Citation Nr: 1333275 Decision Date: 10/23/13 Archive Date: 10/24/13 DOCKET NO. 08-14 404 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to a compensable initial rating for hemorrhoids. 2. Entitlement to an initial rating in excess of 50 percent for seasonal affective disorder and panic disorder without agoraphobia. 3. Entitlement to an initial compensable rating for tendonitis of the right wrist. 4. Entitlement to an initial compensable rating for tendonitis of the left wrist. 5. Entitlement to an initial compensable rating for tendonitis of the right ankle. 6. Entitlement to an initial compensable rating for tendonitis of the left ankle. 7. Entitlement to an initial compensable rating for epicondylitis of the right elbow. 8. Entitlement to an initial compensable rating for epicondylitis of the left elbow. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. Henriquez, Counsel INTRODUCTION The Veteran served on active duty from October 1981 to July 2005. This case comes before the Board of Veterans' Appeals (Board) on appeal of a May 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. When the case was before the Board in December 2010, it was decided in part and remanded in part. In a November 2011 rating decision, the Appeals Management Center (AMC) increased the rating for the service-connected psychiatric disability to 50 percent, effective August 1, 2005 (the date of service connection.). The record before the Board consists of the Veteran's paper claims files and an electronic file known as Virtual VA. The issue of entitlement to an initial evaluation in excess of 50 percent for seasonal affective disorder and panic disorder without agoraphobia is addressed in the REMAND that follows the ORDER section of this decision. FINDINGS OF FACT 1. From the August 1, 2005, through August 20, 2009, the Veteran's hemorrhoid disability was manifested by large or thrombotic hemorrhoids with excessive redundant tissue, evidencing frequent recurrences. 2. From August 21, 2009, the Veteran's hemorrhoid disability has been manifested by not more than mild to moderate symptoms; the hemorrhoids have not been large or thrombotic, irreducible with excessive redundant tissue, evidencing frequent recurrences; nor have they resulted in persistent bleeding with anemia or fissures. 3. For the period of the claim, the Veteran's right wrist tendonitis has never resulted in dorsiflexion less than 15 degrees or palmar flexion limited in line with forearm, but it has been productive of tenderness or pain. 4. For the period of the claim, the Veteran's left wrist tendonitis has never resulted in dorsiflexion less than 15 degrees or palmar flexion limited in line with forearm, but it has been productive of tenderness or pain. 5. For the period of the claim, the Veteran's right ankle tendonitis has not been manifested by limitation of motion or X-ray evidence of arthritis, but it has been productive of tenderness or pain. 6. For the period of the claim, the Veteran's left ankle tendonitis has not been manifested by limitation of motion or X-ray evidence of arthritis but it has been productive of tenderness or pain. 7. For the period of the claim, the Veteran's epicondylitis of the right elbow has not been productive of any significant symptoms or functional impairment. 8. For the period of the claim, the Veteran's epicondylitis of the left elbow has not been productive of any significant symptoms or functional impairment. CONCLUSIONS OF LAW 1. From August 1, 2005 to August 20, 2009, an initial 10 percent disability rating, but no higher, is warranted for the Veteran's hemorrhoids. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.114, Diagnostic Code 7336 (2013). 2. From August 21, 2009, the criteria for a compensable disability rating for hemorrhoids have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.114, Diagnostic Code 7336 (2013). 3. The criteria for an initial 10 percent rating, but not higher, for tendonitis of the right wrist have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008); 38 C.F.R. §§ 4.7, 4.20, 4.71a, Diagnostic Codes 5024-5215 (2013). 4. The criteria for an initial 10 percent rating, but not higher, for tendonitis of the left wrist have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008); 38 C.F.R. §§ 4.7, 4.20, 4.71a, Diagnostic Codes 5024-5215 (2013). 5. The criteria for an initial 10 percent rating, but not higher, for tendonitis of the right ankle have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008); 38 C.F.R. §§ 4.7, 4.20, 4.71a, Diagnostic Codes 5024-5271 (2013). 6. The criteria for an initial 10 percent rating, but not higher, for tendonitis of the left ankle have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008); 38 C.F.R. §§ 4.7, 4.20, 4.71a, Diagnostic Codes 5024-5271 (2013). 7. The criteria for an initial compensable rating for epicondylitis of the right elbow have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5024 (2013). 8. The criteria for an initial compensable rating for epicondylitis of the left elbow have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5024 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2013), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided 'at the time' that or 'immediately after' VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the Veteran was provided all required notice in letters mailed in February and March 2006, prior to the initial adjudication of the claims. The record also reflects that the Veteran's service treatment records and VA and private treatment records have been obtained. The Board's December 2010 remand directed that records pertaining to the treatment of the Veteran after a September 2006 hemorrhoidectomy should be obtained. Accordingly, the originating agency sent a letter to the Veteran in December 2010 requesting that he complete the necessary authorization form to enable VA to obtain these records. The review of the records reflects that the Veteran did not respond to this request. VA's duty to assist a claimant is not always a one-way street. A claimant seeking help cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining putative evidence. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Veteran was afforded VA examinations in November 2005 in conjunction with his claims. Additionally, the Board remanded the claims in December 2010 to afford the Veteran for further VA examinations to assess the current severity of his service-connected disabilities of the wrists, ankles and elbows. In March 2011, the Veteran was provided a VA examination in connection with his claims. The examination report contains sufficient evidence by which to evaluate each of the Veteran's service-connected disabilities. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board is satisfied that the originating agency substantially complied with the development requested on remand. See Stegall v. West, 11 Vet. App. 268 (1998). Neither the Veteran nor his representative has identified any outstanding, existing evidence that could be obtained to substantiate the claims. The Board is also unaware of any such evidence. Accordingly, the Board concludes that VA has complied with its duty to assist the Veteran in the development of the facts pertinent to these claims. II. General Legal Criteria Disability evaluations are determined by comparing a Veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). In determining the degree of limitation of motion, the provisions of 38 C.F.R. § 4.40 concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups; the provisions of 38 C.F.R. § 4.45 concerning weakened movement, excess fatigability, and incoordination; and the provisions of 38 C.F.R. § 4.10 concerning the effects of the disability on the veteran's ordinary activity are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). III. Factual Background and Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2013) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disabilities. Hemorrhoids In this case, the Veteran's hemorrhoids are evaluated as noncompensable under 38 C.F.R. § 4.114, Diagnostic Code 7336, from the effective date of service connection, August 1, 2005. Under this code, a noncompensable rating is warranted for mild or moderate hemorrhoids. A 10 percent rating is warranted for large or thrombotic, irreducible hemorrhoids, with excessive redundant tissue, evidencing frequent recurrences. The maximum schedular rating of 20 percent is warranted for hemorrhoids with persistent bleeding and secondary anemia, or with fissures. A November 2005 VA examination report reflected the Veteran's reports of flare- ups of hemorrhoids roughly once per month aggravated by exercise and constipation. The Veteran stated that he took Metamucil on a daily basis to control the symptoms. He reported that he developed some bleeding associated with the hemorrhoids which occurred every two months. He used cortisone and Preparation-H to treat the bleeding. He reported that he had to miss two days of work in the past two years due to severe hemorrhoid flares. Physical examination revealed two large, mildly tender hemorrhoids which were non-pliable. The diagnosis was rectal hemorrhoids. Private treatment records show that the Veteran was hospitalized in September 2006 due to bleeding hemorrhoids. He underwent an emergency hemorrhoidectomy because of the bleeding. On the third day of hospitalization, he was discharged home. At that time his hemorrhoidal area was mildly inflamed but stable. The Veteran was instructed to continue mineral oil, Colace, Metamucil, and Percocet and was to be seen for follow-up on an outpatient basis in one week. An August 2009 VA examination report indicates that the Veteran did not have any complaints referable to hemorrhoids except occasional blood "spotting." The examiner noted that the Veteran was status post hemorrhoidectomy in September 2006. The Veteran did not report any current treatment. He stated that the condition was not incapacitating and that he could function and perform his daily activities. The hemorrhoid disability did not prevent him from being employed. Physical examination revealed one medium-sized, unremarkable, external hemorrhoid. There was no blood or fecal leakage present. No other pathology was noted. The diagnosis was status post hemorrhoidectomy, residuals as noted. Extending reasonable doubt to the Veteran, the Board finds that a disability rating of 10 percent is warranted for the Veteran's hemorrhoid disability from August 1, 2005 (date of service connection) to August 20, 2009. The evidence during this time period indicates that the Veteran had large, non-pliable hemorrhoids. Moreover, the Veteran reported regular flare-ups of the hemorrhoids. He subsequently underwent a hemorrhoidectomy in September 2006 to treat bleeding hemorrhoids. The Board finds that this evidence supports a 10 percent rating. An even higher 20 percent disability rating from August 1, 2005, to August 20, 2009, is not warranted as the Veteran's hemorrhoid disability has not been manifested by persistent bleeding and secondary anemia, or fissures. While the Veteran did undergo an emergency hemorrhoidectomy in September 2006 to treat bleeding hemorrhoids, there is no evidence that the bleeding was persistent subsequent to this procedure or that there was persistent bleeding before the procedure. Furthermore, there is no evidence of secondary anemia or fissures. On the other hand, the Board finds that the preponderance of the evidence is against a compensable rating for hemorrhoids from the date of the August 21, 2009, VA examination report. The examination report reflects the Veteran's only complaint referable to his hemorrhoid disability was occasional blood "spotting." Only one external hemorrhoid was present which was noted to be of medium size and unremarkable. The hemorrhoid was not identified as large, thrombotic or irreducible. Excessive redundant tissue was not noted. Further, there is no evidence that the Veteran experiences hemorrhoids with persistent bleeding and secondary anemia, or with fissures. Accordingly, a compensable rating from August 21, 2009, is not warranted. Right and Left Wrists The Veteran has been diagnosed with tendonitis of the right and left wrists. Noncompensable ratings were assigned for each wrist under 38 C.F.R. § 4.71a, Diagnostic Codes 5024-5215, effective August 1, 2005, the effective date of service connection. Under Diagnostic Code 5024, tenosynovitis is rated on limitation of motion of the affected parts, as for degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5024 (2013). The diagnostic code applicable to degenerative arthritis provides that when x-ray evidence of degenerative arthritis is presented but the loss of range of motion is noncompensable, a 10 percent disability rating is warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2013). Diagnostic Code 5215 provides ratings based on limitation of motion of the wrist. Limitation of palmar flexion in line with the forearm is rated 10 percent disabling for the major and minor wrist. Limitation of dorsiflexion to less than 15 degrees is rated 10 percent disabling for the major and minor wrist. For VA purposes, normal dorsiflexion of the wrist is from 0 to 70 degrees, and normal palmar flexion is from 0 to 80 degrees. Normal radial deviation of the wrist is from 0 to 20 degrees, and normal ulnar deviation is from 0 to 45 degrees. 38 C.F.R. § 4.71, Plate I (2013). A November 2005 VA examination report notes that the Veteran denied experiencing wrist pain during the past 6 to 8 months. The Veteran reported that his new job was not affected by the wrist pain, and he denied any affect on outside activities. Physical examination of the wrists revealed that they were normal in appearance with no effusion, erythema or increased warmth. There was no tenderness to palpation. There was full range of motion with flexion, extension and radial and ulnar deviation. The wrists did not exhibit weakened movement, incoordination or fatigability on examination. There was no worsening of pain or change of range of motion with repetition. The diagnosis was bilateral wrist tendonitis. A March 2011 VA examination report documents the Veteran's reports of constant pain in both wrists which occasionally radiated down to his fingers with occasional numbness. The Veteran used wrist braces at night. He also complained of bilateral wrist stiffness and weakness. He denied other symptoms related to his wrists such as swelling or pain flare-ups. There were no constitutional symptoms of arthritis. Physical examination of the wrists revealed symmetry, with no swelling, redness or warmth. There was tenderness upon palpation of both wrists on the dorsal and palmar side. Range of motion was full in both wrists. Range of motion testing was done three times and revealed no pain, fatigue or decrease in motion. The Veteran had normal and equal 5/5 strength in both wrists. There was decrease and equal 4/5 strength of the bilateral hand grip and finger abductions. Phalen sign and Tinel sign were both positive in both wrists. The examiner noted constant pain in both wrists with occasional numbness and pain that radiated town to the fingers. There were no pain flare-ups or incapacitating episodes of pain. There was normal range of motion of both wrists with no decrease in range of motion upon repetition. The examiner further noted decreased strength of the Veteran's hands due to wrist pain and carpal tunnel syndrome. The examiner noted no significant effect on the Veteran's usual occupational activities. The Veteran's bilateral wrist condition limited his use in activities such as computing, heavy lifting and physical activities. The bilateral wrist disability did not have other significant effects on his usual daily activities. Based on the record, the Board finds that initial compensable evaluations for the Veteran's right and left wrist tendonitis disabilities are not warranted on the basis of limitation of motion. The Veteran has not demonstrated limitation of palmar flexion in line with the forearm, or limitation of dorsiflexion to less than 15 degrees in either wrist to warrant a 10 percent disabling. See 38 C.F.R. § 4.71a, Diagnostic Code 5215 (2013). Indeed, the medical evidence of record shows that the Veteran had full range of motion of his wrists at both of VA examinations, and other than reported pain with occasional numbness, both wrists were found to be normal. Therefore, increased initial ratings for the Veteran's tendonitis of the right and left wrists are not warranted. In considering the applicability of other Diagnostic Codes, the Board finds that Diagnostic Codes 5214 (ankylosis of the wrist), 5228 (limitation of motion of the thumb), 5229 (limitation of motion of the index or long finger), 5230 (limitation of motion of the ring or little finger), and 5307 (flexion of wrist and fingers) are not applicable because the evidence does not show that the Veteran has any of those conditions. Regarding any neurological symptoms related to the Veteran's bilateral wrist disability, the Board notes that VA neurological examination has established the presence of right ulnar sensory neuropathy. Accordingly, the RO granted service connection for neuropathy of the right ulnar nerve in a May 2012 rating decision, and any neurological symptoms stemming from a wrist disability are not at issue in this appeal. Moreover, in reaching this conclusion, the Board has considered additional functional limitation due to factors such as pain and weakness. However, in evaluating musculoskeletal disabilities, the Board must also consider additional functional limitation due to factors such as pain, weakness, fatigability, and incoordination. See DeLuca, 8 Vet. App. 202, 206-07 (1995). Here, however, the examinations of record clearly indicated that there was no additional functional limitation of either wrist with repetitive movement. The Board has determined that a 10 percent rating is warranted for each wrist throughout the initial rating period by analogy to a painful scar under Diagnostic Code 7804. In this regard, the Board notes that the medical evidence shows that the tendonitis has been productive of tenderness or pain throughout the initial evaluation period. Right and Left Ankles The Veteran has been diagnosed with tendonitis of the right and left ankles. A noncompensable rating has been assigned for each ankle under 38 C.F.R. § 4.71a, Diagnostic Codes 5024-5271, effective August 1, 2005, the effective date of service connection. Under Diagnostic Code 5024, tenosynovitis is rated on limitation of motion of the affected parts, as for degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5024 (2013). The diagnostic code applicable to degenerative arthritis provides that when X-ray evidence of degenerative arthritis is presented but the loss of range of motion is noncompensable, a 10 percent disability rating is warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2013). Under the Diagnostic Code 5271, a 10 percent evaluation applies to a "moderate" limitation of ankle motion, and a 20 percent evaluation applies to a "marked" limitation of ankle motion. See 38 C.F.R. §4.71a, Diagnostic Code 5271 (2013). The Rating Schedules does not define the words "moderate" and "marked." When evaluating whether the Veteran's limitation of ankle motion is moderate or marked, rather than applying a mechanical formula, the Board will evaluate all of the evidence to ensure that its decision is equitable and just. See 38 C.F.R. 4.6 (2013). A normal range of motion for the ankle is 20 degrees of dorsiflexion and 45 degrees of plantar flexion. See 38 C.F.R. § 4.71, Plate II (2013). A November 2005 VA examination report shows that the Veteran reported experiencing pain in his Achilles' tendon approximately once per week and that the condition was aggravated by walking or aerobic exercises. He did not take any medications but did stretches and used ice to control his symptoms. The Veteran reported that he exercised less frequently when the ankle bothered him. He also reported that the ankle disability impaired his ability to do yard work and other household activities. Physical examination of the ankles revealed that they were normal in appearance, with no effusion, erythmia or increased warmth. Both Achilles' tendons were tender to palpation. The ankles had a full range of motion. The ankles did not exhibit weakened movement, incoordination or fatigability. There was worsening of pain upon repetitive motion but this did not alter the range of motion. The diagnosis was bilateral Achilles' tendonitis. At a March 2011 VA examination, the Veteran complained of constant pain in the Achilles. He used orthotics and took Motrin 2-3 times a week. The Veteran also reported that experienced mild bilateral ankle stiffness and swelling at times. He denied other symptoms related to the ankles such as flare-ups, instability or weakness. There were no constitutional symptoms of arthritis. Physical examination showed that the Veteran walked with a normal gait. He was able to walk on his toes, heels and do a deep knee bend. The ankles were symmetric with no swelling, redness or warmth. There was tenderness upon palpation of Achilles tendon of both ankles. There was full range of motion of each ankle. Range of motion testing was done times three with no pain, fatigue or decreased in range of motion upon repetition. The Veteran had normal and equal 5/5 strength of both ankles. There was no ankle instability on either side. There was no varus or valgus angulation. The diagnosis was bilateral ankle Achilles' tendonitis. The examiner noted that Veteran currently exhibited pain in both ankles. He did not have pain flare-ups or incapacitating episodes of pain. He had a normal range of motion of both ankles with no decrease in range of motion upon repetition. The examiner stated that the Veteran's bilateral ankle condition had no significant effect on his usual occupational activities. His bilateral ankle condition limited his choice of sports, exercises and other physical activities. It did not have other significant effects on his usual daily activities. Based on the record, the Board finds that initial compensable evaluations for the Veteran's right and left ankle tendonitis disabilities are not warranted on the basis of limitation of motion. The Veteran has not had limited motion of either ankle ankle, even taking into account pain, fatigue, weakness, incoordination, or lack of endurance. A compensable evaluation based on limitation of motion of the ankle is therefore unavailable. Additionally, the record contains no radiographic evidence of arthritis of either ankle. A compensable evaluation based on degenerative arthritis, which provides for compensable ratings only when arthritis is established by X-ray findings, is therefore unavailable. In addition, there is no evidence that either ankle is manifested by ankylosis (Diagnostic Codes 5270 and 5272) or malunion (Diagnostic Code 5273) so a compensable rating is not warranted under those Diagnostic Codes. The evidence does confirm that each ankle disability has been manifested by tenderness or pain throughout the initial evaluation period. Therefore, the Board concludes that a 10 percent rating is warranted for each disability by analogy to a painful scar under Diagnostic Code 7804. Right and Left Elbows The Veteran has been diagnosed with epicondylitis of the elbows. Epicondylitis is an unlisted disorder that the RO rated by analogy under Diagnostic Code 5020, which pertains to synovitis. Under Diagnostic Code 5020, synovitis is to be rated based on limitation of motion, as arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5020. The diagnostic code applicable to degenerative arthritis provides that when X-ray evidence of degenerative arthritis is presented but the loss of range of motion is noncompensable, a 10 percent disability rating is warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2013). Flexion of the major and minor forearm limited to 110 degrees is rated as noncompensably (0 percent) disabling; flexion limited to 100 degrees is rated as 10 percent disabling; flexion limited to 90 degrees is rated as 20 percent disabling; flexion limited to 70 degrees is rated as 30 percent disabling for the major extremity and 20 percent for the minor extremity; flexion limited to 55 degrees is rated as 40 percent disabling for the major extremity and 30 percent for the minor extremity; and flexion limited to 45 degrees is rated as 50 percent disabling for the major extremity and 40 percent for the minor extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5206. Extension of the major forearm limited to 45 degrees is rated as 10 percent disabling for the major and minor extremities; extension limited to 60 degrees is rated as 10 percent disabling; extension limited to 75 degrees is rated as 20 percent disabling; extension limited to 90 degrees is rated as 30 percent disabling for the major extremity and 20 percent for the minor extremity; extension limited to 100 degrees is rated as 40 percent disabling for the major extremity and 30 percent for the minor extremity; and extension limited to 110 degrees is rated as 50 percent disabling for the major extremity and 40 percent for the minor extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5207. Limitation of flexion of the major and minor forearm to 100 degrees with forearm extension limited to 45 degrees is rated as 20 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5208. Supination of the forearm limited to 30 degrees or less is rated 10 percent disabling for the major and minor sides. Limitation of pronation with motion lost beyond the last quarter of arc, so the hand does not approach full pronation, is rated 20 percent disabling for the major and minor sides; limitation of pronation with motion lost beyond the middle of arc is rated 30 percent for the major side and 20 percent disabling for the minor side. Loss of supination or pronation due to bone fusion, with the hand fixed near the middle of the arc or moderate pronation, is rated 20 percent disabling for the major and minor sides; loss of supination or pronation due to bone fusion, with the hand fixed in full pronation, is rated 30 percent in the major side and 20 percent disabling for the minor side; and loss of supination or pronation due to bone fusion, with the hand fixed in supination or hyperpronation, is rated 40 percent in the major side and 30 percent disabling for the minor side. 38 C.F.R. § 4.71a, Diagnostic Code 5213. The normal range of motion of the elbow is from 0 degrees extension to 145 degrees flexion; normal forearm pronation is from 0 to 80 degrees, and normal forearm supination is from 0 to 85 degrees. 38 C.F.R. § 4.71, Plate I (2013). A November 2005 VA examination report shows that the Veteran complained of elbow pain. Physical examination of the elbows revealed that they were non-tender to palpation. There was no effusion, erythema or increased warmth. There was full range of motion of each elbow. The elbows did not exhibit weakened movement, incoordination or fatigability. There was no worsening of pain or change of range of motion with repetition. There were no constitutional symptoms of arthritis. The diagnosis was bilateral lateral epicondylitis. A March 2011 VA examination report indicates that the Veteran denied having any problems with either elbow, including pain, flare-ups, stiffness, weakness or swelling. There was full range of motion of each elbow. There was no objective evidence of pain or limitation of motion following repetitive motion of both elbows. The examiner noted that the Veteran had bilateral elbow problems in service and that this problem had resolved with no residuals. The Veteran had no symptoms or problems related to either elbow. The examiner noted that the Veteran had a normal physical examination, including normal range of motion of both elbows with no decrease in range of motion upon repetition. There were no significant effects on the Veteran's usual occupation or on his daily activities. On the above VA examinations in November 2005 and March 2011, the Veteran had full range of motion of both elbows with no additional limitation caused by pain or repetitive use. Thus, a compensable rating is not warranted based on limitation of motion. Even considering the Veteran's subjective complaints of pain on VA examination in November 2005, the medical evidence of record does not show any limitation of motion or functional impairment that would support a compensable evaluation at any time during the appeal period. See DeLuca, 8 Vet. App. 202; 38 C.F.R. § 4.40; see also 38 C.F.R. §§ 4.45, 4.59. Compensable ratings could also be assigned for ankylosis of the elbow; elbow flail joint; or malunion or nonunion of the ulna or radius. See 38 C.F.R. § 4.71a, Diagnostic Codes 5205, 5209, 5210, 5211, 5212. However, none of these disabilities have been reported after examination, and the Veteran has not reported having any of these disabilities. Moreover, in view of the absence of any objective evidence of pain or tenderness of either elbow, the Board finds that a compensable rating is not warranted by analogy to a painful scar. Additional Considerations Consideration has been given to assigning a staged rating in addition to that assigned for the Veteran's hemorrhoids; however, at no time during the period in question have the disabilities warranted more than the assigned ratings, to include the increases granted herein. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board has also considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(a). In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the record reflects that the manifestations of each disability are specifically contemplated by the schedular criteria. Accordingly, the Board has concluded that referral of this case for extra-schedular consideration is not in order. Thun v. Peake, 22 Vet. App. 111, 115 (2008). ORDER The Board having determined that the Veteran's hemorrhoids warrant a 10 percent rating, but not higher, from August 1, 2005, through August 20, 2009, and a noncompensable rating thereafter, the benefit sought on appeal is granted to this extent and subject to the criteria applicable to the payment of monetary benefits. A 10 percent rating, but not higher, for tendonitis of the right wrist is granted throughout the initial rating period, subject to the criteria applicable to the payment of monetary benefits. A 10 percent rating, but not higher, for tendonitis of the left wrist is granted throughout the initial rating period, subject to the criteria applicable to the payment of monetary benefits. A 10 percent rating, but not higher, for tendonitis of the right ankle is granted throughout the initial rating period, subject to the criteria applicable to the payment of monetary benefits. A 10 percent rating, but not higher, for tendonitis of the left ankle is granted throughout the initial rating period, subject to the criteria applicable to the payment of monetary benefits. An initial compensable rating for epicondylitis of the right elbow is denied. An initial compensable rating for epicondylitis of the left elbow is denied. REMAND The Board finds that further development is required before the claim of entitlement to an initial rating in excess of 50 percent for seasonal affective disorder and panic disorder is adjudicated. The evidence indicates that the Veteran is in receipt of private mental health treatment. Specifically, a March 2011 VA psychiatric examination report notes that since 2004 the Veteran has been receiving private mental health treatment at the St. Clements Medical Center in Leonardtown, Maryland. There is no indication in the claims file or Virtual VA that an attempt has been made to obtain records of that treatment. Since the private treatment records could be supportive of the Veteran's claim, further development to obtain those records is in order. Accordingly, this case is REMANDED to the RO or the Appeals Management Center (AMC), in Washington, D.C., for the following actions: 1. The RO or the AMC should undertake appropriate development to obtain all outstanding mental health treatment records, to include records from St. Clements Medical Center in Leonardtown, Maryland. 2. The RO or the AMC should also undertake any other development it determines to be warranted, to include affording the Veteran a current VA examination if there is an indication that the Veteran's psychiatric disability has increased in severity since the most recent VA psychiatric examination in March 2011. 3. Then, the RO or the AMC should readjudicate the claim on appeal in light of all pertinent evidence and legal authority. If the benefit sought on appeal is not granted to the Veteran's satisfaction, the RO or the AMC should furnish to the Veteran and his representative a Supplemental Statement of the Case and afford them the appropriate time period for response before the case is returned to the Board for further appellate action. By this remand the Board intimates no opinion as to any final outcome warranted. No action is required of the appellant until she is otherwise notified; but she has the right to submit additional evidence and argument on the matter the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs