Citation Nr: 25004528 Decision Date: 04/02/25 Archive Date: 04/02/25 DOCKET NO. 16-02 331 DATE: April 2, 2025 ORDER Entitlement to an initial rating in excess of 20 percent for a left elbow disability, prior to January 17, 2024, is denied. Entitlement to a disability rating in excess of 50 percent for a left elbow disability, effective January 17, 2024, is denied. Entitlement to an initial rating in excess of 20 percent, prior to January 27, 2020, for a left shoulder disability is denied. Entitlement to a disability rating in excess of 30 percent, effective January 27, 2020, for a left shoulder disability is denied. Entitlement to special monthly compensation (SMC) based on the loss of use of the left arm is denied. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance or by reason of being housebound is denied. FINDINGS OF FACT 1. The Veteran's dominant hand is the left hand. 2. For the period of appeal prior to January 17, 2024, the Veteran's left elbow disability was not manifested by flexion limited to 70 degrees or less. 3. Effective January 17, 2024, the Veteran is in receipt of the highest possible rating for a left elbow disability based on limitation of flexion. 4. For the period of appeal prior to January 27, 2020, a left (major) shoulder disability was not shown to result in limitation of motion of the major arm to midway between side and shoulder level; or limitation of motion of the major arm midway between side and shoulder level which is defined as flexion or abduction limited to 45 degrees. 5. For the period of appeal from January 27, 2020, a left (major) shoulder disability has not been shown to result in limitation of motion of the major arm to 25 degrees from the side; or flexion and/or abduction limited to 25 degrees from the side in the major arm. 6. The competent and credible evidence of record persuasively establishes a finding that the functioning of upper extremities is not so diminished that amputation with prosthesis would equally serve the Veteran. 7. During the course of this appeal, the Veteran did not have a single service-connected disability rated 100 percent with separate service-connected disabilities rated 60 percent or more and the Veteran was not permanently confined to his immediate premises as a result of service-connected disabilities, and the evidence does not show the actual need for aid and attendance of another person. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent rating for a left elbow disability, prior to January 17, 2024, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5206. 2. The criteria for a rating in excess of 50 percent for a left elbow disability as of January 17, 2024, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5206. 3. The criteria for an initial rating in excess of 20 percent for a left shoulder disability prior to January 27, 2020, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5201. 4. The criteria for a disability rating in excess of 30 percent for a left shoulder disability as of January 27, 2020, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5201. 5. The criteria for entitlement to special monthly compensation (SMC) based on the loss of use of the left arm have not been met. 38 U.S.C. §§ 1114 , 5107; 38 C.F.R. §§ 3.102, 3.350, 4.63. 6. The criteria for entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance or by reason of being housebound have not been met. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. §§ 3.350, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty for training (ACDUTRA) in the United States Air Force from July 1979 to October 1979, with additional service in the Air Force Reserves that included various periods of ACDUTRA and inactive duty for training (INACDUTRA). This matter comes to the Board of Veterans' Appeals (Board) on appeal from January 2014 and October 2018 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO), which is the Agency or Original Jurisdiction (AOJ). In November 2020 and December 2023, the Board remanded these claims to the AOJ for additional action. In September 2018, the Board denied increased ratings for a left elbow disability. The Veteran appealed the September 2018 Board decision to the Court of Appeals for Veterans Claims (Court) denial of entitlement to an initial rating in excess of 10 percent prior to January 25, 2013, and in excess of 20 percent as of January 25, 2013, for a service-connected left elbow disability. In a March 2020 Memorandum Decision, the Court vacated the Board's denial of left elbow increased ratings, and remanded the matter for further consideration consistent with the decision. In a November 2022 Board decision, the Board awarded an initial 20 percent rating for the left elbow disability prior to January 25, 2013, and denied a rating in excess of 20 percent as of January 25, 2013; and denied entitlement to a rating in excess of 20 percent prior to January 27, 2020, and granted a rating of 30 percent as of January 27, 2020, for the left shoulder disability. The Veteran appealed that Board decision to the United States Court of Appeals for Veterans Claim (Court). The Court granted a July 2023 Joint Motion for Partial Remand for those issues. The issues have since returned to the Board for appellate review. The Board acknowledges that the Veteran is also seeking entitlement to increased ratings for limited left elbow extension, supination, and pronation impairment of the left elbow, chronic left wrist strain, and a total rating based on individual unemployability. In July 2024 and October 2024, the Veteran submitted VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), with respect to those issues. Consequently, those claims are before the Board under the Appeals Modernization Act docket for adjudicating appeals. Therefore, those claims will not be addressed in this decision but a separate decision. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Schedule is primarily a guide in the rating 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 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. 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). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period for which the appeal has been pending. Powell v. West, 13?Vet. App.?31 (1999). Consideration must be given as to whether staged ratings should be assigned to compensate entitlement to a higher rating at any point during the pendency of the claim. When the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. Fenderson v. West, 12?Vet. App.?119 (1999); Hart v. Mansfield, 21?Vet. App.?505 (2007). While the Board must provide reasons and bases supporting a decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (Board must review the entire record but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence of record. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed. Timberlake v. Gober, 14?Vet. App.?122 (2000). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not given to each piece of evidence contained in the record. Every item of evidence does not have the same probative value. When the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in approximate balance, with the Veteran prevailing in either event, or whether a weight of the evidence is against a claim, in which case the claim is denied. 1. Entitlement to an initial rating in excess of 20 percent for a left elbow disability, prior to January 17, 2024. 2. Entitlement to a disability rating in excess of 50 percent for a left elbow disability, effective January 17, 2024. The Veteran is currently assigned a 20 percent rating, prior to January 17, 2024; and 50 percent thereafter, for left elbow post-traumatic arthritis, pursuant to Diagnostic Code 5206. Under Diagnostic Code 5206, limitation of flexion of the forearm warrants a 0 percent rating is assigned for limitation to 110 degrees for both arms. A 10 percent rating is assigned for flexion limited to 100 degrees for both arms. A 20 percent rating is assigned for flexion limited to 90 degrees for both arms. A 20 percent rating is assigned for flexion limited to 70 degrees for the minor arm, and 30 percent for flexion limited to 70 degrees for the major arm. A 30 percent rating is assigned for flexion limited to 55 degrees for the minor arm, and 40 percent when limited to 45 degrees for the major arm. 38 C.F.R. § 4.71a, Diagnostic Code 5206. Normal flexion and extension of the elbow is from 0 degrees of extension to 145 degrees of flexion, normal forearm pronation is from 0 to 80 degrees, and normal forearm supination is from 0 to 85 degrees. 38 C.F.R. § 4.71a, Plate I. The Board notes as a preliminary matter that the Veteran's dominant hand is his left hand, as noted consistently in medical records. Therefore, the left elbow and left shoulder disabilities are disabilities of the major arm. 38 C.F.R. § 4.69. Private treatment records dated in August 2011, just prior to the period of appeal, indicate that the Veteran was seen for left elbow pain. He reported that since injuring the left elbow in service, he had never been able to fully extend it, but was still active and worked out. The treating doctor indicated that the Veteran was approximately 15 to 20 degrees short of full extension, and with some degree of coaxing was 10 to 12 degrees sort of full extension. The Veteran also had tenderness to palpation over the radiocapitellar and humeral joints, 10 degrees short of full flexion, full pronation, and 70 degrees of supination. X-rays showed posttraumatic arthritic change, limited range of motion with some degree of arthrofibrosis, and loose bodies. The Veteran clarified in an August 2012 statement that he only worked out by walking. The Veteran stated that the left elbow caused constant pain and prevented him from getting restful sleep due to the popping and catching. At an August 2012 VA elbow examination, the Veteran reported that since service, he had "occasionally" received medication and was seen by an orthopedist and no surgery was advised. During flare-ups, he had constant pain. The examiner indicated that the Veteran's dominant hand was the left hand. On examination, the left elbow range of motion measurements included flexion to 100 degrees and extension to 30 degrees, with pain on movement. After repetitive-use testing with three repetitions of movement, range of motion was unchanged. Results of muscle strength testing in left elbow flexion and extension were normal (5/5), and there was no ankylosis, flail joint, joint fracture, or impairment of supination or pronation. X-rays showed arthritis. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. The examiner indicated that there were no other pertinent physical findings related to the left elbow condition, and opined that the Veteran's left elbow disability was mild. In a January 2013 Elbow and Forearm Conditions Disability Benefits Questionnaire (DBQ) completed by a private physician, the Veteran reported that left elbow pain caused decreased range of motion and the inability to lift and pull. The dominant hand was the left hand. On examination, initial range of motion measurements included flexion to 140 degrees with objective evidence of painful motion at 90 degrees, and 90 degrees of extension with painful motion at 90 degrees. The Veteran was unable to perform repetitive-use testing, but was noted to have additional limitation in range of motion following repetitive-use testing. He also had swelling and pain on palpation. Results of muscle strength testing showed active movement against gravity (3/5) in flexion and active movement with gravity eliminated (2/5) in extension. There was no ankylosis, flail joint, joint fracture, or impairment of supination or pronation. The doctor noted that functioning was so diminished that amputation with prosthesis would equally serve the Veteran, indicating that the Veteran had popping and locking/catching-type symptoms of the left elbow, and associated pain, resulting in that finding. VA treatment records indicate that in May 2013, the Veteran reported having left elbow pain. He also noted that he had an exercise routine that he did three times per week or daily. In an August 2013 mental health consult, the Veteran reported that left elbow pain sometimes woke him up at night, and that he could no longer do things he used to do, such as boxing. At a November 2013 VA elbow examination, the Veteran reported having pain and incomplete extension. During flare-ups, he had difficulty with basic tasks such as opening doors and lifting, and he experienced elbow locking. Flare-ups did not further limit range of motion. On examination, the left elbow had flexion to 90 degrees and extension to 30 degrees, with pain at the endpoints of movement. After repetitive-use testing with three repetitions, there was no additional limitation in range of motion. There was also no localized tenderness or pain on palpation, muscle strength was normal in elbow flexion and extension. There was no ankylosis, flail joint, joint fracture, or impairment of supination or pronation, and functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. The examiner indicated that there were no other pertinent physical findings related to the left elbow condition. At a July 2014 VA appointment, the Veteran reported left elbow pain. He stated that he worked, lifted light weights, and jogged. In an August 2016 VA appointment, the Veteran stated that left elbow symptoms included pain, stiffness, and popping, and prevented him from sleeping at night. He was noted to be wearing a Velcro elbow brace. An X-ray showed advanced degenerative changes with multiple large spurs, marginal osteophytes, and a few intra-articular loose bodies. At an August 2017 VA appointment, the Veteran rated left elbow and shoulder pain as a 7 (on a scale of 1 to 10), and described it as constant, aching, throbbing, radiating, and dull. He stated that the worst pain level in the last month was a 9, and the least pain level in the last month was a 2. He also stated that he had been out of pain medication for months. In October 2017, the Veteran reported that his left elbow locked up at times, and that he went to the gym three days per week. In a February 2018 VA orthopedic surgery consultation, the Veteran stated that he had pain and stiffness in the left elbow, which he treated with Tylenol. Flexion was noted to be from 75 degrees to 110 degrees, with effusion and mild to moderate pain on motion. X-rays showed posttraumatic arthritis with multiple loose bodies. The Veteran indicated that he did not want surgery. In September 2018, the Veteran reported that he had intermittent aching pain with decreased range of motion and intermittent locking. He stated that he did light weight-lifting three times per week, and speed boxing with a punching bag. At a March 2019 VA appointment, the Veteran reported having left elbow pain. He stated that the elbow locked up "at times." In June 2019, the Veteran was noted to have left elbow tenderness. X-rays did not show any substantial changes compared to the prior study, and he was assessed as having olecranon (elbow) bursitis. At a January 2020 VA pain management appointment, the Veteran rated the left elbow pain as 8 out of 10. In December 2020, the Veteran reported that he had constant left elbow pain, which he rated as 7 out of 10. At an April 2021 VA elbow examination, the Veteran reported symptoms of pain and incomplete extension. In addition, the elbow locked up while attempting to open a door, eventually easing up and popping, and intermittent throbbing and sharp pain that he rated a 7 out of 10. He used diclofenac gel daily for pain. During flare-ups, which occurred 5 days per week and lasted 8 to 10 hours, he had intermittent throbbing and sharp pain that was 10 out of 10, and he could not lift anything or dress himself. The examiner indicated that the Veteran's dominant hand was the left hand. On examination, the left elbow had flexion to 90 degrees, extension to 20 degrees, forearm supination to 10 degrees, and forearm pronation to 10 degrees, with pain on all four movements. Active and passive ranges of motion were the same. After repetitive-use testing with three repetitions, there was no additional limitation in range of motion. After repetitive use over time, estimated ranges of motion included flexion to 85 degrees, extension to 25 degrees, forearm supination to 5 degrees, and forearm pronation to 5 degrees. During flare-ups, estimated ranges of motion included flexion to 80 degrees, extension to 30 degrees, 0 degrees of forearm supination, and 0 degrees of forearm pronation. There was no evidence of crepitus, localized tenderness or pain on palpation, or muscle atrophy. There was also no evidence of flail joint, joint fracture, nonunion of the radius and ulna with flail false joint, impairment of the ulna, impairment of the radius, or impairment of supination and pronation. The examiner indicated that functioning was not so diminished that amputation with prosthesis would equally serve the Veteran . There were no other pertinent physical findings related to the left elbow condition. In August 2021, the same VA examiner that conducted the April 2021 VA elbow examination provided an addendum medical opinion. The examiner opined that left elbow range of motion during flare-ups prior to January 25, 2013, included flexion limited to 95 degrees with pain at the end point of the motion. The examiner also concurred with the November 2013 VA examiner that flare-ups did not further limit range of motion, although they did cause difficulty with tasks such as opening doors and lifting with the left arm. The examiner clarified that despite checking a box in the examination report that the left elbow had favorable ankylosis at an angle between 90 degrees and 70 degrees, the left elbow was not ankylosed. The Veteran asserted in an August 2022 affidavit that the left elbow was locking up daily, and was the reason why he retired from his job at a maximum security prison in 2009 . The Veteran's attorney asserted in an August 2022 statement that the Veteran was entitled to an initial rating of at least 20 percent for left elbow limitation of flexion, and three separate ratings for limitation of extension, supination, and pronation, effective no later than October 12, 2011. At a January 2024 VA examination, range of motion testing was, at worst, to 40 degrees of flexion, 0 degrees of extension, 5 degrees of supination, and 5 degrees of pronation. The condition was not found to result in muscle atrophy or ankylosis. The Veteran did not use any assistive devices as a result of the condition. The condition was not found to result in such 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 condition resulted in elbow pain, stiffness, limited range of motion, difficulty with heavy lifting over 5 pounds or repetitive motion over 10 minutes. Accordingly, the Board next finds that a rating in excess of 20 percent for left elbow disability was not warranted prior to January 17, 2024, under Diagnostic Code 5206. A higher 30 percent rating requires flexion limited to 70 degrees. The Veteran has been found to have flexion limited to no worse than 80 degrees, including four VA examinations and a private examination, and including consideration of repetitive use over time and during flare-ups. Effective January 17, 2024, the Board finds that a disability rating in excess of 50 percent for the left elbow disability with limitation of flexion is not warranted. During that period, the Veteran's flexion was limited to, at worst, 40 degrees flexion, which corresponds to a 50 percent disability rating under Diagnostic Code 5206. That represents of the highest schedular rating for flexion. Additionally, the evidence does not show that the left elbow disability with limitation of flexion is so exceptional or unusual so as to make the rating schedule inadequate for rating purposes. Ankylosis has not been shown as there was range of motion found. The Board has considered whether separate or increased ratings may be assigned under other relevant diagnostic codes. The Board finds that there is no competent medical evidence, including four VA examinations and a private examination, of left elbow ankylosis, impairment of flail joint, or nonunion or impairment of the ulna or radius that would support a separate or increased evaluation under the criteria set forth in Diagnostic Codes 5205 (ankylosis), 5209 (impairment of flail joint), or 5210-5212 (nonunion and impairment of the radius and ulna). 38 C.F.R. § 4.71a, Diagnostic Codes 5256-5263. With regard to limitation of extension and impairment of supination and/or pronation for the service-connected left elbow disability, the Board notes that those increased rating claims are before the Board under the Appeals Modernization Act framework of adjudicating appeals and will not be addressed in this decision but a separate decision. Accordingly, the Board finds that the weight of the evidence is against the assignment of any higher or separate ratings, the criteria for higher ratings are not met or more nearly approximated, that the evidence is not in approximate balance, and that there is no reasonable doubt to resolve in favor of the Veteran. Therefore, the claim for any higher or separate ratings must be denied. 3. Entitlement to an initial rating in excess of 20 percent, prior to January 27, 2020, for a left shoulder disability. 4. Entitlement to a disability rating in excess of 30 percent, effective January 27, 2020, for a left shoulder disability. The Veteran's left shoulder disability has been assigned an initial 20 percent rating, prior to January 17, 2020; and a 30 percent rating as of January 27, 2020, under Diagnostic Code 5201. Prior to February 7, 2021, under Diagnostic Code 5201, used for rating limitation of motion of the arm, a 20 percent rating was assigned for limitation of motion of the major arm or minor arm to the shoulder level, or for limitation of motion of the minor arm to midway between the side and shoulder level. A 30 percent rating was warranted for limitation of motion of the major arm to midway between the side and shoulder level, or for limitation of motion of the minor arm to 25 degrees from the side. A schedular maximum 40 percent rating was warranted for limitation of motion of the major arm to 25 degrees from the side. 38 C.F.R. § 4.71a , Diagnostic Code 5201 (2020). Effective February 7, 2021, the revised version of Diagnostic Code 5201 clarifies that a 20 percent rating is warranted for flexion and/or abduction limited to 90 degrees (shoulder level) in the major arm or minor arm, or for flexion and/or abduction limited to 45 degrees (midway between the side and shoulder level) in the minor arm. A 30 percent rating is warranted for flexion and/or abduction limited to 45 degrees (midway between the side and shoulder level) in the major arm, or for flexion and/or abduction limited to 25 degrees from the side in the minor arm. A schedular maximum 40 percent rating is warranted for flexion and/or abduction limited to 25 degrees from the side in the major arm. 38 C.F.R. § 4.71a , Diagnostic Code 5201. Normal range of motion for the shoulder includes forward flexion from 0 to 180 degrees, abduction from 0 to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. 38 C.F.R. § 4.71, Plate I. A private treatment record dated in August 2011, just prior to the period of appeal, indicates that the Veteran had some degree of shoulder pain and a subcutaneous lipoma at the superior-anterior aspect of the left shoulder. In a May 2013 VA appointment, the Veteran was noted to have a fatty tumor on the left shoulder. He was also noted to be seen by a private orthopedic doctor. At a November 2013 VA shoulder examination, the Veteran reported having intermittent left shoulder pain since injuring the left elbow. During flare-ups, he had difficulty with overhead motion and with any strenuous task with the left arm, due partly to shoulder pain. Flare-ups did not result in additional loss in range of motion. The diagnosis was posttraumatic arthritis. On examination, left shoulder range of motion measurements was to 100 degrees of flexion and 100 degrees of abduction, with objective evidence of painful motion at the endpoints of the motions. After repetitive-use testing with three repetitions, ranges of motion were unchanged. There was no localized tenderness, pain on palpation, or guarding. Muscle strength was normal in abduction and flexion. A Hawkins' Impingement Test was positive, indicating that the Veteran could have rotator cuff tendinopathy or tear. There was a history of mechanical symptoms (clicking, catching, etc.), and no history of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint, acromioclavicular (AC) joint condition, or any other impairment of the clavicle or scapula. The examiner indicated that functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. There were no other pertinent physical findings related to the left shoulder condition. In a July 2014 VA appointment, the Veteran reported left shoulder pain. In a March 2015 VA appointment, the Veteran reported having left shoulder pain, which he rated as 7 out of 10. At an August 2016 VA appointment, the Veteran reported that left elbow pain was affecting the left shoulder, as he began having left shoulder pain when he had left elbow pain. An X-ray of the left shoulder showed mild to moderate degenerative changes of the glenohumeral and AC joints, and a small subacromial spur and small osteophyte forming at the inferior margin of the AC joint, which may result in impingement syndrome. Private treatment records indicate that the Veteran was seen intermittently from January 2017 through December 2020 for chiropractic and physical therapy treatment of the shoulder, neck, and back. The left shoulder symptoms were consistently described as tightness and between a 5 and 6 out of 10 in severity. In an August 2017 VA appointment, the Veteran rated left elbow and shoulder pain as 7, and described it as constant, aching, throbbing, radiating, and dull. He stated that the worst pain level in the last month was a 9, and the least pain level in the last month was 2. He also stated that he had been out of pain medication for months. The Veteran submitted a medical opinion on the left shoulder condition, which was completed by a private physician, Dr. A.A., in November 2017. After reviewing the Veteran's claims file, Dr. A.A. opined that it was just as likely as not that the Veteran developed post-traumatic adhesive capsulitis in the left shoulder due to the left shoulder disability. That doctor noted that the Veteran's symptoms included decreased range of motion, pain with motion, and no loss of strength, and did not further elaborate on the symptoms. At a January 2018 VA appointment, the Veteran reported having neck, left collar bone, and left shoulder pain. In September 2018, the Veteran reported that he had intermittent aching pain of the left shoulder. He stated that he did light weight-lifting three times per week, and speed boxing with a punching bag. At a March 2019 VA appointment, the Veteran reported having left shoulder pain. At a January 27, 2020, VA shoulder examination, the Veteran reported that left shoulder pain had worsened in 2004, and denied any evaluation by orthopedics. He used Tylenol and was followed periodically by a chiropractor. During flare-ups, the pain increased to moderate. Flare-ups occurred on a daily basis and lasted for several hours. The left shoulder condition caused problems with strenuous labor or any construction, working overhead, and working out and weightlifting. On examination, left shoulder range of motion measurements was to 90 degrees of flexion, 90 degrees of abduction, 80 degrees of internal rotation, and 80 degrees of external rotation, with pain noted on examination that did not result in functional loss. There was no evidence of pain with weight-bearing, localized tenderness or pain in palpation, or crepitus. There was also no evidence of pain on passive range of motion or evidence of pain when the joint was used in non-weight bearing. After repetitive-use testing with at least three repetitions or repetitive use over time, flexion decreased to 80 degrees, abduction decreased to 70 degrees, and external and internal rotation were unchanged. During flare-ups, flexion decreased to 75 degrees, abduction decreased to 65, external rotation decreased to 75 degrees, and internal rotation decreased to 75 degrees. The Veteran was not being examined immediately after repetitive use over time or during a flare-up, but the examination was consistent with his statements describing functional loss with repetitive use over time. Results of muscle strength testing in forward flexion and abduction were normal, and there was no muscle atrophy or ankylosis. A Hawkins' Impingement Test was positive, indicating that the Veteran could have rotator cuff tendinopathy or tear. There was no evidence of shoulder instability, dislocation, labral pathology; clavicle, scapula, AC joint, or sternoclavicular joint condition; or condition or impairment of the humerus. X-rays showed mild AC joint hypertrophic change. The examiner indicated that functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. There were no other pertinent physical findings related to the left shoulder condition. The January 2020 VA examiner also provided a medical opinion that the Veteran's left shoulder lipoma, which was excised in 2014, was less likely than not proximately due to or the result of the service-connected left shoulder disability. The examiner acknowledged and discussed the internet article submitted by the Veteran's representative that was printed from the Cleveland Clinic website, but noted that although some lipomas "may be" related to blunt trauma, there was no consensus in the scientific realm related to the exact etiology. However, the examiner stated that there was no evidence of any recent trauma to the Veteran's left shoulder, and the Veteran reported the initial presentation of the lipoma in 2011. If the lipoma was related to the shoulder injury, it was more likely that it would have manifested sooner than 29 years later. In December 2020, the Veteran reported chronic intermittent pain of the left shoulder. He described the pain as sharp, achy, and dull, and 5 out of 10 in severity. He was advised to use heat and diclofenac gel as needed. The Veteran asserted in an August 2022 affidavit that he could not move the left shoulder past halfway to the chest level, which prevented him from being able to wash his back. He also had been having difficulty rotating the left wrist upwards and downwards since a shoulder surgery in 2007. At a January 2024 VA shoulder examination, range of motion testing was to, at worst, 60 degrees of flexion, 60 degrees of abduction, 35 degrees of internal rotation, and 35 degrees of external rotation. The Veteran was not found to have muscle atrophy, ankylosis, recurrent subluxation, flail shoulder, false flail shoulder, or fibrous union of the humerus. The Veteran did regularly use a sling. The condition was not found to result in 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. The condition resulted in shoulder pain, stiffness, limited range of motion, difficulty with lifting repetitively over five pounds. The Board finds that a rating in excess of 20 percent is not warranted for a left shoulder disability prior to January 27, 2020, under Diagnostic Code 5201. For a higher 30 percent rating under the criteria in force prior to February 7, 2021, the evidence must show limitation of motion of the major arm to midway between the side and shoulder level. Here, the evidence shows that for the period of appeal prior to January 27, 2020, the left shoulder disability manifested in pain and a range of motion including 100 degrees of flexion and 100 degrees of abduction, including consideration of repetitive use and flare-ups. The Board equates these ranges of motion to be at least at shoulder level. The Board next finds that a rating in excess of 30 percent is not warranted at any point during the period of appeal. A higher 40 percent rating under the criteria in force prior to February 7, 2021, and the rating criteria currently in force, requires limitation of motion of the major arm to 25 degrees from the side. The left shoulder disability has not shown less than 60 degrees of flexion and 60 degrees of abduction during the period under consideration, even considering repetitive use and flare-ups. The Board has considered whether separate ratings may be assigned under other diagnostic codes. 38 C.F.R. § 4.71a, Diagnostic Codes 5200-5203. The Board finds no basis on which to assign a separate rating for the left shoulder disability other than the issue of a separate rating for residuals of a left shoulder lipoma, which is remanded herein. The Board notes that the medical evidence lacks indications of ankylosis of the scapulohumeral articulation, other impairment of the humerus, or impairment of clavicle or scapula to warrant rating either shoulder disability under Diagnostic Codes 5200 (ankylosis of the scapulohumeral articulation), 5202 (other impairment of humerus), or 5203 (impairment of clavicle or scapula). 38 C.F.R. § 4.71a. In reaching the foregoing conclusions, the Board has considered the evidence of functionally limiting factors caused by limitation of motion due to painful motion, excess motion, weakened motion, fatigability, incoordination, and flare up. Deluca v. Brown, 8 Vet. App. 202 (1995). While the Veteran has shown objective evidence of pain throughout the appeal, the record does not show that pain has resulted additional functional limitation consistent with the assignment of any higher rating. Accordingly, the Board finds that the weight of the evidence is against the assignment of a rating in excess of 20 percent for a left shoulder disability, prior to January 27, 2020; and in excess of 30 percent as of January 27, 2020.? The Board finds that the weight of the evidence is against the assignment of any higher ratings. The Board finds that the criteria for a higher rating are not met, the evidence is not in approximate balance, and there is no reasonable doubt to be resolved in favor of the Veteran. Therefore, the appeal must be denied. 38 U.S.C. §?5107;?38?C.F.R. §?3.102. 5. Entitlement to special monthly compensation (SMC) based on the loss of use of the left arm. The Veteran contends that he is entitled to SMC based upon loss of use of the left arm. The Veteran has established service connection for left elbow, left shoulder, and left wrist disabilities. SMC is warranted for certain specified service-connected disabilities. 38 U.S.C. § 1114. SMC is provided for the anatomical loss or loss of use of both arms with factors preventing natural elbow action with prostheses in place. 38 U.S.C. § 1114(n). Loss of use of a hand or a foot, for the purpose of special monthly compensation, will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below elbow or knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function of the hand or foot, whether the acts of grasping, manipulation, etc., in the case of the hand, or of balance and propulsion, etc., in the case of the foot, could be accomplished equally well by an amputation stump with prosthesis. Complete ankylosis of two major joints of an upper extremity will be taken as loss of use of the hand involved. 38 C.F.R. § 4.63. The Veteran contends that he has lost all functional use of the left arm. At an August 2012 VA elbow examination, the examiner found that the Veteran did not have ankylosis in the left elbow. The examiner opined that the Veteran's elbow condition did not result in 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. In a private January 2013 elbow examination, the examiner stated that the Veteran's condition resulted in functional impairment of an extremity such that no effective function remained other than that which would be equally served by an amputation with prosthesis. The Board notes that examiner did not find the elbow disability to resulted in ankylosis. At a November 2013 VA elbow and shoulder examination, the examiner found that the Veteran did not have ankylosis in the shoulder or elbow. The examiner opined that the Veteran's elbow and shoulder conditions did not result in 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. At a January 2020 VA shoulder examination, the examiner found that the Veteran did not have ankylosis in the shoulder. The examiner opined that the Veteran's shoulder condition did not result in 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. At an April 2021 VA elbow examination, the examiner found that the Veteran had favorable ankylosis in the left shoulder at an angle between 90 degrees and 70 degrees. During flare ups, the Veteran was found to have range of motion to, at worst, 80 degrees of flexion, 30 degrees of extension, 0 degrees of supination, and 0 degrees of pronation. However, the Veteran's shoulder condition was not found to result in functional impairment of an extremity such that no effective function remains other than that which would be equally well-served by an amputation with prosthesis. In an August 2021 addendum to the April 2021 VA examination, the examiner stated that the Veteran did not have left elbow ankylosis. At a January 2023 VA elbow examination, the examiner found that the Veteran did not have ankylosis in the elbow. The examiner opined that the Veteran's elbow condition did not result in 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. At a January 2023 VA wrist examination, the examiner found that the Veteran did not have ankylosis in the wrist. The examiner opined that the Veteran's wrist condition did not result in 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. At a January 2024 VA elbow and shoulder examination, the examiner found that the Veteran did not have ankylosis in the shoulder or elbow. The examiner opined that the Veteran's elbow and shoulder conditions did not result in 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. In a January 2024 examination for housebound status or permanent need for regular aid and attendance, the Veteran was noted as being able to feed himself and prepare his own meals. The Veteran was not bedridden and was able to bathe and tend to other hygiene needs. The Veteran was not blind, did not require nursing home care, and did not need help managing medications. The Veteran was found capable of managing his own financial affairs. The left shoulder and elbow conditions resulted in pain, stiffness, limited range of motion, and difficulty with heavy lifting over 5 pounds or repetitive motion over 10 minutes. The Veteran had no limitations in the ability to leave the home or immediate premise and did not use assistive devices to aid in locomotion. In a November 2024 VA opinion, a physician opined that, after review of the record, the Veteran's elbow had worsened. The flexion and extension in the VA examinations from 2013 to 2024 had worsened from 90 to 70. However, the examiner did not see any evidence that the elbow condition would be equal to having a prosthesis. The examiner opined that the Veteran still had use of the elbow. In several written statements to VA, including an October 2024 affidavit, the Veteran reiterated that he had constant left forearm and elbow pain which had worsened over the years and affected the ability to use the left arm. The Veteran stated that, in 2018, an orthopedic specialist told him the only way to fix the left elbow extension would be to amputate and use a prosthetic. The Board finds that the weight of competent, probative medical evidence is against finding a loss of use of the left arm. To the extent the Veteran relies on his own assertions and reports, the Board finds that, as a lay person, the Veteran is competent to report symptoms. However, loss of use is a technical term with a specific meaning and requires detailed medical findings to determine. The Veteran is not competent to make such determinations. Davidson v. Shinseki, 581 F.3d 1313 (2009); King v. Shinseki, 700 F.3d at 1339 (2012). Even if the Veteran's opinion were accepted as competent on this issue, the Board finds that the overwhelming medical evidence outweighs the lay opinion. The Board acknowledges and has taken into consideration that a private January 2013 examiner stated that the Veteran's elbow condition resulted in 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. However, in view of that evidence and the record as a whole, the January 2013 examination is not found to be persuasive as to a finding of functional impairment with regard to amputation. The January 2013 VA examination is incongruent with the evidence of record and inconsistent with the additional medical evidence of record. The record largely suggests that the Veteran's service-connected left upper extremity disabilities significantly impact the use of the left arm. However, the Veteran has been able to maintain some use of the left upper extremity and the functional impairment of the left upper extremity is not such that no effective function remains other than that which would be equally well-served by an amputation with prosthesis. The Board notes that it is the Board's responsibility to determine whether loss of use exists. Tucker v. West, 11 Vet. App. 369 (1998). That determination has been confirmed through the greater weight of evidence consisting of reliable medical statements discussed above. That determination was made after a review of the Veteran's complete medical file, claims folder, and physical examinations. As the weight of the medical evidence is against a finding that the Veteran had amputation of the left upper extremity or its functional equivalent, the Board finds that there is no loss of use of the left upper extremity to warrant special monthly compensation. The evidence does not show ankylosis of two major joints of the left upper extremity, and the Board finds that the weight of the evidence is against a finding that the Veteran has no function remaining of the left arm other than that which would be equally well-served by amputation with prosthesis. The Board finds that the evidence is not in approximate balance and there is no reasonable doubt to resolve in favor of the Veteran. Therefore, the appeal is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 6. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance or by reason of being housebound. Special monthly compensation (SMC) is payable under 38 U.S.C. § 1114(l) if, as the result of service-connected disability, the Veteran is permanently bedridden or is so helpless as to be in need of regular aid and attendance of another person. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). The need for aid and attendance means being so helpless as to require the regular aid and attendance of another person. 38 C.F.R. § 3.350(b). The criteria for establishing that need include whether the Veteran is permanently bedridden or is so helpless as to be in need of regular aid and attendance as determined under criteria enumerated under 38 C.F.R. § 3.352(a). The following factors will be accorded consideration in determining whether the Veteran is in need of regular aid and attendance of another person: (1) inability of the Veteran to dress or undress himself, or to keep himself ordinarily clean and presentable; (2) frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without such aid; (3) inability of the Veteran to feed himself because of the loss of coordination of upper extremities or because of extreme weakness; (4) inability to attend to the wants of nature; or (5) physical or mental incapacity which requires care or assistance on a regular basis to protect the Veteran from the hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352(a). It is not required that all of the disabling conditions enumerated in 38 C.F.R. § 3.352(a) be found to exist before a favorable rating may be made. The particular personal functions which the Veteran is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that the Veteran is so helpless as to need regular aid and attendance not that there is a constant need for aid and attendance. Turco v. Brown, 9 Vet. App. 222 (1996) (at least one factor listed in 38 C.F.R. § 3.352(a) must be present to grant special monthly compensation based on the need for aid and attendance). Special monthly compensation at the housebound rate is payable when a Veteran has a single service-connected disability rated 100 percent and (1) has additional service-connected disability or disabilities independently rated 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i)(1). The requirements of 38 U.S.C. § 1114(s)(2) are met when a Veteran is substantially confined as a direct result of service-connected disabilities to his dwelling and the immediate premises or, if institutionalized, to the ward or clinical area, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his lifetime. 38 C.F.R. § 3.350(i)(2). The Veteran asserts that special monthly compensation based on the need for regular aid and attendance, being permanently housebound, or at the housebound rate was warranted as the service-connected disabilities resulted in the need for regular aid and attendance of another individual to perform activities of daily living, made him permanently housebound, and/or met the criteria for special monthly compensation at the housebound rate. The Board, after a thorough review of the relevant medical and lay evidence of record, finds that the criteria for an allowance of the claim are not met. The Veteran has established service connection for sleep apnea, post-traumatic left elbow arthritis, left shoulder strain, impairment of supination and pronation of the left elbow, chronic left wrist strain, and limited extension of the left elbow. The combined service-connected disability rating is 70 percent, effective October 12, 2011; 80 percent, effective January 27, 2020; and 90 percent, effective January 17, 2024. At an August 2012 VA elbow examination, the left elbow condition was not found to impact the Veteran's ability to work. In a private January 2013 elbow examination, the examiner found that the elbow condition impacted the Veteran's ability to work in that he was unable to lift and pull or bend the elbow. At a November 2013 VA elbow and shoulder examination, the left elbow and shoulder conditions were not found to impact the Veteran's ability to work. In a July 2014 treatment note, the Veteran stated that he worked, lifted weights, and jogged. At a January 2020 VA shoulder examination, the examiner found that the elbow condition impacted the Veteran's ability to work in that the Veteran had problems with strenuous labor or construction, especially working overhead. The Veteran also had problems when weightlifting and had pain when sleeping on the left shoulder. A private December 2020 vocational assessment notes the Veteran as occasionally receiving assistance from his fiancé with washing and dressing. The Veteran was able to perform simple household chores on a piecemeal basis, as he must take breaks as needed due to difficulty lifting, carrying, and reaching. The Veteran was able to grocery shop independently and limited his driving to local destinations. The Veteran's son assisted with lawn maintenance. At an April 2021 VA elbow examination, the examiner found that the elbow condition impacted the Veteran's ability to work in that he could not lift anything nor dress himself during a flare-up of the disability. In an August 2021 addendum to the April 2021 VA examination, the examiner stated that the Veteran did not have left elbow ankylosis. At a January 2023 VA elbow and wrist examination, the examiner found that the conditions impacted the Veteran's ability to work in that it limited the Veteran's ability to open doors. At a January 2024 VA elbow and shoulder examination, the examiner found that the elbow and shoulder conditions impacted the Veteran's ability to work in that the Veteran experienced elbow and shoulder pain, stiffness, limited range of motion, and difficulty with heavy lifting over 5 pounds or repetitive motion over 10 minutes. In a January 2024 examination for housebound status or permanent need for regular aid and attendance, the Veteran was noted as being able to feed himself and prepare his own meals. The Veteran was not bedridden and was able to bath and tend to other hygiene needs. The Veteran was not blind, did not require nursing home care, and did not need help managing medications. The Veteran was found capable of managing his own financial affairs. The left shoulder and elbow conditions resulted in pain, stiffness, limited range of motion, and difficulty with heavy lifting over 5 pounds or repetitive motion over 10 minutes. The Veteran had no limitations in the ability to leave the home or immediate premise and did not use assistive devices to aid in locomotion. In several written statements to VA, including an October 2024 affidavit, the Veteran reiterated that he has constant left forearm and elbow pain which have worsened over the years and affect his ability to use the left arm. The Veteran stated that the conditions affected his ability to sleep, get dressed, put on clothes, open doors, wash himself, work out, and functionally use the left arm. The Board finds that the Veteran is not entitled to SMC based on the need for regular aid and attendance of another person as a result of service-connected disabilities or being housebound. The weight of the evidence of record does not show that the Veteran was permanently bedridden, was unable to dress or undress himself consistently or keep himself ordinarily clean and presentable, required assistance adjusting any special prosthetic or orthopedic appliances, was unable to feed himself, was unable to attend to the wants of nature, or required care or assistance on a regular basis to protect him from hazards or dangers incident to his daily environment as a result of the service-connected connected disabilities. The evidence also does not show that the Veteran was substantially confined to his home or premises due to the service-connected disabilities. The Board acknowledges that service-connected disabilities may increase difficulty in performing certain activities of daily living. However, the evidence of record suggests that the service-connected disabilities do not preclude those activities. The evidence of record, taken altogether, suggests that the Veteran is able to perform the activities of daily living and does not need protection from the hazards or dangers present in his daily life as a result of service-connected disabilities alone. There is no indication that the Veteran was permanently bedridden or housebound as a result of service-connected disabilities. The medical evidence of record does not show that the Veteran requires constant assistance or the restriction of activities as a result of service-connected disabilities. As recently as January 2024, the Veteran was explicitly found to be able to feed himself, tend to his own hygiene and bathing needs, and leave his home with no limitations. The Board notes that treatment records also indicate that the Veteran has ongoing issues with the back. However, the Veteran has not established service connection for any back disability at the time of this decision. Therefore, that condition may not be considered in adjudication of this appeal. Accordingly, the Board finds that the Veteran was not entitled to SMC based on the need for regular aid and attendance of another person as a result of service-connected disabilities at any point during the course of this appeal. The Board finds that the weight of the evidence of record does not show that the service-connected disabilities, alone, kept the Veteran permanently bedridden, or made the Veteran unable to stay ordinarily clean and presentable, unable to feed himself, unable to attend to the wants of nature, or unable to protect him from hazards or dangers incident to his daily environment. Additionally, the Board finds that the Veteran is not entitled to SMC by reason of being factually housebound, as there is no indication from the record that he was confined to his home or the immediate premises as a result of service- connected disabilities. The Veteran has been able to leave the home as he desires. The Veteran does not have a disability rated 100 percent, and additional service-connected disability or disabilities independently rated 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. Therefore, the Veteran does not currently meet the criteria for SMC pursuant to 38 U.S.C. § 1114(s). The Board recognizes the statements that the Veteran's disabilities make him require the aid and attendance of another person. With respect to those contentions, the Board acknowledges that the Veteran can attest to factual matters of which he has first-hand knowledge, such as ongoing physical problems and symptoms. Washington v. Nicholson, 19 Vet. App. 362 (2005). However, to the extent that the Veteran has reported that he was unable to perform tasks due to service-connected disabilities, those assertions are outweighed by the objective clinical findings suggesting that the Veteran is able to perform such activities. Accordingly, the Board finds that the weight of the evidence is against the claim and entitlement to SMC based on the need for the regular aid and attendance of another person or being housebound is not warranted. The Board finds that the evidence is not in approximate balance and there is no reasonable doubt to resolve in favor of the Veteran. Therefore, the claim is denied. 38 U.S.C. § 5107. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mondesir, Eric 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.