Citation Nr: 1242001 Decision Date: 12/10/12 Archive Date: 12/20/12 DOCKET NO. 08-34 580 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to an initial compensable rating for status post right elbow arthroscopy with loose body retrieval (hereinafter, "right elbow disability") for the period prior to October 17, 2006. 2. Entitlement to an initial rating in excess of 10 percent for right elbow disability for the period from October 17, 2006, to the present. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). ATTORNEY FOR THE BOARD A.E.H. Gibson, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from March 1990 to July 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. Procedural history In July 1993, the Veteran filed a service-connection claim for a right elbow disability, among other claims discussed below. The RO denied the Veteran's claim in a September 1994 rating decision, and the Veteran did not appeal. In October 2006, the Veteran requested to reopen his right elbow disability claim. In a May 2008 rating decision, the RO granted service connection for the right elbow disability and assigned a rating of 0 percent effective October 17, 2006. The RO, finding that it had incorrectly applied the law in establishing the effective date, readjudicated the Veteran's claim. On October 30, 2008, the RO issued a statement of the case (SOC), along with another rating decision, wherein the effective date of the Veteran's service connected right elbow disability was reassigned to July 12, 1993, the date of his original claim. In these decisions, the Veteran's 0 percent rating for his right elbow disability was continued for the period from July 12, 1993, to October 16, 2006, and rated at 10 percent disabling from October 17, 2006, onward. The Veteran timely perfected an appeal as to the assigned disability ratings. Issues not appealed The Board notes the Veteran's July 1993 claim also sought service connection for left wrist disability, low back disability, left leg disability, hypertension, and migraines due to neck strain. He added bilateral knee disability and depression claims in a statement to the RO filed in August 1993. These claims were all denied in the September 1994 rating decision discussed above, and not appealed by the Veteran. See 38 U.S.C.A. § 7105(a) (West 2002). In October 2006, the Veteran requested that his claims for left wrist and bilateral knee disabilities be reopened along with his right elbow claim. This request was granted in the August 2007 rating decision. These claims, along with all of the other claims denied in 1993, were reopened and then denied on the merits. Shortly thereafter, the Veteran notified the RO via letter that his intention was to seek a reopening of his elbow and bilateral knee claims only. The subsequent rating decision, issued in May 2008, only addressed the Veteran's elbow disability. However, the Veteran's bilateral knee claim was addressed in the October 2008 SOC. The Veteran's appeal (VA Form 9), filed November 2008, specified that the only issue he wanted the Board to consider were the ratings assigned to his right elbow disability. To the Board's knowledge, the Veteran has not appealed the RO's decision, as set forth in the August 2007 rating decision and the October 2008 SOC, regarding the claim for a bilateral knee disability. See id. Finally, the Veteran filed a claim for a total disability rating due to individual unemployability in October 2008. The RO adjudicated and denied the claim in a February 2010 rating decision. This decision was not appealed by the Veteran. See id. FINDINGS OF FACT 1. The Veteran has degenerative arthritis in the right elbow, confirmed by X-ray, resulting in painful motion. 2. The Veteran's right elbow disability is manifested by pain and limited extension well below 45 degrees. 3. The Veteran's service connected disability does not render him unemployable. CONCLUSIONS OF LAW 1. The criteria for a 10 percent disability rating, but no higher, for right elbow disability for the period from July 12, 1993, to October 16, 2007, have been met. 38 C.F.R §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003 (2012). 2. The criteria for a rating in excess of 10 percent for right elbow disability for the period from October 17, 2007, onward have not been met. 38 C.F.R §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5206, 5207, 5208, 5213 (2012). 3. The criteria for entitlement to TDIU have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.321, 4.16, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file, and is obligated to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104 (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board must review the entire record, but need not discuss each piece of evidence. See Gonzales, 218 F.3d at 1380-81. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume the Board has overlooked evidence that is not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. Id. 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. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Id. Veterans Claim Assistance Act (VCAA) The Veterans Claims Assistance Act (VCAA) provides that VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 , 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of what is needed to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2011); 38 C.F.R. § 3.159(b) (2012). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). All notice under the VCAA should generally be provided prior to an initial decision on a claim by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). The issuance of a fully compliant VCAA notification followed by readjudication of the claim is sufficient to cure a timing defect. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370 (2006). A service connection claim consists of five elements: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006); 38 U.S.C. § 5103(a) (West 2002 & Supp. 2011). Compliance with the first Quartuccio element requires notice of these five elements. See Dingess/Hartman, 19 Vet. App. at 486. In cases where service connection has been granted and an initial disability rating and effective date have been assigned, notice under section 5103(a) is no longer required because the purpose that the notice is intended to serve has been fulfilled. See Dingess, 19 Vet. App. at 490-91. Thus, because service connection for a right elbow disability has already been granted, VA's notice obligations with respect to the issue of entitlement to a higher initial evaluation for that disability is fully satisfied, and any defect in the notice is not prejudicial. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (where a claim has been substantiated, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). In any event, the record reflects that the originating agency provided the Veteran with the notice required under the VCAA and under Dingess by letters mailed January 13, 2007, and September 30, 2009. VA also has a duty to assist the claimant in the development of the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). This duty includes assisting him in obtaining service treatment records and other pertinent treatment records, as well as providing an examination or obtaining a medical opinion when such is necessary to make a decision on the claim. See id. In this case, the Veteran has been afforded two VA examinations that assessed the severity of his right elbow disability, in August 2008 and June 2009, respectively. In December 2009, the VA examination report was supplemented to address the impact of the Veteran's right elbow disability on employment. The Board finds that these examination reports contain findings that are more than adequate to adjudicate the Veteran's claim for a higher initial disability rating on the merits. Indeed, both examination reports, as well as associated addendums, reflect that the examiner was made aware of the Veteran's relevant past medical history, recorded his current complaints, conducted an appropriate examination, and rendered diagnoses consistent with the evidence of record. Accordingly, the Board finds that VA's duty to assist with respect to obtaining examinations or opinions concerning the issue on appeal have been met. 38 C.F.R. § 3.159(c)(4) (2011); Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board will address the claim on the merits. Factual background The Veteran is seeking an increased initial rating for his service-connected right elbow disability. Specifically, he believes that, for the period prior to October 17, 2006, his disability should have been rated at 10 percent, rather than 0 percent, and that, for the period from October 17, 2006, to the present, his disability should be rated at 20 percent, rather than 10 percent. For the reasons discussed below, the Board finds that the Veteran is entitled to a 10 percent disability rating, but no higher, for the entire period from July 12, 1993, to the present. Service treatment records (STRs) show that the Veteran did not complain of a history of painful or "trick" elbow upon enlistment, and that his upper extremities were found normal. In March 1992, less than six months before discharge, records show the Veteran complained of pain in his right elbow. The physician noted a prominent radial head, and that active range of motion was decreased. The Veteran had pain on supination and extension. The physician noted possible degenerative changes in the right elbow. A radiology report indicated a deformity of the head of the radius and coronoid process of the ulna, probably secondary to trauma, and with resulting degenerative changes. See STR dated March 17, 1992. The orthopedic consult noted that the Veteran was unable to straighten his elbow and had occasional locking. The elbow was swollen, at 10 degrees fixed flexion, and with decreased supination and pronation. An X-ray confirmed the presence of arthritis. A loose body was found in the elbow joint, and an arthroscopy was scheduled to have it removed. On May 28, 1992, an osteocartilaginous fragment was removed from the Veteran's right elbow. The operation report, which specified right hand dominance, indicated that the anterior rim of the radial head showed some deformity, consistent with a history of fracture. Following surgery, the Veteran's range of motion was from 5 to 120 degrees. The Veteran separated from service in July 1992. The Veteran underwent a VA examination in August 1993. He complained of pain in his right elbow, which showed full range of motion. He clarified that strenuous use brings about pain, and that he must rest it for relief. The VA examiner indicated the Veteran had possible degenerative joint disease. A radiology report confirmed mild to moderate arthritic changes in the right elbow, with hypertrophic spur formation as well as narrowing of the elbow joint space. Records from the VA medical center (VAMC) indicate the Veteran continued to experience pain in his right elbow periodically, especially upon extension. The Veteran consulted with a private physician in May 2008, who found the Veteran to have full flexion, and all but the last 10 degrees of extension and supination. The Veteran's X-rays revealed moderately-severe osteoarthritis of the right elbow. Another VA examination was conducted in August 2008. The Veteran complained of pain when attempting to flex and extend his elbow through its full arc, and that he occasionally has to work through a catching sensation that interferes with motion. The physical examination revealed no visible deformity of the elbow, and no muscle loss. The Veteran had normal arcs of movement in pronation and supination. Flexion and extension were repeated three times, showing full flexion but extension lacking the final 10 degrees. The VA examiner found no functional, power, or sensory loss in the elbow, however, the Veteran complained that he was unable to straighten his arm fully due to the pain. X-rays did not reveal increased degenerative changes. The VA examiner diagnosed residual partial ankylosis of the right elbow. The Veteran revisited the August 2008 VA examiner in June 2009. He had normal pronation and supination, and flexion from 18 to 120 degrees. The Veteran lacked the final 18 degrees of active extension, and the VA examiner was not able to forcibly extend it any farther. The Veteran told the VA examiner that his level of pain was four out of ten, and that it did not affect his ability to take part in non-work related activities. He was able to flex and extend his forearm four times without fatigue or loss of movement. The VA examiner opined that the Veteran's only work requirements would be to limit repetitive lifting of twenty-five pounds or more. In December 2009, the VA examiner was asked to address the Veteran's disability in regard to his inability to find a job. He concluded, again, that the Veteran is able to work, but that he should limit lifting to under 25 pounds, as well as repetitive lifting. Other than that, the VA examiner indicated that no further restrictions would be necessary. Increased rating Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2012). Separate diagnostic codes (DCs) identify the various disabilities. See 38 C.F.R. Part 4 (2012). If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2012). Pyramiding, the evaluation of the same disability under various diagnoses, is to be avoided. 38 C.F.R. § 4.14 (2012). Consistent with the facts found, the rating may be higher or lower for periods of the time under review on appeal, that is, the rating may be "staged." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Veteran's rating has already been broken into stages by the RO. When evaluating musculoskeletal system disabilities that are based on limitation of motion, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 (2012). Pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability. 38 C.F.R. § 4.45 (2012). Painful, unstable, or malaligned joints, due to a healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59 (2012). The rule against pyramiding does not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including use during flare-ups. DeLuca v. Brown, 8 Vet. App. 202 (1995). However, although VA is required to apply 38 C.F.R. §§ 4.40 and 4.45, pertaining to functional impairment for disabilities evaluated on the basis of limitation of motion, where the claimant is in receipt of the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis, these regulations are not for application. Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). As noted above, the Veteran is seeking an increased rating for his right elbow disability, which has been evaluated as 0 percent disabling prior to October 17, 2006, and 10 percent disabling from October 17, 2006, onward. Initially, the Board observes that the Veteran was diagnosed with degenerative arthritis in the right elbow, confirmed by X-ray, in March 1992. This diagnosis was confirmed in 1993 and in 2008. Therefore, DC 5003 (degenerative arthritis) is applicable to the Veteran's disability. Under DC 5003, degenerative arthritis, as 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. See id. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. Id. In the absence of limitation of motion, a 20 percent rating is assigned for arthritis when there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. If there are no incapacitating exacerbations, a 10 percent rating is assigned. Id. In applying DC 5003, "painful motion of a major joint...caused by degenerative arthritis, where the arthritis is established by X-ray, is deemed to be limited motion and entitled to a minimum 10 percent rating, per joint, combined under DC 5003, even though there is no actual limitation of motion." See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991); see also 38 C.F.R. § 4.59 (2012). In this regard, the Board notes that with any form of arthritis, painful motion is an important factor of disability. See id. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. 38 C.F.R. § 4.59 (2012); see also Burton v. Shinseki, 25 Vet. App. 1 (2012) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis). The Board notes that in the case of Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2012), the Court clarified its holding in Lichtenfels, explaining that the evaluation of painful motion as limited motion only applies to the evaluation of arthritis under DC 5003, as mandated by the express language in that provision, and only when limitation of motion is noncompensable under the applicable diagnostic code. The Court further explained that although painful motion is entitled to a minimum 10 percent rating under Lichtenfels and DC 5003, it does not follow that the maximum rating is warranted under the applicable diagnostic code pertaining to range of motion simply because pain is present throughout the range of motion. See id. Rather, the pain "must actually affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance' [under] 38 C.F.R. § 4.40 in order to constitute functional loss" warranting a higher rating. See id., at 43. As set forth above, since March 1992, X-ray findings of the right elbow have been demonstrative of degenerative arthritis. The Veteran's medical records consistently indicate pain on motion. However, even though his range of motion has been limited, it was never so limited as to reach a compensable level of disability, as discussed in more detail below. Where there is limitation of motion, but the limitation of motion is noncompensable under the relevant diagnostic codes, X-ray confirmation of the affected joint will warrant a 10 percent disability rating under DC 5003. Based on the Veteran's medical records, this degree of impairment has been present since the date of his claim. The Board finds that the assignment of a 10 percent disability evaluation is warranted under DC 5003 for degenerative arthritis of the right elbow since July 12, 1993. Accordingly, because the Veteran has been entitled to a 10 percent rating since the date of his initial claim, July 12, 1993, which is granted here, the issue now becomes whether the Veteran is entitled to a rating in excess of 10 percent at any time since then. The Veteran's right elbow disability has been rated by analogy under 38 C.F.R. § 4.71a, DC 5299-5207, which pertains to limitation of motion of the forearm. The Board notes that there are no diagnostic codes that address the Veteran's specific disability, status post right elbow arthroscopy with loose body retrieval. Normal range of motion of the elbow is defined as extension to 0 degrees and flexion to 145 degrees. Normal pronation of the forearm is to 80 degrees of pronation and 85 degrees of supination. See id., Plate I (2012). The record reflects that the Veteran is right-handed. As such, his right elbow disability affects his major extremity. See 38 C.F.R. § 4.69 (2012). Based on the Veteran's documented range of motion, as set forth in the medical evidence compiled since the filing of the Veteran's initial claim, a rating in excess of 10 percent is not warranted at any time since July 12, 1993, under the relevant diagnostic codes. Under DC 5207, the Veteran's currently assigned diagnostice code, limitation of extension of the forearm, a 10 percent rating is assigned when extension of the major elbow is limited to 45 or 60 degrees; a 20 percent rating is warranted for extension of the major forearm limited to 75 degrees; a 30 percent rating is warranted for extension of the major forearm limited to 90 degrees; and, a 40 percent rating is warranted for extension of the major forearm limited to 100 degrees. A 50 percent rating is warranted for extension of the major forearm limited to 110 degrees. See 38 C.F.R. § 4.71a (2012). The evidence of record shows the Veteran is able to extend his forearm to well below 45 degrees, which is the minimal limitation of extension for a 10 percent rating. Other relevant diagnostic codes pertaining to range of motion of the arm apply to limitation of flexion of the forearm (DC 5206), limitation of flexion and extension of the forearm (DC 5208), and impairment of supination and pronation (DC 5213). See id. Under DC 5206, limitation of flexion to 45 degrees is assigned a 50 percent rating for the major extremity. Limitation of flexion to 55 degrees is assigned a 50 percent rating for the major extremity. Limitation of flexion to 70 degrees is assigned a rating of 30 percent for the major extremity. Limitation of flexion to 90 degrees is assigned a 20 percent rating for both arms. Limitation of flexion to 100 degrees is assigned a 10 percent rating for both arms. Limitation of motion to 110 degrees is assigned a noncompensable rating for both arms. See id. The Veteran was able to flex his forearm to more than 110 degrees, which is the minimal limitation for even a 0 percent rating. Under DC 5208, limitation of flexion to 100 degrees and of extension to 45 degrees is assigned a 20 percent rating. See id. The Veteran is not able to be evaluated under this diagnostic code, since his flexion exceeds 100 degrees and his extension falls below 45 degrees. Under DC 5213, loss of supination and pronation due to bone fusion is assigned a 40 percent rating for the major extremity when the hand is fixed in supination or hyperpronation. When the hand is fixed in full pronation, a 30 percent rating is assigned for the major extremity. When the hand is fixed near the middle of the arc or moderate pronation, regardless of extremity, a 20 percent rating is assigned. Limitation of pronation beyond the middle of the arc is assigned a 30 percent rating for the major extremity. Loss of pronation beyond the last quarter of the arc, where the hand does not approach full pronation, is assigned a 20 percent evaluation for both arms. Limitation of supination to 30 degrees or less is assigned a 10 percent rating for both arms. See id. The Veteran is not entitled to a higher rating under this diagnostic code. Although he showed decreased supination and pronation prior to his in-service arthroscopy, he generally had normal arcs of movement after, except for an instance where he was unable to supinate his forearm the final 10 degrees, which is noncompensable under this diagnostic code. The record contains no evidence showing the Veteran has had ankylosis of the elbow, impairment of the flail joint, joint fracture with marked cubitus varus or cubitus valgus deformity or with ununited fracture of head of radius, nonunion of the radius and ulna, or impairment of the radius or ulna at any point during the pendency of this claim. Thus, DCs 5205, 5209, 5210, 5211, and 5212, which pertain to these conditions, respectively, do not apply. See 38 C.F.R. § 4.71a (2012). The Board has considered whether a higher rating is warranted based on functional loss due to pain, weakness, excess fatigability, and incoordination causing additional disability beyond that reflected on range of motion measurements. See 38 C.F.R. §§ 4.40, 4.45 (2012); DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); Johnson v. Brown, 9 Vet. App. 7 (1996) (holding that the provisions of 38 C.F.R. §§ 4.40 and 4.45 should only be considered in conjunction with the diagnostic codes predicated on limitation of motion). The Court has held that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). 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., quoting 38 C.F.R. § 4.40 (2012). Here, the Board does not find a rating in excess of 10 percent due to functional loss is warranted. In this regard, at that June 2009 VA examination, the Veteran was able to flex and extend his forearm three times without fatigue or loss of movement. At the August 2008 VA examination, the VA examiner observed that the Veteran's elbow audibly clicked when flexing and extending, but that the Veteran was able to work through the pain up to the final 10 degrees of extension. The Board finds that the medical evidence simply does not reflect that the Veteran's functional impairment has been so disabling as to effectively result in limitation of motion of the forearm such that he is unable to extend it beyond 75 degrees, or flex it beyond 90 degrees, as would be required for assignment a 20 percent rating under DC 5207 or 5206. While acknowledging the functional limitations imposed by the Veteran's right elbow disability, the Board notes that the factors enumerated in 38 C.F.R. §§ 4.40 and 4.45, as discussed in Deluca, overlap with the factors addressed in DC 5003. These factors, specifically painful motion, are found in this case, and provide the support to assign a 10 percent rating under DC 5003. Simultaneous compensation for functional loss as well as degenerative arthritis amounts to pyramiding, that is, duplicate compensation for identical symptoms, which is prohibited. See 38 C.F.R. § 4.14 (2012). With regard to staged ratings, there is no evidence showing that the Veteran is entitled to a rating in excess of 10 percent for his right elbow disability at any point during the pendency of this claim, for the reasons discussed above. The Veteran's range of motion, as set forth in the evidence of record, always exceeded the requirements of 5206 and 5207, even for a minimum rating. Thus, staged ratings are not appropriate for the relevant time frame. See Fenderson v. West, 12 Vet. App. 119 (1999). Extraschedular considerations The Board has considered whether the claim should be referred for an extraschedular rating. See 38 C.F.R. § 3.321(b) (2012). Because the ratings under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual claimant's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Thun v. Peake, 22 Vet. App. 111, 114 (2008). In exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these cases is a finding that the disability presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2012). The determination of whether a claimant is entitled to an extraschedular rating under 38 C.F.R. § 3.321(b) is a three-step inquiry. Thun v. Peake, 22 Vet. App. 111, 115 (2008). First, there must be a finding that the evidence of record presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. In this regard, the Board must compare the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. See id. If the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Id. Second, if the schedular criteria are found to be inadequate to evaluate the disability, the Board must determine whether the exceptional disability exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. If so, then the third step requires the case to be referred to the Under Secretary for Benefits or the Director of Compensation and Pension Services to determine whether the disability requires the assignment of an extraschedular rating. Id. The Board finds that referral for extraschedular consideration is not warranted in this case. The Veteran's reported symptoms (i.e., pain and limitation of motion) are contemplated by the rating criteria, as discussed above. There are no symptoms left uncompensated or unaccounted for by the assignment of a schedular rating. The evidence does not indicate that the right elbow disability presents "such an exceptional or unusual disability picture... as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b) (2012). The Veteran's assertion that his right elbow disability limits his ability to work in certain capacities is contemplated by the rating, which is designed to compensate for the average impairment of earning capacity due to a particular disability. See VAOPGCPREC 6-96. The fact that circumstances specific to a particular claimant may cause the effects of a service-connected disability to be more profound in that claimant's case does not ordinarily provide a basis for extraschedular consideration. Id. Rather, the impairment must be one that is so unusual as to be unanticipated by the rating criteria. See id. Because the Board finds that the symptoms and functional limitations caused by the Veteran's right elbow disability are contemplated by the rating criteria, there is no need to consider whether it causes marked interference with employment. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, the Board finds that the available schedular evaluations are adequate to rate this disability, and therefore referral for extraschedular consideration is not warranted. See 38 C.F.R. § 3.321(b) (2011); Thun v. Peake, 22 Vet. App. 111, 115 (2008). Total disability due to individual unemployability (TDIU) The Board has also considered the issue of TDIU. See 38 C.F.R. §§ 3.340, 4.16 (2012). The Court has held that a request for TDIU is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). If the claimant or the record reasonably raises the question of whether the veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel of that claim for an increased rating is the issue of whether a total rating based on individual unemployability as a result of that disability is warranted. Id. at 455. Here, although the RO denied entitlement to TDIU in an unappealed February 2010 rating decision, the Veteran has nonetheless re-asserted that his right elbow disability prevents him from finding gainful employment. Where a veteran's schedular rating is less than total, a total disability rating may nevertheless be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided certain requirements are met. Under 38 C.F.R. § 4.16(a), if the veteran has only one such disability, then this disability shall be ratable at 60 percent or more; if the veteran has two or more such disabilities, then there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a) (2011); see also 38 C.F.R. § 4.25 (2011). VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the veteran is precluded, by reason of his service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2011). Consideration may be given to a veteran's level of education, special training, and previous work experience, but not to his or her age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2011). Under 38 C.F.R. § 4.16(b), when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but fails to meet the percentage requirements for eligibility for a total rating as set forth in 38 C.F.R. § 4.16(a), above, the RO may submit such case to the Director of Compensation and Pension Services for extraschedular consideration. 38 C.F.R. § 4.16(b) (2011). The Board is precluded from granting a total rating under section 4.16(b) in the first instance because the authority to grant such a rating is vested specifically in the Director of Compensation and Pension Services. Should the Board find that a case it is reviewing on appeal is worthy of consideration under section 4.16(b), the Board may remand the case to the RO for referral to the Director of Compensation and Pension Services, but the Board may not grant a total rating in the first instance under 4.16(b). See Floyd v. Brown, 9 Vet. App. 88, 95 (1996) (noting that Board may consider whether referral to "appropriate first-line officials" for extra-schedular rating is required); see also Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). For a veteran to prevail on a claim based on unemployability, it is necessary that the record reflect some factor which places him or her in a different position than other veterans with the same disability rating. The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In this case, the Veteran is currently assigned a 10 percent disability evaluation for a right elbow disability, which is his only service connected disability. Thus, the Veteran does not meet the schedular requirements necessary for the assignment of a total rating under 38 C.F.R. § 4.16(a) (2012). Nevertheless, as previously noted, veterans who are found to be unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Therefore, rating boards may submit claims to the Director of Compensation and Pension Services for extraschedular consideration in claims that fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). Here, the RO denied referral for consideration of the Veteran's TDIU claim on an extraschedular basis in a February 2010 rating decision. The record shows that the Veteran is currently unemployed. He has stated many times that his right elbow disability has prevented him from obtaining and keeping a good job. However, the fact that the Veteran is unemployed or has difficulty obtaining employment is not enough. As noted above, the question is whether the Veteran is capable of performing the physical and mental acts required by employment. With respect to the Veteran's right elbow disability, the evidence indicates that he is able to extend his forearm to 18 degrees, and that he is able to fully flex. He is able to fully pronate his forearm, and has only shown limited supination on one occurrence, where he was unable to supinate it the final ten degrees. See 38 C.F.R. § 4.71a (2012) (Plate I). Although the Veteran has consistently reported that the pain in his elbow prevents him from being able to lift objects, which prevents him from obtaining a job, he also told the June 2009 VA examiner that his elbow has not affected his personal activity level. The June 2009 VA examiner addressed the Veteran's unemployability and opined that the Veteran is employable, but would need to avoid heavy or repetitive lifting. The Veteran's last employer indicated that the Veteran did not need any concessions made for his disability, and that he quit working because the company had to cut his hours due to lack of work. Although it is clear that the Veteran has limited range of motion and pain of the right elbow, the medical evidence does not suggest that this disability renders him unemployable. His disability is shown on examination to result in mild to moderate impairment and impact on his activities, and he retains substantial range of motion in the joint. The Board acknowledges his statements that he is unable to work due to his disability, however, the Veteran is not competent to offer evidence that requires medical knowledge. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The issue of whether a disability's severity renders a person unemployable, is, in the Board's opinion, a matter requiring medical expertise. There is no indication that the Veteran is a medical professional, and consequently, he lacks the competency to address the employability question at issue in this case. Based on the foregoing, the evidence does not show the Veteran to be unemployable due solely to his service-connected disabilities. While the Veteran's right elbow disability undoubtedly causes some impairment, the evidence does not show that this alone precludes him from obtaining gainful employment. Therefore, a referral for extraschedular consideration for a TDIU is not warranted. 38 C.F.R. § 4.16(b) (2012). Accordingly, the Board finds that the evidence supports a rating of 10 percent for the period prior to October 17, 2006, and that the preponderance of the evidence is against a rating in excess of 10 percent for the period after October 17, 2006, for the Veteran's right elbow disability. Further, the Board finds that the preponderance of the evidence does not support a total rating based on individual unemployability. Under these circumstances, and with respect to the denial of a rating higher than 10 percent for the elbow disorder and with respect to the denial of a TDIU, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). See also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to an initial compensable rating for the period from July 12, 1993, to October 16, 2006, for a right elbow disability is granted. Entitlement to an initial rating in excess of 10 percent for the period from October 17, 2006, onward for a right elbow disability is denied. Entitlement to a TDIU is denied. ____________________________________________ Thomas H. O'Shay Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs