Citation Nr: 1311768 Decision Date: 04/09/13 Archive Date: 04/19/13 DOCKET NO. 08-03 462 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 30 percent for migraine headaches. 2. Entitlement to a higher rating for dysthymic disorder, rated as 30 percent prior to August 16, 2011, and as 70 percent since August 16, 2011. 3. Entitlement to a rating in excess of 20 percent for a cervical spine disability. 4. Entitlement to a higher rating for a right shoulder disability, rated as 10 percent prior to August 15, 2011, and as 20 percent since August 15, 2011. 5. Entitlement to a rating in excess of 10 percent for a left elbow disability. 6. Entitlement to a rating in excess of 10 percent for a right hip disability. 7. Entitlement to a rating in excess of 10 percent for a right knee disability. 8. Entitlement to a rating in excess of 10 percent for a left knee disability. REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs ATTORNEY FOR THE BOARD A.M. Ivory, Counsel INTRODUCTION The Veteran served on active duty from August 1989 to October 2003. This case is before the Board of Veterans' Appeals (Board) on appeal from a May 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, that denied the benefits being sought on appeal. That decision also proposed a reduction of the Veteran's 20 percent disability rating for a cervical spine disability to 0 percent. However, a June 2005 rating decision continued the 20 percent disability rating. In July 2011, the Board remanded all of the issues on appeal for VA examinations. As the requested development has been completed, no further action to ensure compliance with the remand directive is required. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). During the pendency of the appeal, the September 2012 rating decision granted the Veteran entitlement to a total disability rating for individual unemployability (TDIU). Thus, the September 2012 rating decision granted all of the benefits sought on appeal, and thus, the issue of entitlement to a TDIU is no longer on appeal. The September 2012 rating decision also granted the Veteran a higher initial rating of 70 percent for the service-connected dysthymic disorder, effective August 16, 2011, and a higher initial rating of 20 percent for the service-connected right shoulder disability, effective August 15, 2011. Inasmuch as higher ratings for the service-connected dysthymic disorder and right shoulder disability are available, and inasmuch as a claimant is presumed to be seeking the maximum available benefit for a given disability, the claims for higher ratings, as reflected on the title page, remain viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In a February 2008 substantive appeal, the Veteran requested a hearing before the Board. However, in August 2010, the Veteran withdrew her hearing request. Thus, her hearing request is deemed withdrawn. 38 C.F.R. § 20.704(e) (2012). A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. The service-connected migraine headaches are not shown to be productive of a clinical picture with manifestations of very frequent and completely prostrating and prolonged attacks that cause severe economic inadaptability. 2. Since the date of claim, the Veteran's dysthymic disorder has been manifested by avoidance behavior, difficulty with social interactions, crying spells, and hyperventilation. However, at no point during the pendency of the appeal has the Veteran's dysthymic disorder been manifested by total occupational and social impairment. 3. The Veteran's cervical spine disability is not manifested by forward flexion of the cervical spine 15 degrees or less, or favorable ankylosis of the entire cervical spine. 4. The Veteran's peripheral neuropathy of the left upper extremity is manifested by mild incomplete paralysis and not by moderate incomplete paralysis. 5. Since the date of claim, the Veteran's service-connected right shoulder disability has been manifested by limitation of the arm at shoulder level; however, it is not manifested by motion limited to midway between the side and shoulder level or by fibrous union. 6. The Veteran's service-connected left elbow disability is manifested by 135 degrees flexion and no limitation of extension. It is not manifested by limitation of flexion to 70 degrees, limitation of extension to 90 degrees, flexion limited to 100 degrees and extension limited to 45 degrees, or by limitation of pronation. 7. The Veteran's service-connected bursitis of the right hip is manifested by normal range of motion and not by flexion of the thigh limited to 30 degrees. 8. The Veteran's service-connected right knee disability is manifested by osteoarthritis, normal range of motion, and no instability or subluxation. 9. The Veteran's service-connected left knee disability is manifested by osteoarthritis, normal range of motion, and no instability or subluxation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for the service-connected migraine headaches have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.124a, Diagnostic Code 8100 (2012). 2. Since the date of claim, the criteria for the assignment of a rating of 70 percent, but not higher, for dysthymic disorder were met. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9433 (2012). 3. The criteria for a rating in excess of 20 percent for the service-connected cervical spine disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.71a, Diagnostic Code 5237 (2012). 4. The criteria for an initial rating of 10 percent, but not higher, for peripheral neuropathy of the left upper extremity have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.124a, Diagnostic Code 8515 (2012). 5. Since the date of claim, the criteria for a rating of 20 percent, but not higher, for the service-connected right shoulder disability have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5200, 5201, 5202, 5203 (2012). 6. The criteria for a rating in excess of 10 percent for the service-connected left elbow disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5024, 5206, 5207, 5208, 5213 (2012). 7. The criteria for a rating in excess of 10 percent for the service-connected right hip disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5252 (2012). 8. The criteria for a rating in excess of 10 percent for the service-connected right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (2012). 9. The criteria for a rating in excess of 10 percent for the service-connected left knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act (VCAA), codified, in part, at 38 U.S.C.A. § 5103, was signed into law on November 9, 2000. Implementing regulations are 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, she was provided notice of the VCAA in March 2005. The VCAA letter indicated the types of information and evidence necessary to substantiate the claims, 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 September 2012 Supplemental Statement of the Case (SSOC) also pertained to the downstream disability rating and effective date elements of her claims. Dingess v. Nicholson, 19 Vet. App. 473 (2006); see also Mayfield and Pelegrini, both supra. The Board finds that no prejudice to the Veteran will result from the adjudication of her claims at this time. Remanding this case back to the RO for further VCAA development would be an essentially redundant exercise and would result only in additional delay with no benefit flowing 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 herein decided has been identified and obtained, to the extent possible. The evidence of record includes VA outpatient treatment reports, VA examinations, and statements and testimony from the Veteran and her representative. The Veteran was afforded VA examinations in April 2005 and April 2011. The Board finds that these examinations are adequate for rating purposes because they convey pertinent medical findings stated in terms conforming to the applicable rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994). The Veteran has not indicated that she 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 her representative have been accorded ample opportunity to present evidence and argument in support of her 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). II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. VA should interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. When considering functional impairment caused by a service-connected disorder, evaluations should be based on an assessment of the lack of usefulness, and adjudicators should consider the effects of the disabilities upon the person's ordinary activity. 38 C.F.R. § 4.10. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Migraine Headaches The May 2005 RO rating decision continued the Veteran's 30 disability rating for migraine headaches. The Veteran's migraine headaches have been rated under 38 C.F.R. § 4.124a, Diagnostic Code 8100. Under Diagnostic Code 8100, a 10 percent evaluation is warranted for characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is granted if there are prostrating attacks occurring on an average once a month over the last several months. The highest rating is 50 percent, which is assignable for very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability. At the April 2005 VA examination the Veteran reported that in the past, her headaches were severe. However, she stated that two weeks ago she started a new medication that she took at the onset of her headaches, and the frequency of the headaches were now only one to two episodes. In the past, her headaches lasted up to three days, and now with the new medication, they were shortened to less than two hours. She felt considerable improvement and indicated that they were less of a severe problem. She stated that she had some nausea with the headaches but no vomiting. She also had some dizziness and intolerance to light and sound. She reported no major migraine headaches over the last three weeks. It was noted that the Veteran's migraines seemed to be better controlled with her new medication, and they affected her employability to a limited extent. The Veteran was afforded a VA examination in April 2011. She reported that two to three times a month, she had headaches where her whole head hurt, and that if she opened her eyes, it caused her head to hurt more. If she did not take her medication on time, the headache lasted four to five days, but if she did take her medication on time, then it lasted one day. The severity was a 10, and the Veteran reported that every migraine was prostrating. She reported that she could not do anything during an attack. She was diagnosed with migraines of mild functional limitation. It was also noted that she was employable in sedentary and physical occupations consistent with her education and experience if she chooses. After careful review of the entire record, the Board finds that the service-connected migraine headaches are not shown to be productive of a disability picture manifested by very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability. In May 2005, it was noted that the Veteran's migraines seemed to be better controlled with her new medication and that they affected her employability to a limited extent. While the Veteran reported in April 2011 that she had prostrating headaches about two to three times a month, they were diagnosed as only mildly functionally limiting. In addition, the April 2011 VA examiner found the Veteran to be employable. Thus, the Board finds that the Veteran's migraine headaches are not manifested as severe economic disruption due to her migraine headaches. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that though the Veteran stated that her migraine headaches interfered with work, her service-connected migraine headaches are contemplated by the rating criteria, and there is no evidence of an exceptional or unusual disability picture. In addition, the VA examiner stated that she was able to work as a result of her migraine headaches. Therefore, an extraschedular rating is not warranted. Accordingly, the Board finds the Veteran's migraine headaches are not manifested by very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability. Thus, a rating in excess of 30 percent for the service-connected migraine headaches is not warranted. Dysthymic Disorder The May 2005 rating decision continued the Veteran's 30 percent disability rating for her service-connected dysthymic disorder. During the pendency of the appeal, the September 2012 rating decision granted the Veteran a higher rating of 70 percent for the service-connected dysthymic disorder, effective August 16, 2011. The RO assigned the Veteran's 30 and 70 percent disability ratings for the dysthymic disorder pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9433 (reflecting service connection for dysthymic disorder). According to 38 C.F.R.§ 4.126(a), a mental disorder shall be evaluated "based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of examination." 38 C.F.R. § 4.126(a) (2012). The regulations establish a general rating formula for mental disorders. 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). The general rating formula for evaluating disability due to mental disorders is found at 38 C.F.R. § 4.130. The Veteran's dysthymic disorder is currently rated as 30 percent disabling prior to August 16, 2011, and 70 percent disabling since August 16, 2011, under 38 C.F.R.§ 4.130, Diagnostic Code 9433. A rating of 10 percent is assignable for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). To warrant a 50 percent rating under that code, the evidence must show occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. To warrant the next higher (70 percent) rating, the evidence must show occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and an inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. In rating the severity of the Veteran's service-connected psychiatric disability under the criteria listed above, the Board is aware of the fact that psychiatric health care providers have their own system for rating psychiatric disability. This is the Global Assessment of Functioning (GAF) rating scale, and it is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV); Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing DSM-IV. The GAF scale score assigned does not determine the disability rating VA assigns; rather, it is one of the medical findings employed in that determination. The medical evidence shows a number of GAF scores have been assigned during the pendency of this claim. See Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). An examiner's classification of the level of psychiatric impairment, by words or by a score, is to be considered but is not determinative of the percentage rating to be assigned. VAOPGCPREC 10-95 (March 31, 1995). A GAF score, however, is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). A review of the Veteran's claims file reveals that the Veteran has been assigned a GAF score between 41 and 50. GAF scores between 41 and 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). The Board finds that after a review of the Veteran's claims file and affording the Veteran the benefit of the doubt, a rating of 70 percent, but no higher, is warranted since the date of claim. At the Veteran's April 2005 VA examination, she reported that she has been experiencing a worsening of her anxiety disorder and lately has become more afraid to face people and leave her house. She reported numerous crying spells and hyperventilation. She was afraid of talking to people and stated that when she worked as a hair stylist, she would run to the bathroom each time a customer walked in. She was on medication that helped improve her condition, but she still had difficulty with social interactions. On examination, she exhibited some signs of nervousness and anxiety. She spoke fast and in bursts. She reported that she got lost on her way to the examination though she had been there in the past. She also reported that on one occasion, she was crawling on the ground because of her anxiety and made it into a game with her six year old so he would not guess how anxious she was. The Veteran was afforded a VA examination in August 2011. She reported that sometimes she had a hard time getting started and did not get started. She indicated that she never knew from day to day or minute to minute how she was going to feel. On examination, she was noted to have a depressed mood; anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, direction, or recent events; flattened affect; panic attacks more than once a week; disturbances of motivation and mood; difficulty in establishing and maintaining effective and social relationships; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; spatial disorientation; inability to establish and maintain effective relationships; and persistent delusions or hallucinations. At another August 2011 VA examination, the Veteran reported that she was not able to work because she did not feel like getting up and that sometimes she was confused. She reported that she was hurting everywhere and that she could not look up without pain and could not keep her arms elevated. She had three children and directed and guided them with her 18 year old daughter helping out at home. She stated that she did not do much on a good day but might go grocery shopping with her daughter because her daughter could help her pick things up. Other than her activities of daily living, she watched television and hobbled around the house. The Board finds that since the date of claim, the Veteran's symptoms have been manifested by deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: decreased interest in social activities, avoidance behavior, difficulty in adapting to stressful circumstances (including work or a work like setting), and an inability to establish and maintain effective relationships. Therefore, a 70 percent evaluation is warranted. However, the Board finds that while the Veteran's dysthymic disorder warrants a 70 percent disability rating, at no point during the pendency of the appeal, is the Veteran's dysthymic disorder manifested as total occupational and social impairment. While there is evidence of persistent delusions or hallucinations, the Veteran's symptomatology as a whole does not mostly approximate the criteria for total occupational and social impairment. On examination, it was noted that the Veteran spoke in fast bursts; however, there was no indication that she had gross impairment in thought processes or communication. The only behavior the Veteran reported was related to anxiety. Specifically, it was the inability to greet her customers and being afraid of talking to customers. However, there is no evidence of inappropriate behavior or persistent danger of hurting self or others. There is also no evidence of the intermittent inability to perform activities of daily living as the result of the Veteran's dysthymic disorder. Instead, the Veteran reported that she was able to direct and guide her children and only needed help doing the grocery shopping because she could not pick up items as the result of her shoulders. The only disorientation that the Veteran reported was spatial disorientation, and thus, there is no evidence of disorientation to time or place. The Veteran's memory loss was noted to be mild, and there was no indication that it was manifested as memory loss for names of close relatives, own occupation, or own name. Therefore, the Board finds that the Veteran's psychiatric symptoms do not demonstrate a disability picture that more nearly approximates the higher 100 percent evaluation. As noted above, in exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Board finds that the Veteran's dysthymic disorder is contemplated by the rating criteria. The Veteran reported that she could not keep her arms elevated and that she did have anxiety dealing with customers; however, the Board finds that these dysthymic disorder symptoms were all taken into consideration in the grant of her 70 percent disability rating. Thus, the rating criteria are therefore adequate to evaluate the Veteran's disability, and referral for consideration of extraschedular rating is not warranted. In sum, the Board finds that since the date of claim, the Veteran's dysthymic disorder is manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Thus, a 70 percent disability rating is warranted since the date of claim. However, the Board also finds that the Veteran's dysthymic disorder is not manifested by total occupational and social impairment. Therefore, a 70 percent disability rating, but not higher, is warranted since the date of claim. Cervical Spine Disability The March 2005 rating decision proposed to decrease the Veteran's 20 percent disability rating for her service-connected cervical spine disability; however, the June 2005 rating decision continued the Veteran's 20 percent disability rating. Thus, the Veteran is currently rated as 20 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5237. The former rating criteria for evaluating the spine were in effect through September 22, 2002, and then were revised beginning on September 23, 2002. Effective September 26, 2003, the diagnostic codes were renumbered and criteria for evaluating disorders of the spine were substantially revised. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243. VA General Counsel found that an amended version shall apply only to periods from and after the effective date of the amendment. See VAOPGCPREC 7-2003 (Nov. 19, 2003). However, the prior version(s) shall apply to periods preceding the amendment but may also apply after the effective date of the amendment if more favorable to the claimant. VAOGCPREC 3-2000 (Apr. 10, 2000) (see also 38 U.S.C.A. § 5110(g) (a liberalizing law shall not be earlier than the effective date thereof)). See, too, 38 C.F.R. § 3.114 and Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Since the Veteran filed her claim for an increased rating in March 2005, only the newest rating criteria applies. Under 38 C.F.R. § 4.71a, Diagnostic Code 5237, a 10 percent evaluation is in order for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or abnormal spinal contour; or a vertebral body fracture with loss of 50 percent or more of height. A 20 percent evaluation is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; a combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent evaluation is assigned in cases of forward flexion of the cervical spine of 15 degrees or less, or favorable ankylosis of the entire cervical spine. A 40 percent evaluation is in order for unfavorable ankylosis of the entire cervical spine. A 100 percent evaluation contemplates unfavorable ankylosis of the entire spine. Also, under these revisions, the "combined range of motion" refers to the sum of forward flexion, extension, left and right lateral flexion, and left and right rotation. 38 C.F.R. § 4.71a (Plate V) indicates that normal range of motion of the thoracolumbar spine encompasses flexion to 90 degrees and extension, bilateral lateral flexion, and bilateral rotation to 30 degrees. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. In addition, the Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. The Board notes that the terms "mild," "moderate" and "severe" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The Court has held that functional loss, supported by adequate pathology and evidenced by visible behavior of the Veteran undertaking the motion, is recognized as resulting in disability. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.10, 4.40, 4.45. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. In order for the Veteran's cervical spine to warrant a higher rating, there needs to be evidence of forward flexion of the cervical spine of 15 degrees or less, or favorable ankylosis of the entire cervical spine. However, the Veteran's range of motion at her April 2005 VA examination was within normal limits, and at the August 2011 VA examination, the Veteran's range of motion was limited to 35 degrees with no pain. Thus, the Veteran does not meet the rating criteria for a higher rating. The Board also finds that there is no evidence of functional loss after repetitive use or due to pain, weakness, or incoordination. At the April 2005 VA examination, it was noted that the Veteran had moderate to severe pain during a flare-up and additional limitation that varied between 25 and 50 percent with the ability to turn her neck, stiff neck muscles, and spasms. At the August 2011 VA examination, it was noted that after repetitive use, the Veteran's range of motion was still the same, 35 degrees. It was also noted that the Veteran had no functional limitation for her cervical strain and had only some mild functional limitations as the result of her degenerative disk disease/degenerative joint disease/spondylosis of the cervical spine. Thus, the Board finds that any additional limitations have been contemplated by the rating criteria. After a careful review of the medical evidence, the preponderance of the evidence is against a separate rating for any bladder impairments. There is no evidence that the Veteran ever reported any bowel or bladder problems related to her service-connected cervical spine disability. Therefore, the Board finds that there is no medical evidence that the Veteran has bladder dysfunction that is secondary to her cervical spine disability. Accordingly, a separate rating for bladder impairment is not warranted. As noted above, in exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Board finds that the orthopedic manifestations of the Veteran's cervical spine disability are contemplated by the rating criteria. The Board finds that there is no evidence that the Veteran's cervical spine disability is manifested by frequent hospitalizations or a marked interference with employment. In addition, it was noted at the August 2011 VA examination that based upon her service-connected cervical spine condition alone, the Veteran is employable in sedentary/physical occupations consistent with her education and experience if she chooses. Thus, the Board finds that the rating criteria are adequate to evaluate the Veteran's disability, and referral for consideration of extraschedular rating is not warranted. In sum, the Board finds that the Veteran's cervical spine disability is manifested by range of motion for forward flexion to 35 degrees and not by forward flexion of the cervical spine of 15 degrees or less, or favorable ankylosis of the entire cervical spine. Thus, a rating in excess of 20 percent is not warranted for the orthopedic manifestations of the Veteran's cervical spine disability. Neurological Manifestations After a careful review of the Veteran's claims file, the Board finds that the Veteran warrants a separate disability rating for neuropathy of the left upper extremity in accordance with the Notes following the General Rating Formula for Diseases and Injuries of the Spine, which provide further guidance in rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Under 38 C.F.R. § 4.124a, Diagnostic Code 8515 provides ratings for paralysis of the median nerve. Diagnostic Code 8515 provides that mild incomplete paralysis is rated 10 percent disabling on the major side and 10 percent on the minor side; moderate incomplete paralysis is rated 30 percent disabling on the major side and 20 percent on the minor side; and severe incomplete paralysis is rated 50 percent disabling on the major side and 40 percent on the minor side. Complete paralysis of the median nerve, with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances, is rated 70 percent disabling on the major side and 60 percent on the minor side. The Board notes that the term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. At the Veteran's August 2011 VA examination, it was noted that though the Veteran had a normal pinprick, she did have radicular pain due to radiculopathy. The pain was noted to be only on the left upper extremity and was described as mild intermittent pain (usually dull); mild paresthesias and/or dysesthesias; and mild numbness. The Veteran was also noted to have neck pain radiation from the posterior neck downward into the left upper extremity, as well as tingling and numbness in the left upper extremity. The upper radicular group, middle radicular group, and lower radicular group were all noted to be involved. It was noted that despite these subjective symptoms, there was no objective evidence of radiculopathy. The Board finds that though there is no objective evidence of radiculopathy of the left upper extremity, there is evidence of subjective symptoms of involvement of the upper radicular group, middle radicular group, and lower radicular group. Thus, resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran warrants a separate disability rating of 10 percent for mild radicular symptoms to the left upper extremity. However, the Board finds that there is no evidence that the Veteran's left upper extremity radiculopathy is manifested as moderate radiculopathy. Therefore, the Board finds that the Veteran warrants a separate rating of 10 percent, but not higher. In sum, the Board finds that in accordance with Note 1 following the General Rating Formula for Diseases and Injuries of the Spine, the Veteran warrants a separate 10 percent disability rating, but not higher, for mild radiculopathy of the left upper extremity secondary to her service-connected cervical spine disability. Right Shoulder Disability The May 2005 rating decision continued the Veteran's 10 percent disability rating for her service-connected right shoulder disability. During the pendency of the appeal, a September 2012 rating decision granted the Veteran a higher rating of 20 percent effective August 15, 2011. Under 38 C.F.R. § 4.71a, Diagnostic Code 5200, ankylosis of the scapulohumeral articulation (which moves as one piece), when in a favorable position, with abduction to 60 degrees, and ability to reach the mouth and head is retained, a 30 percent evaluation is warranted for the major extremity and 20 percent for the minor extremity. When in an intermediate position between favorable and unfavorable, 40 percent is warranted for the major extremity and 30 percent for the minor extremity. Under Diagnostic Code 5201, limitation of an arm at the shoulder level warrants a 20 evaluation whether it is the major or minor extremity. When motion is limited to midway between the side and shoulder level, a 30 percent evaluation is warranted for the major extremity and 20 percent for the minor extremity. When motion is limited to 25 degrees from the side, a 40 percent evaluation is warranted for the major extremity and 30 percent for the minor extremity. Under 38 C.F.R. § 4.71a, Diagnostic Code 5202, a 20 percent is warranted for impairment of the humerus, regardless of whether the major or minor extremity is affected, when there is either malunion with moderate deformity or when there are recurrent dislocations of the scapulohumeral joint which are infrequent and there is guarding of movement only at the shoulder level. For the next higher rating in excess of 20 percent for impairment of the humerus, of 40 percent there must be fibrous union. Diagnostic Code 5203 provides ratings for other impairment of the clavicle or scapula. Malunion of the clavicle or scapula is rated as 10 percent for the major shoulder and 10 percent for the minor shoulder. Nonunion of the clavicle or scapula without loose movement is rated as 10 percent for the major shoulder and 10 percent for the minor shoulder; nonunion of the clavicle or scapula with loose movement is rated as 20 percent for the major shoulder and 20 percent for the minor shoulder. Dislocation of the clavicle or scapula with loose movement is rated as 20 percent for the major shoulder and 20 percent for the minor shoulder. Diagnostic Code 5203 provides an alternative rating based on impairment of function of the contiguous joint. 38 C.F.R. § 4.71a. Normal flexion (forward elevation of the arm) and normal abduction (movement of the arm away from the side) of the shoulder are to 180 degrees. Normal internal rotation and external rotations of the shoulder are to 90 degrees. 38 C.F.R. § 4.71, Plate 1 (2012). Ankylosis is immobility and consolidation of a joint due to disease, injury or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992) (memorandum decision); Nix v. Brown, 4 Vet. App. 462, 465 (1993); and Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. The Board notes that VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). At the Veteran's April 2005 VA examination, she reported that she occasionally had flare-ups of her right shoulder disability, but she did not have any current complaints. The Veteran was afforded a VA examination in August 2011. She reported constant pain in her right shoulder and indicated that reaching behind and above shoulder level to do any task was difficult. The Veteran's range of motion for both her right shoulder flexion and abduction was 90 degrees with objective evidence of painful motion at 85 degrees. After repetitive motion, the Veteran's range of motion was still 90 degrees for flexion and abduction. The Veteran reported that she had no flare-ups that impacted the function of her shoulder. It was noted that x-ray studies revealed degenerative or traumatic arthritis on the right side. The functional impact was that it was very difficult for her to hold her right arm above shoulder level to perform any overhead task. The VA examiner diagnosed the Veteran with service connection of the right shoulder impingement with mild functional limitation and right shoulder AC joint degeneration with mild functional limitation. It was noted that based on the service-connected condition alone, the Veteran was employable in sedentary/light duty occupations consistent with her education/experience, if she so chooses. In order for the Veteran to warrant a rating in excess of 10 percent prior to August 15, 2011, there needs to be evidence of limitation of the arm at shoulder level, impairment of the humerus, nonunion of the clavicle or scapula with loose movement, or dislocation or the clavicle or scapula with loose movement. Though the Veteran reported at her April 2005 VA examination that she had no current complaints, it was noted at the August 2011 VA examination that she was unemployed for the past four years because she could not lift her arm in order to work as a hairdresser. In addition, at the August 2011 VA examination, the Veteran's right shoulder was manifested by limitation of the arm at shoulder level. Therefore, the Board finds that the Veteran warrants a 20 percent disability rating since the date of claim. In order for the Veteran to warrant a rating higher than 20 percent since the date of claim, there needs to be evidence that the Veteran's right shoulder is manifested by motion to midway between the side and shoulder level or by fibrous union. However, at the April 2005 VA examination, she had no current complaints, and at the August 2011 VA examination, her range of motion for both her right shoulder flexion and abduction was 90 degrees with objective evidence of painful motion at 85 degrees. After repetitive motion, the Veteran's range of motion was still 90 degrees for flexion and abduction. In addition, the Board finds that throughout the pendency of the appeal, there is no evidence of any additional functional limitations after repetitive use or by pain, weakness, or incoordination. Moreover, the Veteran stated that it was very difficult for her to hold her right arm above shoulder level to perform any overhead task. Thus, the Board finds that there is no evidence that since the date of claim, the Veteran's right shoulder disability was manifested by motion limited to midway between the side and shoulder level; therefore, a rating higher than 20 percent is not warranted. As noted above, in exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Board finds that the Veteran's right shoulder disability is contemplated by the rating criteria. The Board finds that there is no evidence that the Veteran's right shoulder disability is manifested by frequent hospitalizations or a marked interference with employment. In addition, it was noted at the August 2011 VA examination that based upon her service-connected right shoulder impingement condition alone, the Veteran is employable in a sedentary/physical occupation consistent with her education and experience if she chooses. Thus, the Board finds that the rating criteria are adequate to evaluate the Veteran's disability, and referral for consideration of extraschedular rating is not warranted. In sum, the Board finds that since the date of claim, the Veteran's right shoulder disability has been manifested by limitation of the arm at shoulder level, impairment of the humerus, nonunion of the clavicle or scapula with loose movement, or dislocation or the clavicle or scapula with loose movement. However, at no point during the pendency of the appeal was the Veteran's right shoulder disability manifested by motion limited to midway between the side and shoulder level or by fibrous union. Thus, a 20 percent disability rating, but not higher, is warranted since the date of claim. Left Elbow Disability The May 2005 rating decision continued the Veteran's 10 percent disability rating for her service-connected left elbow disability. The RO granted the rating by analogy to tenosynovitis under 38 C.F.R. § 4.71a, Diagnostic Code 5099-5024, which provides that such a disability should be rated based on limitation of motion. The Board notes that as there is no medical evidence of ankylosis, fracture, or malunion or nonunion of the major bone structures, Diagnostic Codes 5205, 5210-5212 do not apply. In June 2006, the RO continued the Veteran's 10 percent disability rating for her service-connected tendonitis of the left elbow. Under Diagnostic Code 5206, limitation of flexion of the non-dominant forearm warrants a 10 percent rating if flexion is limited to 100 degrees, a 20 percent rating if limited to 70 degrees, a 30 percent rating if limited to 55 degrees, and a 40 percent rating if limited to 45 degrees. Under Diagnostic Code 5207, limitation of extension of the non-dominant forearm warrants a 10 percent rating if limited to 45 to 60 degrees, a 20 percent rating if limited to 90 degrees, a 30 percent rating if limited to 100 degrees, and a 40 percent rating if limited to 110 degrees. Under Diagnostic Code 5208, a 20 percent rating is warranted if flexion is limited to 100 degrees and extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5208. Under Diagnostic Code 5213 for the non-dominant forearm, limitation of supination to 30 degrees or less warrants a 10 percent rating. Limitation of pronation warrants a 20 percent rating. Higher ratings are warranted for fixation in certain positions. Under 38 C.F.R. § 4.71a, Diagnostic Code 5024, tenosynovitis is rated on limitation of motion of the affected parts, as degenerative arthritis. Degenerative arthritis established by X-ray findings are rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. In the absence of limitation of motion, a 10 percent evaluation will be assigned where there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups. At the Veteran's April 2005 VA examination, she reported that she occasionally had flare-ups of the left elbow but she not have any current complaints. At the Veteran's August 2011 VA examination, she reported flare-ups two to three times a month that lasted four to seven days. During a flare-up, she could not move the elbow and had difficulty doing any task with the left upper extremity. As a baseline, she has a constant low grade pain in the elbow. The Veteran's range of motion for flexion was to 135 degrees with painful motion at 130 degrees, and there was no limitation of extension. After repetitive use testing, there was no change in range of motion, but it was also noted that there was less movement than normal due to left elbow osteophyte and pain. However, there was no functional loss of the left upper extremity, weakened movement, excess fatigability, incoordination, swelling, deformity, or atrophy of disuse. The VA examiner further noted that there was no loss of function with repetitive use, except as noted. The examiner also found no loss of function due to flare-ups and indicated that the loss could not be determined without resorting to mere speculation. It was noted that an August 2011 x-ray study revealed osteophyte arising from the anterior articular portion of the distal humerus at the coronoid articulation. The VA examiner diagnosed the Veteran with osteoarthritis of the left elbow with mild functional limitation and no functional limitation of the service-connected left elbow condition. It was noted that the Veteran was employable in sedentary/physical occupations consistent with her education and experience if she so chooses. After a careful review of the Veteran's claims file, the Board finds that the Veteran's left elbow disability does not warrant a rating in excess of 10 percent. Under Diagnostic Code 5206, the Veteran's left elbow would need to be manifested by limitation of flexion to 70 degrees; however, her range of motion for flexion was to 135 degrees. Under Diagnostic Code 5207, the Veteran's left elbow was not manifested by range of motion for extension to 90 degrees, and there is no evidence that the Veteran has any limitation of extension. Thus, since the Veteran's range of motion for flexion is 135 degrees and there is no limitation of extension, she does not meet the criteria under Diagnostic Code 5208, which is flexion limited to 100 degrees and extension limited to 45 degrees. In addition, there is no evidence of limitation of pronation for a higher rating under Diagnostic Code 5213. The Board also finds that though there was less movement after repetitive testing due to pain, there was no evidence of functional loss, weakness of movement, excess fatigability, incoordination, swelling, deformity, or atrophy of disuse. Thus, the Board finds that the Veteran's left elbow disability does not warrant a rating higher than 10 percent. As noted above, in exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Board finds that the Veteran's left elbow disability is contemplated by the rating criteria. The Board finds that there is no evidence that the Veteran's left elbow disability is manifested by frequent hospitalizations or a marked interference with employment. In addition it was noted at the August 2011 VA examination that, based upon her service-connected left elbow condition alone, the Veteran is employable in a sedentary/physical occupations consistent with her education and experience if she chooses. Thus, the Board finds that the rating criteria are adequate to evaluate the Veteran's disability, and referral for consideration of extraschedular rating is not warranted. In sum, the Board finds that the Veteran's left elbow disability is manifested by range of motion for flexion of 135 degrees and no limitation of extension. Thus, her left elbow disability is not manifested by limitation of flexion to 70 degrees, limitation of extension to 90 degrees, flexion limited to 100 degrees and extension limited to 45 degrees, or by limitation of pronation. Therefore, a rating higher than 10 percent for the left elbow disability is not warranted. Right Hip Disability The May 2005 rating decision continued the Veteran's 10 percent disability rating for her service-connected bursitis of the right hip. The Veteran is currently rated a 10 percent disability rating under 38 C.F.R. § 4.71a, Diagnostic Code 5252. Diagnostic Code 5252 provides ratings based on limitation of flexion of the thigh. A 10 percent disability rating is for flexion of the thigh that is limited to 45 degrees; a 20 percent rating is for flexion of the thigh that is limited to 30 degrees; a 30 percent rating is for flexion of the thigh that is limited to 20 degrees; and a 40 percent rating is for flexion of the thigh that is limited to 10 degrees. Normal ranges of motion of the hip are from hip flexion from 0 degrees to 125 degrees, and hip abduction from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. At the Veteran's April 2005 VA examination, she reported that she occasionally had flare-ups of the right hip but did not have any current complaints. The Veteran was afforded a VA examination in August 2011, and she reported constant pain, but no flare-ups that impacted the function of the hip or thigh. The Veteran's range of motion for flexion was to 120 degrees with no objective evidence of painful motion, and extension ended at greater than 5. Abduction was lost beyond 10 degrees, but adduction was not limited so that the Veteran could not cross her legs, and her rotation was not limited such that she could not toe out more than 15 degrees. It was noted that there was no functional loss or impairment for the right lower extremity. It was noted that the Veteran used a cane on a regular basis. The Board finds that after a careful review of the Veteran's claims file, the Veteran's bursitis of the right hip does not warrant a higher rating in excess of 10 percent. In order for the Veteran to warrant a higher rating, her right hip must be manifested by flexion of the thigh limited to 30 degrees; however, at the August 2011 VA examination her range of motion for flexion was to 120 degrees. Thus, the Board finds that the Veteran does not warrant a higher rating in excess of 10 percent for bursitis of the right hip. In addition, there is no objective evidence of painful motion after repetitive use, nor is there evidence of any functional loss or impairment of the right hip. As noted above, in exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Board finds that the Veteran's right hip disability is contemplated by the rating criteria. The Board finds that there is no evidence that the Veteran's right hip disability is manifested by frequent hospitalizations or a marked interference with employment. In addition, it was noted at the August 2011 VA examination that the Veteran's right hip did not impact her ability to work. Thus, the Board finds that the rating criteria are adequate to evaluate the Veteran's disability, and referral for consideration of extraschedular rating is not warranted. In sum, the Veteran's bursitis of the right hip was manifested by range of motion for flexion to 120 degrees and 30 degrees for extension. Therefore, the Board finds that the Veteran's bursitis of the right hip does not warrant a higher rating in excess of 10 percent. Bilateral Knee Disabilities The May 2005 rating decision continued the Veteran's 10 percent disability ratings for the Veteran's service-connected right knee disability and left knee disability. The Board notes that the relevant diagnostic criteria are Diagnostic Codes 5003, 5010, 5256-5262. Diagnostic Code 5010, which addresses traumatic arthritis, provides ratings for arthritis due to trauma, substantiated by x-ray findings will be rated as degenerative arthritis, Diagnostic Code 5003. Diagnostic Code 5003 provides that when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic 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 Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, warrants a 10 percent evaluation; with the addition of occasional incapacitating exacerbations, a 20 percent evaluation is warranted. The rating codes for limitation of motion of the leg state that under 38 C.F.R. § 4.71a, Diagnostic Code 5260, a 10 percent rating is warranted where flexion of the leg is limited to 45 degrees; a 20 percent rating is warranted where flexion is limited to 30 degrees; and a 30 percent rating is appropriate where flexion is limited to 15 degrees. Under 38 C.F.R. § 4.71a, Diagnostic Code 5261, a 10 percent rating is appropriate where extension of the leg is limited to 10 degrees; a 20 percent rating is warranted for extension limited to 15 degrees; a 30 percent rating is warranted for extension limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is warranted for extension limited to 45 degrees. Under the provisions of 38 C.F.R. § 4.40 the disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Painful motion with the joint or particular pathology, which produces a disability, warrants the minimum compensation. DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran was afforded a VA examination in April 2005, and she reported that after surgery to the left knee in 2000, her pain worsened and she was diagnosed with degenerative joint disease. She also reported that she wore a knee brace on her left knee. She reported no constitutional symptoms and was on medication. She reported that her job activities were affected in that she could not do prolonged standing or walking. She reported that she could not dance, crawl, play games, or do prolonged driving. On examination of the left knee, there was no erythema and inflammation or gross demonstration of pain with movement; there was mild tenderness. The Veteran's range of motion for the left knee was 0 degrees to 110 degrees, and for the right knee, her range of motion was 0 degrees to 120 degrees. It was noted that the joints were stable bilaterally, and there was no change in range of motion with a limited test of repetition. The Veteran was diagnosed with left knee strain with mild functional loss of range of motion. It was also noted that the Veteran's left knee strain affected her physical employability to a limited extent. At the Veteran's August 2011 VA examination, she reported that there was constant pain and swelling of the left knee, but the right knee did not hurt anymore. She denied seeking care for her knee conditions since separation from service. She stated that her knees were stable now that she did not do any running. She reported that she has no flare-ups that impacted the function of her knees or lower legs. The Veteran's range of motion for both her right knee and left knee was 0 to 130 degrees with no objective evidence of painful motion. Moreover, after repetitive use testing, there were no additional limitations of range of motion. It was further noted that the Veteran did not have any other additional limitations such as: more movement than normal; weakened movement; excess fatigability; incoordination with impaired ability to execute skilled movements smoothly; pain on movement; swelling; deformity; atrophy of disuse; instability of station; disturbance of locomotion; and no interference with sitting, standing, and weight bearing. The Veteran also had no tenderness or pain of the joint line or soft tissue of either knee. The joint stability tests for anterior instability, posterior instability, and medial-lateral instability were all normal. Moreover, there was no evidence or history of recurrent patellar subluxation or dislocation. It was noted that the Veteran used a cane on a regular basis, but it was due to an unrelated back condition and right hip condition. It was noted that the Veteran's knee conditions did not impact her ability to work. She was diagnosed with bilateral knee osteoarthritis with no functional limitations. In order for the Veteran to warrant an increased rating of 20 percent for either her left knee disability or her right knee disability, there needs to be evidence of flexion limited to 15 degrees or extension limited to 20 degrees. However, the Veteran's range of motion for her left knee was from 0 to 110 degrees, and for her right knee it was 0 to 120 degrees. In addition, after repetitive testing, there was no additional limitation of range of motion. There was also no evidence of additional limitations such as: more movement than normal; weakened movement; excess fatigability; incoordination with impaired ability to execute skilled movements smoothly; pain on movement; swelling; deformity; atrophy of disuse; instability of station; disturbance of locomotion; and no interference with sitting, standing, and weight bearing. Thus, the Board finds that both the Veteran's right knee disability and left knee disability do not warrant ratings in excess of 10 percent and that any pain has been taken into consideration in granting her 10 percent disability ratings. The Board notes that separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. Esteban, 6 Vet. App. at 262. For example, the VA Office of General Counsel has stated that compensating a claimant for separate functional impairment under Diagnostic Code 5257 and 5003 does not constitute pyramiding. VAOPGCPREC 23-97 (July 1, 1997). In this opinion, the VA General Counsel held that a Veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating is based upon additional disability. Subsequently, in VAOPGCPREC 9-98, the VA General Counsel further explained that if a Veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. However, there is no evidence of any subluxation and instability. Moreover, the Veteran reported that she used a cane for different disabilities, her back and right hip disabilities. Thus, separate disability ratings are not warranted. As noted above, in exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Board finds that the Veteran's bilateral knee disabilities are contemplated by the rating criteria. The Board finds that there is no evidence that the Veteran's bilateral knee disabilities are manifested by frequent hospitalizations or a marked interference with employment. In addition, it was noted at the August 2011 VA examination that the Veteran's bilateral knee disabilities did not impact her ability to work. Thus, the Board finds that the rating criteria are adequate to evaluate the Veteran's disabilities, and referral for consideration of extraschedular rating is not warranted. In sum, the Board finds that the Veteran's left knee disability is manifested by range of motion of 0 degrees to 110 degrees, and her right knee disability is manifested by range of motion of 0 to 120 degrees. In addition, there is no evidence of any decreased range of motion after repetitive use, nor is there evidence of any instability or subluxation of either knee. Thus, the Board finds that the Veteran's bilateral knee disabilities do not warrant ratings higher than 10 percent. (CONTINUED ON NEXT PAGE) ORDER A rating in excess of 30 percent for migraine headaches is denied. Since the date of claim, a 70 percent disability, but not higher, for the dysthymic disorder is granted, subject to the regulations governing the payment of VA monetary benefits. A rating in excess of 20 percent for a cervical spine disability is denied. A separate rating of 10 percent for the peripheral neuropathy of the left upper extremity is granted, subject to the regulations governing the payment of VA monetary benefits. Since the date of claim, a 20 percent disability rating, but not higher, for the right shoulder disability is granted, subject to the regulations governing the payment of VA monetary benefits. A rating in excess of 10 percent for a left elbow disability is denied. A rating in excess of 10 percent for a right hip disability is denied. A rating in excess of 10 percent for a right knee is denied. A rating in excess of 10 percent for a left knee disability is denied. ____________________________________________ JENNIFER HWA Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs