Citation Nr: 1305131 Decision Date: 02/12/13 Archive Date: 02/21/13 DOCKET NO. 09-37 212A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to a compensable rating for epicondylitis of the right elbow from May 1, 2006 to May 13, 2011, and entitlement to a rating higher than 30 percent thereafter. 2. Entitlement to a compensable rating for epicondylitis of the left elbow from May 1, 2006 to May 13, 2011, and entitlement to a rating higher than 10 percent thereafter. 3. Whether any hand or finger disability (excluding the service-connected residuals of the 4th and 5th metacarpal of the right hand and right wrist tendonitis) is part of or related to the Veteran's service-connected bilateral elbow disabilities. ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran retired from active military service in April 2006 with more than 20 years of active military service. This appeal comes to the Board of Veterans' Appeals (Board) from an April 2007 rating decision, which in pertinent part, granted service connection for bilateral epicondylitis, and assigned noncompensable disability ratings, effective May 1, 2006. In April 2011, the Board remanded the claims for additional development. By a rating decision in May 2012, the Veteran's disability ratings for right and left epicondylitis were increased to 30 and 10 percent, respectively, effective May 13, 2011. Correspondence received in July 2012 noted that The American Legion was the Veteran's representative, however, the record did not contain a valid authorization designating The American Legion as the Veteran's representative of record. Accordingly, in November 2012, the Board requested clarification, furnished the appropriate form to appoint a new representative, and indicated to the Veteran that if he did not respond, it would be assumed he wished to represent himself. The appellant failed to respond and did not provide a valid authorization (VA Form 21-22 or VA Form 21-22a) signed by a representative. Therefore, the Board finds that the appellant is not represented by any organization at this time before VA. Finally, the Board does not find that this case raises a claim for a total disability evaluation based upon individual unemployability (TDIU). See Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). The evidence of record, to include the May 2011 VA examination report, shows that the Veteran remains employed full-time as a force protection officer for the state of Louisiana and has missed no work in the last 12 months on account of his service-connected bilateral elbow disabilities. Therefore, a claim for TDIU has not been raised by the record. The issue of whether the Veteran has hand and finger manifestations related to his service-connected elbow disabilities is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. From May 1, 2006 to May 12, 2011, epicondylitis of the right and left elbow was manifested by pain; flexion of the right and left elbows was to 145 degrees, extension was to 0 degrees, pronation was to 80 degrees, and supination was to 85 degrees, bilaterally; ankylosis or impairment of flail joint, radius or ulna were not shown; and the right and left elbow disabilities were not shown to be productive of a fracture with marked cubitus varus or cubitus valgus deformity or with ununited fracture of head of radius. 2. Effective May 13, 2011, epicondylitis of the left elbow is manifested by pain; flexion of the left elbow is limited by pain to 90 degrees; extension of the left forearm is not shown to be limited to at least 100 degrees, and the hand is not fixed in supination or pronation; and ankylosis or impairment of flail joint, radius or ulna are not shown. 3. Effective May 13, 2011, the preponderance of the evidence shows that the Veteran's epicondylitis of the right elbow does not result in actual, or the functional equivalent, of limitation of flexion to 55 degrees or less or extension to 100 degrees or more; impairment of the ulna or radius with bone loss and marked deformity; elbow or wrist ankylosis; or that the right hand is fixed in supination. CONCLUSIONS OF LAW 1. From May 1, 2006 to May 12, 2011, a compensable rating for epicondylitis of the right elbow is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5024, 5205-5213 (2012). 2. From May 1, 2006 to May 12, 2011, a compensable rating for epicondylitis of the left elbow is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5024, 5205-5213 (2012). 3. Effective May 13, 2011, the criteria for a 20 percent rating, but no higher, for epicondylitis of the left elbow have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.2, 4.7, 4.10, 4.40, 4.45, 4.55, 4.59, 4.71a, Diagnostic Codes 5024, 5205-5213 (2012). 4. Effective May 13, 2011, the criteria for a disability rating higher than 30 percent for epicondylitis of the right elbow have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5024, 5205-5213 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to provide the Veteran notification of the information and evidence necessary to substantiate the claims submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The notice requirements were accomplished in letters sent in September 2006 and April 2011. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006). The letters also provided notice of the type of evidence necessary to establish a disability rating or effective date for the claimed disabilities under consideration, pursuant to the recent holding in Dingess v. Nicholson, 19 Vet App 473 (2006). The notice was timely because the claims were readjudicated in the May 2012 supplemental statements of the case. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Board also finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issues has been obtained. The Veteran's service treatment records, and available private and VA treatment records have been obtained. In addition, he has been provided with appropriate VA examinations in connection with the claims which sufficiently describe the manifestations of the Veteran's elbow disabilities for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Moreover, he has not indicated there are any additional records that VA should seek to obtain on his behalf. Therefore, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claims, and no further assistance to develop evidence is required. Increased Ratings Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, 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). 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). Where, as here, the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West 12 Vet. App. 119, 126 (1999). The Veteran is presumed to be seeking the maximum benefit allowed by law and regulation. AB v. Brown, 6 Vet. App. 35, (1993). 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). Thus, the analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). 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 (2011). 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. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not necessary, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Entitlement to a compensable rating for bilateral epicondylitis of the elbows from May 1, 2006 to May 13, 2011. Historically, based on symptoms noted in service and in a post-service VA examination, by an April 2007 rating decision, the RO granted service connection for bilateral epicondylitis, and assigned noncompensable disability ratings, effective May 1, 2006. Prior to May 13, 2011, the Veteran's bilateral lateral epicondylitis was rated 0 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5024 for tenosynovitis. Under Diagnostic Code 5024, tenosynovitis is to be rated based on limitation of motion as arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5024. 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 5205. Flexion of the major and minor forearm limited to 110 degrees is rated as noncompensably (0 percent) disabling; flexion limited to 100 degrees is rated as 10 percent disabling; flexion limited to 90 degrees is rated as 20 percent disabling; flexion limited to 70 degrees is rated as 30 percent disabling for the major extremity and 20 percent for the minor extremity; flexion limited to 55 degrees is rated as 40 percent disabling for the major extremity and 30 percent for the minor extremity; and flexion limited to 45 degrees is rated as 50 percent disabling for the major extremity and 40 percent for the minor extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5206. Extension of the major forearm limited to 45 degrees is rated as 10 percent disabling for the major and minor extremities; extension limited to 60 degrees is rated as 10 percent disabling; extension limited to 75 degrees is rated as 20 percent disabling; extension limited to 90 degrees is rated as 30 percent disabling for the major extremity and 20 percent for the minor extremity; extension limited to 100 degrees is rated as 40 percent disabling for the major extremity and 30 percent for the minor extremity; and extension limited to 110 degrees is rated as 50 percent disabling for the major extremity and 40 percent for the minor extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5207. Limitation of flexion of the major and minor forearm to 100 degrees with forearm extension limited to 45 degrees is rated as 20 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5208. Other impairment of the elbow with joint fracture, with marked cubitus varus or cubitus valgus deformity or with ununited fracture of the head of the radius, is rated 20 percent disabling for the major and minor sides. Flail joint of the elbow is rated 60 percent disabling for the major side and 50 percent for the minor side. 38 C.F.R. § 4.71a, Diagnostic Code 5209. Flexion of the elbow to 145 degrees is considered full and extension to 0 degrees is considered full. See 38 C.F.R. § 4.71, Plate I. Diagnostic Code 5210 provides that nonunion of the radius and ulna, with flail false joint, is rated 50 percent disabling for the major side, and 40 percent for the minor side. 38 C.F.R. § 4.71a, Diagnostic Code 5210. The evidence does not demonstrate that the Veteran has nonunion of the radius or ulna. 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 and minor sides; nonunion of the ulna in the lower half is rated 20 percent for the major and minor sides; nonunion of the ulna in the upper half, with false movement, without loss of bone substance or deformity is evaluated 30 percent for the major side and 20 percent for the minor 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 and 30 percent for the minor side. 38 C.F.R. § 4.71a, Diagnostic Code 5211. The Veteran does not have these disabilities. 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 and minor sides; nonunion of the radius in the upper half is rated 20 percent disabling for the major and minor sides; nonunion of the radius in the lower half, with false movement, without loss of bone substance or deformity is rated 30 percent in the major side and 20 percent disabling for the minor 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 in the major side and 30 percent disabling for the minor side. 38 C.F.R. § 4.71a. The Veteran does not have these disabilities. 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 and minor sides. 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 and minor sides; limitation of pronation with motion lost beyond the middle of arc is rated 30 percent for the major side and 20 percent disabling for the minor 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 and minor sides; loss of supination or pronation due to bone fusion, with the hand fixed in full pronation, is rated 30 percent in the major side and 20 percent disabling for the minor side; and loss of supination or pronation due to bone fusion, with the hand fixed in supination or hyperpronation, is rated 40 percent in the major side and 30 percent disabling for the minor side. 38 C.F.R. § 4.71a. The Veteran has greater movement than these criteria specify. Under 38 C.F.R. § 4.71a, a note indicates that in all forearm arm and wrist injuries, Diagnostic Codes 5205 through 5213, multiple impaired fingers movements due to tendon tie-up, muscle or nerve injury, are to be separately rated and combined not to exceed the rating for loss of use of the hand. Based on a review of the evidence of record, the Board concludes that the Veteran is not entitled to an initial compensable rating for either right or left elbow epicondylitis from May 1, 2006 to May 13, 2011. A close review of the record reveals no distinct period during which the criteria for the next higher (10 percent) ratings were met during this time frame. On VA examination in October 2006, the Veteran was noted to be right-hand dominant. He complained of constant aching pain in both elbows, rated as 2/10. He reported onset of elbow pain during service due to typing. He related a history of treatment with therapy and injections, until he underwent surgery in the right elbow in May 2006 and in the left elbow in March 2006. Reportedly, at that time, he took medication and used a bilateral wrist brace while doing yard work. On examination, flexion of the right and left elbows was to 145 degrees, extension was to 0 degrees, pronation was to 80 degrees, and supination was to 85 degrees, bilaterally. There was no pain or additional limitation of motion with repetitive motion. The elbows were tender on examination. X-rays of the elbows revealed no abnormalities and were noted as negative. The examiner diagnosed bilateral epicondylitis, status post-surgical repair of the medial epicondyle with residual numbness of the right and left forearms. The elbow disabilities were noted not to affect the Veteran's ability to perform activities of daily living. There is no other medical evidence demonstrating more severe symptoms of either elbow until May 13, 2011. Accordingly, the record shows that from May 1, 2006 to May 13, 2011, the Veteran had full range of motion with subjective complaints of pain. Even considering 38 C.F.R. §§ 4.40, 4.45, such limitation did not more nearly approximate flexion limited to 100 degrees or extension limited to 45 degrees, and consequently do not warrant separate 10 percent ratings under Codes 5206 and 5207, respectively. As no limitation of supination or pronation was shown and the Veteran did not complain of such, a compensable rating on such basis, under Code 5213, is not warranted. Similarly, as ankylosis or impairment of flail joint, radius or ulna are not shown, Codes 5205, 5209, 5210, 5211 and 5212 need not be considered and, as the Veteran did not have flexion limited to 100 degrees and extension limited to 45 degrees, Code 5208 does not apply. Furthermore, a higher disability rating under Diagnostic Code 5209 is not warranted, as the Veteran's right and left elbow disabilities were not shown to be productive of a fracture with marked cubitus varus or cubitus valgus deformity or with ununited fracture of head of radius. As noted above, x-ray examination of the bilateral elbows was negative. Entitlement to higher disability ratings effective May 13, 2011. By a rating decision in May 2012, the Veteran's disability ratings for right and left epicondylitis were increased to 30 and 10 percent, respectively, effective May 13, 2011. On VA examination in May 2011, the Veteran complained of bilateral elbow pain and persistent paresthesias in both arms, right worse than the left. The examiner noted that these complaints appeared to be positional. The Veteran also described occasional tingling and numbness in the hands and fingers, as well as giving way. The symptoms interfered with his ability to perform manual tasks. Reportedly, he had to grasp the steering wheel at the bottom while driving. He denied instability, incoordination, flare-ups in pain, locking episodes, symptoms of inflammation, dislocation or sublaxation. The examiner noted a history of lateral epicondylar release in both elbows, in 2006. On physical examination, the examiner noted that the Veteran exhibited guarding on motion of the right elbow, as well as pain and radicular sensation in the right hand at about 35 degrees of pronation, although he was able to go another 5 degrees, for a total of 40 degrees of pronation. Flexion of the right elbow was from 90 to 145 degrees, extension was from 90 to 10 degrees, pronation was to 40 degrees, and supination was to 80 degrees. There was objective evidence of pain with repetitive motion, without additional limitation of motion with repetitive use. On the left, flexion of the elbow was from 90 to 145 degrees, extension was from 90 to 0 degrees, pronation was to 80 degrees, and supination was to 85 degrees. There was objective evidence of pain with repetitive motion, without additional limitation of motion with repetitive use. There was no loss of bone or ankylosis of either elbow. X-rays of the elbows revealed large triceps enthesophyte on the ocleron. No fracture, sublaxation or soft tissue lesion was noted. The impression was ocrenanon osteophyte. It was noted that the Veteran had been employed full time for a period of 2 to 5 years, and had lost no time from work in the previous 12 months due to the bilateral elbow disability. However, the examiner indicated that the condition was productive of significant occupational impairment in that the Veteran had problems lifting and carrying, as well as decreased strength. The condition was productive of none, to mild to moderate impairment on the Veteran's ability to perform activities of daily living. The examiner diagnosed status post right and left lateral epicondylar surgery, with residual parasthesias into the hand, with no range of motion limitation problems. Effective May 13, 2011, the Veteran's left elbow disability is evaluated as 10 percent disabling. Based on a review of the evidence of record, however, the Board concludes that the Veteran is entitled to an increased rating of 20 percent for his left elbow disability for this period. On examination, flexion of the elbow was limited to 90 degrees with pain. Therefore, taking into account the Veteran's complaints of pain, as per 38 C.F.R. §§ 4.40, 4.45 (2012) and the Court's holding in DeLuca, supra, the Board finds that flexion of the left forearm is limited to 90 degrees. Accordingly, a 20 percent evaluation is warranted under Diagnostic Code 5206. The evidence shows that the even taking into account the Veteran's complaints of pain, flexion of the left forearm is not limited to anywhere near 55 degrees (i.e., because at its worst it was 90 degrees). In this regard, the Board observes that while there was objective evidence of pain with repetitive motion, there was no additional limitation of motion with repetitive use. Additionally, taking into account the Veteran's complaints of pain, extension of the left forearm is not shown to be limited to at least 100 degrees, and the hand was not fixed in supination or pronation. As such, the Board finds that higher evaluations are not warranted under Diagnostic Codes 5206, 5207, 5208, or 5213. Finally, as ankylosis or impairment of flail joint, radius or ulna are not shown, Diagnostic Codes 5205, 5209, 5210, 5211 and 5212 need not be considered. Accordingly, the Board resolves reasonable doubt in favor of the Veteran and finds that effective May 13, 2011, the criteria for a 20 percent rating, but no higher, were met for the service-connected left elbow epicondylitis. To that extent only is the appeal granted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Effective May 13, 2011, the Veteran's right (major) elbow disability is evaluated as 30 percent disabling. Based on a review of the evidence of record, the Board concludes that the Veteran is not entitled to a rating higher than 30 percent for his right elbow disability for this period. First, the evidence shows that flexion is limited to no less than 90 degrees. Thus, the evidence does not show flexion limited to 55 degrees or less. Second, the evidence shows extension limited to 90 degrees, at most. Accordingly, the evidence does not show extension limited to 100 degrees or more. The Board acknowledges that there was objective evidence of pain with repetitive motion at the May 2011 VA examination, however, the examination report reflected that there was no evidence of additional limitation of motion with repetitive use. The Board has specifically considered the guidance of 38 C.F.R. §§4.40, 4.45, 4.59. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In that regard, the Board notes that the Veteran is competent to report his symptoms and the Board does not doubt he has symptoms, to include pain on motion; however, the most competent and probative evidence does not establish that the right elbow disability results in actual, or the functional equivalent of, limitation of flexion that more closely approximates 55 degrees or less or extension that more closely approximates limitation to 100 degrees or more. In addition, on examination in May 2011, the examiner noted that the Veteran exhibited guarding on motion of the right elbow, as well as pain and radicular sensation in the right hand at about 35 degrees of pronation, although he was able to go another 5 degrees, for a total of 40 degrees of pronation, and supination was to 80 degrees. As previously noted, there was objective evidence of pain with repetitive motion, without additional limitation of motion with repetitive use. There is no evidence of loss of supination or pronation due to bone fusion, with the hand fixed in supination or hyperpronation that would warrant a higher rating under Diagnostic Code 5213. The Board further finds that neither higher nor separate evaluations are warranted under Diagnostic Codes 5207 or 5208. Finally, as ankylosis or impairment of flail joint, radius or ulna are not shown, Diagnostic Codes 5205, 5209, 5210, 5211 and 5212 need not be considered. In sum, effective May 13, 2011, the weight of the evidence demonstrates that the Veteran's right elbow epicondylitis does not warrant a rating in excess of 30 percent. At no point during this period on appeal did the Veteran's residuals of right elbow epicondylitis manifest in actual, or the functional equivalent of, limitation of flexion that closely approximated 55 degrees or less or extension that closely approximated to 100 degrees or more. Nor was there evidence of impairment of the ulna or radius with bone loss and marked deformity, elbow or wrist ankylosis, or a right hand fixed in supination. In reaching a determination that a rating in excess of 30 percent is not warranted for the right elbow disability and that a rating in excess of 20 percent is not warranted for the left elbow disability, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the Veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, the Board finds no other provision upon which to assign a higher rating. The Board has considered the statements of the Veteran regarding the severity of the service-connected right elbow epicondylitis. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997); Layno v. Brown, 6 Vet. App. 465 (1994); Cartright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). In this case, the Veteran is competent to report symptoms because that requires only personal knowledge as it comes to him through his senses, and the Board has considered these statements. Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds, however, the medical evidence from the examinations during the appeal period to be more competent to identify a specific level of disability according to the appropriate diagnostic codes. In particular, more competent evidence concerning the nature and extent of the Veteran's right and elbow epicondylitis has been provided by the medical personnel who have examined the Veteran during the current appeal and who have rendered pertinent opinions in conjunction with the examinations. The medical findings as provided in the examination reports directly address the criteria under which the service-connected disabilities are rated. Therefore, the Board finds the examination reports to be more probative than the Veteran's subjective evidence of complaints regarding the severity of symptomatology because they provide objective medical evidence of the manifestations of the service-connected disabilities and these findings are directly responsive to the applicable rating criteria. Cartright v. Derwinski, 2 Vet. App. 24 (1991). As the preponderance of the evidence is against the claim for assignment of any higher rating the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An initial compensable rating for epicondylitis of the right elbow from May 1, 2006 to May 12, 2011, is denied. An initial compensable rating for epicondylitis of the left elbow from May 1, 2006 to May 12, 2011, is denied. Effective May 13, 2011, a disability rating of 20 percent, but not higher, for left elbow epicondylitis is granted. Effective May 13, 2011, a disability rating higher than 30 percent for right elbow epicondylitis is denied. REMAND 38 C.F.R. § 4.71(a) states that, in all disabilities covered by Diagnostic Codes 5205-5213, impaired finger movements due to tendon tie-up or muscle or nerve injuries are to be separately rated and combined, not to exceed rating for loss of use of hand. The May 2011 VA examination reflects that the Veteran complained of bilateral elbow pain and persistent parasthesias, with occasional tingling and numbness in the hands and fingers. The VA examiner noted that the Veteran said his hands and fingers feel like "water was injected" into them in describing a heavy, thick feeling that affects his hands and fingers. The Veteran claimed that this sensation limited his functioning in that he had to grip the steering wheel differently when driving and he was unable to use a hammer for very long. The Veteran is currently service-connected for right wrist tendonitis and residual fractures of the right and 4th and 5th metacarpal, which have been assigned separate disability ratings (these issues are not before the Board at this time). Additionally, the Veteran underwent a VA nerve conduction study and electromyography (NCS/EMG) in June 2011, for the purpose of ruling out any neuropraxia of the ulnar nerve in the left upper extremity. The clinician noted tenderness in the left elbow. Muscle strength was 5/5, sensation was intact and there was no hand atrophy. The impression was normal NCS with left elbow epicondylitis. However, no VA examination has been provided to determine the underlying disability, if any, causing the Veteran's hand and finger symptoms, and whether they are part of the service-connected bilateral elbow disability. It is imperative that the Veteran be provided such an examination in this case as the May 2011 VA examiner indicates that these symptoms are related to the service-connected elbow disability. As such, a remand is warranted to afford the Veteran a VA examination to diagnose any current hand and finger disability related to his currently service-connected bilateral elbow disability. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Additionally, the Board finds that the record raises the issue of consideration of extraschedular ratings for the Veteran's service-connected bilateral elbow disorders. Under the applicable VA regulations, a case may be submitted to the Under Secretary for Benefits of the Director of Compensation and Pension Service for the potential authorization of an extraschedular evaluation based upon a finding that the service-connected disorder presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2012). There must be sufficient evidence showing that a Veteran's disability picture is not contemplated by the rating schedule in order for the case to be referred for a determination of whether the assignment of an extraschedular rating is warranted. Thun v. Peake, 22 Vet. App. 111 (2008). On VA examination in May 2011, the examiner determined that symptoms associated with the bilateral elbow condition were productive of "significant occupational impairment" because these interfered with the Veteran's ability to perform manual tasks, caused problems lifting and carrying, and resulted in decreased strength. Accordingly, it appears that the schedular criteria may not be adequate with respect to the Veteran's bilateral elbow disorders given that the schedular criteria focus primarily on limitation of range of motion or malunion. Additionally, as the May 2011 VA examiner has indicated that the Veteran's disability results in "significant occupational impairment", it appears that there may be marked interference with employment. As such, the RO should expressly consider referral of this matter to the Under Secretary for Benefits or the Director, VA Compensation and Pension Service for consideration of assignment of an extraschedular rating. 38 C.F.R. § 3.321 (2012). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate specialist to ascertain the nature and severity of his complaints of the hands and fingers, to include numbness and tingling. The claims folder, to include any relevant documents in Virtual VA, should be reviewed by the examiner, and the examination report should note that review. The examiner should provide a rationale for all opinions. Specifically, the VA examiner should address the following: a) Provide diagnoses for all disabilities of the hands and fingers found on examination (excluding the residuals of the 4th and 5th metacarpal of the right hand and the right wrist tendonitis for which the Veteran is already service connected), if any. Any tests deemed necessary should be performed. b) State whether it is at least as likely as not (a degree of probability of 50 percent or higher) that any hand or finger disability found on examination is part of or related to the Veteran's service-connected bilateral elbow disabilities. 2. After the development requested above, as well as any additional development deemed necessary, has been completed, readjudicate the claims remaining on appeal considering all applicable schedular rating criteria. The RO should expressly consider if the Veteran's symptoms warrant referral to the Under Secretary for Benefits or the Director, VA Compensation and Pension Service for assignment of extraschedular rating under the provisions of 38 C.F.R. § 3.321. If any aspect of the decision remains adverse to the Veteran, issue a supplemental statement of the case. Allow the appropriate time for response. Then, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ M. N. HYLAND Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs