Citation Nr: 1008683 Decision Date: 03/08/10 Archive Date: 03/17/10 DOCKET NO. 06-30 829 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased disability rating for degenerative joint disease of the right elbow, currently evaluated as 10 percent disabling. 2. Entitlement to an increased disability rating for residuals of right knee trauma with arthritis and Baker's cyst, currently evaluated as 10 percent disabling. 3. Entitlement to an increased disability rating for a right ulnar neuropathy, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Marine Corps League ATTORNEY FOR THE BOARD A. Hinton, Counsel INTRODUCTION The Veteran served on active duty from October 1983 to October 1986. This case comes before the Board of Veterans' Appeals (Board) from rating decisions of the Regional Office (RO) of the Department of Veterans Affairs (VA), in St. Petersburg, Florida. In a December 2005 rating decision the RO in part denied claims for increased ratings for (1) traumatic arthritis the right knee with Bakers cyst, and (2) degenerative joint disease of the right elbow. In a February 2007 rating decision the RO denied a claim for an increased rating for a right ulnar neuropathy. The Veteran perfected appeals to the Board for each of these denials. In August 2006 the Veteran testified before a RO Decision Review Officer at the RO. In December 2008, the Board remanded the case regarding all three issues on appeal. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The veteran's degenerative joint disease of the right elbow, at its worst, was manifested by pain, flexion to 125 degrees, and extension to 15 degrees but was not manifested by ankylosis, flail joint, nonunion of the radius and ulna, impairment of the ulna or marked deformity, impairment of the radius with marked deformity, or impairment of supination or pronation. 2. The Veteran's residuals of right knee trauma with arthritis and Baker's cyst is manifested by painful motion; but is not manifested by flexion limited to 30 degrees or less, or extension limited to 15 degrees or less; or by subluxation or lateral instability, dislocated semilunar cartilage, or malunion or nonunion of the tibia and fibula, or genu recurvatum. 3. The Veteran's right ulnar neuropathy is productive of no more than a moderate incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for degenerative joint disease of the right elbow are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5205 to 5213 (2009). 2. The criteria for a rating in excess of 10 percent for residuals of right knee trauma with arthritis and Baker's cyst have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5260, 5261 (2009). 3. The criteria for a disability rating of 30 percent, but no more, for right ulnar neuropathy, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code 8516 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Preliminary Matters The Veterans Claims Assistance Act of 2000 (VCAA), codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented at 38 C.F.R. § 3.159, amended VA's duties to notify and assist a claimant in developing the information and evidence necessary to substantiate a claim. Under 38 U.S.C.A. § 5103, VA must notify the claimant of any information or evidence not of record that is necessary to substantiate the claim, as well as what parts of that information or evidence VA will seek to provide, and what parts VA expects the claimant to provide. 38 C.F.R. § 3.159(b). VA must provide such notice to a claimant prior to an initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (AOJ), even if the adjudication occurred prior to the enactment of the VCAA. See Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004). VCAA requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all elements of a claim for service connection, so that VA must provide notice that a disability rating and an effective date will be assigned if service connection is awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Though notification to the Veteran may not have met all of the requirements of the VCAA and related case law, the matter decided below may be addressed at this time, without further remand, because no errors in notice are prejudicial, and the Veteran has been provided all information needed for a reasonable person to prove these claims. In any event, the Federal Circuit recently vacated the Court's previous decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), concluding that generic notice in response to a claim for an increased rating is all that is required. See Vazquez-Flores v. Shinseki, No. 08-7150 (Fed. Cir. Sep. 4, 2009). VA notified the Veteran of the information and evidence needed to substantiate and complete a claim by way of a number of letters dated from in May 2005 and February 2009. These documents provided notice of what part of that evidence is to be provided by the claimant, and notice of what part VA will attempt to obtain. The RO informed the Veteran of the specific rating criteria that would provide a basis for the rating claims on appeal and decided below. The RO has provided adequate notice of how effective dates are assigned. The claims were subsequently readjudicated most recently in a May 2009 supplemental statement of the case. To the extent the appellant did not receive full notice prior to the initial decision, after pertinent notice was provided, the claimant was afforded a meaningful opportunity to participate in the adjudication of the claim on appeal. In any event, the Veteran has never alleged how any content error prevented him from meaningfully participating in the adjudication of his claims. As such, he has not established prejudicial error in the content of VCAA notice. See Shinseki v. Sanders / Simmons, 129 S. Ct. 1696 (2009). The claimant was provided the opportunity to present pertinent evidence. The record contains service treatment and personnel records, and records of medical treatment received from VA and privately, and VA examination reports. VA most recently examined the Veteran for compensation purposes in April 2009 for his disabilities on appeal. Findings from this examination, and other medical records on file, are adequate for the purposes of deciding the claims on appeal. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). There is no evidentiary indication that the conditions under review here have worsened since these evaluations so as to require any additional examination. In sum, there is no evidence of any VA error in notifying or assisting the appellant that reasonably affects the fairness of this adjudication. VA has fulfilled its duty to assist the claimant by obtaining identified and available evidence needed to substantiate the claims, and, as warranted by law. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). In this regard, the Board is satisfied as to compliance with the instructions from its December 2008 remand. Specifically, the RO was instructed to obtain current treatment records and provide the Veteran with a VA examination to determine the current nature and severity of the service-connected disabilities on appeal, and readjudicate the claims, providing a supplemental statement of the case if any determination remained unfavorable to the appellant. The records were obtained and the Veteran was provided with the required examination in April 2009. The Board finds that the VA examination reports meet the remand requirements. In addition, the RO readjudicated the Veteran's claims and provided him with a supplemental statement of the case in May 2009. As such, the Board finds that the RO has substantially complied with its remand instructions. Stegall, supra. Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Law The following general VA law and regulation on disability ratings apply in this case. Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002). Evaluations of a service-connected disability require review of the entire medical history regarding the disability. 38 C.F.R. §§ 4.1, 4.2 . If there is a question that arises as to which evaluation to apply, the higher evaluation is for application if the disability more closely approximates the criteria for that rating; otherwise, the lower rating is for assignment. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. VA regulations require that disability evaluations be based upon the most complete evaluation of the condition that can be feasibly constructed with interpretation of examination reports, in light of the whole history, so as to reflect all elements of the disability. Medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. Functional impairment is based on lack of usefulness and may be due to pain, supported by adequate pathology and evidenced by visible behavior during motion. Many factors are to be considered in evaluating disabilities of the musculoskeletal system and these include pain, weakness, limitation of motion, and atrophy. Painful motion with the joint or periarticular pathology, which produces disability, warrants the minimum compensation. 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59 (2009); DeLuca v. Brown, 8 Vet. App. 202 (1995). Under VA regulations, separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). However, the evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14; Fanning v. Brown, 4 Vet. App. 225 (1993). When a disability is not specifically listed in the Rating Schedule, it may be rated under a closely related injury in which the functions affected and the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2009). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The words "slight", "moderate", and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence with the objective that its decisions are "equitable and just". 38 C.F.R. § 4.6 (2009). Although a medical examiner's use of descriptive terminology such as "mild" is an element of evidence to be considered by the Board, it is not dispositive of an issue. The Board must evaluate all evidence in arriving at a decision regarding an increased rating. 38 U.S.C.A. § 7104(a) (2009); 38 C.F.R. §§ 4.2, 4.6. The Veteran's statements describing the symptoms of his service-connected disorder are deemed competent evidence. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). However, these statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria. If a Veteran appeals a rating decision seeking an increased rating for a disability for which service connection has already been established, such as here with all three claims on appeal, then the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). See also Hart v. Mansfield, 21 Vet. App. 505 (2007) (finding a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made, allowing for staged ratings in cases for which service connection has already been established). Thus, in deciding the claims below, the Board is cognizant of the importance of the present level of disability and has also considered whether different ratings may be warranted for different time periods based on the evidence of record. III. Recent Factual Background The present level of disability of the three service- connected disabilities on appeal is reflected in the most recent factual background, which is most clearly shown in the well-detailed report of the recent VA examination conducted in April 2009, discussed below. In that report the VA examiner addressed the condition of each of the three disabilities at that time. Other material medical evidence covering the entire period under consideration is discussed in the analysis section further below, with emphasis on any variance in findings from that of the April 2009 VA examination. Notably, prior to the most recent VA examination in April 2009, the Veteran underwent pertinent VA examinations in September 2004, August 2005, November 2005, September 2006, December 2006, and June 2008; for all of which, the Board reviewed and considered the examination reports in adjudicating these claims on appeal. The report of the April 2009 VA examination shows that the Veteran was examined for musculoskeletal condition of his right knee and elbow disabilities; and for the peripheral neurological condition of his right ulnar neuropathy, including any apparent musculoskeletal conditions of that disability. On musculoskeletal examination, the Veteran reported complaints of constant pain of the right knee. The Veteran reported that he had constant pain at the right elbow, made worse by activities involving use of the elbow, and decreased range of motion. He reported that he took medication that helped with the pain. The April 2009 VA examination report contains a medical history showing right knee cartilage removal in 1986; right ulnar nerve transposition in 2005; and right knee arthroscopy due to arthritis in 2006. The report contains a summary of reported joint symptoms for the right knee including that there was giving way, instability, pain, stiffness, weakness and incoordination; but no deformity or decreased speed of joint motion. There were no episodes of dislocation, subluxation, or locking; no evidence of inflammation; and no flare-ups. A baker cyst had to be drained three to four times in the past. The condition did affect the motion of the joint. The report contains a summary of reported joint symptoms for the right elbow including that there was no deformity, giving way, or instability. There was pain and stiffness, but no weakness or incoordination. There was no decreased speed of joint motion. There were no episodes of dislocation, subluxation, or locking; no evidence of inflammation or effusion; and no flare-ups. The condition did not affect the motion of the joint. On examination of the right elbow the examiner made findings that there was abnormal motion. On range of motion study of the right elbow, flexion was from 20 to 145 degrees; extension was from 145 to 20 degrees; pronation was from zero to 60 degrees; and supination was from zero to 60 degrees. There was objective evidence of pain following repetitive motion. After repetitions there was no additional limitation in the range of motion. On examination of the right knee, the Veteran had an antalgic gait but no other evidence of abnormal weight bearing, and there was no loss of a bone or part of a bone. The examiner made findings of abnormal motion. There were no: bumps consistent with Osgood-Schlatter's Disease, crepitation, mass behind the knee, clicks or snaps or grinding; instability, patellar abnormality or meniscus abnormality. On range of motion study of the right knee, flexion was from zero to 124 degrees; and extension was normal, to zero degrees. There was objective evidence of pain following repetitive motion. After repetitions there was no additional limitation in the range of motion. There was no evidence of ankylosis. On X-ray examination, the impression for the right elbow was "no acute fracture or dislocation; degenerative changes of the elbow joint again demonstrated and do appear stable." For the right knee, the impression was "no acute fracture or dislocation appreciated. After a magnetic resonance imaging (MRI) examination of the right knee, the impression was osteochondral defect of the medial condyle, cause unknown. The examiner noted that the Veteran had lost time from work in the last year due to an unrelated condition. After musculoskeletal examination of the right knee, the report contains diagnoses of (1) right medial condyle defect (on MRI); (2) subjective statement of right knee pain (not a diagnosis); (3) status post right knee surgery times two; (4) right elbow degenerative joint disease, mild to moderate; (5) decreased right elbow range of motion; and (6) subjective statement of right elbow pain (not a diagnosis). The examiner opined that the right knee and right elbow disabilities each had no significant effect on the Veteran's usual occupation; and they each did have effects on the usual daily activities as follows: mild effects on doing chores and shopping; moderate effects on doing exercise and sports; and no effects with respect to recreation, traveling, feeding, bathing, dressing, toileting, grooming, and driving. On peripheral neurological examination, the Veteran reported complaints of experiencing intermittent sharp pain in fingers number 3, 4, and 5 of the right hand. He also reported that he had constant decreased sensation in the right hand fingers number 3, 4, and 5. He rated the pain as a 7 to 8 on a scale of 10 with activities. He also reported having a decreased right hand grip. He received some relief of pain with medication. The Veteran also reported complaints of having numbness, paresthesias, pain, hand grip weakness, and impaired coordination of the right hand palm and fingers (3, 4, and 5). The report records that the Veteran had right ulnar nerve transposition surgery in 2005. On motor examination of the right side, the report contains findings that the affected muscles were Group VII, VIII, and IX; muscle strength was 5; and that the motor function impairment consisted of a slight decrease in strength of the right hand grip involving fingers number 3, 4, and 5. The affected nerve was the ulnar. On sensory function examination, pain was absent in fingers number 3, 4 and 5. The position sense was normal and the affected nerve was the ulnar. On reflex examination the right bicep reflex (cranial nerves C5-C6), right tricep reflex (C6-C8), and right brachioradialis reflex were all measured to be 2+ each. There was no muscle atrophy present; no abnormal muscle tone or bulk; no tremors, tics, or other abnormal movements; and the examiner opined that a joint was affected by the nerve disorder. The examiner noted that the Veteran had lost time at his employment in the last year due to an unrelated condition. After peripheral neurological examination of the right ulnar neuropathy, the report contains a diagnosis of (1) right ulnar nerve neuropathy status post ulnar nerve transposition; and (2) right number 3, 4, and 5 fingers neuropathy, right palm neuropathy. The examiner further diagnosed that nerve dysfunction was present including mild incomplete paralysis; and neuralgia; but no neuritis was present. The examiner opined that the right ulnar neuropathy had no significant effect on the Veteran's usual occupation; and did have effects on the usual daily activities as follows: mild effects on doing chores, shopping, exercise, and sports; and no effects with respect to other activities cited. During the April 2009 VA examination the examiner also examined the Veteran's hand and fingers for musculoskeletal condition. The Veteran's complaints were the same as reported above on peripheral neurological examination. The examiner found that the right hand was the dominant hand; and that there was an overall decrease in hand strength, but no other symptoms of the hand, and no history of flare-ups of joint symptoms. On range of motion study of the right hand, there was no objective evidence of pain on active range of motion by the Veteran. Extension of the DIP joint was normal; Extension of PIP joint was normal; extension of MP joint was normal; and there was no gap between the index finger and proximal transverse crease of the hand on maximum flexion of the finger. On repetitions of motion there was no objective evidence of pain or additional limitation of motion possible. The service-connected condition did not manifest any present: ankylosis; amputation of a digit or part of a digit; or deformity of a digit. There was a slight decreased strength of the hand grip. The report contains a diagnosis of (1) right ulnar nerve neuropathy involving right number 3, 4, and 5 fingers, right palm; and (2) slight decreased range of motion of right number 3, 4, 5, fingers. The examiner opined that the right ulnar neuropathy had no significant effect on the Veteran's usual occupation; and did have effects on the usual daily activities as follows: mild effects on doing chores, shopping, exercise, and sports; and no effects with respect to other activities cited. A. Degenerative Joint Disease of the Right Elbow The Veteran's degenerative joint disease of the right elbow is evaluated as 10 percent disabling under rating criteria for evaluating the musculoskeletal system found at 38 C.F.R. § 4.71a (2009). Specifically, under 38 C.F.R. § 4.71a, the RO assigned the service-connected degenerative joint disease of the right elbow a hyphenated Diagnostic Code of 5010-5207. The hyphenated diagnostic code in this case indicates that the service-connected disability is considered arthritis due to trauma (5010), associated with a residual condition of limitation of extension of the forearm (5207). 38 C.F.R. § 4.71a, Diagnostic Code 5010 provides that arthritis due to trauma that is substantiated by X-ray findings is to be rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved, which here is the right elbow. Pursuant to the foregoing, the Veteran's service-connected right elbow disability is currently rated 10 percent disabling pursuant to 38 C.F.R. §§ 4.71a, Diagnostic Code 5207. The Veteran's right arm is documented to be his "major" arm for the purposes of applying the rating criteria. Under 38 C.F.R. § 4.71, Plate I, normal ranges of motion of the elbow and forearm are from 0 degrees to 145 degrees of elbow flexion. 38 C.F.R. § 4.71, Plate I. Potentially applicable diagnostic codes addressing musculoskeletal conditions of the elbow include the following. Diagnostic Code 5205 provides that ankylosis of the major elbow is to be rated as follows: for favorable ankylosis of the elbow at an angle between 90 degrees and 70 degrees, 40 percent; for intermediate ankylosis of the elbow, at an angle of more than 90 degrees, or between 70 degrees and 50 degrees, 50 percent; for unfavorable ankylosis of the elbow, at an angle of less than 50 degrees or with complete loss of supination or pronation, 60 percent. 38 C.F.R. § 4.71a. Diagnostic Code 5206 provides that flexion of the major forearm limited to 100 degrees is rated 10 percent disabling; limited to 90 degrees is rated 20 percent; limited to 70 degrees is rated 30 percent disabling; limited to 55 degrees is rated 40 percent disabling; and limited to 45 degrees is rated 50 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5207 provides that extension of the major forearm limited to 45 degrees is rated 10 percent; limited to 60 degrees is rated 10 percent; limited to 75 degrees is rated as 20 percent; limited to 90 degrees is rated 30 percent; limited to 100 degrees is rated 40 percent; and limited to 110 degrees is rated 50 percent. 38 C.F.R. § 4.71a. Diagnostic Code 5208 provides that major forearm flexion limited to 100 degrees with forearm extension limited to 45 degrees is rated 20 percent. 38 C.F.R. § 4.71a. Diagnostic Code 5209 provides ratings for other impairment of the elbow. Joint fracture, with marked cubitus varus or cubitus valgus deformity or with ununited fracture of head of radius, is rated 20 percent disabling for the major side. Flail joint of the elbow is rated 60 percent disabling for the major side. 38 C.F.R. § 4.71a. Diagnostic Code 5210 provides that nonunion of the radius and ulna, with flail false joint, is rated 50 percent disabling for the major side. 38 C.F.R. § 4.71a. Diagnostic Code 5211 provides for ratings based on impairment of the ulna. Malunion of the ulna with bad alignment is rated 10 percent for the major side; nonunion of the ulna in the lower half is rated 20 percent for the major side; nonunion of the ulna in the upper half, with false movement, without loss of bone substance or deformity is rated 30 percent for the major side; nonunion of the ulna in the upper half, with false movement, with loss of bone substance (1 inch (2.5cms) or more) and marked deformity is rated 40 percent for the major side. 38 C.F.R. § 4.71a. Diagnostic Code 5212 provides for ratings based on impairment of the radius. Malunion of the radius with bad alignment is rated 10 percent disabling for the major side; nonunion of the radius in the upper half is rated 20 percent disabling for the major side; nonunion of the radius in the lower half, with false movement, without loss of bone substance or deformity is rated 30 percent disabling for the major side; nonunion of the radius in the lower half, with false movement, with loss of bone substance (1 inch (2.5cms) or more) and marked deformity is rated 40 percent disabling for the major side. 38 C.F.R. § 4.71a. Normal forearm supination is from 0 degrees to 80 degrees. Normal forearm pronation is from 0 degrees to 85 degrees. 38 C.F.R. § 4.71, Plate I. Diagnostic Code 5213 provides ratings based on impairment of supination and pronation of the forearm. Diagnostic Code 5213 provides that supination of the forearm limited to 30 degrees or less is rated 10 percent disabling for the major side. Limitation of pronation with motion lost beyond the last quarter of arc, so the hand does not approach full pronation, is rated 20 percent disabling for the major side; limitation of pronation with motion lost beyond the middle of arc is rated 30 percent disabling for the major side. Loss of supination or pronation due to bone fusion, with the hand fixed near the middle of the arc or moderate pronation, is rated 20 percent disabling for the major side; loss of supination or pronation due to bone fusion, with the hand fixed in full pronation, is rated 30 percent disabling for the major side; and loss of supination or pronation due to bone fusion, with the hand fixed in supination or hyperpronation, is rated 40 percent disabling for the major side. 38 C.F.R. § 4.71a. As noted above, if evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. There is no evidence in the clinical record on file of any right elbow condition of ankylosis, flail joint, nonunion of the radius and ulna, impairment of the ulna or marked deformity, or impairment of supination or pronation. Therefore, respectively, Diagnostic Codes 5205, 5209, 5210, 5211, 5212, and 5213 are not applicable in this case. 38 C.F.R. §§ 4.71a, Diagnostic Codes 5205, 5209, 5210, 5211, 5212, 5213 (2009). Of note, review of the VA examination reports dated from September 2004 to April 2009 show essentially full supination and pronation. Basically, the Veteran's service-connected degenerative joint disease of the right elbow is shown by the evidence on file to be manifested pain and by limitation of motion; this symptomatology is best evaluated under Diagnostic Codes 5206 and 5207. 38 C.F.R. § 4.71a, Diagnostic Codes 5206, 5207. As reflected in the range of motion findings at the April 2009 VA examination, the right elbow disability does not meet the criteria for a disability rating in excess of the existing 10 percent under either of these codes. At that examination flexion was to 145 degrees, which is full flexion, and does not warrant a rating in excess of 10 percent under Diagnostic Code 5206 because under that code the next higher rating of 20 percent would require a flexion limited to 90 degrees. Also, at that examination, extension was limited to 20 degrees. This would not meet the criteria for a rating in excess of 10 percent. A much greater limitation of extension, of 75 degrees, is required to warrant the next higher rating of 20 percent under the criteria of Diagnostic Code 5207. Review of the remainder of the medical evidence on file does not otherwise show limitations of flexion or extension so as to warrant a rating in excess of the 10 percent in effect for the right elbow disability. On review of the reports of VA examination in September 2004, August 2005, November 2005, September 2006, December 2006, and June 2008, the record does not show evidence of limitation of flexion or extension of the right elbow to an extent so as to warrant a disability rating in excess of 10 percent. The worst case was during the September 2006 VA examination, when the findings showed that flexion was to 125 degrees and extension was to 15 degrees. Neither of these findings would warrant a rating in excess of 10 percent because they do not meet the criteria of limitation of flexion to 90 degrees, or of extension to 75 degrees, required to meet the criteria for a 20 percent rating. The Board has also considered whether the Veteran is entitled to a higher rating on the basis of functional loss due to pain pursuant to DeLuca, supra. However, there is no objective clinical indication he has symptoms causing functional limitation to a degree that would support an evaluation in excess of 10 percent for the right elbow disability. Accordingly, the Board finds that the preponderance of the evidence is against a disability rating in excess of 10 percent for the Veteran's service-connected degenerative joint disease of the right elbow. 38 C.F.R. § 4.3. The Board adds that it does not find that the Veteran's service-connected degenerative joint disease of the right elbow should be increased for any other separate period based on the facts found during the appeal period. Hart, supra. B. Residuals of Right Knee Trauma With Arthritis and Baker's Cyst The Veteran's residuals of right knee trauma with arthritis and Baker's cyst is evaluated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5260. Under that code, the right knee disability is evaluated on the basis of limitation of flexion of the leg at the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The potentially applicable diagnostic code criteria addressing musculoskeletal conditions of the knee include the following. Limitation of flexion of a leg (knee) is rated 10 percent when limited to 45 degrees, 20 percent when limited to 30 degrees, and 30 percent when limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of a leg (knee) is rated 10 percent when limited to 10 degrees, 20 percent when limited to 15 degrees, 30 percent when limited to 20 degrees, 40 percent when limited to 30 degrees, and 50 percent when limited to 45 degrees. 38 C.F.R. § 4.71a, Code 5261. Normal (full) range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II (2009). Diagnostic Code 5257 provides a 10 percent evaluation for knee impairment with slight recurrent subluxation or lateral instability, a 20 percent evaluation for moderate recurrent subluxation or lateral instability, and a 30 percent evaluation for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Notably, in a recent rating decision in January 2009, the RO restored a prior 20 percent evaluation for instability of the right knee, effective from August 1, 2007. In this decision, the Board of course shall still consider whether the claimed increase for the right knee disability is warranted on all bases of evaluation. Separate ratings under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension), both codified at 38 C.F.R. §4.71a, may be assigned for disability of the same joint. See VAOPGCPREC 9- 2004. VA General Counsel Opinions VAOPGCPREC 23-97 (July 1, 24, 1997) and VAOPGCPREC 9-98 (Aug. 14, 1998) provide guidance on when separate ratings for knee disability may be assigned under the limitation of motion codes in addition to ratings under Diagnostic Code 5257 for subluxation/instability. Essentially, these opinions suggest that separate compensable ratings may be assigned when reported limitation of knee motion shown is compensable or when there is x-ray evidence of arthritis together with a finding of painful motion. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). As reflected in the April 2009 VA examination findings, the Veteran's right knee does not meet the criteria for a disability rating in excess of 10 percent for limitation of flexion or of extension. At that examination the range of motion of the knee was from zero degrees of extension to 124 degrees of flexion. Neither of these findings or other reviewed evidence on file shows that the right knee disability would warrant a disability rating in excess of the 10 percent in effect, for limitation of flexion or extension, under Diagnostic Codes 5260 or 5261. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. On review of the reports of VA examination in September 2004, August 2005, November 2005, September 2006, December 2006, and June 2008, the record does not show evidence of limitation of flexion or extension to an extent so as to warrant a disability rating in excess of 10 percent for the right knee disability. Predominately, albeit with pain shown at the endpoint of flexion, the findings showed that flexion of the right knee was to 120 degrees and extension was to zero degrees; except for November 2005 when flexion was to 140 degrees. Even when considering these findings in light of DeLuca, given the small amount of the limitation of motion of the right knee, which does not even meet criteria for a zero percent disability rating, the findings from the medical records do not support a schedular rating in excess of the 10 percent in effect for the right knee under the relevant diagnostic criteria. See 38 C.F.R. § Diagnostic Codes 5260 or 5261. Moreover, the most recent VA examination findings are that there was no additional limitation following repetitive use with range of motion of the right knee. Further, there is no evidence of any ankylosis of the right knee; recurrent subluxation or lateral instability; episodes of locking pain, and effusion into the joint due to dislocated semilunar cartilage; or malunion or nonunion impairment of the tibia and fibula. Thus, evaluation under relevant diagnostic code criteria would be of no benefit to the Veteran's claim. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5257, 5258, 5262. The Board has also considered whether the Veteran is entitled to a higher rating on the basis of functional loss due to pain pursuant to DeLuca, supra. However, there is no objective clinical indication he has symptoms causing functional limitation to a degree that would support an evaluation in excess of 10 percent for the right knee disability. Accordingly, the Board finds that the preponderance of the evidence is against a disability rating in excess of 10 percent for the Veteran's service-connected residuals of right knee trauma with arthritis and Baker's cyst. 38 C.F.R. § 4.3. The Board adds that it does not find that the Veteran's service-connected residuals of right knee trauma with arthritis and Baker's cyst should be increased for any other separate period based on the facts found during the appeal period. Hart, supra. C. Right Ulnar Neuropathy The Veteran's right ulnar neuropathy is evaluated pursuant to diagnostic criteria contained in the Rating Schedule under the section for neurological conditions, and specifically diseases of the peripheral nerves pursuant to 38 C.F.R. § 4.124a. Neurological conditions of the peripheral nerves as this pertains to the case here, are ordinarily rated in proportion to the impairment of motor and sensory function; with consideration especially of complete or partial loss of use of one or more extremities, or of tremors. In rating peripheral nerve injuries and residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes is that for moderate, incomplete paralysis. 38 C.F.R. § 4.123. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. With partial loss of use of one or more extremities from neurological lesions, rate by comparison with the mild, moderate, severe, or complete paralysis of peripheral nerves. 38 C.F.R. § 4.124a. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with the nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. The Veteran's right ulnar neuropathy is assigned a 10 percent disability rating, under Diagnostic Code 8516, which addresses impairment of the ulnar nerve nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8515. Under that code: A 10 percent rating is assigned for either the major or minor hand, if for the affected side, there is mild incomplete paralysis of the median nerve. A 30 percent rating is assigned for the major hand, and a 20 percent rating is assigned for the minor hand, if for the respective side, there is moderate incomplete paralysis. A 40 percent rating is assigned for the major hand, and a 30 percent rating is assigned for the minor hand, if for the respective side, there is severe incomplete paralysis. A 60 percent rating is assigned for the major hand, and a 50 percent rating is assigned for the minor hand, if for the respective side, there is complete paralysis of the ulnar nerve manifested by the "griffin claw" deformity due to flexor contraction of the ring and little fingers, very marked atrophy in the dorsal interspace and thenar and hypothenar eminences; loss of extension of the ring and little fingers, inability to spread the fingers (or reverse), inability to adduct the thumb; and weakened flexion of the wrist. 38 C.F.R. § 4.124a, Diagnostic Code 8515. With respect to diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis for a particular nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. When the involvement is bilateral, the ratings should be combined with application of the bilateral factor. 38 C.F.R. § 4.124a. On consideration of the foregoing evidence in light of the applicable law and regulation, a 30 percent disability rating and no more is warranted for the right ulnar neuropathy. There is competent evidence of more than just sensory involvement. The Veteran, who is competent to make such a finding, has reported such complaints as numbness paresthesias, pain, hand grip weakness, and impaired coordination of the right hand palm and fingers number 3, 4, and 5. As there is also competent medical evidence of an overall slight decrease in hand strength associated with the right ulnar neuropathy, a rating reflecting moderate impairment is warranted. 38 C.F.R. § 4.124a. These findings thus support a 30 percent evaluation for right ulnar neuropathy under Diagnostic Code 8516 for the entire appeal period. Hart, supra. However, the evidence does not show that the symptoms are productive of more than moderate incomplete paralysis of the ulnar nerve, so as to warrant a disability rating in excess of 30 percent. The record does not show symptoms that would approximate a disability picture of severe incomplete paralysis of the ulnar nerve so as to warrant a rating in excess of 30 percent. In this regard, at the April 2009 VA examination, neurological examination revealed that motor function impairment consisted of only a slight decrease in strength of the right hand grip. There was no muscle atrophy shown. The examiner opined that the nerve dysfunction included mild incomplete paralysis, neuralgia, but no neuritis. The Board thereby concludes that the overall neurological symptomatology of the right ulnar neuropathy approximates no more than moderate symptoms warranting 30 percent disability rating for the dominant right arm ulnar neuropathy; however, the preponderance of the evidence is against a higher rating for the neurological symptomatology. The Board has considered whether a higher rating for the disability is feasible by evaluating the disability under any potentially relevant diagnostic code criteria other than that of Diagnostic Code 8516. As the disability is associated with the anatomical locations of the right wrist and hand (including fingers) joints, the Board has considered whether a higher disability rating than 30 percent is warranted under diagnostic criteria for rating musculoskeletal conditions. However, applicable diagnostic criteria under 38 C.F.R. § 4.71a pertaining to range of motion/weakness of the right wrist/hand, do not afford disability ratings in excess of the 30 percent assigned here unless there is evidence of ankylosis. See 38 C.F.R. § 4.71a, Diagnostic Codes 5214, 5216-5223 (2009). The evidence does not show that condition. D. Conclusions The above determinations are based on application of pertinent provisions of the VA's Rating Schedule. The Board also considered whether it would be proper to refer the case for the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1). But the Board finds no basis for further action on this question as there are no circumstances presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. There is no showing that the Veteran's service-connected disabilities on appeal reflect so exceptional or unusual a disability picture as to warrant the assignment of higher ratings. See 38 C.F.R. § 3.321(b)(1). There is no indication that any of the three disabilities results in marked interference with employment (i.e., beyond that contemplated in the assigned evaluations) for any period since the Veteran submitted his claims. Moreover, the conditions are not, separately or in combination, shown to warrant frequent periods of hospitalization, or to otherwise render impractical the application of the regular schedular standards. In the absence of evidence of such factors, the Board is not required to remand the claims to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER A disability rating in excess of 10 percent for degenerative joint disease of the right elbow is denied. A disability rating in excess of 10 percent for residuals of right knee trauma with arthritis and Baker's cyst is denied. A 30 percent rating is granted for right ulnar neuropathy, subject to the controlling regulations governing the payment of monetary benefits. ____________________________________________ A. BRYANT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs