Citation Nr: 1305909 Decision Date: 02/21/13 Archive Date: 02/27/13 DOCKET NO. 08-37 404 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial rating greater than 40 percent for gout of the bilateral ankles, bilateral elbows, and bilateral knees, with osteoarthritis of the right knee and left elbow, prior to April 28, 2010. 2. Entitlement to an initial rating greater than 20 percent for gout of the right ankle since April 28, 2010. 3. Entitlement to an initial rating greater than 20 percent for gout of the left ankle since April 28, 2010. 4. Entitlement to an initial rating greater than 10 percent for gout and osteoarthritis of the left elbow from April 28, 2010, to August 30, 2010. 5. Entitlement to an initial rating greater than 20 percent for gout and osteoarthritis of the left elbow since August 31, 2010. 6. Entitlement to an initial compensable rating for supination impairment associated with gout and osteoarthritis of the left elbow since August 31, 2010. 7. Entitlement to an initial rating greater than 10 percent for gout of the right elbow since April 28, 2010. 8. Entitlement to an initial rating greater than 10 percent for gout of the left knee since April 28, 2010. 9. Entitlement to an initial rating greater than 10 percent for gout and osteoarthritis of the right knee since April 28, 2010. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran and his wife ATTORNEY FOR THE BOARD Anthony M. Flamini, Counsel INTRODUCTION The Veteran served on active duty from October 1985 to September 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The claims file was subsequently transferred to the RO in Atlanta, Georgia. The Veteran testified at a July 2012 hearing before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the claims file. The Board recognizes that the Veteran perfected an appeal with respect to the issue of entitlement to an effective date earlier than April 28, 2010, for the grant of separate evaluations for gout of the right ankle, left ankle, right elbow, left elbow, right knee, and left knee. However, the Board has reviewed the entire claims file and notes that the Veteran's original claim seeking service connection for gout was submitted in September 2005 and from this date he has continued to prosecute his appeal. Given the history discussed more extensively below, the Board has characterized the issue on appeal as it appears on the first page of this decision, because the claim is one for an increased rating for the period on appeal, rather than as a claim for an earlier effective date. The RO issued a "staged" rating and the entire period since the claim was filed is on appeal. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In Rice v. Shinseki, 22 Vet. App. 447, 451 (2009), the Court of Appeals for Veterans Claims held that once a Veteran submits evidence of a medical disability, makes a claim for the highest rating possible, and submits evidence of unemployability, 38 C.F.R. § 3.155(a) (2012) requires that VA must consider whether the claimant is entitled to a total disability rating for compensation on the basis of individual unemployability (TDIU) rating. However, the Veteran has indicated as recently as his July 2012 Travel Board hearing that he is currently employed. Because the Veteran has made it clear that he continues to be employed on a fulltime basis, further consideration of entitlement to TDIU is not required. The issues of entitlement to separate initial ratings greater than 20 percent for gout of the right and left ankles since April 28, 2010; an initial rating greater than 20 percent for gout and osteoarthritis of the left elbow since August 31, 2010; an initial compensable rating for supination impairment associated with gout and osteoarthritis of the left elbow since August 31, 2010; and separate initial ratings greater than 10 percent for gout of the right elbow, left knee, right knee since April 28, 2010, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to April 28, 2010, the Veteran's gout of the right ankle was manifested by noncompensable limitation of motion of a major joint. 2. Prior to April 28, 2010, the Veteran's gout of the left ankle was manifested by noncompensable limitation of motion of a major joint. 3. Prior to April 28, 2010, the Veteran's gout of the right elbow was manifested by noncompensable limitation of motion of a major joint. 4. Prior to April 28, 2010, the Veteran's gout and osteoarthritis of the left elbow was manifested by noncompensable limitation of motion of a major joint. 5. Prior to April 28, 2010, the Veteran's gout and osteoarthritis of the right knee was manifested by noncompensable limitation of motion of a major joint. 6. Prior to April 28, 2010, the Veteran's gout of the left knee was manifested by noncompensable limitation of motion of a major joint. 7. From April 28, 2010, to August 30, 2010, the Veteran's gout and osteoarthritis of the left elbow was manifested by flexion limited to 145 degrees, extension limited to 45 degrees, supination limited to 60 degrees, and pronation limited to 40 degrees. CONCLUSIONS OF LAW 1. Prior to April 28, 2010, the criteria for a separate 10 percent rating, but no greater, for gout of the right ankle have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5002 (2012). 2. Prior to April 28, 2010, the criteria for a separate 10 percent rating, but no greater, for gout of the left ankle have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5002 (2012). 3. Prior to April 28, 2010, the criteria for a separate 10 percent rating, but no greater, for gout of the right elbow have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5002 (2012). 4. Prior to April 28, 2010, the criteria for a separate 10 percent rating, but no greater, for gout and osteoarthritis of the left elbow have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5002 (2012). 5. Prior to April 28, 2010, the criteria for a separate 10 percent rating, but no greater, for gout and osteoarthritis of the right knee have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5002 (2012). 6. Prior to April 28, 2010, the criteria for a separate 10 percent rating, but no greater, for gout of the left knee have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5002 (2012). 7. From April 28, 2010, to August 30, 2010, the criteria for a 20 percent rating, but no greater, for gout and osteoarthritis of the left elbow have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5017-5213 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Prior to the Veteran's separation from service, he was provided with notice as part of the Benefits Delivery at Discharge (BDD) program; his acknowledgement of this notice, to include that of regulations pertinent to the establishment of an effective date and of the disability rating, was received by VA in September 2005. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Veteran was subsequently provided with notice concerning how VA determines disability ratings and effective dates in July 2010, and the claims were readjudicated in November 2011. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's service treatment records, VA medical treatment records, and identified private medical records have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The record does not reflect that the Veteran is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159 (c) (2); Golz v. Shinseki, 590 F.3d 1317, 1320-21 (Fed. Cir. 2010). VA examinations were performed in October 2005, April 2010, and August 2010; the record does not reflect that any of these examinations were inadequate for rating purposes. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Each examiner conducted a physical examination, recorded clinical findings to include range of motion testing, and documented the Veteran's subjective complaints. No additional evidence relevant to the issues adjudicated in this decision appears to be available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). Initial Rating Greater than 40 Percent for Gout of the Bilateral Ankles, Bilateral Elbows, and Bilateral Knees prior to April 28, 2010 Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). Where the Rating Schedule does not provide for a noncompensable evaluation for a diagnostic code, a noncompensable evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2012). The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. VA has a duty to consider the possibility of assigning staged ratings in all claims for increase. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the Veteran initially filed a claim for entitlement to service connection for gout upon his separation from active service in September 2005. In a January 2006 rating decision, the RO granted entitlement to service connection for gout of the bilateral ankles, bilateral elbows, and bilateral knees, with osteoarthritis of the right knee and left elbow, and assigned a single 40 percent rating for the disability under Diagnostic Code 5002 effective January 1, 2006. The Veteran filed a notice of disagreement with this decision in December 2006, and asserted that his single 40 percent rating should be higher. He was provided a VA examination in April 2010, and, based on the results of that examination, in a May 2010 rating decision, the RO assigned separate evaluations for each joint effected by gout, which resulted in a higher combined evaluation, effective April 28, 2010, the date of the VA examination. Specifically, the May 2010 rating decision granted entitlement to a 20 percent rating for gout of the right ankle, a 20 percent rating for gout of the left ankle, a 10 percent rating for gout and osteoarthritis of the left elbow, a 10 percent for gout of the right elbow, a 10 percent rating for gout of the left knee, and a 10 percent rating for gout and osteoarthritis of the right knee. The Veteran was provided another VA examination in August 2010, and based on the results of that examination, in a November 2011 rating decision, the RO granted entitlement to a 20 percent rating for gout and osteoarthritis of the left elbow and also awarded a separate grant of service connection for supination impairment of the left elbow associated with gout and osteoarthritis, rated as noncompensable under Diagnostic Codes 5017-5213, effective August 31, 2010, the date of the VA examination. The Board finds that the issues of entitlement to separate initial ratings greater than 20 percent for gout of the right and left ankles since April 28, 2010; an initial rating greater than 20 percent for gout and osteoarthritis of the left elbow since August 31, 2010; an initial compensable rating for supination impairment associated with gout and osteoarthritis of the left elbow since August 31, 2010; and separate initial ratings greater than 10 percent for gout of the right elbow, left knee, right knee since April 28, 2010, require additional development and will be discussed below in the Remand section of this decision. At this time, the Board will adjudicate the Veteran's claims for entitlement to an initial rating greater than 40 percent for gout of the bilateral ankles, bilateral elbows, and bilateral knees, with osteoarthritis of the right knee and left elbow, prior to April 28, 2010, and entitlement to an initial rating greater than 10 percent for gout and osteoarthritis of the left elbow from April 28, 2010, to August 30, 2010. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14 (2012). A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his [or her] earning capacity." See 38 U.S.C.A. § 1155 (2011); Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a Veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). The Veteran bears the burden of presenting and supporting his claim for benefits. 38 U.S.C.A. § 5107(a) (West 2002). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b) (West 2002). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. Id. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See 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 relevant medical history, the current diagnosis, and the demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Prior to April 2010, the Veteran's service-connected gout of multiple joints had been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5002. The criteria provide that diseases rated under diagnostic codes 5013 through 5024 should be rated based on limitation of motion of the affected parts as degenerative arthritis, except gout, which should be rated under DC 5002, the criteria for evaluating rheumatoid arthritis. DC 5002 assigns various ratings based on whether rheumatoid arthritis is an active process or is manifested by chronic residuals. The ratings for the active process will not be combined with the residual ratings for limitation of motion or ankylosis. The higher evaluation will be assigned. When rating rheumatoid arthritis as an active process, DC 5002 provides that a 20 percent rating is assigned for one or two exacerbations a year in a well-established diagnosis. A 40 percent rating is assigned for symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year. A 60 percent rating is assigned for less than the criteria for 100 percent, but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods. Finally, a 100 percent rating is assigned for constitutional manifestations associated with active joint involvement that is totally incapacitating. When rating rheumatoid arthritis under the criteria for chronic residuals, DC 5002 provides that the residuals, such as limitation of motion or ankylosis, are to be rated under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added, under DC 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. For the purpose of rating disability from arthritis, the shoulder, elbow, wrist, hip, knee, and ankle are considered major joints; multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities, the interphalangeal, metatarsal and tarsal joints of the lower extremities, the cervical vertebrae, the dorsal vertebrae, and the lumbar vertebrae, are considered groups of minor joints, ratable on a parity with major joints. See 38 C.F.R. § 4.45 (2012). The Veteran was provided a VA examination in October 2005, at which time he was diagnosed with gout of the bilateral knees, ankles, and elbows. Subjectively, the Veteran described his symptoms as pain, swelling, and redness in the affected joints. With respect to his knees, the Veteran indicated that the symptoms occurred as often as 8 times per year, with each occurrence lasting 7 days. His ability to perform daily functions during flare-ups was limited, as he was unable to walk and used crutches for the first 2 to 3 days of a flare-up. He indicated that incapacitating episodes occurred as often as 7 times per year, and lasted for 3 days. Over the past year, he related 6 incidents of incapacitation totaling 20 days. Upon objective examination, the general appearance of the bilateral knee joints was normal. Range of motion testing revealed flexion to 140 degrees and extension to zero degrees, bilaterally; joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Drawer testing and McMurray circumduction testing of the bilateral knees was within normal limits. With respect to his elbows, the Veteran indicated that the symptoms occurred as often as 2 times per year, with each occurrence lasting 6 days. His ability to perform daily functions during flare-ups was limited, as he experienced difficulty with lifting, pushing, pulling, and driving. He indicated that incapacitating episodes occurred as often as 2 times per year, and lasted for 12 days. Over the past year, he related 2 incidents of incapacitation totaling 24 days. Upon objective examination, the general appearance of the bilateral elbow joints was normal. Range of motion testing revealed flexion to 145 degrees, extension to zero degrees, supination to 85 degrees, and pronation to 80 degrees, bilaterally; joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. With respect to his ankles, the Veteran indicated that the symptoms occurred as often as 4 times per year, with each occurrence lasting 7 days. His ability to perform daily functions during flare-ups was limited, as he was unable to walk and used crutches for the first 2 to 3 days of a flare-up. He indicated that incapacitating episodes occurred as often as 4 times per year, and lasted for 4 days. Over the past year, he related 4 incidents of incapacitation totaling 16 days. Upon objective examination, the general appearance of the bilateral ankle joints was normal. Range of motion testing revealed dorsiflexion to 20 degrees and plantar flexion to 45 degrees; joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. In correspondence dated in November 2008, a the Veteran's treating VA physician's assistant described that he experienced an increasing number of flare-ups of his gout over the past 3 to 4 years requiring more usage of Allopurinol and Colchicine. On several occasions, low level narcotics were used to relieve his immediate discomfort. The physician's assistant also indicated that the Veteran had missed several days of work over the past several years due to the intensity of the pain associated with his gout. Applying these findings to the rating criteria, the Board recognizes that the Veteran exhibited full ranges of motion in the bilateral knees, elbows, and ankles at the time of the October 2005 examination, although this examination was not conducted during one of his frequent flare-ups of gout. Motion of the affected joints was noted to be limited due to pain during his flare-ups of gout, as evidenced in his service treatment records, the medical history given at his October 2005 examination, and the November 2008 correspondence from the VA physician's assistant; however, the precise extent of these limitations in terms degrees is uncertain. As such, limitation of motion of the affected joints would be noncompensable under the relevant codes. However, under Diagnostic Code 5002, where the limitation of motion of the specific joint or joints involved is noncompensable under the codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added. As indicated above, for the purpose of rating disability from arthritis, the elbow, knee, and ankle are considered major joints. Accordingly, the Veteran would be entitled to separate 10 percent ratings for the left knee, right knee, left elbow, right elbow, left ankle, and right ankle effective January 1, 2006. The Board notes that, under 38 C.F.R. §§ 4.25, 4.26 (accounting for the bilateral factor), the combined value of these disabilities would be 49, converted to 50 percent as the final degree of disability. This combined 50 percent rating is greater than the single 40 percent rating assigned by the RO for all affected joints prior to April 28, 2010. As such, the Board finds that the Veteran is entitled to separate 10 percent ratings for his gout of the right knee, left knee, right elbow, left elbow, right ankle, and left ankle prior to April 28, 2010. However, the Board finds that the Veteran is not entitled to higher ratings for the affected joints prior to April 28, 2010. Specifically, there was no evidence of weight loss and anemia productive of severe impairment of health, severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods, or constitutional manifestations associated with active joint involvement that are totally incapacitating during this period of time. As such, a higher rating is not warranted under Diagnostic Code 5002 prior to April 28, 2010. Initial Rating Greater than 10 Percent for Gout and Osteoarthritis of the Left Elbow from April 28, 2010, to August 30, 2010 The Board will now consider the propriety of the 10 percent rating for gout and osteoarthritis of the left elbow assigned from April 28, 2010, to August 30, 2010. As mentioned above, the Veteran was provided a VA examination in April 2010, and, based on the results of that examination, in a May 2010 rating decision, the RO assigned a separate 10 percent rating for gout and osteoarthritis of the left elbow under Diagnostic Codes 5017-5207 effective April 28, 2010, the date of the examination. Normal ranges of motion of the elbow are zero degrees in extension, 145 degrees in flexion, 80 degrees of pronation, and 85 degrees of supination. 38 C.F.R. § 4.71, Plate I. The Veteran is left-hand dominant. Under Diagnostic Code 5206, limitation of flexion of the major forearm to 45 degrees warrants a 50 percent rating, to 55 degrees warrants a 40 percent rating, to 70 degrees warrants a 30 percent rating, to 90 degrees warrants a 20 percent rating, to 100 degrees warrants a 10 percent rating, and to 110 degrees warrants a noncompensable rating. 38 C.F.R. § 4.71a. Under Diagnostic Code 5207, limitation of extension of the major forearm to 110 degrees warrants a 50 percent rating, to 100 degrees warrants a 40 percent rating, to 90 degrees warrants a 30 percent rating, to 75 degrees warrants a 20 percent rating, to 60 degrees warrants a 10 percent rating, and to 45 degrees warrants a 10 percent rating. 38 C.F.R. § 4.71a. Under Diagnostic Code 5213, limitation of pronation beyond the middle of arc warrants a 30 percent rating; limitation of pronation beyond the last quarter of arc, with the hand not approaching full pronation, warrants a 20 percent rating; and limitation of supination to 30 degrees or less warrants a 10 percent rating. 38 C.F.R. § 4.71a. At the April 2010 VA examination, the Veteran subjectively described pain, weakness, stiffness, swelling, heat, redness, lack of endurance, locking, deformity, and tenderness of the left elbow. He denied any instances of giving way, fatigability, drainage, effusion, subluxation, or dislocation. The Veteran indicated that he experienced spontaneous flare-ups as often as 3 times per day, each lasting approximately 2 hours. During these flare-ups, he experienced an inability to lift and limitation of range of motion within the joint. He further indicated that the condition had not resulted in any incapacitation within the past 12 months, nor had it caused any overall functional impairment. Upon objective examination, there was evidence of edema, tenderness, and guarding of movement. However, there was no evidence of instability, abnormal movement, effusion, weakness, redness, heat, deformity, malalignment, subluxation, ankylosis, or drainage. Range of motion testing revealed flexion to 145 degrees, extension to 45 degrees, supination to 60 degrees, and pronation to 40 degrees. The May 2010 rating decision awarded the Veteran a separate 10 percent rating for gout and osteoarthritis of the left elbow based on the findings of the April 2010 VA examination which showed left elbow extension limited to 45 degrees. However, applying the results of the April 2010 examination to the applicable Diagnostic Codes reveals that the Veteran's pronation, which was limited to 40 degrees, would warrant a 20 percent rating under Diagnostic Code 5213 because there is a limitation of pronation beyond the last quarter of arc, with the hand not approaching full pronation. A such, the Board finds that the Veteran is entitled to a 20 percent rating for gout and osteoarthritis of the left elbow under Diagnostic Codes 5017-5213 effective April 28, 2010. However, the Board further finds that the Veteran is not entitled to a rating higher than 20 percent for gout and osteoarthritis of the left elbow for the period from April 28, 2010, to August 30, 2010. Specifically, the evidence does not show flexion limited to 70 degrees to warrant a higher evaluation under Diagnostic Code 5206, extension limited to 90 degrees to warrant a higher evaluation under Diagnostic Code 5207, or limitation of pronation beyond the middle of arc to warrant a higher evaluation under Diagnostic Code 5213. Extraschedular Consideration An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extraschedular evaluation. 38 C.F.R. § 3.321(b) (1) (2012). Otherwise, the schedular evaluation is adequate, and referral is not required. Thun, 22 Vet. App. at 116. The schedular ratings in this case are adequate. Ratings in excess of those assigned are provided for certain manifestations of the Veteran's service-connected disabilities on appeal, but those symptoms are not present. The diagnostic criteria also adequately describe the severity and symptomatology of the various joint disabilities over the appeal period. Therefore, the Veteran's disability picture is contemplated by the Rating Schedule; no extraschedular referral is required. ORDER Entitlement to a separate 10 percent rating for gout of the right ankle prior to April 28, 2010, is granted, subject to the applicable regulations concerning the payment of monetary benefits. Entitlement to a separate 10 percent rating for gout of the left ankle prior to April 28, 2010, is granted, subject to the applicable regulations concerning the payment of monetary benefits. Entitlement to a separate 10 percent rating for gout of the right elbow prior to April 28, 2010, is granted, subject to the applicable regulations concerning the payment of monetary benefits. Entitlement to a separate 10 percent rating for gout and osteoarthritis of the left elbow prior to April 28, 2010, is granted, subject to the applicable regulations concerning the payment of monetary benefits. Entitlement to a separate 10 percent rating for gout and osteoarthritis of the right knee prior to April 28, 2010, is granted, subject to the applicable regulations concerning the payment of monetary benefits. Entitlement to a separate 10 percent rating for gout of the left knee prior to April 28, 2010, is granted, subject to the applicable regulations concerning the payment of monetary benefits. Entitlement to a 20 percent rating for gout and osteoarthritis of the left elbow from April 28, 2010, to August 30, 2010, is granted, subject to the applicable regulations concerning the payment of monetary benefits. REMAND The Veteran also seeks entitlement to separate initial ratings greater than 20 percent for gout of the right and left ankles since April 28, 2010; an initial rating greater than 20 percent for gout and osteoarthritis of the left elbow since August 31, 2010; an initial compensable rating for supination impairment associated with gout and osteoarthritis of the left elbow since August 31, 2010; and separate initial ratings greater than 10 percent for gout of the right elbow, left knee, right knee since April 28, 2010. After having carefully considered these matters, and for reasons expressed immediately below, the Board finds that these claims must be remanded for further development. The Veteran was last provided with a VA examination specific to his gout disability in August 2010, and an addendum to that examination report was issued in September 2011. At his July 2012 Travel Board hearing, the Veteran testified that his gout disability had significantly worsened since his most recent VA examination. He additionally testified that his medications were increased from one dose every four hours to two doses every four hours in June 2012. His wife testified that the Veteran gout disability worsened in March 2012. A review of the Veteran's VA treatment records confirms that he was seen in March 2012 and April 2012 for severe, unbearable gout-related pain. As such, the Board finds that the Veteran should be afforded an adequate contemporaneous VA examination as to the severity of the manifestations of his gout disability. See VAOPGCPREC 11-95 (April 7, 1995); Snuffer v. Gober, 10 Vet. App. 400 (1997); Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the veteran with a thorough and contemporaneous medical examination). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA orthopedic examination to determine the current nature and severity of his service-connected manifestations of gout disability, to include the bilateral elbows, ankles, and knees. The claims file and a copy of this Remand must be provided to and reviewed by the examiner in conjunction with the examination. The VA examiner is requested to identify all orthopedic pathology related to the Veteran's service-connected gout disability. All necessary tests, to include X-rays and range of motion studies of the affected joints in degrees, should be conducted. The examiner should also identify whether the Veteran has additional functional loss from his gout disability due to pain, weakened movement, excess fatigability, or incoordination resulting from the respective service-connected disabilities. See DeLuca v. Brown, 8 Vet. App. 202 (1995). A complete rationale must be provided for any opinion expressed, to include reference to specific documents in the claims file as appropriate. 2. Notify the Veteran that it is his responsibility to report for the examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). If the Veteran does not report for the aforementioned examination, obtain documentation showing that notice scheduling the examination was sent to the last known address of record, and indicate whether any notice that was sent was returned as undeliverable. 3. After undertaking the development above, readjudicate the Veteran's claims. If any benefit sought on appeal remains denied, provide a supplemental statement of the case to the Veteran and his representative, and an appropriate period of time in which to respond. 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). ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs