Citation Nr: 1314931 Decision Date: 05/06/13 Archive Date: 05/15/13 DOCKET NO. 07-17 188A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE 1. Entitlement to a rating in excess of 10 percent for right (major) elbow disability. 2. Entitlement to a rating in excess of 10 percent for left (minor) elbow disability REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Andrea Johnson, Associate Counsel INTRODUCTION The Veteran had active military service from January 1952 to August 1980. This appeal comes to the Board of Veterans' Appeals (Board) from a November 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to ensure a total review of the evidence. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran has not had anklyosis of either elbow at any time during the period on appeal. 2. Even considering functional limitation caused by pain, weakness, stiffness, fatigability, and lack of endurance, etc., the Veteran consistently demonstrated forearm flexion that exceeded 90 degrees and forearm extension that exceeded 45 degrees in each elbow. 3. The evidence of record fails to show that the Veteran has experienced any joint fracture, bone malunion, or bone loss in either elbow at any point during the period on appeal. 4. The evidence of record does establish the Veteran had supination limited to 30 degrees or less in each elbow, but no greater impairment of supination or pronation during the period on appeal. CONCLUSIONS OF LAW 1. A disability rating not to exceed 20 percent for right (major) elbow disability is warranted (two separate 10 percent disability evaluations, as addressed below). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.7, 4.25, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5024, 5205-5213 (2012). 2. A disability rating not to exceed 20 percent for left (minor) elbow disability is warranted (two separate 10 percent disability evaluations, as addressed below). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.7, 4.25, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5024, 5205-5213 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Board notes that while the regulations require review of the recorded history of a disability by the adjudicator to ensure an accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). It is also noted that staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, the Veteran is seeking an increased rating for his bilateral elbow condition due to tenosynovitis. Under the rating criteria at Diagnostic Code 5024 tenosynovitis will be rated based on limitation of motion of the affected parts, here the diagnostic codes related to movement of the elbow and forearm at Diagnostic Codes 5205 through 5213. 38 C.F.R. § 4.71a. Normal range of motion of the elbow and forearm are 0 degrees to 145 degrees in elbow flexion. 38 C.F.R. § 4.71, Plate I. In all the forearm and wrist injuries, Diagnostic Codes 5205 through 5213, multiple impaired finger movements due to tendon tie-up, muscle injury, or nerve injury are to be separately rated and combined, not to exceed the rating for loss of use of the hand. Diagnostic Code 5205 provides that ankylosis of the elbow is to be rated as follows: for favorable ankylosis of the elbow at an angle between 90 degrees and 70 degrees, 40 percent for the major elbow and 30 percent for the minor elbow; for intermediate ankylosis of the elbow, at an angle of more than 90 degrees, or between 70 degrees and 50 degrees, 50 percent for the major elbow and 40 percent for the minor elbow; for unfavorable ankylosis of the elbow, at an angle of less than 50 degrees or with complete loss of supination or pronation, 60 percent for the major elbow and 50 percent for the minor elbow. 38 C.F.R. § 4.71a. Diagnostic Code 5206 provides that flexion of the forearm limited to 110 degrees is rated as noncompensably (0 percent) disabling for the major side and noncompensably (0 percent) disabling for the minor side; flexion of the forearm limited to 100 degrees is rated 10 percent disabling for the major side and 10 percent for the minor side; flexion of the forearm limited to 90 degrees is rated 20 percent for the major side and 20 percent for the minor side; flexion of the forearm limited to 70 degrees is rated 30 percent disabling for the major side and 20 percent for the minor side; flexion of the forearm limited to 55 degrees is rated 40 percent disabling for the major side and 30 percent for the minor side; and flexion of the forearm limited to 45 degrees is rated 50 percent disabling for the major side and 40 percent for the minor side. 38 C.F.R. § 4.71a. Diagnostic Code 5207 provides that extension of the forearm limited to 45 degrees is rated 10 percent for the major side and 10 percent for the minor side; extension of the forearm limited to 60 degrees is rated 10 percent for the major side and 10 percent for the minor side; extension of the forearm limited to 75 degrees is rated as 20 percent for the major side and 20 percent for the minor side; extension of the forearm limited to 90 degrees is rated 30 percent for the major side and 20 percent for the minor side; extension of the forearm limited to 100 degrees is rated 40 percent for the major side and 30 percent for the minor side; and extension of the forearm limited to 110 degrees is rated 50 percent for the major side and 40 percent for the minor side. 38 C.F.R. § 4.71a. Diagnostic Code 5208 provides that forearm flexion limited to 100 degrees with forearm extension limited to 45 degrees is rated 20 percent for the major side and 20 percent for the minor side. 38 C.F.R. § 4.71a. Diagnostic Code 5209 provides ratings for other impairment of the elbow. Joint fracture, with marked cubitus varus or cubitus valgus deformity or with ununited fracture of head of radius, is rated 20 percent disabling for the major side and 20 percent for the minor side. Flail joint of the elbow is rated 60 percent disabling for the major side and 50 percent for the minor side. 38 C.F.R. § 4.71a. Diagnostic Code 5210 provides that nonunion of the radius and ulna, with flail false joint, is rated 50 percent disabling for the major side and 40 percent for the minor side. 38 C.F.R. § 4.71a. Diagnostic Code 5211 provides for ratings based on impairment of the ulna. Malunion of the ulna with bad alignment is rated 10 percent for the major side and 10 percent for the minor side; nonunion of the ulna in the lower half is rated 20 percent for the major side and 20 percent for the minor side; nonunion of the ulna in the upper half, with false movement, without loss of bone substance or deformity is rated 30 percent for the major side and 20 percent for the minor side; nonunion of the ulna in the upper half, with false movement, with loss of bone substance (1 inch (2.5cms) or more) and marked deformity is rated 40 percent for the major side and 30 percent for the minor side. 38 C.F.R. § 4.71a. Diagnostic Code 5212 provides for ratings based on impairment of the radius. Malunion of the radius with bad alignment is rated 10 percent disabling for the major side and 10 percent for the minor side; nonunion of the radius in the upper half is rated 20 percent disabling for the major side and 20 percent for the minor side; nonunion of the radius in the lower half, with false movement, without loss of bone substance or deformity is rated 30 percent disabling for the major side and 20 percent for the minor side; nonunion of the radius in the lower half, with false movement, with loss of bone substance (1 inch (2.5cms) or more) and marked deformity is rated 40 percent disabling for the major side and 30 percent for the minor side. 38 C.F.R. § 4.71a. Diagnostic Code 5213 provides ratings based on impairment of supination and pronation of the forearm. Normal forearm supination is from 0 degrees to 85 degrees. Normal forearm pronation is from 0 degrees to 80 degrees. 38 C.F.R. § 4.71, Plate I. Diagnostic Code 5213 provides that supination of the forearm limited to 30 degrees or less is rated 10 percent disabling for the major side and 10 percent for the minor side. Limitation of pronation with motion lost beyond the last quarter of arc, so the hand does not approach full pronation, is rated 20 percent disabling for the major side and 20 percent for the minor side; limitation of pronation with motion lost beyond the middle of arc is rated 30 percent disabling for the major side and 20 percent for the minor side. Loss of supination or pronation due to bone fusion, with the hand fixed near the middle of the arc or moderate pronation, is rated 20 percent disabling for the major side and 20 percent for the minor side; loss of supination or pronation due to bone fusion, with the hand fixed in full pronation, is rated 30 percent disabling for the major side and 20 percent for the minor side; and loss of supination or pronation due to bone fusion, with the hand fixed in supination or hyperpronation, is rated 40 percent disabling for the major side and 30 percent for the minor side. 38 C.F.R. § 4.71a. In a January 1982 rating decision the Veteran was granted service connection for his elbow condition and granted a 10 percent rating in each arm effective September 1980. In June 2004 the Veteran filed the current claim for an increased rating for his bilateral elbow condition. The Board notes this issue has previously been remanded by the Board twice, in February 2011 and October 2012. The Board finds the most recent remand directives were completed by the agency of original jurisdiction, and the Veteran was provided a new VA examination regarding his elbow condition. Furthermore, the Veteran's representative concedes that all remand directives were completed in his March 2013 written post-remand brief. As such, the Board finds the directives in the previous remand order were complied with, and adjudication may proceed. Stegall v. West, 11 Vet. App. 268 (1998). All evidence has been reviewed and considered and relevant evidence will be summarized below. In July 2004 the Veteran was provided with a VA examination regarding his bilateral elbow condition. The Veteran described pain in both elbows and limited range of motion. The examiner noted the Veteran indicated he was experiencing pain in the lateral aspect of his elbows. The examiner then conducted range of motion testing which revealed the Veteran had lack of 10 degrees of full extension bilaterally and experienced pain with flexion beyond 120 degrees in both elbows. Radiologic exams were also conducted and revealed moderate degenerative changes in both elbows, but right more so than left. The x-rays also showed osteophytes in epicondyles, radial heads, olcranon processes and coronoid processes of ulnas in both elbows with some narrowing of joint spaces. The examiner noted bone spurring throughout the Veteran's elbows. Based on the foregoing the examiner opined the Veteran had epicondylitis with degenerative disk disease in both elbows and was moderately symptomatic. The Board notes the results of this range of motion testing from July 2004 revealed the Veteran had further range of flexion than even is contemplated by a noncompensable rating. The Veteran had flexion of 130 degrees in each elbow, with pain beginning at 120 degrees. Under Diagnostic Code 5206 a noncompensable rating is awarded when the Veteran has flexion limited to 110 degrees. As such, the Board finds the Veteran had pain-free flexion throughout the entire range of motion as contemplated by a noncompensable rating. As such, the results of the July 2004 examination do not establish the Veteran was entitled to a rating in excess of 10 percent based on limitation of flexion at this time. In November 2005 the Veteran submitted a written notice of disagreement and asserted that the July 2004 examiner did not properly assess the condition of his elbows. The Veteran reported that nearly every time he moved his arm it caused an obvious cracking noise in his right elbow, which was not noted by the examiner. The Veteran also reported experiencing such pain in his right elbow that it woke him up at night and limited his ability to move his right arm. The Veteran also re-stated these assertions in an October 2006 written statement he submitted to the VA. The Board notes that as a lay person, the Veteran is considered to be competent to report what comes to him through his senses, such as experiencing pain in his elbow and hearing a loud cracking sound upon movement. Layno v. Brown, 6 Vet. App. 465 (1994). Therefore, the Board finds the Veteran is competent to report the pain he unfortunately experienced in both elbows. However, the rating criteria in the applicable VA regulations rate the level of elbow impairment based on range of motion and damage to the involved bones, not simply on level of pain. The Veteran lacks the medical training and experience to assess the level of motion impairment and bone damage in his own bilateral elbow condition. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). As such, the Board will consider the Veteran's statements regarding the pain he experienced and also look to medical range of motion and radiological testing to evaluate the proper rating. In March 2007 the Veteran was provided with an additional VA examination. The examiner noted the Veteran had a history of bilateral tennis elbow, tendonitis, since service in the 1970s, and his condition had gotten progressively worse. The Veteran reported daily pain in both elbows, with flare-ups every three to four months. During flare-ups he had mild functional impairment. Flare-ups were triggered by overuse of the hand; the Veteran treated these episodes with medication and rest. The examiner conducted range of motion testing which revealed the Veteran had flexion in his right elbow until 100 degrees with pain beginning at 80 degrees. Extension of right elbow was 30 to 100 degrees, pronation was 0 to 60 degrees, and supination was 0 to 65 degrees. Flexion in the Veteran's left elbow was 0 to 120 degrees, with pain beginning at 100 degrees. Extension of the left elbow was 30 to 100 degrees, pronation 0 to 60 degrees, and supination 0 to 65 degrees. The Veteran did not experience additional loss of motion on repetitive use of either elbow. The examiner also noted no joint ankylosis in either arm. The examiner also tested the muscle strength of each of the Veteran's elbows which revealed flexion was 5 out of 5 bilaterally on bicep and tricep muscles, suggesting active movement against full resistance. X-rays were also conducted and revealed moderate degenerative changes bilaterally with osteophytes in the epicondyles, radial heads, olecranon processes, and noronoid processes of the ulnas in both elbows with some narrowing of joint spaces. Based on the foregoing the examiner opined the Veteran had degenerative joint disease in his elbows with lateral epicondylitis bilaterally. The examiner opined this condition prevented the Veteran from performing chores, exercise, sports, recreation, and traveling, created a severe impairment in shopping, bathing, and grooming, and provided moderate impairment in feeding, dressing, and toileting. The Board notes the results of this range of motion testing suggest the Veteran's condition had worsened, but still does not establish the Veteran was entitled to a rating in excess of 10 percent. The Veteran demonstrated additional limitations in his right elbow flexion to only 100 degrees, which would merit a 10 percent rating under Diagnostic Code 5206. However, flexion of 120 degrees in the Veteran's left elbow suggests he still merited a noncompensable rating in the left elbow under code 5206 at this time. In June 2007 the Veteran submitted a written substantive appeal to the VA. He reported that due to his elbow condition he could not dress himself in the normal way, but instead he had to put his sleeves on his arms in front of him and then flip the shirt over his head. He also reported it was difficult for him to use shirts with buttons due to his elbow pain. In November 2009 the Veteran was provided with an additional VA examination. The examiner reviewed the Veteran's claims file and personally examined the Veteran. He then conducted range of motion testing which revealed the Veteran had full extension in his right elbow, but could only flex to 100 degrees. The Veteran also had supination to 85 degrees and pronation to 80 degrees. The Veteran's left elbow had flexion from 20 to 145 degrees, supination to 85 degrees, and pronation to 80 degrees. The Veteran did not have additional pain, weakness, or fatigue upon repetitive motion in either elbow. X-rays were also conducted and revealed moderate degenerative changes bilaterally, but no fracture, dislocation, effusion, or erosion. The examiner opined the Veteran had degenerative joint disease of his elbows bilaterally. The Board notes the results of this range of motion testing continue to reflect the Veteran merited a 10 percent rating in his right elbow and non-compensable rating in his left based on limitation of flexion. In October 2012 the Board remanded this issue for a new medical examination based on the suggestion that his condition had worsened. The new VA examination was conducted in December 2012. The examiner was able to review the Veteran's claims file as well as personally examine the Veteran. He reported chronic pain, limited range of motion, and sense of giving way when he tried to lift more than a couple pounds. The examiner noted the Veteran did not experience flare-ups which impacted the function of his elbow or forearm. The examiner then conducted range of motion testing which revealed the Veteran had flexion of 120 degrees without pain in both elbows. The Veteran was able to extend his right elbow 10 degrees, while extension ended at 20 degrees in his left elbow. The Veteran was also able to perform repetitive-use testing with three repetitions and maintain the same range of motion. The examiner noted the Veteran had less movement than normal, weakened movement, excess fatigability, pain on movement, and localized pain or tenderness on palpation of the joint in both elbows. The Veteran's muscle strength was 4 out of 5 on both extension and flexion bilaterally, indicating active movement against some resistance. The Veteran did not have ankylosis of the elbow. He did have supination limited to 30 degrees or less in both elbows. X-rays were conducted and revealed degenerative arthritis in both elbows. Based on the foregoing the examiner opined the Veteran's elbow condition did not impact his ability to work, as the Veteran was eighty years old and retired. The Board notes the results of this range of motion testing suggests the Veteran had improved flexion in both elbows which would again result in a noncompensable rating bilaterally. Treatment records have also been reviewed. The Board notes that the Veteran reported pain in his elbows, right more so than left, throughout the period on appeal. However, it does not appear the Veteran received any additional treatment for his elbow pain than is noted above. As will be discussed below, the Board finds the Veteran's current bilateral elbow condition merits an increased rating not to exceed 20 percent in each elbow. As discussed above, diagnostic code 5205 relates to ankylosis of the elbow. The evidence of record does not suggest the Veteran experienced ankylosis of the elbow at any point during the period on appeal. The examiners from March 2007 and December 2012 both specifically found no ankylosis of the elbow. As such, the Board finds the Veteran is not entitled to a rating under this code. 38 C.F.R. § 4.71a. As the Board has discussed throughout the decision, the evidence of record establishes the Veteran does have some limitation of flexion of his elbow as contemplated by diagnostic code 5206. Range of motion testing from March 2007 and November 2009 both reveal flexion of the Veteran's right (major) elbow was limited to 100 degrees, suggesting he is entitled to a 10 percent rating for his right (major) elbow under this diagnostic code. The evidence of record also establishes the Veteran has some limited flexion in his left (minor) elbow, but the evidence does not reflect range of motion testing which revealed he had flexion of less than 110 degrees in his left elbow to warrant a 10 percent rating. However, based on the benefit of the doubt principal the Veteran has been previously granted 10 percent rating. See 38 C.F.R. § 3.102. As such, the Board finds the evidence of record establishes the Veteran is entitled to a 10 percent rating in each elbow under this diagnostic code, but no higher. While the evidence of record does establish the Veteran has limited extension of both elbows, the evidence does not establish his extension is limited to 45 degrees in order to merit a compensable rating under diagnostic code 5207. Instead, various range of motion testing conducted throughout the period on appeal reveal the Veteran continues to have extension to 20 or 30 degrees in both elbows. Since the Veteran consistently demonstrated extension of both elbows in excess of 45 degrees the Board finds a rating under this diagnostic code is not warranted. Similarly a rating under diagnostic code 5208, based in part on extension limited to 45 degrees, is also not applicable. Diagnostic codes 5209 through 5212 all contemplate structural impairment of the joint bones. Diagnostic code 5209 relates to joint fracture, and codes 5210-5212 relate to poor union of the bones composing the forearm. However, x-rays taken throughout the period on appeal consistently noted the Veteran had degenerative joint disease and bone spurring, but did not reveal any fracture, dislocation, effusion, or erosion. Therefore the Board finds a rating under these diagnostic codes is not warranted in this case. Finally, diagnostic code 5213 relates to impairment of supination and pronation of the elbow. Under this code a 10 percent rating is assigned when the Veteran has limitation of supination to 30 degrees or less. In his December 2012 report the examiner indicated the Veteran had supination limited to 30 degrees or less in both wrists. As this December 2012 range of motion testing is the most recent, and therefore provides the most accurate deception of the Veteran's current condition, it is afforded great probative weight. As such, the Board finds the Veteran has met the criteria for a 10 percent rating under this diagnostic code. A higher 20 percent rating is warranted under this code if the Veteran has pronation limited beyond last quarter of arc or the hand is fixed near the middle of the arc or moderate pronation. However, the December 2012 examiner did not indicate the Veteran demonstrated either of these criteria. Therefore, the Board finds the Veteran is not entitled to a rating in excess of 10 percent under this code. 38 C.F.R. § 4.71a. Based on the foregoing the Board finds the Veteran is entitled to a 10 percent rating in each wrist under both diagnostic codes 5206 and 5213. A note in the regulations following the diagnostic codes related to the elbow indicates that codes 5205 through 5213 are to be separately rated and combined. Therefore the Veteran's 10 percent ratings under codes 5206 and 5213 for each elbow shall be combined using the Combined Ratings Table at 38 C.F.R. § 4.25, Table 1. This table provides that a 10 percent rating combined with a 10 percent rating will yield a 19 percent rating. The regulations also provide that all rating must be converted to the nearest degree divisible by 10. As such, the Board finds the Veteran's 10 percent ratings under codes 5206 and 5213 combine for a total 20 percent rating for each elbow under the schedular criteria. 38 C.F.R. § 4.25. Therefore, the Board finds the Veteran is entitled to an increased rating for his bilateral elbow condition not to exceed 20 percent in each elbow. In reaching this conclusion, the Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Additionally, painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In this case, the examiners in March 2007, November 2009, and December 2012 each specifically noted the Veteran did not exhibit any additional loss in range of motion due to pain or fatigue upon repetitive use. Furthermore, in the most recent range of motion testing in December 2012 the Veteran was able to move the full range of motion contemplated with his schedular rating criteria without experiencing pain. As such, the Board finds a higher disability evaluated based on the DeLuca factors are not merited in this case. The Board has also considered whether referral for consideration of an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a veteran is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. This means that initially there must be a comparison between the level of severity and symptomatology of the veteran's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the veteran's disability level and symptomatology, then the veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral is required. If the criteria do not reasonably describe the veteran's disability level and symptomatology, a determination must be made whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. In this case, the Board finds that the schedular rating criteria reasonably describes the Veteran's symptomatology and disability level. The Veteran's primary complaints are pain, cracking sounds in his elbow, and limited movement. The Board finds that the Veteran's range of motion and pain have been specifically contemplated by the rating criteria and the DeLuca factors. The Board also finds the Veteran's assertions of a loud cracking noise in his elbows alone do not constitute an exceptional disability. Instead, the Board notes the Veteran primarily describes the cracking noise as an additional symptom of his pain and limited motion, conditions already contemplated under the rating criteria. As such, the Board finds the Veteran's disability picture is not exceptional, and an extraschedular consideration is not required. The Board has also considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. However, the Board notes in the October 2012 decision the consideration of TDIU was specifically remanded to the RO to issue a separate rating action directly addressing TDIU. As such, the Board finds a separate rating decision will specifically address the Veteran's entitlement to TDIU. This separate rating decision has not been appealed by the Veteran, and is therefore not before the Board at this time. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to veterans. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a veteran before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and must: (1) inform the veteran about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the veteran about the information and evidence that VA will seek to provide; and (3) inform the veteran about the information and evidence the veteran is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to service connection claims, a section 5103(a) notice should also advise a veteran of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In the present case, the Veteran was initially provided notice by a letter dated in July 2004, which informed the Veteran of all the elements required by the Pelegrini II Court as stated above. While this claim was still pending the Veteran was provided with an additional letter in October 2009 which informed the Veteran how disability ratings and effective dates were established. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to content. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). VA and private treatment records have been obtained, as have service treatment records. Additionally, the Veteran was offered the opportunity to testify at a hearing before the Board, but he declined. The Veteran was also provided with several VA examinations throughout the course of this appeal, the reports of which has been associated with the claims file. The Board finds the VA examinations were thorough and adequate and provide a sound basis upon which to base a decision with regard to the Veteran's claim. The VA examiners personally interviewed and examined the Veteran, including eliciting a history from him, and provided the information necessary to evaluate his disability. The Board notes that the Veteran has asserted his July 2004 examination was inadequate because the examiner only spent approximately 15 minutes examining him. However, the Board finds the evidence of record reflects the examiner was able to personally interview the Veteran as well as conduct objective testing measuring his range of motion. Furthermore, the Veteran was provided with several other VA examinations during the course of his appeal whose adequacy has not been challenged by the Veteran. All medical evidence was reviewed and considered by the Board. As such, the Board finds the Veteran's July 2004 examination was adequate and did not prejudice the Veteran's claim. As discussed, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER The Veteran's claim for an increased rating for his service-connected right (major) elbow disability is granted, not to exceed 20 percent (two separate 10 percent disability evaluations, as addressed above), subject to the laws and regulations governing the award of monetary benefits. The Veteran's claim for an increased rating for his service-connected left (minor) elbow disability is granted, not to exceed 20 percent (two ten percent disability evaluations, as addressed above), subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs