Citation Nr: 1342147 Decision Date: 12/19/13 Archive Date: 12/31/13 DOCKET NO. 07-25 086 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to an initial disability rating in excess of 10 percent for right elbow fracture residuals. 2. Entitlement to an initial disability rating in excess of 10 percent for left wrist fracture residuals. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD James G. Reinhart, Counsel INTRODUCTION The Veteran had active service from January 1975 to September 1995. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In that decision, the RO granted service connection for residuals of a left wrist fracture and for residuals of a right elbow fracture and assigned initial noncompensable evaluations, effective February 28, 2005. Jurisdiction was subsequently transferred to the RO in Detroit, Michigan. In January 2009, the Detroit RO awarded compensable evaluations of 10 percent for each of these disabilities, effective February 28, 2005. The Veteran testified at a hearing before a Decision Review Officer (DRO) in April 2008. A transcript of that hearing is associated with the claims file. In August 2011, March 2013, and July 2013, the Board remanded these matters for additional development. The matters have been properly returned to the Board for appellate consideration. FINDINGS OF FACT 1. The Veteran's residuals of left wrist fracture have not, during any time subject to this appeal, resulted in left wrist palmar flexion that approximated limitation to a position in line with the forearm, or to left wrist dorsiflexion less than 15 degrees. 2. The Veteran's residuals of right elbow fracture have not, during any time subject to this appeal, manifested as malunion, nonunion, or bad alignment of the right radius or the right ulna, have not resulted in limitation of flexion of the right forearm to 100 degrees or less, have not resulted in limitation of extension of the right forearm to 45 degrees or less, and have not resulted in fixation or limitation of pronation to beyond the last quarter of the arc of forearm motion or to supination to 30 degrees or less. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for left wrist fracture residuals have not been met for any period of time on appeal. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.21, 4.71a Diagnostic Codes 5003, 5215 (2013). 2. The criteria for a disability rating in excess of 10 percent for right elbow fracture residuals have not been met for any period of time on appeal. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.21, 4.71a Diagnostic Codes 5003, 5206, 5207, 5211, 5212, 5213 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process VA has a duty to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, 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). Proper notice from VA 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. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For service-connection claims, this notice must address the downstream elements of disability rating and effective date. Dingess v. Nicholson, 19 Vet. App. 473 (2006). All other required notice was provided in letters sent to the Veteran in February 2005, February 2006, and June 2006. Notice as to those downstream elements was provided in the June 2006 letter, after the initial adjudication of his claims. The timing error in the notice was cured as the Veteran had a meaningful opportunity to participate effectively in the processing of his claim after the June 2006 letter was sent and the Agency of Original Jurisdiction (AOJ), either the RO or the AMC in this case, readjudicated his claim by way of a May 2007 Statement of the Case and June 2009, February 2012, April 2013, and August 2013 Supplemental Statements of the Case. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of service and other pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO has obtained the Veteran's service treatment records and VA treatment records, and has provided all necessary assistance to the Veteran in obtaining private treatment records. VA afforded the Veteran relevant examinations in March 2006 and September 2011 as to both disabilities and in September 2013 as to the left wrist disability. These examinations are adequate as they were conducted with review of the relevant history of the disabilities, included sufficient descriptions of the disabilities, and included adequate rationale to the extent applicable. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). VA scheduled another examination in April 2013, pursuant to a Board Remand the prior month. A Report of General Information, dated in April 2013, documents that the Veteran failed to report for the examination. There is no indication of good cause for the failure to report. Although in a September 2013, Post Remand Brief, the Veteran's representative stated that the Veteran's disabilities continue to worsen, VA has already made the required efforts to provide the Veteran with an additional examination and he did not report for the examination without providing good cause for such failure. The Board thus finds that it has fulfilled its duty to assist in providing examinations and obtaining expert opinions as to the issues on appeal. The Board here adjudicates the appeal based on the evidence of record. 38 C.F.R. § 3.655(a),(b) (2013). In August 2011, the Board remanded these issues so that the AOJ must assist the Veteran in obtaining any outstanding relevant treatment records. It also directed that the Veteran should be referred for a VA examination to determine the nature and severity of the disabilities that are the subject of this appeal and to then readjudicate the issues on appeal. Following that Remand, the Veteran underwent the requested examination, the AOJ made all necessary efforts to assist the Veteran in obtaining any outstanding relevant evidence, and the AOJ readjudicated the issues on appeal. In March 2013, the Board again remanded these issues so that the AOJ could make efforts to obtain any updated VA treatment records, to include records from the Cleveland VA Medical Center (VAMC) since September 2011, and to provide the Veteran with an examination as to the severity of the disabilities on appeal. In March 2013, the AMC requested such records. In April 2013 it issued a Supplemental Statement of the Case that noted that there was no response from the request for records to the VAMC Cleveland and noted that the Veteran failed to report for the VA examination scheduled in April 2013. The Board again remanded these issues in July 2013 for the AOJ to make as many requests as necessary to obtain any updated VA treatment records, provide the Veteran with sufficient notice of its efforts, and readjudicate the issues on appeal. Following that July 2013 Remand, the AOJ again requested any additional outstanding relevant VA treatment records. In August 2013, the VA Medical Center (VAMC) responded to the AOJ request, indicating on a VA Form 10-7131 that the request was completed and enclosed with that response a copy of the September 2011 Compensation and Pension examination report. Following that response, the AOJ issued an August 2013 Supplemental Statement of the Case that provided sufficient notice of its actions and readjudicated the issues on appeal. In September 2013, the Veteran provided a document indicating that he waived any consideration by the AOJ of any additional evidence that may be added to the record. Thus, the Board here considers the September 2013 examination of his wrist in the first instance. In a September 2013, Post Remand Brief, the Veteran's representative stated that its review of the claims file indicated that the AOJ had complied with the Board's Remand directives. The Board concludes that there has been compliance with the directives of these Remands. See Stegall v. West, 11 Vet. App. 268 (1998). In April 2008, the Veteran testified before a DRO at the RO. With the assistance of the Veteran's representative, the DRO sufficiently explained the issues that are the subject of this appeal. It is clear from the testimony that there was no additional evidence that may have been overlooked with regard to the wrist issue and the Veteran testified as to what he recalls a private physician telling him about his right elbow. There is no indication that the DRO did not comply with the requirements of 38 C.F.R. § 3.102(c)(2) (2013) Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist under the VCAA. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). [Continued on Next Page] II. Merits The Veteran seeks disability ratings higher than the 10 percent assigned for residuals of left wrist fracture and the 10 percent assigned for residuals of right elbow fracture. In this section, the Board first explains how disability ratings are assigned in general, and then lists the specific regulatory criteria that are potentially applicable for assigning disability ratings in this case. It then explains the relevant facts of the case and applies the regulations to those facts. Finally, it explains why the case does not warrant referral for consideration of ratings outside of those specific regulatory criteria. Ultimately it concludes that the appeal must be denied as to both issues. Because the amount of evidence is not great and both disabilities share the same examinations, the facts are related at the same time. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2013). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2 (2013); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2013). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2013). This appeal arises from the rating decision that granted service connection right elbow fracture residuals and left wrist fracture residuals. As such, the Board has considered whether different ratings for different periods of time, based on the facts found, are warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). Such ratings are referred to as "staged ratings." Id. Both issues on appeal concern the appropriate evaluation for musculoskeletal disability. In rating musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40 (2013), functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45 (2013), factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59 (2013), painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. See Burton v. Shinseki, 25 Vet. App. 1, 5 (2011) (explaining that VA must address the applicability of § 4.59 in claims involving joint disability whether or not the condition at issue is arthritis). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). It is functional loss of a joint that can give rise to a higher schedular rating, to include if such functional loss is due to pain, but pain in itself is not limited motion and does not rise to the level of functional loss contemplated by VA regulations. See Mitchell v. Shinseki, 25 Vet. App. 32, 37-38 (2011). In some instances a different rating is assigned when the disability is of the major, or dominant side as opposed to the minor, or nondominant side. 38 C.F.R. § 4.69 (2013). This refers to "handedness." Id. Here, the September 2011 medical examination report documents that the Veteran is right handed. Hence his left wrist disability is a disability of the minor side and his right elbow disability is a disability of the major side. All ratings described below take into account these facts. The RO has rated the Veteran's residuals of left wrist fracture under the criteria found at 38 C.F.R. § 4.71a, Diagnostic Code 5215 (2013), the criteria for limitation of motion of the wrist. Normal range of flexion and extension of the wrist is from 0 to 80 degrees of palmar flexion and 0 to 70 degrees of dorsiflexion (extension), with 0 degrees the point where the wrist is in line with the forearm. See 38 C.F.R. § 4.71a, Plate I (2013). Also of note, normal wrist ulnar and radial deviation is from 0 to 45 degrees and from 0 to 20 degrees, respectively. Id. For wrist dorsiflexion less than 15 degrees a 10 percent rating is warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5215. For wrist palmar flexion limited in line with the forearm (0 degrees) a 10 percent rating is warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5215. The Veteran has never been found to have ankylosis of the left wrist so a rating under 38 C.F.R. § 4.71a, Diagnostic Code 5214 (2013) is not warranted. The RO has rated the Veteran's residuals of right elbow fracture by analogy to the criteria found at 38 C.F.R. § 4.71a, Diagnostic Code 5212 (2013), for impairment of the radius. Under those criteria, where there is nonunion in the lower half, with loss of bone substance ( inch (2.5 centimeters) or more) and marked deformity, a 40 percent rating is assigned. Id. With nonunion in the lower half, without loss of bone or deformity, a 30 percent rating is assigned. Id. With nonunion in the upper half, a 20 percent rating is assigned. With malunion or bad alignment, a 10 percent rating is assigned. Id. The Board has also considered the criteria for impairment of the ulna under 38 C.F.R. § 4.71a, Diagnostic Code 5211 (2013). Under those criteria, where there is nonunion in the upper half, with false movement, and with loss of bone substance ( inch (2.5 centimeters) or more) and marked deformity, a 40 percent rating is assigned. Id. With nonunion in the upper half, without loss of bone or deformity, a 30 percent rating is assigned. Id. With nonunion in the upper half, a 20 percent rating is assigned. Id. With malunion or bad alignment, a 10 percent rating is assigned. Id. Also considered by the Board is whether a rating is warranted for limitation of motion of the forearm (by operation of the elbow) under 38 C.F.R. § 4.71a, Diagnostic Codes 5206 and 5207 (2013) or for impairment manifested by loss of supination or pronation under 38 C.F.R. § 4.71a, Diagnostic Code 5213. Normal range of motion of the forearm (about the elbow joint) is from 0 to 145 degrees of flexion, with 0 degrees the point where the upper and lower arms form a straight line (elbow fully extended), and 145 degrees the point of full flexion. See 38 C.F.R. § 4.71a, Plate I. Normal forearm pronation (by operation of the elbow) is from 0 to 80 degrees and normal forearm supination (by operation of the elbow) is from 0 degrees to 85 degrees; with 0 degrees the point where the wrist is in a neutral position. 38 C.F.R. § 4.71a, Plate I. For limitation of flexion of the forearm to 45 degrees a 50 percent rating is assigned; for limitation of flexion to 55 degrees a 40 percent rating is assigned; for limitation of flexion to 70 degrees a 30 percent rating is assigned; for limitation of flexion to 90 degrees a 20 percent rating is assigned; for limitation of flexion to 100 degrees a 10 percent rating is assigned; for limitation of flexion to 110 degrees a 0 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5206. For limitation of extension of the forearm to 110 degrees a 50 percent rating is assigned; for limitation of extension to 100 degrees a 40 percent rating is assigned; for limitation of extension to 90 degrees a 30 percent rating is assigned; for limitation of extension to 75 degrees a 20 percent rating is assigned; for limitation of extension to 60 or to 45 degrees a 10 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5207. Where there is loss of supination and pronation of the forearm due to bone fusion ratings of 20, 30, or 70 percent are available, depending on where the hand is fixed. 38 C.F.R. § 7.41a, Diagnostic Code 5213. For limitation of pronation with motion lost beyond middle of the arc a 30 percent rating is assigned. Id. For limitation of pronation with motion lost beyond the last quarter of the arc, the hand does not approach full pronation, a 20 percent rating is assigned. Id. For limitation of supination to 30 degrees or less a 10 percent rating is assigned. Id. As there is some indication of arthritis in this case, for example in November - December 2006 VA treatment notes, the Board has considered the criteria for rating arthritis. Both traumatic and degenerative arthritis are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5003, on the basis of limitation of motion as per the diagnostic codes for the specific joint. If the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is assigned for each major joint or group of minor joints affected by limitation of motion. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, a 10 percent rating can be assigned for x-ray evidence of 2 or more major joints or 2 or more minor joint groups and a 20 percent rating can be assigned if such involvement includes occasional incapacitating episodes. Id. Note (1) under Diagnostic Code 5003 provides that the 20 percent and 10 percent ratings based on x-ray findings will not be combined with rating based on limitation of motion. Id. It is noted that the RO assigned each 10 percent rating in this case based on pain on motion and the Board finds no other basis for assignment of any rating. Hence, application of Diagnostic Code 5003 does not result in any higher or additional rating in this case. The Board has reviewed all relevant evidence of record. Service treatment records document that the Veteran fractured his left wrist in 1985 and his right elbow in 1992. A report of medical examination in May 1994 documents normal upper extremities and an associated report of medical history includes a medical professional's comment that he had excellent functional result of treatment for his right elbow fracture. Reports of medical history from 1986 and 1991 include a medical professional's comments that he fractured his left wrist in 1985 with no sequalae. The records do not show that there was any malunion, fixation, nonunion, or malalignment with regard to either fracture. Private treatment records do not provide evidence tending to show that the disabilities on appeal warrant a higher rating for any period on appeal. Fairview Hospital treatment records from December 2004 document nerve condition study results with regard to right carpal tunnel syndrome. The RO adjudicated the Veteran's claim of entitlement to service connection for carpal tunnel syndrome in May 2006, the Veteran did not appeal that determination, and this issue is therefore not before the Board. VA treatment records also do not provide evidence tending to show that the disabilities on appeal warrant a higher rating for any period on appeal. For example, a June 2006 VA Pain Medicine Note documents only that the Veteran has painful joints, including his wrist and elbow, a symptom that is reflected in the examination report. The Veteran submitted a memorandum dated in October 2013 showing that he received less than a fully successful determination as to one element of his work performance and this an acknowledgment that he has health related issues. Those issues are listed as skin cancer, a recent broken arm, and service-connected neck/back and nerve conditions. This document does not tend to show that either disability on appeal approximates the criteria for a higher schedular rating. Nor does it, or any other evidence, raise the question of whether a total rating based on individual unemployability is raised, in that there is no evidence that the Veteran is not employed. The Veteran's claims file was not available to the examiner who conducted the March 2006 examination. However an adequate history of his left wrist and right elbow fracture was obtained from the Veteran and recorded in the examination report. The Veteran reported that he suffered a fracture of his left wrist in 1985 and of his right elbow in 1992 and still had a little bit of aching pain, stiffness, and soreness in both joints, was bothered by repetitive use and weather changes, no braces were needed, no flare ups were noted, and he was able to function on the job and in normal daily activities. Examination of his right elbow revealed a small amount of pain and tenderness and pain on motion. Right elbow motion was from 10 to 120 degrees of flexion, with normal pronation and supination. Left wrist motion was from 70 degrees of dorsiflexion and plantar flexion, radial deviation was to 20 degrees, and ulnar deviation was to 40 degrees. He had pain at the extremes of motion for both joints. There was no bony deformity identified. The examiner stated that repetitive use caused increase in ache and pain, soreness, tenderness, and fatigability, but no change was noted on examinations. Pursuant to the Board's August 2011 Remand, the Veteran underwent another examination of his left wrist and right elbow in September 2011. That examination included review of the claims file by the examiner. The examiner indicated that, from that review, x-rays showed old fracture of the radial head and proximal ulna of the right elbow. The examiner also stated that an x-ray was not needed. An accurate history of his injuries was documented. The examiner noted the Veteran's report that, over the years, he had some left wrist and right elbow pain and some aching, soreness, tenderness and stiffness. The Veteran also reported that at times he wore a brace on his left wrist. He also reported normal daily activity and that he was able to function in his job but does have difficulty with the left wrist with heavy gripping and grabbing and difficulty with the right elbow on repetitive use. He reported that he had flare-ups with heavy repetitive use. The examiner also stated that an x-ray was not needed. Range of motion of the left wrist was measured as dorsiflexion to 20 degrees, palmer flexion to 50 degrees, radial deviation to 20 degrees, and ulnar deviation to 20 degrees, with pain throughout the range of motion in all directions. Right elbow motion was described as lacking 15 degrees in full extension, and flexion to 105 degrees, supination to 80 degrees, with pain at the extremes of flexion - extension. The examiner stated that repetitive use did not cause any change in pain, range of motion, or other findings. He also noted that flare-ups were reported as occurring with heavy repetitive use. The September 2013 examination report shows that the examiner reviewed the Veteran's claims file. The report documents that left wrist palmar flexion was to 30 degrees with pain beginning at that point and left wrist dorsiflexion was to 40 degrees with pain beginning at that point. Following repetitive motion, the range of motion was unchanged. The examiner indicated that he had pain on movement, swelling, and less movement than normal as to the left wrist. He had normal strength as to wrist flexion and extension and did not have ankylosis. The examiner indicated that his left wrist condition did impact on his ability to work in that frequent bending of the wrist and lifting of objects heavier than 20 pounds was not recommended. The Board has not ignored the Veteran's April 2008 testimony before the DRO that an x-ray was taken of his right elbow a couple months prior to that hearing and that he was referred to an orthopedic surgeon because something was not normal. The Veteran also testified that the private physician that took the x-ray did not see the x-ray. His representative asked the Veteran if he was told that the elbow was "still malaligned" to which the Veteran replied in the affirmative. There are no private treatment records that indicate that there is any malalignment, malunion, or nonunion of the right ulna or radius. The September 2011 examiner indicated that the medical records documented an old fracture of the radial head and proximal ulna and, significantly, indicated that an x-ray was not needed, as to the September 2011 examination. Moreover, the April 2006 examination report indicates that whether there was a bony abnormality present was considered but none is mentioned. As between the Veteran's report of what he was told as to malalignment of the right elbow and the findings in the examiner reports just described, the Board affords more weight to the findings of the examiners. This is particularly the case here where the examiner indicated that they he was an orthopedist. The Board therefore concludes that there is no malunion, nonunion, or bad alignment of the right radius or right ulna. Hence, the Veteran's residuals of right elbow fracture do not approximate the criteria for a higher rating under Diagnostic Codes 5211 or 5212. The most severe limitation of forearm extension is that noted during the September 2011 examination. Limitation to 45 degrees is required for a compensable rating and the Veteran's limitation to 15 degrees does not approximate that criterion. Similarly, his most severe limitation of flexion was to 105 degrees, which does not approximate the limitation to 100 degrees required for a compensable rating. His normal pronation and supination upon examination in 2006 and the finding of supination to 80 degrees in 2011 does not approximate the motion lost beyond the last quarter of the arc. In this regard, as the arc is from 0 to 80 degrees, motion lost beyond the last quarter of the arc is motion lost beyond 60 degrees. Here, the Veteran had motion to 80 degrees. Nor does his the motion approach the 30 degree or less of supination required for a compensable rating. The evidence shows that the most severe limitation of motion of the wrist is to 20 degrees of dorsiflexion and 50 degrees of palmar flexion. Range of motion is thus not so limited as to approximate a compensable rating under Diagnostic Code 5215. Although ulnar deviation was approximately half that of normal, the rating criteria does not provide for ratings based on limitation of that motion. The Board has, however considered that for painful motion, at least the minimum compensable rating for the joint should be assigned. Here, the minimum compensable rating is 10 percent and has been in place since the date that service connection was established. The Board finds no evidence to show that the Veteran's residuals of left wrist fracture approximates the schedular criteria for a higher rating for any period of time on appeal. Although the Veteran has reported pain on motion the evidence shows that the pain on motion does not result in additional limitation of function. The 10 percent rating currently in place for residuals of left wrist fracture and the 10 percent rating currently in place for residuals of right elbow fracture are in compliance with application of 38 C.F.R. § 4.59, and given the findings from the examination report, the Board finds that neither the residuals of fracture of the right elbow nor the residuals of fracture of his right wrist approximate a higher schedular rating for any time on appeal. Also considered by the Board is whether referral is warranted for a rating outside of the schedule. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2013). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. 38 C.F.R. § 3.321(b). Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board or the RO must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. Here, the symptoms reported are pain, weakness and lack of endurance, or fatigability for both joints and swelling of the left wrist. His reports of difficulty gripping and grabbing difficulty fall into such categories. These symptoms are contemplated by the criteria already discussed, including application of 38 C.F.R. §§ 4.40, 4.45, and § 4.59. As to the level of disability, the schedule provides for more compensation for limitation of function greater than that demonstrated in this case with regard to each disability. Therefore, the first element of the Thun analysis is not satisfied in this case and referral for extraschedular consideration is not warranted. The Board has not ignored the evidence submitted by the Veteran, dated in October 2013, indicating that he has failed to meet minimum production standards in his occupation. That evidence however not only refers to conditions other than those before the Board at present, but without a showing that the rating schedule is not adequate to address his disabilities, cannot result in a finding that referral for extraschedular consideration is warranted. As to both the schedular criteria and whether referral is warranted for extraschedular consideration, the Board has considered the Veteran's statements with regard to why he believes higher ratings are warranted. As between the Veteran's statements and the evidence just discussed, the Board finds the examination reports and treatment records to be the most probative evidence of record and to outweigh the Veteran's statements. This finding encompasses his reports of flare-ups. The treatment records and examination reports do not show that the flare-ups he reports have ever approximated the criteria for higher or additional ratings for either disability subject to this appeal. The Board finds this evidence to be more probative than the Veteran's statements as it would reasonably be expected that there would be at least some indication from such evidence that the reported flare-ups resulted in manifestations that approximated the criteria for a higher or additional rating. For the reasons just discussed, the Board concludes that the preponderance of evidence is against findings that a disability rating higher than 10 percent is warranted for residuals of left wrist fracture or residuals of right elbow fracture for any period of time on appeal and is against remanding this case for referral for extraschedular consideration. The appeal must therefore be denied as to both issues. There is no reasonable doubt to be resolved as to these issues. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an initial disability rating in excess of 10 percent for right elbow fracture residuals is denied. Entitlement to an initial disability rating in excess of 10 percent for left wrist fracture residuals is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs