Citation Nr: 22018512 Decision Date: 03/29/22 Archive Date: 03/29/22 DOCKET NO. 17-55 439 DATE: March 29, 2022 ORDER Entitlement to an initial rating in excess of 10 percent prior to September 9, 2019, and in excess of 30 percent thereafter for cervical strain is denied. Entitlement to a 40 percent rating from September 9, 2019, for radiculopathy of the right upper extremity associated with cervical strain is granted. Entitlement to service connection for right knee pain is denied. Entitlement to service connection for left knee pain is denied. Entitlement to service connection for a left shoulder disorder is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to September 9, 2019, the Veteran's cervical spine disability was manifested by, at worst, flexion to 45 degrees, without evidence of intervertebral disc syndrome (IVDS) lasting at least 2 weeks but less than 4 weeks, or ankylosis. 2. From September 9, 2019, the Veteran's cervical spine disability was manifested by, at worst, flexion to 10 degrees, without evidence of IVDS with incapacitating episodes lasting at least four weeks or more, or ankylosis. 3. From September 9, 2019, the Veteran's radiculopathy of the right upper extremity associated with cervical spine disability was moderate in severity. 4. The Veteran is not shown to have a diagnosis of a right knee disorder, and the right knee pain is not so severe as to cause functional impairment that affects his earning capacity. 5. The Veteran is not shown to have a diagnosis of a left knee disorder, and the left knee pain is not so severe as to cause functional impairment that affects his earning capacity. 6. The Veteran is not shown to have a diagnosis of a left shoulder disorder, and the left shoulder pain is not so severe as to cause functional impairment that affects his earning capacity. CONCLUSIONS OF LAW 1. Prior to September 9, 2019, the criteria for a rating in excess of 10 percent for cervical strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5237, 5242, 5243. 2. From September 9, 2019, the criteria for a rating in excess of 30 percent for cervical strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5237, 5242, 5243. 3. From September 9, 2019, the criteria for a 40 percent rating for radiculopathy of the right upper extremity associated with cervical strain have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8512. 4. The criteria for service connection for right knee pain have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for service connection for left knee pain have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for service connection for a left shoulder disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1986 to February 2016. These matters are before the Board of Veterans' Appeals (Board) on appeal from a May 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a videoconference hearing held before the undersigned Veterans Law Judge in October 2021. A transcript is of record. 1. Entitlement to an initial rating in excess of 10 percent prior to September 9, 2019, and in excess of 30 percent thereafter for cervical strain is denied. 2. Entitlement to a 40 percent rating from September 9, 2019, for radiculopathy of the right upper extremity associated with cervical strain is granted. By way of background, in May 2016, the Veteran was granted a 10 percent rating for his cervical spine disability effective March 1, 2016, which is the day after discharge from active service. In June 2020, the RO increased the rating to 30 percent effective September 9, 2019. The Veteran contends that he is entitled to a higher initial rating. The appeal period before the Board begins on March 1, 2016. The Veteran's cervical spine disability was rated under Diagnostic Code 5237 prior to September 9, 2019, and under Diagnostic Code 5243 thereafter. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 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 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Unfavorable ankylosis is defined as "a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching." Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is "always" considered favorable ankylosis. Id. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Spine disabilities may be rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. This formula provides a 20 percent rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted for IVDS with 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 is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. See 38 C.F.R. § 4.71a, Note (1). The rating criteria for the spine were amended on February 7, 2021. There were no changes to Diagnostic Code 5237. Diagnostic Code 5242 was amended to make clear that its application was for degenerative arthritis/disc disease of the spine other than IVDS. Diagnostic Code 5243 was amended to make clear that it should only be applied for disc herniation with compression and/or irritation of the adjacent nerve root, and that all other disc diagnoses should be rated under Diagnostic Code 5242. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use, and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). In a May 2019 service treatment record, the cervical spine MRI revealed multilevel uncovertebral joint degenerative joint disease with some foraminal narrowing. The assessment was a cervical spondylosis. A July 2019 service treatment record noted diagnoses of multilevel cervical spondylosis and multilevel thoracic IVDS. The Veteran underwent a VA examination for neck conditions in October 2015. He was diagnosed with cervical strain and right upper extremity radiculopathy. The Veteran reported stiffness, dull to sharp pain, and problems with turning to right. He reported flare-ups in cool, damp weather; he did not specify the symptoms. He reported functional impairment of reduced turn to right. Upon objective examination, the range of motion measurements were "all normal." Forward flexion and extension were from 0 to 45 degrees; right and left lateral flexion was from 0 to 45 degrees; and right and left lateral rotation was from 0 to 80 degrees. Pain was noted in all ranges of motion but did not result in functional loss; there was no objective evidence of localized tenderness or pain on palpation. He was able to perform repetitive-use testing with at least three repetitions without additional functional loss or range of motion. The examiner noted that he was not examined during a flare-up and thus it was not possible to determine without resorting to mere speculation to estimate loss of range of motion because there is no conceptual or empirical basis for making such a determination without directly observing function under such condition. There was no muscle spasm, localized tenderness, or guarding. Muscle strength was normal. There was no muscle atrophy or ankylosis. Reflex and sensory exams were normal. There was no IVDS or arthritis of the cervical spine. The Veteran's right hand was dominant. His right upper extremity radiculopathy reportedly manifested with symptoms of constant pain, paresthesias and/or dysesthesias, and numbness that were mild. The radiculopathy involved C8/T1 nerve roots. The severity of the radiculopathy was mild. The examiner noted his neck condition impacts his ability to work; the Veteran stated he has difficulty turning his head, and had 0-1 week work time lost in the last 12 months. The Veteran underwent a VA examination in September 2019 for neck conditions. He was diagnosed with cervical strain, cervical radiculopathy (bilateral), degenerative arthritis of the spine, and IVDS. He reported daily stiff neck pain, inability to sleep, difficulty driving, and that cannot stay in one position and has to shift his position constantly. He reported flare-ups described as pain in physical exertion, which is much worse in cold, damp conditions; he stated the flare-ups were severe, lasted 2-3 days, and were precipitated by driving, holding arms above heart, and quick movement on neck. The functional impairments were driving, holding arms above heart, and quick movement on neck. Upon objective examination, the forward flexion and extension were limited to 20 degrees; right and left lateral flexions were limited to 20 degrees; and right and left lateral rotations were limited to 40 degrees. Pain was noted in all ranges of motion, and caused functional loss. There was pain with weight bearing. There was no localized tenderness. He was able to perform repetitive-use testing with at least three repetitions without additional functional loss or range of motion. He was examined immediately after repetitive use over time; pain, weakness, fatiguability, or incoordination did not limit functional ability with repeated use over time. Pain during flare-ups caused functional loss. The examiner estimated that, in terms of range of motion, the forward flexion and extension would be limited to 10 degrees; right and left lateral flexions limited to 10 degrees; and right and left lateral rotations limited to 20 degrees. He had muscle spasm; it did not result in abnormal gait or abnormal spinal contour. There was no guarding. Muscle strength was normal, and there was no muscle atrophy. Reflex and sensory exams were normal. There was no ankylosis. The examiner noted the Veteran had IVDS of the cervical spine but without any episodes of acute signs and symptoms that required bed rest prescribed by a physician or treatment by a physician in the past 12 months. His right upper extremity radiculopathy displayed intermittent pain, paresthesias and/or dysesthesias, and numbness that were moderate. The radiculopathy involved C5/C6 and C7 nerve roots. The severity of the radiculopathy was moderate. The examiner noted the Veteran's neck condition impacts his ability to work; there was pain with working overhead, lifting greater than 15 pounds overhead, or standing longer than 10 minutes. In a September 2019 addendum to the September 2019 VA examination report, the examiner noted that there is clear diagnostic support for a spondylosis and IVDS while the claimant was still on active duty as shown by his May 2015 MRI record noting multilevel uncovertebral joint degenerative joint disease with some foraminal narrowing. At the October 2021 Board hearing, the Veteran stated he can move his neck but with difficulty. He reported his neck snaps, crackles, and pops. He stated he is limited in how much he can move his neck and upper body. He indicated that there was progressive worsening of the limited movement of his neck from 2016. The Veteran's VA and private treatment records during the appeal period did not reveal any range of motion testing of his cervical spine nor any prescription of bedrest by a doctor. After careful review, the Board concludes that the evidence of record persuasively weighs against a rating higher than 10 percent prior to September 9, 2019, and a rating higher than 30 percent thereafter for his cervical spine disability; the evidence does reveal right upper extremity radiculopathy with moderate severity from September 9, 2019. Prior to September 9, 2019 During this period, the Veteran's cervical spine displayed normal ranges of motion. Assignment of the next highest rating of 20 percent rating would require 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. However, the evidence obtained at the 2015 VA examination demonstrates forward flexion was to 45 degrees, the combined range of motion was 340 degrees, and there was no muscle spasm or guarding that resulted in an abnormal gait or abnormal spinal contour. There was no additional limitation of motion during the repetitive motion testing, which is sufficient to demonstrate function with repeated use over time. The Board is mindful that the Veteran reported flare-ups at his 2015 VA examination, but the examiner did not provide an estimate regarding the additional loss of motion upon flare-ups as is required by Sharp v. Shulkin, 29 Vet. App. 26, 34-35 (2017). However, the Board can use the most recent examination as a guide in assessing the additional range of motion loss due to flare-ups. The 2019 VA examiner estimated that the Veteran's functional impairment would result in an additional 10 degrees of limited motion of flexion, extension, lateral flexion and rotation. Thus, even considering the Veteran's lay reports of symptoms and noted functional loss due to pain, the degree of additional limitation shown at the 2015 VA examination would not result in limitation of motion more nearly approximating forward flexion of the cervical spine to 30 degrees or less. The estimated additional 10 degrees lost that would occur during flare-ups, as noted by the 2019 VA examiner, also does not more nearly approximate the combined degrees of limited motion required for a 20 percent rating or higher under DC 5235. Rather, forward flexion would, at worst, be between 35 and 45 degrees, even considering flare-ups and repeated use over time. A higher rating is not warranted under DC 5235 or DC 5245 for this appeal period prior to September 9, 2019. In the addendum to the September 2019 VA examination, the examiner clarified that the Veteran currently has and has had IVDS during active service. A 20 percent rating under Diagnostic Code 5243 requires incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. However, the Veteran has not reported any incapacitating episodes due to his cervical IVDS, nor is there any record of such episode at any time during the appeal period. Thus, a higher rating under Diagnostic Code 5243 is not warranted. From September 9, 2019 During this period, the Veteran is in receipt of a 30 percent rating under Diagnostic Code 5243. A higher rating under Diagnostic Code 5243 requires incapacitating episodes that last at least 4 weeks but less than 6 weeks during the past 12 months. However, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. As noted above, Diagnostic Code 5243 was amended in February 2021, which requires it to be only applied when there is disc herniation with compression and/or irritation of the adjacent nerve root, and Diagnostic Code 5242 is to be assigned for all other disc diagnoses. It is unclear from the record whether the Veteran has cervical disc herniation with compression and/or irritation of the adjacent nerve root from February 2021. Under Diagnostic Code 5242, which is rated pursuant to the General Rating Formula for Diseases and Injuries of the Spine as Diagnostic Code 5237, a rating higher than 30 percent requires unfavorable ankylosis of the entire cervical spine. However, there was no actual or functional cervical ankylosis throughout the period on appeal. Therefore, a rating higher than 30 percent is not warranted under Diagnostic Code 5242. The Board considered whether a separate evaluation may be warranted for any associated objective neurological abnormalities under an appropriate diagnostic code. See 38 C.F.R. §§ 4.71a Note 1. The Veteran is already in receipt of 20 percent rating for his radiculopathy of the right upper extremity associated with his cervical strain effective March 1, 2016. See May 2016 rating decision; 38 C.F.R. § 4.124a, Diagnostic Code 8512. The October 2015 examination shows the severity of the right upper radiculopathy was mild. However, at the September 2019 examination, the radiculopathy displayed symptoms of intermittent pain, paresthesias and/or dysesthesias, and numbness that were moderate. The examiner noted that the severity of the radiculopathy was moderate. As the radiculopathy is moderate and the Veteran is right-handed, the Board finds that a 40 percent rating is warranted under 38 C.F.R. § 4.124a, Diagnostic Code 8512. A higher rating is not warranted for the record fails to show that his radicular symptoms are severe. Id. In short, a rating higher than 10 percent prior to September 9, 2019, and a rating higher than 30 percent thereafter for the Veteran's cervical spine disability is not warranted. His right upper extremity radiculopathy associated with the cervical spine disability displayed moderate severity from September 9, 2019, and warrants a 40 percent rating. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to service connection for right knee pain is denied. 4. Entitlement to service connection for left knee pain is denied. 5. Entitlement to service connection for a left shoulder disorder is denied. The Veteran contends that his bilateral knee pain and his left shoulder condition are due to injuries he incurred from a parachute landing in 1995; he also asserts that the knee pain is from wearing body armor during active service. See Board hearing transcript at 4-5. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be granted for a Persian Gulf Veteran with objective indications of a qualifying chronic disability that manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2026. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). A qualifying chronic disability is a chronic disability that may result from an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317(a)(2)(i). The term chronic means that the disability has existed for 6 months or more, to include intermittent episodes of improvement or worsening over that period. 38 C.F.R. § 3.317 (a)(4). The Veteran had active service in Southwest Asia, including in Kuwait from February 2003 to January 2004, in Iraq from September 2007 to November 2008, and in Afghanistan from January 2010 to February 2011. Therefore, he is considered a Persian Gulf Veteran. 38 C.F.R. § 3.317(e). The Veteran's service treatment records are silent for any complaints or treatment for a knee or a shoulder condition except for reports of knee and shoulder pain during the retirement exam. The Veteran's bilateral upper and lower extremities were normal at his August 1985 enlistment exam. An August 1995 emergency room (ER) treatment record from Baynes Jones Hospital noted right ankle fracture; There was no indication of a knee or a shoulder condition. The follow-up records did not reveal any complaints or treatment for a knee or shoulder condition. A May 2006 periodic exam noted normal upper and lower extremities. A March 2015 physical examination of the shoulders showed no tenderness on palpation, no decreased response to tactile stimulation, and no shoulder weakness. In a September 2015 retirement report of medical history, the Veteran reported his left shoulder is much weaker than right due to a bad parachute landing in 1994; he reported his left knee is weaker than his right, and makes balance difficult at times. The September 2015 retirement examination shows normal clinical evaluation of his upper and lower extremities; the summary of defects and diagnoses noted shoulder weakness and multiple joint injuries. An October 2015 VA separation health assessment shows "left shoulder pain due to injury 1995" for medical history. Upon physical examination, no problems were found his left shoulder or knees. The examiner noted that the Veteran's knees and the left shoulder were "normal," and no clinical diagnosis was rendered for his left shoulder or knees. In an October 2015 VA examination for knee and lower leg conditions, the examiner noted that the Veteran's knees were normal; no clinical diagnosis was made. The Veteran reported bilateral knee pain that started over time. He reported constant dull pain in the knees, and weakness in the left leg. He did not report any flare-ups or functional impairment. Upon physical examination, both knees displayed full ranges of motion without pain. There was no arthritis. The examiner noted that the Veteran's knee condition did not impact his ability to work. In an October 2015 VA examination for shoulder and arm conditions, the examiner noted that the Veteran's shoulders are normal; no clinical diagnosis was made. The Veteran reported he injured his left shoulder in 1995 during an airplane jump landing. He reported constant dull pain and weakness. He did not report any flare-ups or functional impairment. Upon examination, the left shoulder exhibited full ranges of motion; flexion and abduction exhibited pain but did not result in functional loss. The examiner noted his shoulder condition impacts his ability to work, and noted, "0-1 week/yr work time lost[;] reports of pain and weakness with excessive use and holding objects." The examiner noted in the remarks that the "symptoms of pain noted on day of exam are subjective only and of no clinical significance. No diagnosis warranted." In the August 2016 VA Form 21-4138, the Veteran stated he has jumped out of airplanes and helicopters for over 30 years as an infantryman and was always more concerned about his back pain than any other. He stated he did not have the time to spend at the medical clinic for the pain in his knees, and treated the pain with over-the-counter medications, rest, and relaxation. He also stated he hurt his left shoulder during a bad parachute jump and still has problems with lifting items over his head. He stated his shoulder was completely dislocated from the injury and had to be put back in place. At the October 2021 Board hearing, the Veteran testified that he injured his left knee and left hip during a parachute landing in 1995, and was not able to walk or run correctly for about a year. He reported pain in both knees which can be very excruciating sometimes. He stated he had physical therapy on two occasions during active service for his left knee, and was provided with rubber bands for knee flexion. He reported his left shoulder was also injured during that same 1995 parachute landing. He stated he hit the aircraft on his exit. He stated his left shoulder was completely dislocated and spent a night in the ER. He stated he has chronic pain, and that his left shoulder comes out of socket once every few years. A November 2021 private x-ray report noted the Veteran is a patient with history of shoulder injury during active service, and has increased pain and decreased range of motion over the past few months. The x-ray of the left shoulder revealed the following findings: 4 views of the shoulder show normal glenohumeral articulation; there is no fracture, arthritic process, radiopaque foreign body, or focal soft tissue swelling; the visualized scapula, clavicle, and hemithorax were all unremarkable; there are horizontal superior glenoid transverse lucencies, perpendicular to the glenoid surface. The impression was "Question of prior superior labral repair otherwise, Negative left shoulder series." After careful review, the Board finds that service connection is not warranted for his bilateral knee pain and left shoulder condition. The Veteran's service treatment records are silent for any complaints or treatment for a knee or a shoulder condition except for his own reports at separation. The Veteran has reported injuries to his left knee and left shoulder from a parachute landing in 1995, but his service treatment records in 1995 reveal treatments for his right ankle fracture only, and his service treatment records are entirely silent for any treatment records or ER visits for his knee or shoulder condition. Further, while he noted in the August 2016 VA Form 21-4138 that he did not have the time to spend at the medical clinic for his knee pain, he reported at the Board hearing that he had physical therapy for his left knee during active service. The Board finds that the Veteran is not a good historian and finds his reports of in-service injury not credible. Further, there is no clinical diagnosis of a current disability. The September 2015 retirement examination noted normal clinical evaluation of his upper and lower extremities. The October 2015 VA separation assessment noted normal knees and normal left shoulder. The October 2015 VA examinations for his knees and left shoulder indicate normal evaluation without any clinical diagnosis; the examiner for the left shoulder specifically noted in the remarks that "pain noted on day of exam are subjective only and of no clinical significance. No diagnosis warranted." The November 2021 x-ray report did not reveal a current diagnosis of a left shoulder disorder. In the absence of proof of a present disability, there is no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board is mindful of Saunders v. Wilkie, in which the Federal Circuit explained that where pain alone results in functional impairment that affects earning capacity, even if there is no identified underlying diagnosis, it can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018). "Functional impairment" is defined as "the ability of the body or a constituent part of it to function under the ordinary conditions of daily life including employment." Id. at 1363 (quoting 38 C.F.R. § 4.10). In this case, there is no current evidence showing the pain from his knees and left shoulder has been so severe as to cause functional impairment that affects his earning capacity. As noted above, the Veteran's knees and left shoulder were clinically evaluated as normal at the October 2015 examinations, and he denied any functional loss or impairment. Service connection can be awarded for certain disabilities occurring in Persian Gulf Veterans. 38 C.F.R. § 3.317. However, one of the requirements for service connection under that regulation is that indications of a qualifying chronic disability, which could include joint pain, must manifest to a degree of 10 percent or more. 38 C.F.R. § 3.317 (a)(1)(i). During the October 2015 examinations, the Veteran was noted to have a normal range of motion of in his knees and left shoulder with no objective functional impairment; these results would not warrant compensable ratings based on the criteria for rating his knees or left shoulder. See 38 C.F.R. § 4.71a, Diagnostic Codes 5200-5203, 5256-5263. A compensable rating can also be awarded based on painful motion of the joint or a painful joint. 38 C.F.R. § 4.59. However, at the October 2015 examinations, the examiner noted there was no objective evidence of painful motion in the knees; the examiner noted pain in his left shoulder that does not result in or cause functional loss. While the Veteran asserts pain, pain alone does not constitute functional loss, but is just one fact to be considered when evaluating functional impairment. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). There is no persuasive evidence that the Veteran suffers from pain that affects some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance that constitutes functional loss. As the Veteran's bilateral knee or left shoulder pain has not manifested to a degree of 10 percent or more, service connection cannot be awarded under 38 C.F.R. § 3.317. The Veteran believes he has current diagnoses of the claimed disabilities and that they are related to his active service. However, he is not competent to render a diagnosis or a nexus opinion. Determining the diagnosis or etiology of a disorder is a complex medical question requiring expertise the Veteran has not been shown to possess. Thus, his assertion is not competent evidence, and the Board gives more probative weight to the October 2015 examiner's opinion. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Unfortunately, the current evidence of record persuasively weighs against service connection for bilateral knee pain and left shoulder disorder at this time. The benefit of the doubt rule is not for application, and service connection is not warranted. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). REASONS FOR REMAND 1. Entitlement to a TDIU is remanded. At the October 2021 Board hearing, the Veteran contended that he has been unable to work as a result of his service-connected lumbar and cervical spine disabilities. See Board hearing transcript at 15-17. Accordingly, the issue of entitlement to a TDIU has been raised by the evidence of record. Rice v. Shinseki, 22 Vet. App. 447 (2009). On remand, the Veteran should be provided a Veterans Claims Assistance Act (VCAA) notice regarding TDIU and the Veteran should be asked to complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. The matters are REMANDED for the following action: Request the Veteran complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, and then undertake any additional development necessary. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Jake Choi, 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.