Citation Nr: 1338137 Decision Date: 11/20/13 Archive Date: 12/06/13 DOCKET NO. 08-05 341 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUE Entitlement to a disability rating in excess of 40 percent for service-connected rheumatoid arthritis. REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney at Law ATTORNEY FOR THE BOARD C. Boyd, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1985 to July 1991 and November 1993 to May 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2007 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho. Following a January 2013 Board decision, counsel for the Veteran and the Secretary of VA filed a Joint Motion for Partial Remand. In that Joint Motion, the parties agreed that the Board's January 2013 decision failed to adequately address the applicability of 38 C.F.R. § 4.59 with regard to the Veteran's claim for an increased rating for rheumatoid arthritis. An Order of the Court dated in July 2013, granted the motion and remanded the issue to this extent. With regard to the 40 percent disability rating granted in the January 2013 Board decision, such decision has not been disturbed. In addition to a paper claims file, there is a Virtual VA electronic file. The Board has reviewed both files prior to reaching this decision. FINDING OF FACT Throughout the entire rating period on appeal, the Veteran's rheumatoid arthritis has been manifested by symptom combinations that more closely approximate a definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year but without weight loss or anemia; objective evidence of painful motion was not shown. CONCLUSIONS OF LAW The criteria for a disability rating in excess of 40 percent for rheumatoid arthritis have not been met. 38 C.F.R. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.3, 4.7, 4.10, 4.59, 4.71a, Diagnostic Code 5002 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. The Veteran was notified via letters dated in February 2007 and May 2008 of the information required to substantiate his claim and of his and VA's respective duties for obtaining evidence. The February 2007 letter informed the Veteran of how VA determined disability ratings and effective dates. See Dingess v. Hartman, 19 Vet. App. 473, 490-491 (2006) aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). He was also provided with information regarding the rating criteria for the diagnostic codes relevant to his disability in the May 2008 letter. Although the May 2008 notice letter was provided after the initial adjudication of his claim in May 2007, the claim was readjudicated thereafter and nothing more is required. VA also has a duty to assist a Veteran in the development of his claim. This duty includes assisting him in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. 38 U.S.C.A. § 5103A ; 38 C.F.R. § 3.159. The RO has obtained available service treatment records and identified VA treatment records. The Veteran also submitted written statements discussing his contentions. Following the Court's Order remanding the claim to the Board, VA retrieved and associated with the claims file all outstanding VA treatment records. To date, neither the Veteran nor his representative has identified any outstanding evidence. The Veteran was also afforded VA examinations with respect to his claim. The Board finds the VA examination reports to be thorough and adequate 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 service-connected disability under the applicable rating criteria. There is also no objective evidence or allegation indicating that there has been a material change in the severity of the Veteran's rheumatoid arthritis since the most recent October 2011 VA examinations. The Veteran was provided the opportunity to meaningfully participate in the development of his claim, including since the filing of the Court's Order remanding the claim to the Board. He did in fact participate. Washington v. Nicholson, 21 Vet. App. 191 (2007). Hence, no further notice or assistance is required to fulfill VA's duties to notify or assist. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F3d. 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Legal Criteria for Increased Disability Ratings Disability evaluations are based upon VA's Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4. Separate Diagnostic Codes identify various disabilities and the criteria for specific ratings for the disabilities. The percentage ratings represent as far as practicably can be determined the average impairment in earning capacity due to a service-connected disability. 38 U.S.C.A. § 1155. The evaluation assigned is determined by comparing the extent to which a Veteran's service-connected disability impairs his ability to function under the ordinary conditions of daily life, as demonstrated by the Veteran's symptomatology, with the schedule of ratings. Id.; 38 C.F.R. § 4.10; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). If two evaluations are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Diagnostic Codes predicated on limitation of motion do not prohibit consideration of a higher rating for flare ups or for functional loss due to weakness, excess fatigability, incoordination, or pain on use. 38 C.F.R. § 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). A finding of functional loss due to pain must be supported by adequate pathology and evidenced by visible behavior, such as facial expression or wincing, of the Veteran undertaking the motion. 38 C.F.R. §§ 4.40, 4.59. The guidance provided under DeLuca must be followed in adjudicating claims where a rating under the diagnostic code provisions governing limitation of motion should be considered. However, the provisions regarding functional loss, should only be considered in conjunction with the diagnostic code provisions predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7, 11 (1996). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and the demonstrated symptomatology. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall resolve the benefit of the doubt in favor of the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Factual Background and Analysis The Veteran's rheumatoid arthritis is rated at 40 percent disabling, effective February 2007. In the Joint Motion, the parties noted that the Veteran did not want this determination to be disturbed, but the parties agreed that the Board's reasons and bases in its January 2013 decision granting such benefit were nevertheless inadequate with regard to whether the Veteran may be entitled to a separate disability rating under other regulatory provisions. Joint Motion at 1. Specifically, the claim was remanded to the Board for a more thorough discussion of whether the Veteran is also entitled to a separate rating for each of his painful joints under 38 C.F.R. § 4.59. The Board has carefully reviewed all evidence of record in coming to the conclusion that a single 40 percent disability rating under Diagnostic Code 5002 for the entire appeals period is the only appropriate outcome. Rheumatoid arthritis is evaluated under 38 C.F.R. § 4.71a , Diagnostic Code 5002. Under Diagnostic Code 5002, rheumatoid arthritis is assigned various ratings based on whether the arthritis is an active process or manifested by chronic residuals. 38 C.F.R. § 4.71a , Diagnostic Code 5002. For arthritis as an active process, a 100 percent rating is assigned for constitutional manifestations associated with active joint involvement, totally incapacitating. Id. A 60 percent rating is assigned where manifestations less than commensurate with criteria for a 100 percent but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods. Id. A 40 percent rating is assigned with symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year. Id. For arthritis as chronic residuals, Diagnostic Code 5002 permits evaluation based on limitation of motion or ankylosis, favorable or unfavorable, of specific joints affected consistent with applicable diagnostic codes. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5002. Id. Such limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. A Note to the Code provides that the rating for active process cannot be combined with that for residuals based on limitation of motion or ankylosis; the higher rating is to be assigned. With any form of arthritis, painful motion is an important factor of disability. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. 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. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. 38 C.F.R. § 4.59. In April 2007, the Veteran underwent a VA examination to assess the severity of his rheumatoid arthritis disability. The history of the disability included a rheumatoid arthritis diagnosis in 1999, with the use of prescription medications to treat the disability since that time. He had been on a new medication since March 2007, and he described his rheumatoid arthritis symptoms as stable. The April 2007 VA examiner determined that the disease was currently present and currently active. The physical examination revealed that the Veteran demonstrated full range of motion of flexion and extension of the bilateral MCP joints from zero to 90 degrees. There was no tenderness of active synovitis present for either hand. Normal range of motion at the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints was noted bilaterally and reported as 80 and 90 degrees, respectively. The Veteran experienced stiffness in both hands with repetitive flexion at the MCP, DIP, and PIP joints, without a loss of range of motion. Examination of the feet was negative for local tenderness or swelling. The Veteran demonstrated full range of motion of both ankles, which was reported as 20 degrees of dorsiflexion, 45 degrees of plantar flexion, 20 degrees of eversion, and 30 degrees of inversion. There was no loss of range of motion, pain, or tenderness with repetitive motion. The Veteran reported experiencing general symptoms of fatigue and exhaustion and reported that exacerbations of his symptoms occurred monthly and lasted for one day; he alleged having had more than six of these episodes during the previous twelve months. The Veteran reported having pain primarily in the metacarpophalangeal (MCP) joints of his hands and pain in both feet. Pain and stiffness occurred every morning and lasted for two hours. His pain was alleviated by activity. At the time of the examination, he stated that his pain was at baseline as he had been up for longer than two hours; he had a dull ache in the MCP joints of both hands. The Veteran denied swelling in his joints. The examiner noted the Veteran's energy level was affected, and he had to curtail the time he spent working in the yard. The Veteran could work no longer than twenty minutes without a rest. He was receiving Remicade infusions with fair control of his symptoms. The examiner concluded that the Veteran's rheumatoid arthritis had significant effects on his usual occupation, as he experienced decreased mobility and manual dexterity, and lacked stamina. The Veteran reported that he was employed full time as a store cashier and that he had not lost any time from work, although he experienced increased tardiness due to the disability. He reported that he recently left a previous job as a delivery driver because he was afraid that he would have an exacerbation of his joint pain while driving. He also reported experiencing increased pain with writing more than five minutes. The disability had mild effects on his recreation and traveling, and moderate effects on his ability to exercise and participate in sports. VA medical records dated throughout the pendency of the appeal show frequent treatment of the Veteran's rheumatoid arthritis disability. They include a June 2006 record documenting the Veteran's report of stiffness in his feet, hands, wrists, elbows, and ankles that had increased for the previous three months. His hands and wrists were swollen in the morning for many hours, but abated during the day. The examiner noted that the Veteran had definite gelling and pain in all of the identified joints. The physical examination revealed tenderness to grade 1 with no synovitis in the elbows; trace swelling in the bilateral wrists and second and third MCP and PIP joints; and minimal crepitance in the knees. The fist was 90 percent bilaterally. The treating physician assessed the Veteran has having a mildly rheumatoid flare, and he was prescribed additional medication. VA records show that the Veteran experienced a flare of his rheumatoid arthritis in February 2007 after stopping one of his medications. He continued to use of a different medication twice a week, but still had increased pain. His shoulders, elbows, wrists, hands, feet, and ankles were the main joints involved. The physical examination revealed grade 1 synovitis of the right wrist; trace in the left wrist; and Grade 1 synovitis bilaterally in the PIP and MCP joints. His physician prescribed Remicade to treat his symptoms. A March 2007 record shows that the Veteran's medication was changed and documents his report of morning stiffness for one to two hours. The physical examination did not reveal any swollen or tender joints. In an August 2007 letter, the Veteran's VA physician stated that the Veteran's rheumatoid arthritis had worsened during the past year and that he required additional medications to control his disease. Additional VA treatment records dated from March 2007 to July 2011 include the Veteran's reports of morning stiffness for approximately two hours and constant fatigue. Following a November 2007 rheumatology consultation, his physician stated that the Veteran's rheumatoid was doing well. In April 2008, the Veteran reported that his pain and swelling affected his feet, ankles, elbows, and occasionally his shoulders. In July 2008, he reported experiencing swelling of his hands after working for a few minutes. A December 2010 record shows that the Veteran had not experienced any acute flares. In February and March of 2011, he reported that his joint pain had improved and that he was without significant aches or stiffness. The Veteran stated that he had pain in his left ankle, left foot, and hips in July 2011; his rheumatoid arthritis was assessed as stable. An October 11, 2011 VA examination report documents the Veteran's continued report of pain and stiffness in his joints. These symptoms occurred daily, and he indicated that it took approximately twenty minutes for the symptoms to resolve in the mornings. He stated that his pain and stiffness affected all joints, hands, feet, and the entire spine. During episodes of flare-ups, his pain was a 10 out of 10 in severity (with 10 being the most severe) and took eight to twelve hours to resolve. Flares occurred approximately two to three times per year. He received Orencia infusions monthly, which he stated were working well, along with the daily use of pain medication. The Veteran described his symptoms as pain and stiffness in the bilateral shoulders, elbows, wrists, hips, knees, and ankles. Flare ups occurred every five to six months. He reportedly had three incapacitating episodes of arthritis per year. The Veteran stated that he missed three to five days of work per year due to his disability. He was able to stand from three to eight hours, with only short rest periods. The physical examination revealed that the Veteran walked with a normal gait. The examiner determined that the rheumatoid arthritis was currently an active process and that there was a definite overall impairment of health. Crepitus was noted in the right wrist, and tenderness was noted in the left knee. Range of motion testing of the bilateral shoulders revealed flexion to 180 degrees; abduction to 180 degrees; and internal and external rotation to 90 degrees. Range of motion of the bilateral elbows revealed flexion to 145 degrees; extension to zero degrees; pronation to 80 degrees; and supination to 85 degrees. Range of motion of the bilateral wrists revealed dorsiflexion to 80 degrees; palmar flexion to 75 degrees; radial deviation to 20 degrees, and ulnar deviation to 45 degrees. Range of motion of the bilateral hips revealed flexion to 110 degrees; extension to 20 degrees; and abduction to 45 degrees. Testing of the range of motion of the bilateral knees revealed flexion to 145 degrees and extension to zero degrees. Testing of the range of motion of the bilateral ankles revealed dorsiflexion to 20 degrees and plantar flexion to 45 degrees. There was no pain with active range of motion testing for any of the joints, or objective evidence of pain or additional limitations following repetitive testing. The examination revealed a diagnosis of rheumatoid arthritis affecting all joints. The examiner noted that the Veteran worked full-time in a big box store, during which he was on his feet for hours and walked approximately seven miles per shift. The Veteran's rheumatoid arthritis had significant effects on his occupation, which were identified as decreased mobility, weakness or fatigue, and pain. The Veteran reportedly missed one week from work during the previous twelve months. The effect of the disability on the Veteran's ability to do chores was mild, and the effect of the disability on his ability to participate in recreation activities was moderate. The Veteran also underwent a VA spine examination on October 11, 2011, at which time he reported having neck and back pain. Flare ups of his symptomatology occurred every five to six months, during which he may have missed a day of work. The Veteran reported experiencing stiffness and fatigue, but denied any weakness or decreased motion of his spine. There was no limitation to walking. The physical examination revealed that the Veteran's posture and gait were normal and without any abnormal spinal curvatures. There was no objective evidence of spasms, atrophy, guarding, pain with motion, tenderness, or weakness for either the cervical or thoracolumbar spine. The Veteran demonstrated cervical spine flexion and extension from zero to 45 degrees, left and right lateral flexion from zero to 30 degrees; and left and right lateral rotation from zero to 80 degrees. He demonstrated thoracolumbar spine flexion from zero to 90 degrees; extension from zero to 30 degrees; and left and right lateral rotation and flexion from zero to 30 degrees. There was no pain with active range of motion testing for any of the joints, or objective evidence of pain or additional limitations following repetitive testing. The reflex and motor examinations of the upper and lower extremities were normal. During the October 11, 2011, VA hand, thumb, and fingers examination, the Veteran reported having flare ups every five to six months of his symptoms that involved all fingers and his thumbs. Active range of motion of the fingers and thumbs of both hands was normal and without objective evidence of pain or additional limitation following repetitive testing. The Veteran could grip 95 pounds on the left and 100 pounds on the right. The October 11, 2011 VA feet examination report documents the Veteran's report of pain and stiffness in the MTPs and toes. Symptoms occurred while walking and standing. Flare ups of his symptomatology occurred one to two times per year. The physical examination of the left foot and right foot was negative for evidence of painful motion, swelling, tenderness, instability, weakness, or abnormal weight bearing. The Veteran walked with a normal gait and without the use of any assistive devices. Following the remand to the Board in July 2013, the VA associated all outstanding VA medical records with the claims file. The Veteran waived RO consideration of this evidence. Therefore, the Board will consider it here as part of its evaluation of whether a 40 percent rating remains an adequate rating subsequent to the October 2011 examination. A VA treatment record from December 2011 indicates no swelling of the joints and that the Veteran's joint pain had improved. He reported he had no significant aches or stiffness in the morning, but did experience some later in the day. The Veteran reported the same experience at a treatment visit in February 2012. In April 2012, the Veteran reported his arthritis symptom severity was around a 4 on average, but that it was 6/10 in the morning with symptoms lasting about 1 to 1.5 hours. He stated the symptoms improved during the day. He reported some mild joint swelling, but that the pain was worse than the swelling. He stated that working at a garden center had worsened his symptoms. He denied significant flare-ups. In July 2012, the Veteran sought treatment for an arthritis flare and sought additional medication. Later that month, the Veteran was seen for a shoulder sprain. As to his arthritis pain, he stated that his pain is chronic, but that his job has him using his arms frequently and he has grandchildren at home with whom he is very active. In August 2012, following an assessment of degenerative disc disease in his cervical spine worst at C6-C7, the Veteran related experiencing left side neck pain, shoulder pain and arm pain that began in July 2012. He stated he had episodes of weakness where sometimes he could not keep ahold of things. He stated his morning stiffness lasted 30 - 60 minutes. The examiner found tenderness in his left hand and left elbow with no swollen joints and full range of motion. Left triceps and possible biceps atrophy was noted. The examiner found normal hand grip and finger abduction bilaterally. In late August 2012, the examiner noted the Veteran's arm pain was "pretty much resolved" and his arm bulk was increasing and arm weakness was lessening. In addition, he was no longer dropping objects. Physical therapy was said to be improving the pain in his neck. In September 2012, the Veteran reported that his arm and neck pain had resolved completely and he went back to work. The Veteran reported that he works manually "throwing packages" with the heaviest weight being the weight of a 5 gallon container of motor oil. He claimed morning stiffness for roughly 30 -45 minutes and no joint swelling was found. In January 2013, the Veteran reported a little bit of joint stiffness and no joint swelling and that he occasionally experiences a brief twinge of pain on the left side of his neck. In May 2013, he related arthritis flare ups occurring after his Orencia infusions that last 2-3 days and that his morning stiffness was lasting 2.5 hours. He reported that his elbows hurt and he had minor swelling in the right knuckles. In July 2013, he reported his arthritis pain was 6/10 (with 10 as the highest). In August 2013, his arthritis was noted to be stable with a flare up every two months and he was not experiencing any additional side effects from the Orencia infusions. He noted stiffness in the mornings lasting an hour on average and that with his last infusion he had not developed joint pain as he experienced following prior infusions. He related that his hands hurt the most and he had pain in the left knee. In September 2013, the Veteran and his daughter submitted affidavits pertaining to the Veteran's arthritis disability. His daughter related that her father is walking slower and needing to take more frequent breaks from activities. She stated she has to provide him assistance, especially in the mornings. She mentioned the pain the Veteran experiences and how it is worse during weather changes and during flare-ups. The Veteran stated his joints are swollen and ache when he wakes up for about an hour or so. He described the pain as "dull" and "throbbing" and that it lasts all day. He stated that he has severe flare-ups about 3 to 4 times a year that will last 2 to 4 days at a time. He reported that his arthritis limits his ability to stand, walk and sit. He stated he is extremely fatigued and has trouble even walking to his mailbox. He indicated he works as a sales associate and his job requires two hours of walking a day. He related that he has about 4 to 5 absences from work a year and misses 2 to 3 days each time. Upon review of the lay and medical evidence, the Board finds that from 2007 to 2013, the Veteran's disability has primarily been manifested by morning stiffness, pain, and periodic swelling of his hands, feet, ankles, elbows, wrists, shoulders, and spine; fatigue; and flare-ups occurring as frequently as once a month to once every five or six months. In addition, there is objective evidence of stiffness, gelling, tenderness, and synovitis affecting multiple joints. Although the evidence between 2007 and 2013 does not show incapacitating exacerbations, the Board must resolve all doubt in the Veteran's favor and conclude that his disability most closely approximates the criteria for a 40 percent rating under Diagnostic Code 5002. In considering whether a rating higher than 40 percent rating may be assigned under Diagnostic Code 5002 at any point during the appeal period, the Board finds that it may not. Although the Veteran has daily symptoms and flare-ups as frequently as once a month, the evidence does not show weight loss and anemia productive of severe impairment of health. There is no objective evidence of, nor has the Veteran claimed to have had, weight loss or anemia during the appeal period. The Board acknowledges the Veteran's reports of significant symptoms and flare-ups, but objective evidence does not support a finding of severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods. That is, the medical evidence does not include symptoms or findings indicative of incapacitation. As reflected above, the Veteran has maintained full time employment during the appeal period, which he indicated required him to stand on his feet for numerous hours, walk a significant distance and make frequent use of his arms. The Board has also considered whether the involved joints should be rated separately as chronic residuals. See 38 C.F.R. § 4.71a, Diagnostic Code 5002. However, the evidence does not suggest that any other diagnostic code would be more appropriate. Notably, there is no indication of ankylosis or limited motion in any particular joint due to the service-connected rheumatoid arthritis which would allow for a higher rating under a different diagnostic code. Thus, separate ratings under the diagnostic codes relevant to the joints affected would not result in a more favorable outcome to the Veteran. See generally, 38 C.F.R. § 4.71a, Diagnostic Codes 5200-5203 (pertaining to the shoulder and arm), Diagnostic Codes 5205 to 5213 (pertaining to the elbow and forearm), Diagnostic Codes 5214 to 5215 (pertaining to the wrist), Diagnostic Codes 5216 to 5230 (pertaining to single and multiple digits of the hand), Diagnostic Code 5235 to 5243 (pertaining to the spine), Diagnostic Codes 5256 to 5262 (pertaining to the knee and leg), Diagnostic Codes 5270 to 5271 (pertaining to the ankle) and Diagnostic Codes 5276 to 5284 (pertaining to the foot). In summary, the Veteran's rheumatoid arthritis warrants a 40 percent schedular rating, but no higher, throughout the entire appeal period. 38 C.F.R. § 4.3, 4.7. As there appears to be no time period identified during the period of the appeal during which this disability manifested symptoms meriting a disability rating in excess of the rating assigned and upheld herein, staged ratings are not warranted. See Hart, 21 Vet. App. 505. In coming to this decision, the Board has analyzed the credibility and probative value of the evidence. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran is competent to report his rheumatoid arthritis symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is not, however, competent to identify a specific level of disability relating rheumatoid arthritis to the appropriate diagnostic codes. On the other hand, such competent evidence concerning the nature and extent of the Veteran's disability has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which his disability is evaluated. The Board now turns to the question of whether the Veteran is potentially entitled to separate ratings for each joint pursuant to 38 C.F.R. § 4.59. The provisions of 38 C.F.R. § 4.59 state, in part, that painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Initially, the Board notes that the Veteran's rheumatoid arthritis is not rated under a provision that is predicated on limited motion; therefore, it is unclear whether the Board is bound to consider, in conjunction with Diagnostic Code 5002, any additional painful motion by virtue of the factors described in 38 C.F.R. § 4.59. See, e.g., Johnson v. Brown, 9 Vet. App. 7, 11 (1996) (noting that where a diagnostic code is not predicated on a limited range of motion alone, the provisions of 38 C.F.R. §§ 4.40 and 4.45, with respect to functional loss due to pain, do not apply). By way of background, in Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991), the Court of Appeals for Veterans Claims (Court) held that when there is painful motion of a major joint caused by degenerative arthritis (rated under Diagnostic Code 5003) that is detected on x-ray, such painful motion, pursuant to § 4.59, will be considered limited motion and entitled to a minimum 10 percent rating, per joint, combined under Diagnostic Code 5003, even though there was no actual limitation of motion. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (wherein the Court distinguished Lichtenfels as limited to the specific situation where a claimant demonstrates noncompensable loss of motion and is rated under Diagnostic Code 5003 (degenerative arthritis established by X-ray findings)). Here, simply because the Veteran has a form of arthritis does not automatically mean § 4.59 applies. Indeed, the record reflects no objective evidence of loss of motion or even limitation of motion in connection with the Veteran's rheumatoid arthritis. Range of motion tests performed during the April 2007 and October 2011 VA examinations demonstrated full range of motion in all joints and no objective evidence of pain on movement even following repetitive testing. There is no doubt pain exists that is daily and causes fatigue and stiffness. This pain, as described by the Veteran, is "dull" and "throbbing" and is part of an active process disability rather than "due to a healed injury" as described in §4.59. The lack of objective evidence of pain or any joint that is unstable or malaligned preponderates against entitlement to a separate rating for each joint pursuant to 38 C.F.R. § 4.59. In addition, the Board's determination that the Veteran's disability more closely approximated the criteria for a 40 percent schedular rating was based on the presence of joint pain. As the 40 percent schedular rating gives consideration to the Veteran's pain, to rate that same symptom again as associated with the same disability would amount to prohibited pyramiding. See 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259 (1994) (stating that separate ratings for the "same manifestation" of the "same disability" is impermissible). Here, to grant entitlement to a separate rating for each joint would be to compensate the Veteran twice for the same symptom, i.e. pain. The Board fully recognizes the Veteran's credible and competent reports that his rheumatoid arthritis is manifested by joint pain. Nonetheless, based on the foregoing, the Board concludes that separate ratings for each joint pursuant to § 4.59 are not warranted. IV. Extraschedular Considerations The Board has also considered whether a referral for extra-schedular rating is warranted for the Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (a threshold finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate is required for extra-schedular consideration referral). The schedular evaluation for the Veteran's rheumatoid arthritis is adequate, despite the Veteran's disagreement with the disability rating. In other words, he does not have any symptoms from his service-connected disorder that are unusual or are different from those contemplated by the schedular criteria. The Veteran does not have an "exceptional or unusual" disability; he merely disagrees with the assigned evaluation for his level of impairment. The available schedular evaluation for these service-connected disability is adequate. Thus, referral for extra-schedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extra-schedular consideration is moot. See Thun, 22 Vet. App. at 115. Lastly, the Board observes that, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims held that a claim for total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU) is part of an increased rating claim when such claim is raised by the record. Throughout the pendency of the appeal, the Veteran has reported that that he is employed full time. He has not claimed, nor does the evidence suggest, that he is unable to secure and maintain gainful employment due to the claimed service-connected disability. Therefore, the question of entitlement to a TDIU has not been raised. Id. at 447; Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). ORDER Entitlement to a disability rating in excess of 40 percent for service-connected rheumatoid arthritis is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs