Citation Nr: 1303161 Decision Date: 01/30/13 Archive Date: 02/05/13 DOCKET NO. 10-13 626A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for arthritis of the left elbow. 2. Entitlement to a disability rating in excess of 10 percent for hypothyroidism. REPRESENTATION Veteran represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD Saira Spicknall, Counsel INTRODUCTION The Veteran served on active duty from July 1972 to July 1975 and from December 1976 to May 1992, with other verified active service from December 1970 to December 1976. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2008 rating decision of the Columbia, South Carolina Department of Veterans Affairs (VA) Regional Office (RO). Notice of the rating decision was sent to the Veteran from the Atlanta, Georgia RO in January 2008. Jurisdiction of the claims on appeal remains with the Atlanta, Georgia RO. In the April 2010 substantive appeal, the Veteran requested that he be scheduled for a hearing before a Veterans Law Judge at the RO, however, he subsequently withdrew his request for a hearing in September 2011. See 38 C.F.R. § 20.704(e) (2012). This case was previously remanded by the Board in February 2012 for additional development. A review of the Virtual VA paperless claims processing system reflects that additional records have been added to the present appeal. These records include VA medical records. A supplemental statement of the case (SSOC) was issued in October 2012, which addressed this additional evidence. FINDINGS OF FACT 1. The Veteran's arthritis of the left elbow has been productive of complaints of pain, stiffness and swelling with objective findings of limitation of motion of the forearm with flexion to 130 degrees and extension ranging from 10 to 25 degrees, X-ray evidence of traumatic arthritis and objective evidence of pain but no additional limitation of motion after repetitive motion; however, this disability has not been productive of ankylosis, impairment of flail joint or joint fracture, impairment of the radius or ulna, or supination or pronation impairment. 2. The Veteran's hypothyroidism has been productive of fatigability, constipation and mental sluggishness. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for arthritis of the left elbow have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5206, 5207 (2012). 1. The criteria for a disability rating of 30 percent, but not higher, for hypothyroidism have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.59, 4.119, Diagnostic Code 7903 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act (VCAA) The VCAA, codified, in part, at 38 U.S.C.A. § 5103, was signed into law on November 9, 2000. Implementing regulations were created, codified at 38 C.F.R. § 3.159 (2012). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2012). The United States Court of Appeals for Veterans Claims (Court) held in Pelegrini v. Principi, 18 Vet. App. 112 (2004) that to the extent possible the VCAA notice, as required by 38 U.S.C.A. § 5103(a) (West 2002), must be provided to a claimant before an initial unfavorable decision on a claim for VA benefits. Pelegrini, 18 Vet. App. at 119-20; see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Prior to the initial adjudication of the Veteran's claims for increased ratings in the January 2008 rating decision, he was provided notice of the VCAA in August 2007. The VCAA letter indicated the types of information and evidence necessary to substantiate the claim, and the division of responsibility between the Veteran and VA for obtaining that evidence, including the information needed to obtain lay evidence and both private and VA medical treatment records. The Veteran also received notice in August 2007 pertaining to the downstream disability rating and effective date elements of his claims. Additional notice was provided to the Veteran by letter dated in March 2009. The Veteran's actions are also indicative of his actual knowledge of the requirements for substantiating his increased rating claim. In a statement attached to the March 2007 claim for increase (previously submitted as VA form 9 but was found to be untimely and construed as a claim for increase), the Veteran reported that he met all the criteria for a 30 percent rating for his hypothyroidism, citing to his chronic constipation, continued medication and psychiatric treatment and medications. The Veteran has also reported his current symptoms of the left elbow and hypothyroidism to VA examiners in connection with his claims. Based on this evidence, the Board is satisfied that the Veteran had actual knowledge of what was necessary to substantiate his increased rating claim. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of his claims in this Board decision. Rather, remanding this case to the RO for further VCAA development would be an essentially redundant exercise and would result only in additional delay with no benefit to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). All relevant evidence necessary for an equitable resolution of the issues on appeal has been identified and obtained, to the extent possible. The evidence of record includes private medical records, VA outpatient treatment reports, VA examinations and statements from the Veteran, other laypersons, and his representative. The Board notes that the May 2012 VA examination reports reflect that the examiner reviewed the Veteran's past medical history, documented his current medical condition, and rendered appropriate diagnoses consistent with the remainder of the evidence of record. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). Consequently, the Board concludes that the medical examinations are adequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). This case was previously remanded by the Board in February 2012 to provide the Veteran with adequate VA examinations for the left elbow and thyroid. As the VA examiner performed all the tests necessary to evaluate the Veteran's current left elbow and thyroid and complied with the Board's remand instructions, the Board is satisfied that the development requested by its February 2012 remand has now been satisfactorily completed and substantially complied with respect to the left elbow and thyroid. See Stegall v. West, 11 Vet. App. 268 (1998) (remand not required under Stegall where Board's remand instructions were substantially complied with). A claim for a total disability rating based upon individual unemployability (TDIU), has not been raised. The evidence does not demonstrate, and the Veteran does not allege, that his left elbow or hypothyroidism causes unemployability or marginal employment. A claim for entitlement to a TDIU rating will not be considered as part of the determination of the claims on appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran has not indicated that he has any further evidence to submit to VA, or which VA needs to obtain. There is no indication that there exists any additional evidence that has a bearing on this case that has not been obtained. The Veteran and his representative have been accorded ample opportunity to present evidence and argument in support of his appeal. Thus, the Board finds that VA has obtained, or made reasonable efforts to obtain, all evidence that might be relevant to the issues on appeal, and that VA has satisfied the duty to assist. All pertinent due process requirements have been met. See 38 C.F.R. § 3.103 (2012). Pertinent Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. See 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. 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). When, as here, the Veteran is requesting an increased rating for an established service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, the most recent examination is not necessarily and always controlling; rather, consideration is given not only to the evidence as a whole but to both the recency and adequacy of examinations. See Powell v, West, 13 Vet. App. 31, 35 (1999). Nevertheless, the Board acknowledges that 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. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different "staged" ratings may be warranted for different time periods. When evaluating musculoskeletal disabilities, VA must consider granting a higher rating in cases in which the veteran experiences functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination (to include during flare-ups or with repeated use), and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2011); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath, 1 Vet. App. at 592. Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Analysis 1. Arthritis of the Left Elbow The Veteran's current arthritis of the left elbow has been rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5010. Diagnostic Code 5010 provides ratings for arthritis due to trauma and substantiated by X-ray findings. 38 C.F.R. § 4.71a (2012). Disabilities provided for under Diagnostic Code 5010 are to be rated as degenerative arthritis. 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. Id. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. The rating criteria provided for limitation of motion of the elbow and forearm are found at 38 C.F.R. § 4.71a, 5206-5208. As the Veteran's left arm is his minor extremity, the Board will only consider the criteria pertaining to the minor extremity. See e.g., May 2012 VA examination report of the elbow and forearm. The normal range of motion for the elbow is flexion to 145 degrees and extension to zero degrees. Normal pronation is from zero to 80 degrees and normal supination is from zero to 85 degrees. 38 C.F.R. § 4.71, Plate I. Under DC 5206, limitation of flexion of the forearm of the minor extremity to 110 degrees is assigned a noncompensable evaluation; a 10 percent evaluation is for application when flexion is limited to 100 degrees; 20 percent evaluations are applied when flexion is limited to 70 degrees or 90 degrees; a 30 percent evaluation is warranted when flexion is limited to 55 degrees; and a 40 percent evaluation is warranted when flexion is limited to 45 degrees. Under DC 5207, limitation of extension of the forearm of the minor extremity to 45 degrees or 60 degrees warrants a 10 percent evaluation; a 20 percent evaluation is for application when extension is limited to 75 degrees or 90 degrees; a 30 percent evaluation is warranted when extension is limited to 100 degrees; and a 40 percent evaluation is warranted when extension is limited to 110 degrees. Under DC 5208, a 20 percent evaluation is warranted when forearm flexion is limited to 100 degrees and extension is limited to 45 degrees in the minor extremity. DC 5213 provides for a 10 percent rating for both the major and minor forearms when supination is limited to 30 degrees or less. Limitation of pronation with motion lost beyond last quarter of arc, and the hand not approaching full pronation, warrants a 20 percent rating for both the major and minor forearms. 38 C.F.R. § 4.71a. In a statement attached to the March 2007 claim for increase, the Veteran reported that his left elbow was productive of pain such that it made it almost unbearable to raise his arm, swelling, and a bone spur which gives it a "deformed appearance." He argued that he should be awarded a 30 percent disability rating for this claim. At an August 2007 VA examination, the Veteran reported that his left elbow hurt about once per week and was precipitated by pressure to the left elbow. He reported that he would take over the counter pain medication. Pain was reportedly at an 8 to 9 out of 10 level on a scale of one to 10, with 10 being worst. The Veteran also reported having some stiffness in the morning, which lasted about an hour. He reported that he was right handed and that he did not use a brace for the elbow. The Veteran did not complain of weakness or fatigue, but indicated that he had some decreased endurance of the left arm. The Veteran also described having restricted movement. The Veteran reported he had not been working for the last three months and that he used to do security guard work. He reported having worked at different places and he worked at his last job for one year, which he had quit due to a lack of stamina, difficulty standing due to ankle pain, fatigue and weakness. The Veteran mentioned his activities of daily living included yard work and gardening, however, the examiner was unable to get the details of the activities and the impact on the Veteran's daily activities despite repeated questioning. A physical examination revealed that the olecranon process was prominent on the left when compared to the right side and there was tenderness over the olecranon. There were no signs of acute inflammation such as redness or warmth. There was no fluid. Range of motion findings revealed flexion was from 25 to 130 degrees, which appeared to require a lot of effort to complete with complaints of pain at the end of flexion. Extension was at -25 degrees (negative 25 degrees) meaning that the Veteran could not bring it from 25 degrees of flexion to the neutral of zero degrees. After repetition, flexion was from 20 to 130 degrees and extension was at -20 degrees (negative 20), indicating again, that he could not bring it from 20 degrees of flexion to the neutral of zero degrees. There was no crepitus of the left elbow. An X-ray of the left elbow revealed a large olecranon spur as well as moderate osteophyte formation arising from the distal humerus and coronoid process of the ulna. There was no fracture or joint effusion. A deformity of the olecranon process was noted as being consistent with an old injury. The Veteran was diagnosed with posttraumatic arthritis of the left elbow with deformity of the olecranon process. In an undated statement which accompanied an April 2009 notice response, the Veteran's wife provided details of the Veteran's disabilities. She reported that the Veteran had severe pain of the feet, ankles and elbow and that the Veteran had a protrusion of his elbow. Private and VA medical records from December 2008 to November 2011 reflect that the Veteran was treated for and diagnosed with left elbow pain, fluctuant swelling on both sides of the olecranon of the left elbow, an enlarged ulercon on the left elbow, bursitis of the left olecranon, and normal motion of the elbows. In addition, pain was noted to be radiating to the left shoulder. However, no further range of motion studies were reflected in these records. A June 2009 private X-ray of the left elbow revealed osteoarthritic changes of the left elbow with multiple spurs and swelling of the olecranon bursa. In a May 2012 VA examination of the elbow and forearm, the Veteran was diagnosed with left elbow degenerative joint disease. He reported current symptoms included intermittent and moderate pain in the left elbow, especially with lifting. He reported that he was right hand dominant. Current treatment included medications, Aleve and Mobic. No assistive devices were used for the left elbow. The Veteran stated that flare-ups impacted the function of the elbow and forearm in that he had worsening pain with prolonged use and lifting. Range of motion findings revealed flexion of the left elbow was to 130 degrees, with objective evidence of pain beginning at 0 degrees. Extension was to 10 degrees with objective evidence of pain beginning at 10 degrees. After repetition, flexion was to 130 degrees and extension was to 10 degrees. No additional limitation in range of motion of the elbow and forearm following repetition was found. The Veteran was noted to have some functional loss or impairment following repetition, including less movement than normal in the left and pain on movement in the left. No localized tenderness or pain on palpation of joints or soft tissue was found. Muscle strength testing revealed normal strength of the left elbow. No ankylosis, flail joint, joint fracture, or joint impairment of supination or pronation was found. No other physical findings, complications, conditions, signs or symptoms related to the left elbow were found. Imaging studies of the left elbow were noted to have been performed, which documented traumatic arthritis of the left elbow. The June 2009 private X-rays were reiterated in the examination report. In addition, a May 2012 X-ray of the left elbow revealed a large olecranon ossific spur at 1.53 cm in length, bursal soft tissue swelling, and an osteophyte from the posterior aspect of the distal humorous and coronoid process. The Veteran's left elbow condition was noted to impact his ability to work and the examiner noted that this condition impacted and prevented heavy physical labor but did not preclude light physical or sedentary work. The Veteran reported he last worked in security last year and he was not currently working due to his inability to find work. After a careful review of the evidence of record, the Board finds that the Veteran's arthritis of the left elbow is appropriately evaluated as 10 percent and this disability does not warrant a higher disability rating at any time during the pendency of the appeal. The evidence of record throughout the duration of the appeal, including the Veteran's lay statements, outpatient treatment reports and VA examinations, demonstrates that the Veteran's arthritis of the left elbow has been productive of complaints of pain, stiffness, and swelling with objective findings of limitation of motion of the forearm with flexion to 130 degrees and extension ranging from 10 to 25 degrees, X-ray evidence of traumatic arthritis and objective evidence of pain, but no additional limitation of motion after repetitive motion. The Board observes, however, this disability has not been productive of flexion limited to 90 degrees or extension limited to 75 degrees, so as to warrant a higher disability rating under Diagnostic Codes 5206 or 5207. 38 C.F.R. § 4.71a. In addition, while the May 2012 VA examiner found that, the Veteran had some functional loss or impairment following repetition, including less movement than normal in the left and pain on movement in the left, he specified that there was no additional limitation in range of motion of the left elbow and forearm following repetition. In fact, the range of motion findings after repetition indicate no change in degrees in the Veteran's flexion or extension. Moreover, although the August 2007 VA examination revealed a change in flexion upon repetitive testing from a range of 25 degrees to 130 degrees to a range of 20 to 130 and a change in extension upon repetitive testing from -25 degrees to -20 degrees these changes reflect an increase in range of motion rather than an increase in limitation of motion. Thus, the record does not reflect any additional limitation of motion and the VA examinations do not demonstrate any other limitation of function of the left elbow joint at any time during the pendency of the appeal. The Board also notes that, absent degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, which is not the case here as the Veteran's left elbow disability consists of only one joint/joint group, a higher disability rating is not warranted under Diagnostic Codes 5003 and 5010. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. The Board has also considered whether there are other appropriate diagnostic codes for application. However, as the Veteran's service-connected left elbow does not reflect findings of ankylosis, forearm flexion limited to 100 degrees and extension limited to 45 degrees, impairment of flail joint or joint fracture, impairment of the radius or ulna or supination or pronation impairment at any time during the pendency of the appeal, Diagnostic Codes 5205, 5208, 5209, 5210, 5211, 5212 and 5213 do not apply. 38 C.F.R. § 4.71a. On VA examination in May 2012, the VA examiner did not check any of the boxes indicative of impairment of supination or pronation. Even considering the Veteran's subjective complaints as outlined above, the medical evidence of record does not reflect any additional limitation of motion demonstrated upon repetitive motion that would support a higher evaluation at any time. The VA examiners identified pain during range of motion testing, but did not indicate that there was additional decreased motion of the left elbow based on the painful motion and such was not demonstrated by the range of motion findings. Although the evidence does show that the Veteran experiences painful motion, it does not result in a higher rating unless it actually results in additional functional loss. See Mitchell, 25 Vet. App. at 38-43; DeLuca, 8 Vet. App. at 204-7. In reaching the above conclusions, the Board has not overlooked the statements by the Veteran and his wife with regard to the severity of his service-connected left elbow. In this regard, the Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing pain and stiffness. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence was provided by the Veteran and his wife during the course of his VA examinations and in statements associated with his claims file. The Veteran is competent to report his current symptomatology as it pertains to his left elbow and the Board finds that the Veteran's statements are credible. With respect to the Rating Schedule, where the criteria set forth therein require medical expertise which the Veteran has not been shown to have or where these types of findings are not readily observable by a lay person, the Board has accorded greater probative weight to objective medical findings and opinions provided by the Veteran's private and VA treatment reports and his VA examination reports. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) ("[t]he probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . the credibility and weight to be attached to these opinions [are] within the province of the adjudicator."). Therefore, the Board has considered the Veteran's reports with respect to experiencing symptoms in evaluating his disability rating in this decision. All things considered, the record as a whole does not show symptoms that equal or more nearly approximate the criteria for an evaluation higher than 10 percent at any time since the date of claim. See Hart v. Mansfield, 21 Vet. App. 505 (2007). That is to say, the Veteran's disability has been no more than 10 percent disabling since the date of his claim, so his rating cannot be "staged" because this represents his greatest level of functional impairment attributable to this condition. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. 38 C.F.R. § 4.3; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The benefit sought on appeal is accordingly denied. 2. Hypothyroidism The Veteran's hypothyroidism has been rated as 10 percent disabling under 38 C.F.R. § 4.119, Diagnostic Code 7903. Under this diagnostic code, hypothyroidism with fatigability or continuous medication required for control, is rated as 10 percent disabling; hypothyroidism with fatigability, constipation, and mental sluggishness is rated as 30 percent disabling; hypothyroidism with muscular weakness, mental disturbance, and weight gain is rated as 60 percent disabling; hypothyroidism with cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness is rated as 100 percent disabling. The criteria of the rating levels under this rating code are nonsuccessive in nature. See Tatum v. Shinseki, 23 Vet. App. 152, 155-56 (2009). In December 2006 and January 2007 letters, Harold W. McRae, Jr., SDA, LPC, MAC, indicated that the had treated the Veteran for severe stress, depression and PTSD. He noted that the Veteran was having problems sleeping, was chronically fatigued and had other psychiatric symptoms. In a statement attached to the March 2007 claim for increase, the Veteran reported that he met the criteria for a 30 percent rating for his thyroid disorder. He stated that he had chronic constipation issues, which he treated with Metamucil and Colace. The Veteran also reported that he was medicated daily with Levothyroxine and was also taking psychiatric medication. In addition, he stated that he had been under the care of a counselor and psychiatrist who prescribed Trazodone, Seroquel, Remeron and Zoloft for his health issues. At an August 2007 VA examination, the Veteran reported that, since he had his parathyroid gland removed in 1996, he had been taking thyroxine pills. He denied any thyroid surgery or radioactive iodine treatment. The Veteran stated that he felt fatigued and tired for the past five years. He also reported that he had hypertension for the last 15 years and diabetes since 1988 or 1989. The Veteran's wife mentioned that he was seeing a psychiatrist for depression and had been taking medicines, however, he did not share what medicines he had been taking. The Veteran was only able to give the names of some medicines, but not the doses or frequency, including Avandia, Zetia, Micronase, Aspirin, Lotensin and Thyroxine. The Veteran did not have cardiovascular disease or stroke. His wife mentioned that he sometimes complained it was too cold or too warm but he was not consistently one way or the other. He also reported having problems with constipation for the last three years and took Metamucil with partial benefit. The Veteran lost weight in the last two to three months, from 235 to 211 pounds. He also reported that he had seen a gastroenterologist for abdomen pain, however, he was not sure about any ultrasound results and he was scheduled for an esophagogastroduodenoscopy. The Veteran reported he had not been working for the last three months and that he used to do security guard work. He also stated that he had worked at different places and he worked at his last job for one year, which he quit due to a lack of stamina, difficulty standing due to ankle pain, fatigue and weakness. The Veteran mentioned his activities of daily living included yard work and gardening, however, the examiner was unable to get the details of the activities and the impact on the Veteran's daily activities despite repeated questioning. A physical examination revealed no thyromegaly or nodules in the area of his thyroid. A heart evaluation did not reveal any abnormalities nor was a diagnosis made. Laboratory testing revealed a TSH of 6.07. The diagnosis was hypothyroidism and the examiner concluded that there was a mild elevation in TSH, which might indicate that replacement therapy might be inadequate. Private and VA medical records from March 2008 to March 2009 reflect that the Veteran was treated for and diagnosed with hypothyroidism, at which time he was prescribed Levothyroxine. November 2008 private thyroid laboratory testing revealed TSH of 2.73, December 2008 VA thyroid laboratory testing revealed TSH of 3.45 and January 2009 private thyroid laboratory testing revealed TSH of 3.75. No explanation other than the TSH readings was provided. In April 2009, the Veteran's friend, E.L., a retired nurse stated that she had known the Veteran for 21 years and had problems with his thyroid, among other conditions noted. She indicated that he easily tired and fatigued, and that he had a depressed affect. E.L. indicated that she felt these symptoms were due to the Veteran's "condition." In an undated statement which accompanied an April 2009 notice response, the Veteran's wife provided details of the Veteran's disabilities. She stated that the Veteran took Synthroid on a daily basis for his hypothyroidism and that he suffered from constipation, which required the use of Metamucil two to three times a week. Finally, she noted that the Veteran was very depressed concerning his condition. Private and VA medical records from May 2009 to July 2011 reflect that the Veteran continued to be treated for and diagnosed with hypothyroidism. Private medical records reflect that chest pain was noted as a problem in the list of disabilities, but all cardiovascular testing was normal. VA outpatient treatment records noted that the Veteran had hypertension, but no coronary artery disease and cardiovascular evaluations performed with the outpatient visits did not reveal any positive findings, other than the hypertension, which is service-connected. A June 2011 VA examination of the joints, specifically the left shoulder, indicated that the Veteran's weight was 220 pounds, indicating a 9 pound weight gain since the last VA examination. In a May 2012 VA examination of the thyroid and parathyroid, the Veteran was diagnosed with hypothyroidism. His current symptoms included intermittent diarrhea and that he felt sluggish and "unable to get started." Current treatment included Synthroid. Continuous medication was found to be required for control of the Veteran's thyroid condition, specifically Synthroid. No radioactive iodine treatment or other treatment for a thyroid condition was noted. No residual endocrine dysfunction following treatment for the thyroid condition was found. The examiner noted the Veteran had findings, signs or symptoms attributable to a hypothyroid condition, which included fatigability, specified as moderate fatigue, and sleepiness. A physical examination revealed normal eyes and neck, a regular pulse and a blood pressure of 111/71. Deep tendon reflexes were normal in all areas tested. No scars or other skin disabilities related to treatment of the thyroid condition were noted. No neoplasm or metastasis related to the diagnosed hypothyroidism was noted. No other pertinent physical findings, complications, conditions, signs or symptoms related to the diagnosed hypothyroidism were found. Laboratory testing revealed a TSH of 3.91. The examiner found that the Veteran's hypothyroidism did not impact his ability to work, explaining that it did not prevent either physical or sedentary work. The examiner noted that a review of the December 2008 findings revealed a euthyroid state and the 2004 and 2007 TSH showed an elevated level consistent with hypothyroidism. Laboratory testing results from August 2007 to May 2012 were reiterated in the examination report, revealing TSH levels ranging from 3.45 to 6.07. It was noted that the testing in December 2008 revealed a euthyroid state. After a careful review of the evidence of record, the Board finds that the Veteran meets the criteria for a disability rating of 30 percent, for hypothyroidism, under Diagnostic Code 7903. In this regard, the Board observes that the probative lay and medical evidence of record demonstrates that the Veteran's hypothyroidism has been productive of fatigability, constipation, and mental sluggishness. Both the August 2007 and May 2012 VA examinations demonstrate the Veteran's primary symptom of hypothyroidism included fatigability. In addition, the Veteran has reported symptoms of constipation to the August 2007 VA examiner and has submitted lay statements from himself and his wife regarding his constant chronic constipation and treatment thereof with Metamucil and Colace. Finally, the Board observes that the Veteran is receiving treatment for depression, stress and PTSD by a private counselor and has reported symptoms of feeling sluggish and the inability to "get started" in the May 2012 VA examination. The Board observes that the Veteran and his wife are competent to report on factual matters of which they had firsthand knowledge, e.g., experiencing or witnessing constipation and depression and treatment thereof. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Board finds that the statements provided by the Veteran and his wife regarding the effects of his current hypothyroidism symptoms on his daily life are competent and credible. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Baldwin v. West, 13 Vet. App. 1 (1999) (the Board must analyze the credibility of the evidence). Therefore, resolving all doubt in favor of the Veteran, the Board finds that his current hypothyroidism more nearly approximates the 30 percent rating criteria under Diagnostic Code 7903. 38 C.F.R. § 4.71a. The Board also finds that the Veteran's hypothyroidism does not meet the criteria for a higher disability rating under Diagnostic Code 7903. While the veteran did have a 9 pound weight gain between August 2007 and June 2011, the evidence of record, including the August 2007 and May 2012 VA examinations, the private and VA medical records and the lay statements of record, does not demonstrate any symptoms of muscular weakness, cold intolerance, cardiovascular involvement or bradycardia. Specifically, at the August 2007 VA examination it was noted that the Veteran did not have cardiovascular disease. His wife mentioned that he sometimes complained it was too cold or too warm but he was not consistently one way or the other. Private and VA medical records from May 2009 to July 2011 reflect that all cardiovascular testing was normal. In the May 2012 VA examination, the Veteran's current symptoms included only intermittent diarrhea and feeling sluggish and "unable to get started." The examiner noted the Veteran had findings, signs or symptoms attributable to a hypothyroid condition, which included fatigability, specified as moderate fatigue, and sleepiness. No other pertinent physical findings, complications, conditions, signs or symptoms related to the diagnosed hypothyroidism were found. Therefore, the Veteran does not meet or more nearly approximate the criteria for a disability rating higher than 30 percent under Diagnostic Code 7903. Thus, the Board finds that a higher evaluation is not warranted. Under the circumstances of this case, and with resolution of all reasonable doubt in the Veteran's favor, the Board finds that the criteria for a disability rating of 30 percent for hypothyroidism, but not higher, are met. 38 C.F.R. § 3.102 (2012). See also 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Extraschedular Consideration The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedural Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996); Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or the Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, supra. In this case, the Board finds that the schedular criteria are adequate to rate the disability under consideration. The rating schedule fully contemplates the described symptomatology (i.e. left elbow pain, swelling, stiffness, and limited motion; and with respect to hypothyroidism, fatigability, constipation, and mental sluggishness) and provides for ratings higher than those assigned based on more significant functional impairment. This matter was implicitly considered and rejected by the RO. See SOC, dated April 2010, citing 38 C.F.R. § 3.321(b)(1). Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (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 arthritis of the left elbow is denied. A disability rating of 30 percent, and not higher, for hypothyroidism is granted, subject to the provisions governing the award of monetary benefits. ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs