. The Board has carefully considered lay evidence, to include the Veteran's reports to treatment providers and examiners as they appear throughout the record. The Board is well aware that lay persons are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses. Nonetheless, the credibility of the Veteran's lay evidence in turn must be weighed against other evidence, as all relevant evidence of varying kinds must be considered. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995). The Veteran's essential contention is, although having undergone neck surgery with some relief from pain, his pain at present is constant, it is aggravated by movement and lying in bed and he experiences stiffness and difficulty bending and turning. The Board has discussed above at length the applicable rating criteria for higher ratings, but findings on examination do not satisfy the criteria for ratings to reflect greater severity. However, most pertinent to the Veteran's contention, symptoms such as pain are considered and factored into the ratings currently assigned the Veteran. As a matter of law, there is no medical evidence on which the Board can base the assignment of higher ratings. Additionally, as the Board does not have the expertise to make medical findings or draw medically-based conclusions from them (See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991)), it therefore assigns more probative weight to the findings of the 3 VA examiners. They are medical professionals who examined and tested the Veteran during in-person sessions, they thoroughly reviewed the Veteran's medical history and record and their findings, for the reasons stated above, are therefore adequate for VA rating purposes. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are separately rated under an appropriate diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code, 5242 at Note (1). The Veteran is already in receipt of separate disability ratings in this regard. He was notified of the rating decisions awarding service connection for these neurological disabilities, and of his appellate rights. He did not appeal any aspect of those determinations, and the Board finds that the matters of entitlement to a higher rating for these disabilities are not within the scope of the claim on appeal. See Chavis v. McDonough, 34 Vet. App. 1 (2021). No other neurological abnormalities associated with the cervical disability were shown on pertinent VA examinations or treatment records. As such, the assignment of any additional ratings based on associated neurological abnormalities is not indicated. After review of the evidence and for the reasons stated, the Board finds the evidence is not in approximate balance, and the assignment of a rating in excess of 20 percent is not warranted. 2. Entitlement to an increased disability evaluation in excess of 20 percent for left-shoulder disorder. The Veteran submitted an informal claim for service connection for left-shoulder disorder, received by VA in July 2014. A March 2015 rating decision granted service connection for the claim at a 10 percent rating, effective July 29, 2014. The Veteran filed a claim for a higher initial disability rating on May 3, 2016. By an August 2016 rating decision, the Agency of Original Jurisdiction (AOJ) granted a 20 percent rating, effective May 3, 2016. The Veteran initiated a timely appeal of that decision by submissions of the NOD, received by VA on May 24, 2017. The appeal period for this claim commences on May 3, 2016, the date of claim for a higher initial rating. The Board has considered evidence 1 year prior to that date. The Veteran's left shoulder disability has been rated under the hyphenated diagnostic code, 5003-5201. Generally, hyphenated diagnostic codes are used when an unlisted disability is at issue. See 38 C.F.R. § 4.27 (2020). In this case, the AOJ assigned a hyphenated diagnostic code to recognize degenerative arthritis (Diagnostic Code 5003) as the Veteran's underlying diagnosis and limitation of arm motion (Diagnostic Code 5201) as the relevant rating criteria. See 38 C.F.R. § 4.20. Put more simply, the Veteran's left shoulder has been diagnosed with arthritis, but it is rated as the resulting loss of motion. The evidence shows that the Veteran is right-handed. Thus, the ratings assigned for limitation of motion of the non-dominant (minor) upper extremity in Diagnostic Code 5201 apply. See 38 C.F.R. § 4.69. Under Diagnostic Code 5201, a rating of 20 percent is warranted when motion of the minor arm is limited to shoulder level. A 20 percent rating is also assigned for limitation of motion of the minor arm midway between the side and shoulder level. A 30 percent rating is warranted when motion of the minor arm is limited to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Limitation of motion under Diagnostic Code 5201 may be compensated based on limitation of abduction or limitation of flexion, being the 2 planes of movement involving lifting the arm from the side, whichever would afford the higher rating. Yonek v. Shinseki, 722 F.3d, 1355, 1358 - 59 (2013) (citing Mariano v. Principi, 17 Vet. App. 305, 314 -16 (2003)). However, separate ratings for both limitation of abduction and flexion are not available. Id. A rating of 20 percent or higher under Diagnostic Code 5201 requires limitation of motion at shoulder level or less. Shoulder flexion and abduction at shoulder level is 90 degrees. See 38 C.F.R. § 4.71, Plate I. The applicable rating criteria for musculoskeletal disorders, in particular shoulder disabilities, under 38 C.F.R. § 4.71a were amended, effective February 7, 2021. Diagnostic Code 5201 now specifies shoulder level is 90 degrees and midway is 45 degrees. The rating criteria were not otherwise further amended. Turning to the record, in June 2016, the Veteran underwent a VA examination for shoulder conditions, in which he examiner diagnosed left-shoulder impingement syndrome and left-glenohumeral joint osteoarthritis. He noted the Veteran's report of undergoing a January 2011 rotator-cuff repair. He further reported pain occurs intermittently, worse at night when lying in bed, and aggravated by turning the steering wheel and overhead activity. Range of motion measurements show left-shoulder forward flexion was from 0 to 180 degrees (180 degrees, normal) and abduction was from 0 to 155 degrees (180 degrees, normal). The Veteran was able to perform repetitive use testing with at least 3 repetitions, but there was no additional functional loss or range of motion. The examiner 's findings did not include passive and active findings or weight-bearing versus non-weight-bearing findings. The examiner did not offer estimated measurements for repeated-use-over-time testing or during a flare-up. The Veteran reported flare-ups induce difficulty sleeping, difficulty turning steering wheel and difficulty with overhead activity. Additionally, the examiner found no ankylosis, no impairment or malunion of the humerus and no clavicle or scapula impairments. He noted available imaging studies document left-shoulder arthritis. The examiner noted the functional impact on the ability to work as difficulty with overhead activity. In an August 2019 VA examination for shoulder and arm conditions, the examiner diagnosed left-rotator cuff tear and left-glenohumeral joint osteoarthritis. She noted the Veteran's reports of constant left-shoulder pain and severe loss of motion and, having received injections 6 weeks prior, although they may give relief for months, sometimes it is only for days. Range of motion measurements show left-shoulder forward flexion was from 0 to 90 degrees and abduction was from 0 to 45 degrees. The Veteran able to perform repetitive use testing with at least 3 repetitions, but there was no additional functional loss or range of motion. Although the examiner made no estimated findings for repeated-use-over-time testing, she estimated loss of range of motion during a flare-up showing no difference from the above measurements. The Veteran himself reported the effects flare-ups as occurring a couple of times monthly with a duration up to 4 days, inducing severe dull pain and loss of motion. Additionally, the examiner found no left-sided ankylosis, no impairment or malunion of the humerus and no clavicle or scapula impairments. She noted available imaging studies document left-shoulder arthritis. She further noted the functional impact on ability to work as being unable to do overhead work or lift greater than 5 pounds above shoulder level. The Board in its September 2021 Remand directed there be a new VA examination, with more complete range-of-motion findings addressing active and passive motion, and in weight bearing and non-weight bearing maneuvers and for estimated range of motion loss for forward flexion and extension due to repeated use over time and during a flare-up. An examination for shoulder and arm conditions followed in October 2021, in which the examiner stated the 2016 diagnosis of left-glenohumeral joint osteoarthritis. In this examination, the Veteran reported the onset date of his disorder in 1983, when he dislocated his left shoulder in a motorcycle accident, with current symptoms of aching pain. Active range of motion measurements show left-shoulder forward flexion ending at 180 degrees and abduction ending at 160 degrees, with pain on movement. Passive range of motion findings were the same. The Veteran was able to perform repetitive-use testing with at least 3 repetitions, but there was no additional functional loss or range of motion. Estimated range-of-motion findings for repeated use over time were the same as the above initial findings, as were the estimated findings for during flare-ups. The Veteran described the effects of flare-ups as occurring 2 to 3 times per week, lasting 4 to 6 hours, caused by physical movement, and inducing aching joint pain and limited left-shoulder mobility. Additionally, the examiner found no left-shoulder ankylosis, no impairment or malunion of the humerus and no clavicle or scapula impairments. She noted there were no available imaging studies. As with the Veteran's cervical-spine disorder, functional impact on work driving from Mercedes-Benz Corporation was the aggravation of left-shoulder pain. A May 2021 VA orthopedic surgery consult note shows, on physical examination, the treatment provider found left-shoulder forward "elevation" ending at 150 degrees and abduction ending at 150 degrees. The foregoing summary of the record of examination indicates no lay or medical evidence showing that left-shoulder motion is limited to 25 degrees from the side or midway between the side and shoulder level. Therefore, a rating greater than 20 percent under Diagnostic Code 5201 is not warranted. Additionally, although evaluated under Diagnostic Codes 5201 and 5003 (degenerative arthritis), as the left-shoulder joint is only one joint, Diagnostic Code 5003 offers no additional rating; that is to say, there can be no "extra" rating added for arthritic pain on movement. 38 C.F.R. § 4.14. Looking to closely related or analogous diagnostic codes, for the entire appeal period the record shows no evidence of ankylosis (Diagnostic Code 5200) and the Board will add, for the same reasons discussed in the previous section, there is no "functional equivalent" of ankylosis, as findings on examination and the Veteran's reports reflect left-shoulder movement is still possible. See Chavis v. McDonough, 34 Vet. App. at 20. "Difficulty" in reaching and driving or pain itself are not a reasonable equivalents to the inability to move at all. Additionally, the record shows no evidence of any impairment or malunion of the humerus (Diagnostic Code 5202). In fact, malunion of the humerus under Diagnostic Code 5202, as well as the related Diagnostic Code 5203, are not applicable, as those diagnostic codes provide for their maximums only a 20 percent rating for evidence of impairment of the clavicle or scapula and the Veteran has already been assigned a 20 percent rating. The prohibition on "pyramiding" prevents adding on "extra" ratings of the same, similar or duplicative symptoms or diagnoses one upon the other. See 38 C.F.R. § 4.14. The Board notes, based on the Veteran's own reports in the above examinations, left-shoulder symptoms of functional loss were noted, as well as changes affecting normal working movements such as "excursion, strength, speed, coordination, and endurance," were sufficiently reviewed, included in the examination findings and considered in the assignment of the Veteran's current disability evaluation, but they have not presented a basis for a higher evaluation beyond the 20 percent assigned. See 38 C.F.R. §§ 4.40, 4.45, 4.59; See DeLuca v. Brown, 8 Vet. App. at 204-07; Mitchell v. Shinseki, 25 Vet. App. at 37; Burton v. Shinseki, 25 Vet. App. at 5. In his reports to examiners and treatment providers, the Veteran contends left-shoulder disorder currently causes severe pain, loss of motion and is exacerbated by certain activities, particularly turning a steering wheel, performing overhead activity and lying in bed. However, on examination, pain did not functionally limit motion to midway between the side and shoulder level or less. Furthermore, pain is contemplated in the assigned evaluation. Therefore, although the Veteran reported limitation in lifting his left arm and generally limited use of his left arm, the statements do not establish limitation of function to midway between the side and shoulder level or less. More specifically, for the entire appeal period, the medical evidence shows left-shoulder flexion was never limited to less than 90 degrees and abduction was never less than 45 degrees. As set forth above, Diagnostic Code 5201 requires non-dominant shoulder flexion and/or abduction limited to 25 degrees for a 30 percent rating. Moreover, the record shows no relevant findings pertaining to the related or analogous diagnostic codes. Therefore, the Board ascribes significant probative weight to the 3 examiners for same reasons stated in the previous section. Consequently, based on all the above evidence and considering the Veteran's reports and statements, there remains in the record no evidentiary basis permitted under the applicable diagnostic codes for higher evaluations for left-shoulder disorder. For the reasons stated, the Board finds the evidence is not in approximate balance, and a rating in excess of 20 percent is not warranted. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. As there is no approximate balance of the evidence for the claims, the doctrine is not applicable and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. J. Smith Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Franke, Associate 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.