Citation Nr: 1340040 Decision Date: 12/04/13 Archive Date: 12/18/13 DOCKET NO. 07-24 375 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUE Entitlement to an increased (compensable) disability rating for polyarthritis. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD C. Fields, Counsel INTRODUCTION The Veteran had active duty service from July 1968 to February 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York. The Board remanded this issue for further development in April 2011 and May 2013. The Veteran wrote in an August 2013 statement that he was requesting his rating to be increased from 0 percent to 10 percent for polyarthritis. Nevertheless, he and his representative have indicated at all other times that he wanted the highest available rating for his joints based on polyarthritis. Therefore, this is not a clear statement of intent to limit the scope of his appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993) (stating that a claimant may limit the appeal to the issue of entitlement to a particular disability rating that is less than the maximum allowed by law for a specific condition, but where there is no clearly expressed intent to limit the appeal, VA must consider all available ratings). FINDINGS OF FACT 1. Polyarthritis affecting the lumbar spine has manifested by forward flexion to greater than 30 degrees, but not greater than 60 degrees, even with consideration additional functional loss due to pain or other factors during flare-ups or with repetitive use; with no ankylosis, associated objective neurological abnormalities, or incapacitating episodes totally at least 4 weeks in any 12-month period. 2. Polyarthritis affecting the shoulders has manifested by limitation of motion due to pain, but with function retained of movement above the shoulder level, even during flare-ups or after repetitive use. 3. Polyarthritis affecting the bilateral hands, knees, ankles, and feet has manifested by intermittent pain during flare-ups several times a month, resulting in functional loss due to painful movement and other factors, but no actual limitation of motion or other impairment to warrant a rating under any applicable diagnostic code. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 20 percent, but no higher, for polyarthritis affecting the lumbar spine have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.10, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5009, 5242 (2013). 2. The criteria for a disability rating of 10 percent, but no higher, for polyarthritis affecting the right shoulder have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.10, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5009. 3. The criteria for a disability rating of 10 percent, but no higher, for polyarthritis affecting the left shoulder have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.10, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5009. 4. The criteria for a disability rating of 10 percent, but no higher, for polyarthritis affecting the right hand have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.10, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5009. 5. The criteria for a disability rating of 10 percent, but no higher, for polyarthritis affecting the left hand have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.10, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5009. 6. The criteria for a disability rating of 10 percent, but no higher, for polyarthritis affecting the right knee have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.10, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5009. 7. The criteria for a disability rating of 10 percent, but no higher, for polyarthritis affecting the left knee have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.10, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5009. 8. The criteria for a disability rating of 10 percent, but no higher, for polyarthritis affecting the right ankle have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.10, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5009. 9. The criteria for a disability rating of 10 percent, but no higher, for polyarthritis affecting the left ankle have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.10, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5009. 10. The criteria for a disability rating of 10 percent, but no higher, for polyarthritis affecting the right foot have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.10, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5009. 11. The criteria for a disability rating of 10 percent, but no higher, for polyarthritis affecting the left foot have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.10, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5009. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations require VA to provide claimants with notice and assistance in substantiating a claim. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper VCAA notice must inform the claimant of any information and evidence not in the 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. Quartuccio v. Principi, 16 Vet. App. 183, 186 (2002). These notice requirements apply to all elements of a claim, including the degree and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Proper VCAA notice must be provided prior to the initial unfavorable decision on the claim. Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004). In this case, the Veteran was advised in May 2006, prior to the initial unfavorable rating decision, of the evidence and information necessary to substantiate his claim (i.e., that his disability has increased in severity), the responsibilities of the Veteran and VA in obtaining such evidence, and the evidence and information necessary to establish a disability rating and an effective date. This is sufficient notice. Concerning the duty to assist, the Veteran's service treatment records and all identified, pertinent post-service treatment records have been obtained and considered. The Board has reviewed both the paper claims file and the Virtual VA paperless claims processing system, and all pertinent records were considered by the agency of original jurisdiction (AOJ). There is no indication that the Veteran receives benefits from the Social Security Administration. As directed in prior remands, the AOJ obtained copies of any VA treatment records dated since April 2007. The Board observes that a July 2007 VA treatment record notes that the Veteran was being followed by outside providers for various conditions. He was requested to identify and provide a release for records from any non-VA providers, or provide the records himself, on several occasions, including in May 2013 as directed in the prior remand. The Veteran did not respond identify any outstanding records in response to this request. VA is only obligated to obtain records that are adequately identified. 38 C.F.R. § 3.159(c)(i)-(ii). Further, the Veteran denied any treatment since 2007 for his joint symptoms in the June 2013 VA examination. As such, there is no indication of pertinent, outstanding records. The Veteran was afforded several VA examinations concerning his claim, most recently in June 2013, as directed in the prior remand. The examiner recorded the Veteran's complaints and measured the manifestations of his disability with appropriate testing, including range of motion measurements for all affected joints, as directed in the prior remand. The examiner indicated that there was functional loss due to painful movement, without indicating a specific degree of such loss. The Board notes that the examiner stated in this report, as well as in a July 2013 addendum, that she could not offer an opinion as to the degree of additional functional loss for the Veteran's affected joints during flare-ups or after repetitive use without resorting to speculation. She explained that she could only base her opinion on her interview and 1.5-hour personal evaluation of the Veteran. There is no argument that this examination or addendum is inadequate. Further, the Veteran has consistently described his symptoms during the course of the appeal, generally indicating pain, stiffness, and swelling, but no actual limitation of motion. As such, the evidence is sufficient to rate the Veteran's polyarthritis, including with consideration of pain and painful movement during flare-ups or with repetitive use. VA has satisfied its duties to inform and assist the Veteran at every stage in this case; at least insofar as any errors committed were not prejudicial or harmful to the essential fairness of the proceedings. The prior remand directives were substantially completed, and the Veteran will not be prejudiced by a decision. II. Analysis VA's percentage ratings are based on the average impairment of earning capacity as a result of service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 262 (1994); see also Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). If the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal, then staged ratings should be assigned. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Veteran's polyarthritis is currently rated under Diagnostic Code (DC) 5009 for arthritis (other types), which is rated as rheumatoid arthritis. See 38 C.F.R. § 4.71a. Rheumatoid arthritis may be rated based either on the active disease process or on chronic residuals, whichever results in a higher overall rating. As an active process, evidence of one or two exacerbations a year in a well-established diagnosis warrants a 20 percent rating. The next higher rating of 40 percent requires evidence of symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring three or more times a year. A 60 percent rating necessitates evidence less than that required for a 100 percent rating, but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring four or more times a year or a lesser number over prolonged periods. A 100 percent rating requires evidence of constitutional manifestations associated with active joint involvement which are totally incapacitating. 38 C.F.R. § 4.71a, DC 5002. Chronic residuals such as limitation of motion or ankylosis will be rated under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes, a rating of 10 percent will be applied for each such major joint or group of minor joints affected by limitation of motion, to be combined, and not added under DC 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. The ratings for the active process of rheumatoid arthritis will not be combined with the residual ratings for limitation of motion or ankylosis; rather, the higher evaluation will be assigned. Id. at Note following DC 5002. When evaluating musculoskeletal disabilities based on limitation of motion, a higher rating must be considered where the evidence demonstrates additional functional loss due to pain, pursuant to 38 C.F.R. §§ 4.40 and 4.45. The codes pertaining to range of motion do not subsume sections 4.40 and 4.45, and the rule against pyramiding does not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including use during flare-ups. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); cf. Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (holding that pain without associated functional impairment could not serve as the basis for a higher rating). In determining if a higher rating is warranted on this basis, pain itself does not constitute functional loss. Similarly, painful motion alone does not constitute limited motion for rating under diagnostic codes pertaining to limitation of motion (as opposed to for the purpose of assigning a minimum rating based on arthritis with painful motion). Pain may result in functional loss, however, if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance, as provided in sections 4.40 and 4.45. Mitchell, 25 Vet. App. 32. Under 38 C.F.R. § 4.59, with any form of arthritis, painful motion is an important factor of disability. The intent of the Rating Schedule is to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. When section 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Here, the Veteran's claim for an increased rating was received in November 2005. He has consistently complained of pain and swollen joints, including the bilateral shoulders, hands, wrists, knees, ankles, feet, and the lumbar spine, with stiffness in the morning and worsening pain during cold and damp weather. His symptoms are treated mainly with aspirin and rest, and he has denied seeking treatment since 2007. See, e.g., VA treatment records dated in May and October 2006; VA examination reports dated in August 2006, April 2007, May 2011, and June 2013. The Veteran is competent to report these observable symptoms of his disability because they are observable by his own senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). There is also no evidence to contradict these statements, or any other reason to find him not credible as to these symptoms (essentially pain and painful motion) during flare-ups and after repetitive use. A VA examiner did opine in August 2006 and April 2007 that the Veteran's joint complaints were not likely related to polyarthritis but, rather, were due to degenerative age-related changes. Nevertheless, the May 2011 VA examiner indicated that polyarthritis was still the correct diagnosis, as the Veteran had osteoarthritis or degenerative joint disease of multiple joints, and the evidence did not establish rheumatoid arthritis. Based on this evidence, in May 2013, the Board denied service connection for rheumatoid arthritis, finding that the record did not show current rheumatoid arthritis, but rather polyarthritis of multiple joints. As such, the Veteran is entitled to the appropriate rating or ratings for his joint symptoms, as shown by the lay and medical evidence of record. Preliminarily, the Board finds that a rating is not warranted for either wrist. Although the Veteran has complained of symptoms in both wrists, the May 2011 examiner opined that, in contrast to the other joints, his wrist symptoms were more consistent with soft tissue calcifications, which were not arthritic in nature. X-rays of the wrists in May 2006 and May 2011 were normal. Although the August 2006 VA examiner recorded a diagnosis of "minimal degenerative joint disease in the hands and wrists," the May 2011 VA examiner was requested to clarify the diagnoses based on all evidence of record, which included the repeat x-rays. There is no other medical evidence to indicate that the Veteran's symptoms in either wrist are arthritic in nature. As such, the May 2011 examiner's opinion is more probative in this regard, and outweighs the prior examiner's statement. The Veteran is not competent as a lay witness to offer a diagnosis or opinion as to whether his wrist symptoms are due to arthritis, as this question requires medical expertise, especially given the Veteran's complicated medical history. See Jandreau, 492 F.3d at 1376-77. Therefore, a rating is not warranted for either wrist, as the evidence does not demonstrate that they are affected by polyarthritis. The Board also notes that the Veteran has occasionally complained of aches and pains in the neck (or cervical spine), elbows, and hips. Nevertheless, he was found to have good range of motion and unremarkable evaluations of these areas, and they were not noted to be affected by the service-connected polyarthritis. See VA treatment records dated in May 2006, October 2006, April 2007, and October 2007. As such, a separate or compensable rating is not warranted for these joints. The Board will now turn to the appropriate ratings for the joints that are affected by the Veteran's service-connected polyarthritis under 38 C.F.R. § 4.71a, DC 5002. Multiple ratings are warranted based on chronic residuals, as discussed below. As these result in a higher rating when combined, they will be explained first. For the lumbar spine, the Veteran has reported significant but intermittent pain, and x-rays have shown degenerative disc disease or degenerative joint disease throughout the appeal. During the August 2006 VA examination, he had forward flexion limited to 30 degrees and combined range of motion to 130 degrees. During the April 2007 VA examination, range of motion was again limited to 40 degrees of forward flexion and 150 degrees of combined range of motion, with pain at the extremes of motion. Thereafter, an October 2007 VA treatment record notes that the Veteran had osteoarthritis that was symptomatic mostly in the low back and the hands, although no ranges of motion were recorded. During the May 2011 VA examination, the Veteran had antalgic gait, and he reported that his walking was affected by his back and his chronic obstructive pulmonary disease (COPD). During the June 2013 VA examination, the Veteran reported continued intermittent low back pain with treatment through chiropractic care and physical therapy that did not relieve pain. As noted above, he did not identify or authorize VA to obtain any outstanding non-VA records. The Veteran reported flare-ups 3-4 times per day that were relieve with rest and hydrocodone. Forward flexion was measured to 90 degrees, with pain starting at 80 degrees, and combined range of motion was 210 degrees, or 185 degrees when accounting for pain. He was noted to have functional loss due to less movement than normal and pain on movement. Disabilities of the spine will be rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), unless the condition is rated as intervertebral disc syndrome (IVDS) under DC 5243. The Veteran has been diagnosed with degenerative disc disease and degenerative joint disease of the lumbar spine, and the May 2013 VA examiner indicated that there was IVDS. Under the General Rating Formula, the ratings are to be assigned with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. 38 C.F.R. § 4.71a, DC 5242. As pertinent to this case, a 20 percent rating is warranted where there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees. Id. The findings during the August 2006 and April 2007 VA examinations warrant such a rating. Although the Veteran had much greater range of motion during the June 2013 VA examination, the Board resolves doubt in his favor and finds that he continued to have limitation of motion to between 30 and 60 degrees when considering his additional functional loss during flare-ups. Nevertheless, the Veteran does not meet the criteria for a rating in excess of 20 percent for the lumbar spine. To warrant a rating of 40 percent under the General Rating Formula, there must be forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. Id. There must be unfavorable ankylosis to warrant a higher rating of 50 or 100 percent. Id. Here, there is no indication that the Veteran's motion was limited to this degree even during flare-ups or after repetitive use, and there were no findings of ankylosis. As such, a higher rating is not warranted on this basis. Additionally, the Veteran has consistently denied any radiating pain or bowel or bladder impairment, and he was found to have no radicular symptoms or associated during neurological abnormalities during the May 2013 VA examination. As such, a separate rating is not warranted on this basis. See id. at Note (1) (providing for a separate rating for any associated objective neurologic abnormalities). A rating in excess of 20 percent is also not warranted under the IVDS Formula. Rather, although the Veteran has reported resting during flare-ups, there is no indication of incapacitating episodes with a total duration of at least 4 weeks during any 12-month period due to polyarthritis affecting the low back, as required for a rating of 40 percent or higher on this basis. See 38 C.F.R. § 4.71a, DC 5242, IVDS Formula. Although the Veteran had frequent flare-ups of the low back and indicated a need to rest to alleviate the pain, there is no indication of bed rest that was prescribed by a physician. Id. at Note (1) (defining incapacitating episodes). For the shoulders, the Veteran has reported intermittent pain and painful motion throughout the appeal. X-rays in May 2011 showed acromioclavicular arthropathy, right greater than left, and the diagnosis was osteoarthritis of the bilateral shoulders with pain. A May 2006 VA treatment record noted mild limitation of motion of the shoulders, but the Veteran had normal range of motion in April 2007 and October 2007. There was decreased range of motion in May 2011 and June 2013. At the May 2011 VA examination, the Veteran reported moderate flare-ups with