Citation Nr: 18160512
Decision Date: 12/26/18	Archive Date: 12/26/18

DOCKET NO. 08-20 784
DATE:	December 26, 2018
ORDER
For the entire appeal period (exclusive of a period of a temporary total evaluation from September 7, 2007 to October 31, 2007), entitlement to a rating in excess of 20 percent for status post residuals of an injury to the left elbow with avulsion bone fragments of the distal humerus (“left elbow disability”) based on limitation of flexion and extension is denied.
For the entire appeal period (exclusive of a period of a temporary total evaluation from September 7, 2007 to October 31, 2007), entitlement to a disability rating of 20 percent, but not higher, for a left elbow disability based on limitation of supination and pronation is granted, subject to the law and regulations governing the criteria for award of monetary benefits.
FINDING OF FACT
For the entire appeal period, the Veteran’s left elbow disability was manifested by arthritis confirmed by x-ray evidence with flexion limited to, at worst, 75 degrees, extension limited to, at worst, 40 degrees, supination limited to, at worst, 20 degrees, and pronation limited to, at worst, 45 degrees; ankylosis, impairment of flail joint, nonunion of the radius and ulna with flail false joint, nonunion or malunion of the ulna, and impairment of the radius were not shown.
CONCLUSIONS OF LAW
1. The criteria for the assignment of a rating in excess of 20 percent for the service-connected left elbow disability based on limitation of flexion and extension have not been met.  38 U.S.C. §§1155, 5107 (2012); 38 C.F.R. §§4.1, 4.2, 4.3, 4.7, 4.10, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5206-5207 (2017).
2. Resolving all reasonable doubt in favor of the Veteran the criteria for a 20 percent rating, but no higher, for the Veteran’s left elbow disability based on limitation of supination and pronation were met or approximated.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.71a, Diagnostic Code 5213 (2017).
REASONS AND BASES FOR FINDING AND CONCLUSIONS
The Veteran served on active duty from March 1964 to March 1968.
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida.
In November 2009, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge at the local RO.  A transcript of this hearing is of record.
The Veteran’s appeal was previously remanded by the Board for development in March 2010, November 2011, October 2014, March 2017, and September 2017.
Increased Rating
The Veteran seeks higher ratings for his left elbow disability.
A. Legal Criteria
Disability ratings are determined by the application of the VA’s Schedule for Rating Disabilities.  Separate diagnostic codes identify the various disabilities.  38 U.S.C. § 1155; 38 C.F.R. § Part 4.  Ratings for service-connected disabilities are determined by comparing the Veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity.  Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating.  Otherwise, the lower rating is to be assigned.  38 C.F.R. § 4.7. 
Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern.  See Francisco v. Brown, 7 Vet. App. 55, 58 (1994).  Here, the relevant evidentiary window begins one year before the Veteran filed his claim for an increased rating, and continues to the present time.  The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal.  Hart v. Mansfield, 21 Vet. App. 505 (2007).
In making all determinations, the Board must fully consider the lay assertions of record.  A Veteran is competent to report on that of which he or she has personal knowledge.  Layno v. Brown, 6 Vet. App. 465, 470 (1994).  When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent.  Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).
Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance.  Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion.  Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled.  38 C.F.R. § 4.40.  In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.”  Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.”  Id.
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 (musculoskeletal system) or § 4.73 (muscle injury); 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 [or 4.73] criteria.”).
B. Factual Background
Turning to the evidence of record, in his February 2006 claim for an increased rating, the Veteran reported that he had “lost almost all use of my left arm.”  
The Veteran was afforded a VA examination in August 2006.  The Veteran reported constant left elbow swelling, pain, and loss of range of motion.  He indicated that the pain was worse with any type of left upper extremity material handling.  He also reported one flare-up per week associated with activity level that lasts anywhere from four hours to the entire day.  The examiner noted that the Veteran was right hand dominant.  
On examination, the Veteran’s left elbow demonstrated a 2+ effusion.  The Veteran had “[m]arked loss of range of motion,” described as 20 degrees of active extension and 75 degrees of flexion with pain.  After a “rapid grip exchange” was performed on the Veteran, reexamination of the left elbow did not demonstrate any further swelling, significant fatigability, or further loss of range of motion, but the Veteran did complain of pain with left upper extremity material handling.  He demonstrated pain to palpation over the mediolateral joint line space and pain with passive motion.  Collateral ligaments were intact without evidence of instability, there was 5/5 motor function of the left elbow, and neurovascular status to the left elbow was intact.  X-rays of the left elbow showed “[m]arked narrowing in the mediolateral joint line space” and “[s]evere posttraumatic osteoarthritis.”  
A September 2007 VA treatment record shows that the Veteran underwent left elbow surgery to remove loose bodies.  
A November 2007 VA treatment record shows that the Veteran’s left elbow range of motion was -20 degrees extension, 85 degrees flexion, 35 degrees supination, and 75 degrees pronation.  A week later, the Veteran’s left elbow range of motion was -20 degrees extension, 110 degrees flexion, 20 degrees supination, and 90 degrees pronation.
During the November 2009 Board hearing, the Veteran testified that his left elbow “just wobbles and there’s nothing…they took all the stuff out of the inside of the elbow.”  He testified that he could not put any pressure on his left elbow, push anything with his left elbow, or lift anything with his left elbow due to pain.  He also reported that he had problems gripping items with his left hand.  
A December 2009 VA treatment record shows that the Veteran was severely limited in any forceful use of the left elbow/extremity.  On examination, there was limited motion from -40 degrees extension to 90 degrees flexion and intact ulnar motor function.  X-rays taken before and after the Veteran’s surgery demonstrated significant bony exostoses about the medial elbow.  
The Veteran was afforded a VA examination in December 2011.  The Veteran reported that his left elbow hurt with movement, worse when leaning on it.  He also reported burning and tingling sensations in his left hand.  He indicated that he was not able to do the things he used to do.  Specifically, he stated that “if I move my arm I have pain, if I throw a ball or anything I have pain, I can’t push up with it, can’t pull up, can’t lift anything.”  The Veteran reported that he was unable to hunt with a regular bow and that he now had to use an automated crossbow.  The examiner noted that the Veteran was right hand dominant.  The examiner also indicated that while the Veteran reported increased pain with activities, the pain was in the same pattern every day, and, therefore, “not considered a flare up.”  
On examination, flexion was limited to 125 degrees, with pain at 100 degrees, and extension was limited to 20 degrees, with pain at 20 degrees.  After three repetitions of motion, there was no additional limitation of range of motion and no functional loss and/or impairment.  The examiner indicated that although the Veteran was able to perform three repetitions of motion without further loss of motion, excessive fatigability, incoordination, or weakness, “this exam is in a very structured setting and results might be different with actual activities in his environment.”  The Veteran had pain on palpation of the joints/soft tissues.  Muscle strength testing was normal, and there was no evidence of ankylosis.  The examiner indicated that the Veteran did not have flail joint, joint fracture, or impairment of supination or pronation.  The examiner also indicated that although the Veteran complained of “awful pain” when the left elbow was palpated and ranged, there was no commensurate objective evidence clinically, such as redness or swelling.  The examiner indicated that the Veteran’s functioning was not so diminished that amputation with prothesis would equally serve the Veteran.  As to functional impact, the examiner noted that the Veteran was independent with self-care activities and driving, that the Veteran hunted and fished “a little bit,” that the Veteran drove a tractor with an automatic lift to decrease strain on this left elbow, and that the Veteran had significant pain with use of his left arm.  
An October 2012 VA treatment record shows that the Veteran reported chronic pain and weakness in his left upper extremity.  He indicated that he had not been able to elevate his arm more than about 90 degrees for a number of years.  He also indicated that the pain and weakness were increasing and that the “arm is now practically useless.”  
A December 2012 VA treatment record shows that the Veteran had significant pain and weakness in his left upper extremity.  He was unable to elevate greater than 90 degrees, unable to supinate, and there was marked weakness on examination of the arm and grip.  
The Veteran was afforded a VA examination in June 2016.  The Veteran reported daily pain in his left elbow, but no flare-ups.  He reported functional impairment in that the pain made it difficult for him to hold on to things.  On examination, the Veteran had flexion from 20 to 120 degrees, extension from 120 to 20 degrees, supination to 55 degrees, and pronation to 80 degrees.  The examiner indicated that the abnormal range of motion itself did not contribute to functional loss, and no pain was noted on exam.  There was no evidence of pain with weight bearing and no objective evidence of localized tenderness or pain on palpation.  There was objective evidence of crepitus.  After three repetitions of motion, there was no additional functional loss or loss of range of motion.  The examiner indicted that less movement than normal was an additional contributing factor of disability.  Muscle strength testing was normal, and there was no evidence of muscle atrophy.  The examiner indicated that the Veteran did not have flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation.  The examiner indicated that the Veteran’s functioning was not so diminished that amputation with prothesis would equally serve the Veteran.
The Veteran was afforded a VA examination in June 2017.  The Veteran reported flare-ups of the left elbow, which he described as “hurt all the time.”  He reported that he could not hold anything or grip things and that he had numbness and tingling in his left arm and hand.  On examination, the Veteran had flexion from 0 to 125 degrees, extension from 125 to 0 degrees, supination to 65 degrees, and pronation to 65 degrees.  Pain was noted with flexion, extension, supination, and pronation, but the examiner indicated that pain did not result in or cause functional loss.  There was objective evidence of pain on passive range of motion and with non-weight bearing.  There was no evidence of localized tenderness or pain on palpation, and there was no objective evidence of crepitus.  After three repetitions of motion, there was no additional functional loss or loss of range of motion.  The examiner indicated that swelling and deformity were additional contributing factors of disability.  Muscle strength testing was normal, and there was no evidence of ankylosis.  The examiner indicated that the Veteran did not have flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation.  The examiner indicated that the Veteran’s functioning was not so diminished that amputation with prothesis would equally serve the Veteran.  As to functional impact, the examiner indicated that the Veteran was unable to push, pull, or lift greater than ten pounds and that he was unable to use his left upper extremity for more than one to two hours.  
In a July 2017 addendum opinion, a VA examiner opined that during flare-ups or when the left elbow was used repeatedly over time, the Veteran’s additional loss of range of motion could be estimated as extension from 90 to 20 degrees, flexion from 20 to 90 degrees, supination from 0 to 45 degrees, and pronation from 0 to 45 degrees.
C. Analysis
The Veteran’s service-connected left elbow disability is currently assigned a 20 percent evaluation for limitation of flexion and extension pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5206-5207.  Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen.  38 C.F.R. § 4.71.  
He is also assigned a 10 percent evaluation for limitation of supination and pronation pursuant to Diagnostic Code 5213.
The evidence of record indicates that the Veteran’s dominant (major) arm is his right arm.  See May 1969 Report of Medical History (The Veteran checking box indicating right handedness); August 2006 VA Examination Report (noting Veteran is right handed); February 2009 VA Examination Report (same effect); December 2011 VA Examination Report (same effect).  Therefore, his left arm is his minor arm.
Diagnostic Code 5205 pertains to ankylosis of the elbow.  There is no evidence of record that the Veteran’s left elbow is ankylosed.  Therefore, Diagnostic Code 5205 is not for application in this case.
Under Diagnostic Code 5206, limitation of flexion of the minor forearm is assigned a noncompensable evaluation where flexion is limited to 110 degrees; a 10 percent evaluation where flexion is limited to 100 degrees; a 20 percent evaluation where flexion is limited to 90 degrees; a 20 percent evaluation where flexion is limited to 70 degrees; a 30 percent evaluation where flexion is limited to 55 degrees; and a 40 percent evaluation where flexion is limited to 45 degrees.
Under Diagnostic Code 5207, limitation of extension of the minor forearm is assigned a 10 percent evaluation where extension is limited to 45 degrees; a 10 percent evaluation where extension is limited to 60 degrees; a 20 percent evaluation where extension is limited to 75 degrees; a 20 percent evaluation where extension is limited to 90 degrees; a 30 percent evaluation where extension is limited to 100 degrees; and a 40 percent evaluation where extension is limited to 110 degrees.
Under Diagnostic Code 5208, a 20 percent evaluation is assigned where minor forearm flexion is limited to 100 degrees and extension is limited to 45 degrees.
Diagnostic Code 5209 pertains to impairment of the flail joint.  Diagnostic Code 5210 pertains to nonunion of the radius and ulna with false flail joint.  Diagnostic Code 5211 pertains to impairment of the ulna.  Diagnostic Code 5212 pertains to impairment of the radius.  These diagnostic codes are not for application in this case.
Under Diagnostic Code 5213, impairment of supination and pronation of the minor forearm is assigned a 10 percent evaluation for limitation of supination to 30 degrees or less.  A 20 percent evaluation for limitation of pronation with motion lost beyond the last quarter of the arc and where the hand does not approach full pronation, or when motion is lost beyond the middle arc.  A 20 percent evaluation is also assigned for loss of supination or pronation (bone fusion) where the hand is fixed near the middle of the arc or moderate pronation, or where the hand is fixed in full pronation.  A 30 percent evaluation is assigned for loss of supination or pronation (bone fusion) where the hand is fixed in supination or hyperpronation.
Normal ranges of motion of the elbow are zero degrees of extension to 145 degrees of flexion.  See 38 C.F.R. § 4.71, Plate I.  Normal ranges of motion of the forearm are 80 degrees of pronation and 85 degrees of supination.  Id.
Initially, the Board notes that the evidence of record documents neurological signs and symptoms associated with the Veteran’s non-service connected ulnar neuropathy and carpel tunnel syndrome.  In a July 2015 rating decision, the Veteran was denied entitlement to service connection for bilateral ulnar neuropathy and carpel tunnel syndrome.  The Veteran timely filed a notice of disagreement in October 2015, and, in November 2018, the Veteran was issued a statement of the case.  To date, the Veteran has not submitted a substantive appeal of these issues.  Because the issue of entitlement to service connection for bilateral ulnar neuropathy and carpel tunnel syndrome is not currently before the Board, however, the Board will not address neurological signs or symptoms affecting the left elbow.
After a review of all the evidence, lay and medical, the Board finds that a rating in excess of 20 percent is not warranted for limitation of flexion of the forearm.  To warrant a higher rating under Diagnostic Code 5206, flexion would have to be limited to 55 degrees.  Here, the Veteran’s flexion was limited, at worst, to 75 degrees in August 2006.  Although the Veteran demonstrated improved flexion throughout the appeal period, such as to 125 degrees (with pain at 100 degrees) in December 2011, to 120 degrees in June 2016, and to 125 degrees in July 2017, the Board notes that the Veteran was frequently unable to flex his elbow past 90 degrees.  Moreover, the July 2017 VA examiner specifically opined that during flare-ups and with repetitive use over time, the Veteran’s left elbow flexion was estimated to be limited to 90 degrees.
Moreover, even acknowledging that the Veteran’s pain, weakness, and limitation of movement may have at times resulted in additional functional loss than that objectively demonstrated, and even when such functional limitations are considered, the preponderance of the evidence is against entitlement to an evaluation in excess of 20 percent for limitation of flexion.  As noted above, the Veteran’s flexion was, at worst, limited to 75 degrees during the August 2006 VA examination, flexion was limited to 125 degrees, with pain at 100, during the December 2011 VA examination, and the July 2017 VA examiner estimated that during flare-ups and with repeated use over time, the Veteran’s flexion would be limited to 90 degrees.  Thus, given the objective findings of limitation of flexion to, at worst, 75 degrees, and most often to 90 degrees, the preponderance of the evidence is against a finding that the Veteran’s left elbow disability resulted in disability comparable to limitation of flexion to 55 degrees, the criterion for a 30 percent evaluation under Diagnostic Code 5206, even considering pain and other functional limitations.
Additionally, the Veteran does not meet the criteria for a separate or increased rating under Diagnostic Code 5207.  To warrant a compensable rating under Diagnostic Code 5206, extension would have to be limited to 45 degrees.  Here, the Veteran’s left elbow extension was limited to, at worst, 40 degrees during VA primary care in December 2009.  Moreover, even acknowledging that the Veteran’s pain, weakness, and limitation of movement may have at times resulted in additional functional loss than that objectively demonstrated, and even when such functional limitations are considered, the preponderance of the evidence is against entitlement to a compensable rating for limitation of extension.  Although the Veteran’s extension was limited to 40 degrees in December 2009, this measurement is not consistent with prior and subsequent findings, which generally show extension limited to 20 degrees, even with pain.  Further, the July 2017 VA examiner estimated that during flare-ups and with repeated use over time, the Veteran’s extension would be limited to 20 degrees.  Thus, given the objective findings of limited extension to, at worst, 40 degrees, and more often to 20 degrees, the preponderance of the evidence is against a finding that the Veteran’s left elbow disability resulted in disability comparable to limitation of extension to 45 degrees, the criterion for a compensable evaluation under Diagnostic Code 5207, even considering pain and other functional limitations.
The Board acknowledges the evidence of arthritis and painful extension.  A compensable evaluation under Diagnostic Code 5003 and 38 C.F.R. § 4.59 (for painful motion) is in order when no compensable limitation of motion of the affected joint is demonstrated.  See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991); see also VAOPCGPREC 9- 98 (Aug. 14, 1998).  However, where a compensable limitation of motion is demonstrated in the joint, the Lichtenfels rule is not applicable.  As the Veteran is in receipt of a compensable rating for limitation of flexion, a separate rating for extension under 38 C.F.R. § 4.49 is not warranted.
However, the Board finds that an increased, 20 percent rating is warranted for impairment of supination and pronation under Diagnostic Code 5213.  See VAOPGCPREC 9-2004; see also VA Adjudication Manual M21.III.iv.4.A.1.a. (instructing raters to apply the principles of VAOGCPREC 9-2004 to separate ratings for elbow flexion, extension, and impairment of either supination or pronation).  
The Veteran is currently in receipt of a 10 percent rating under Diagnostic Code for limitation of supination.  There is no higher rating based solely on limitation of supination.  However, the evidence also reflects that the Veteran has painful and limited pronation, with limitation of pronation estimated to be to 45 degrees during flare-ups or with repeated use over time.  See July 2017 VA Examination Report.  The Board finds that limitation of pronation to 45 degrees warrants a 20 percent rating, as motion is lost beyond the last quarter of the arc.  See 38 C.F.R. § 4.71a, DC 5213.  Separate ratings for both limited supination and pronation are not available.  See Cullen v. Shinseki, 24 Vet. App. 74, 84 (2010) (holding that within a particular diagnostic code, a claimant is not entitled to more than one disability rating for a single disability unless the regulation expressly provides otherwise); see also 38 C.F.R. § 4.71a, DC 5213.
A higher rating under Diagnostic Code 5213 is not warranted.  In order to warrant a higher (maximum) 30 percent rating, the evidence would have to show that the left hand was fixed in supination or hyperpronation.  Here, the record reflects that the Veteran maintained the ability to supinate and pronate his forearm throughout the appeal period.  
The Board acknowledges notations in VA primary care records that the Veteran was “unable to supinate.”  See August 2017 VA Treatment Record; September 2017 VA Treatment Record; December 2012 VA Treatment Record.  However, these statements are not consistent with prior and subsequent findings, which show that while the Veteran’s supination has been extremely limited at times, he has never lost the ability to supinate.  In view of this, the Board finds that these statements are outliers and entitled to little, if any, weight.  The Board finds that the weight of the competent, probative evidence does not show a complete loss of supination at any time during the appeal period.  
A higher or separate rating is not available under another diagnostic code evaluating elbow and forearm disabilities.  The Veteran’s elbow is not ankylosed, and there is no impairment of the flail joint, ulna, or radius.  Therefore, DCs 5205, 5209, 5210, 5211, and 5212 are not for application.
In sum, the evidence in this case shows that the 20 percent rating assigned for limitation of flexion and the 20 percent rating assigned for limitation of supination and pronation appropriately compensate the Veteran to the extent that he did have functional loss due to limited or excess movement, pain, weakness, excess fatigability, and/or incoordination.  See 38 C.F.R. §§ 4.40 and 4.4; DeLuca.  The Board accepts that the Veteran experienced left elbow symptomatology, especially pain and limited motion.  However, the Board finds that the disability evaluation assigned contemplates the degree of pain and functional impairment for the left elbow.  The evidence clearly reflects that the Veteran’s range of motion was affected by pain and weakness; however, he was still able to consistently accomplish left elbow and forearm range of motion as noted above, which warrants, at most, a 20 percent rating for limitation of flexion and a 20 percent rating for limitation of supination and pronation.  
The Board concludes that the objective medical evidence and the Veteran’s statements regarding his symptomatology show disability that most nearly approximates that which warrants the assignment of a 20 percent rating for limitation of flexion and a 20 percent rating for limitation of supination and pronation for the entire period on appeal.  See 38 C.F.R. § 4.7.  As shown above, and as required by Schafrath, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the Veteran.  The Board finds no provision upon which to assign a greater or separate rating.
 
DEBORAH W. SINGLETON
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	R. Kipper, Associate Counsel 

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