pain and other symptoms every 1-2 months lasting 3-7 days, and estimated that he had 50 percent reduction in function during such flare-ups. There was tenderness and guarding upon examination. The Veteran had left shoulder forward flexion to 150 degrees and abduction to 130 degrees; and right shoulder forward flexion to 160 degrees and abduction to 140 degrees. The examiner summarized that it took the Veteran longer to do normal activities due to joint discomfort and stiffness. At the June 2013 VA examination, the Veteran reported having shoulder pain after over-working them and with overhead motion, as well as at night and with damp weather. He reported flare-ups 1-2 times per week but no treatment. There was tenderness and guarding upon examination. The Veteran had left shoulder forward flexion to 160 degrees (with pain starting at 125 degrees) and abduction to 160 degrees (with pain starting at 130 degrees). Right shoulder forward flexion was to 155 degrees (with pain starting at 115 degrees), and abduction to 160 degrees (with pain starting at 120 degrees). The examiner found that there was functional loss of the shoulders due to less movement than normal and pain on movement. Disabilities of the shoulder may be rated based on limitation of motion of the affected arm, with different ratings available based on the major or minor side. See 38 C.F.R. § 4.71a, DC 5201. The Veteran is left-handed, as indicated in several VA examination reports, so the left shoulder would be his major side. To warrant a compensable rating based on limitation of motion of the arm, there must be limitation at the shoulder level, or flexion or abduction to 90 degrees, which warrants a 20 percent rating for either the major or minor side. See id.; see also § 4.71, Plate I (showing normal ranges of motion of the shoulder and arm). Here, the Veteran's measured limitation of motion was to 115 degrees or greater in both shoulders at the VA examinations in 2011 and 2013, even when considering the point at which pain began. There was no change after repetitive use testing. This would be consistent with the previous notation of mild limitation in May 2006. Additionally, the Veteran's estimate of 50 percent reduction in function during flare-ups during the May 2011 VA examination, and his reports of pain or flare-ups after overhead activities would be generally consistent with retained function to above the shoulder level. As such, the Veteran does not meet the criteria for a compensable rating under DC 5201 for limitation of motion of the arm. Disabilities of the shoulder and arm may also be assigned ratings ranging from 10 to 80 percent based on impairment of the clavicle or scapula, impairment of the humerus including recurrent dislocation of the scapulohumeral joint, and ankylosis of scapulohumeral articulation. See 38 C.F.R. § 4.71a, DCs 5200, 5202, 5203. In this case, however, there is no argument or indication that the shoulder disabilities are manifested by ankylosis, recurrent dislocation, or other impairment of the humerus, clavicle or scapula. Therefore, a compensable rating may not be assigned for the Veteran's shoulders for symptoms including limitation of motion under those diagnostic codes. Additionally, although the Veteran has been noted to have arthritis affecting the hands, knees, ankles, and feet, he does not meet the criteria for a compensable rating under any applicable code for limitation of motion. See 38 C.F.R. § 4.71a, DCs 5216 to 5230 (rating ankylosis and limitation of motion of the hand and digits); DCs 5256 to 5263 (rating knee disabilities); DC s 5270 to 5274 (rating ankle disabilities); DCs 5276 to 5284 (rating foot disabilities); see also 38 C.F.R. § 4.71, Plates I, II, and V (showing normal ranges of motion for these joints). In particular, although the Veteran has complained of intermittent stiffness, weakness, pain, and swelling in the hands, knees, ankles, and feet, he has generally been noted to have no measured limitation of motion or other impairment during VA examinations and in his available treatment records. There was also no indication of ankylosis in any affected joint so as to warrant a rating on that basis. He consistently denied any treatment for the hands, knees, ankles, or feet. With respect to the hands, the Veteran was noted to have slight enlargement of joints, but good grip strength, no limitation of motion of the digits or thumb, and no motor or sensory impairment. In October 2007, he reported that his arthritis was mostly symptomatic in the low back and the hands, although he continued to work painting school buses and used his hands all the time. The Veteran continued to report intermittent pain with repetitive use of the hands during the May 2013 VA examination. He had full range of motion without pain, but the examiner summarized that there was functional loss due to pain on movement. For the knees, the Veteran has reported pain with squatting, kneeling, or stooping through the appeal, such as in the August 2006 VA examination. Range of motion was measured from 0 degrees of extension to 130 degrees of flexion, with minimal crepitus. In an October 2006 VA treatment record, the Veteran had crepitus, but no limitation of motion of the knees. During the April 2007 VA examination, the Veteran again reported occasional knee pain, and range of motion was from 0 to 135 degrees. At the May 2011 VA examination, there was crepitus but no other abnormalities of the knees. During the May 2013 VA examination, the Veteran again reported pain while kneeling or squatting, with flare-ups once a month, but there was full range of motion of the knees without pain upon examination. To warrant a compensable rating based on limitation of motion of the knee, there must be extension limited to 10 degrees, or flexion limited to 45 degrees. See 38 C.F.R. § 4.71a, DCs 5260 & 5261. Even with consideration of pain and other functional loss during flare-ups or after repetitive use, there is no indication that the Veteran's limitation rose to this level for flexion or extension of either knee. There was also no indication of ankylosis or any other abnormalities of the knees, such as recurrent subluxation or lateral instability, impaired semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. Id. at DCs 5256 to 5259, 5262, 5263. For the ankles, the Veteran was noted to have mild decreased range of motion on the left, but otherwise unremarkable findings in an April 2007 VA treatment record. During the May 2011 VA examination, he had plantar flexion limited to 40 out of 45 degrees in the left ankle, but otherwise normal range of motion bilaterally. Thereafter, he had full range of motion bilaterally in the June 2013 VA examination. To warrant a compensable rating based for impairment of the ankle, there must be moderate limitation of motion of the ankle, ankylosis, malunion of the os calcis or astragalus, or astragalectomy. See 38 C.F.R. § 4.71a, DCs 5270 to 5274. Even with consideration of pain and other functional loss during flare-ups or after repetitive use, the evidence demonstrates only mild, intermittent limitation of motion of the ankle, with no ankylosis or other impairment. As such, a compensable rating is not warranted for either ankle under these codes. Id. For the feet, the Veteran had significant tenderness at the metatarsophalangeal joint in an October 2006 VA treatment session, with 1+ swelling. X-rays showed soft tissue swelling in distal left foot. The Veteran continued to report occasional foot swelling at an April 2007 VA examination, stating that his symptoms had not changed since the August 2006 VA examination. The examiner noted that there was a small spur at the metatarsophalangeal joints bilaterally, but it did not restrict extension motion of the toes. The diagnosis was minimal bilateral hallux rigidus. In April 2007, the Veteran reported aches and pains in the feet, and was noted to have mild decreased range of motion on the left foot (or ankle). There was no diagnosis or abnormalities of the feet at the May 2013 VA examination. In brief, to warrant a compensable rating based on impairment of the feet, there must be symptoms analogous to moderate acquired flat foot, bilateral weak foot, claw foot, severe hallux valgus or hallux rigidus, hammer toe of all toes, moderate malunion or nonunion of the tarsal or metatarsal bones, or moderate other foot injury. See 38 C.F.R. § 4.71a, DCs 5276 to 5284. Here, the Veteran has only intermittent swelling or pain of the feet, with mild decreased range of motion. The bilateral hallux rigidus found during the August 2006 VA examination was not shown to be related to the Veteran's polyarthritis and, in any event, it was only mild and did not affect the range of motion of the toes. As such, a compensable rating is not warranted under any applicable code for limitation of motion of the feet. Id. In light of the above, the Veteran does not meet the criteria for a compensable rating under the applicable diagnostic codes based on limitation of motion of the shoulders, hands, knees, ankles, and feet. Nevertheless, he has made competent and credible reports of pain and painful motion during flare-ups and after repetitive use, with resulting functional loss including decreased speed of joint motion, weakness, incoordination, and fatigability, as noted by the VA examiners. Resolving doubt in the Veteran's favor, he has had a similar level of impairment throughout the appeal. When considering such additional functional loss, the Veteran is entitled to a minimum rating of 10 percent for each affected major joint or group of minor joints as chronic residuals of his polyarthritis. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5002; see also DeLuca, Mitchell, and Burton. For these purposes, the shoulder, elbow, wrist, hip, knee, and ankle are considered major joints; and multiple involvements of the joints in the hands, feet, and the cervical, dorsal, and lumbar vertebrae are considered groups of minor joints. See 38 C.F.R. §§ 4.45; see also § 4.71a, Plates III and IV (identifying the joints of the hands and feet). Therefore, the Veteran is entitled to a rating of 10 percent for each shoulder, 10 percent for each hand, 10 percent for each knee, 10 percent for each ankle, and 10 percent for each foot. As explained above, the Veteran is also entitled to a 20 percent rating for the lumbar spine under DC 5242 based on demonstrated limitation of motion. These ratings for chronic residuals are to be combined, not added, under DC 5002. See 38 C.F.R. § 4.71a. The Veteran would be entitled to a minimum rating of 20 percent based on polyarthritis as an active process under DC 5002, as he has had frequently recurring symptoms or exacerbations throughout the appeal. See id. Nevertheless, the Veteran is entitled to a rating of 20 percent based on chronic residuals of the lumbar spine, as well as multiple separate ratings of 10 percent based on chronic residuals as summarized above. There is no indication of totally incapacitating constitutional manifestations, weight loss or anemia, definite impairment of health, or severely incapacitating exacerbations due to polyarthritis, as required for a higher rating based on active process. Id. As such, the Veteran is more appropriately rated based on the separate evaluations for chronic residuals. Id. All potentially applicable diagnostic codes have been considered, and a rating in excess of those assigned herein is not warranted for any joint affected by polyarthritis. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Further, staged ratings are not warranted, as the Veteran's symptomatology has remained relatively stable throughout the appeal. Any increases in severity were not sufficient for a higher rating for any affected joint. Hart, 21 Vet. App. at 509-10. Additionally, the Board has considered whether this case should be referred for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1). In this regard, the Veteran's symptoms of polyarthritis include intermittent pain, swelling, and stiffness in the affected joints, with painful or limited motion to the degrees discussed above. Such symptomatology is fully contemplated by the schedular criteria. As such, the rating schedule is adequate, and it is not an exceptional or unusual disability picture. Moreover, there are no related factors such as marked interference with employment or frequent periods of hospitalization due to polyarthritis during the period on appeal. While the Veteran's disability affected his prior employment to some extent, such interference is addressed by the assigned rating. See 38 C.F.R. § 4.1 (stating that schedular ratings are considered adequate to compensate for considerable loss of working time from exacerbations proportionate to the severity of the several grades of disability). Accordingly, it is not impracticable to apply the schedular standards. Referral for consideration of an extra-schedular rating is not necessary. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008) (discussing the three-pronged analysis to determine whether extra-schedular referral is necessary under § 3.321). The Veteran has been unemployed since 2009. When evidence of unemployability is submitted during the course of an appeal from a rating assigned for a disability, a claim for a total disability rating on the basis of individual unemployability due to service-connected disabilities (TDIU) will be considered part and parcel of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Nevertheless, the Veteran reported during the May 2011 VA examination that he retired due to his COPD, which is not service-connected. At the June 2013 VA examination, he reported being laid off in 2009 due to budget cuts, and that he had not returned to work due to multiple medical problems. He has not claimed, and there is no other indication of record, that the Veteran is unemployable due to his polyarthritis. As such, a claim for a TDIU is not raised. The Veteran has been granted higher ratings for his polyarthritis affecting multiple joints to the extent described above based, in part, on application of the benefit-of-the-doubt doctrine. Nevertheless, the preponderance of the evidence is against any further separate or higher ratings and, therefore, reasonable doubt does not arise. As such, the claims must be denied in that respect. 38 C.F.R. § 4.3. (CONTINUED ON NEXT PAGE) ORDER A disability rating of 20 percent for polyarthritis affecting the lumbar spine is granted. A disability rating of 10 percent for polyarthritis affecting the right shoulder is granted. A disability rating of 10 percent for polyarthritis affecting the left shoulder is granted. A disability rating of 10 percent for polyarthritis affecting the right hand is granted. A disability rating of 10 percent for polyarthritis affecting the left hand is granted. A disability rating of 10 percent for polyarthritis affecting the right knee is granted. A disability rating of 10 percent for polyarthritis affecting the left knee is granted. A disability rating of 10 percent for polyarthritis affecting the right ankle is granted. A disability rating of 10 percent for polyarthritis affecting the left ankle is granted. A disability rating of 10 percent for polyarthritis affecting the right foot is granted. A disability rating of 10 percent for polyarthritis affecting the left foot is granted. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs