Citation Nr: 1626251 Decision Date: 06/30/16 Archive Date: 07/11/16 DOCKET NO. 13-18 925 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to an increased rating for ulcerative colitis with backwash ileitis, rated as 30 percent disabling. 2. Entitlement to an increased rating for arthritis of the right ankle, rated as 10 percent disabling. 3. Entitlement to an increased rating for arthritis of the lumbar spine, rated as 10 percent disabling. 4. Entitlement to a compensable rating for arthritis of the right forearm. 5. Entitlement to service connection for a bilateral eye condition, to include as secondary to service-connected disease or injury. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Minot, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from September 1988 to February 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The issues of entitlement to an increased rating for arthritis of the lumbar spine and entitlement to service connection for a bilateral eye condition are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). Upon review of the record, the Board finds that the record raises the issues of entitlement to service connection for bilateral shoulder, wrist/hand, hip, knee, and left ankle disabilities, to include arthritis. See May 2010 VA examination (noting that the Veteran had pain and arthritis in multiple joints which was as likely as not related to his service-connected ulcerative colitis); January 2014 VA addendum opinion (clarifying the joints involved). As these issues have not yet been adjudicated, the Board does not have jurisdiction over them, and they are referred to the AOJ) for appropriate action. 38 C.F.R. § 19.9(b) (2015). FINDINGS OF FACT 1. The Veteran's ulcerative colitis with backwash ileitis has been manifested by moderately severe symptoms with frequent exacerbations; severe symptoms with numerous attacks a year and malnutrition have not been shown. 2. The Veteran's arthritis of the right ankle has been manifested by painful motion and swelling; marked limitation of motion has not been shown. 3. The Veteran's arthritis of the right forearm has been manifested by painful motion and swelling; flexion limited to 90 degrees or extension limited to 75 degrees has not been shown. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for ulcerative colitis with backwash ileitis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.114, Diagnostic Code 7323 (2015). 2. The criteria for a disability rating in excess of 10 percent for arthritis of the right ankle have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.71(a), Diagnostic Code 5271 (2015). 3. The criteria for a 10 percent disability rating, but no higher, for arthritis of the right forearm have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.71(a), Diagnostic Code 5003 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. § 3.159 (2015). In this case, VA's duty to notify was satisfied by a pre-adjudicatory letter mailed to the Veteran in March 2009. See id.; Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate any claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this case, VA fulfilled its duty to assist by obtaining all identified and available evidence needed to substantiate the claims herein decided. Specifically, the Veteran's in-service medical records have been obtained, and updated VA outpatient records have been added to the record and have been reviewed. Social Security Administration (SSA) medical records have also been associated with the claims file. The Veteran has not indicated that there are any outstanding private or Federal records that are pertinent to the claims herein decided. In addition, the Veteran was afforded VA examinations in connection with his ulcerative colitis in May 2010, February 2012, and January 2014. He was also afforded examination of his joints in May 2010 and January 2014. On review, the reports from these examinations, considered collectively, indicate that the examiners reviewed the claims file, performed the appropriate testing (including range of motion testing of the right ankle and right forearm), recorded the results, and elicited a medical history with respect to the Veteran's symptoms and the functional limitations resulting therefrom. The Board finds that these examination reports are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The lay and medical evidence does not reflect a material increase of disability since the most recent VA examination, with respect to the claims herein decided. As such, additional examination is not warranted. For these reasons, the Board concludes that there is no additional evidence which needs to be obtained. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. Principles of Increased Ratings Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In addition, when assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must, in addition to applying schedular criteria, also consider evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-207 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 should only be considered in conjunction with the Diagnostic Codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). "Staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Ulcerative Colitis with Backwash Ileitis The Veteran contends that he is entitled to a rating in excess of 30 percent for his service-connected ulcerative colitis with backwash ileitis. At the outset, the Board notes that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. §§ 4.14 and 4.113. Consequently, a single evaluation will be assigned under the Diagnostic Code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. In this case, the Veteran's symptoms are rated under Diagnostic Code 7323. Id. Under that Diagnostic Code, a 30 percent rating is assignable for moderately severe ulcerative colitis with frequent exacerbations. A 60 percent rating is assignable for severe ulcerative colitis, with numerous attacks a year and malnutrition, the health only fair during remissions. A 100 percent rating is warranted for pronounced ulcerative colitis resulting in marked malnutrition, anemia, and general debility, or with serious complications as liver abscess. The Board notes that the provisions of 38 C.F.R. § 4.112 highlight the importance of weight loss in the evaluation of the impairment resulting from gastrointestinal disorders. For purposes of evaluating conditions in 38 C.F.R. § 4.114, the term "substantial weight loss" means a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer; and the term "minor weight loss" means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. 38 C.F.R. § 4.112. The term "inability to gain weight" means that there has been substantial weight loss with inability to regain it despite appropriate therapy. "Baseline weight" means the average weight for the two-year-period preceding onset of the disease. Historically, the Veteran underwent a medical board due to a diagnosis of ulcerative pan colitis with backwash ileitis. His weight generally measured within 5 pounds of 150 pounds. He was generally described as a slender male. The Veteran was initially service-connected for ulcerative colitis in 1992. The Veteran filed the instant claim for an increased rating in February 2010, reporting that his symptoms had worsened and that he was passing blood in his stools. Along with his claim, he submitted a report from a December 2009 colonoscopy which revealed internal hemorrhoids, diverticula, and a diffuse area of mildly erythematous mucosa in the colon. On VA examination in May 2010, the Veteran reported having symptoms related to his ulcerative colitis almost every month. Specifically, he reported frequent abdominal crampy pains, mostly in the lower abdomen, as well as semisolid loose stools-about 6 to 9 per day-a few times a week, with blood in his stools a few times a week. He denied chronic fever or chills. His appetite was fair; he reported that his weight fluctuated up and down about 10 or 15 pounds. He reported meeting with his gastroenterologist about once a year, and stated that his gastroenterologist recently increased his medication. He noted that he was able to do his daily routine activities, and was currently employed full-time as a housekeeper. Upon physical examination, no obvious nutritional deficiencies were noted. He weighed 250 pounds and was described as obese. The abdomen was flabby, soft, and nontender. No frequent flare-ups or exacerbations were noted. The examiner's impression was ulcerative colitis, currently not in remission, with mild to moderate symptoms. In July 2011, a colonoscopy was performed which revealed normal ileum and mildly erythematous mucosa in the sigmoid colon. Mild atrophy was noted throughout the colon. Mild and moderate diverticulitis and medium-sized, non-bleeding internal hemorrhoids were observed. On VA examination in February 2012, the Veteran reported that he was hospitalized in 2008 for diverticulitis, but had not been hospitalized since. (The examiner noted a history of diverticulitis but found no causal link between that condition and the Veteran's ulcerative colitis.) In terms of current symptomatology, he reported that he had diarrhea and occasional constipation. The examiner noted that there were frequent episodes of bowel disturbance with abdominal distress; however, there had been no episodes of exacerbations and/or attacks over the past year. Blood testing revealed anemia. There was no weight loss attributable to his intestinal condition. The Veteran reported that he worked as a maintenance man and that he had to run to the bathroom many times, which affected his work. (The Board notes that, in a September 2012 rating decision, the RO granted service connection and assigned a noncompensable rating for anemia associated with ulcerative colitis. The RO also denied entitlement to service connection for diverticulitis. In a November 2012 rating decision, the RO denied entitlement to service connection for hemorrhoids. The Veteran did not appeal either rating decision. Regardless, the rating criteria for diseases of the digestive system prohibit the assignment of separate ratings for these conditions. See 38 C.F.R. §§ 4.113, 4.114.) In October 2013, a colonoscopy was performed which revealed normal mucosa, with biopsies showing non-active inflammation, negative for dysplasia. On VA examination in January 2014, the Veteran reported having about 6 bowel movements per day with formed stool, sometimes watery, sometimes mixed with blood. He reported occasional mild abdominal cramps, but denied fever, chills, weight loss, nausea or vomiting. Continuous medication was required for his symptoms. No history of surgical intervention was noted. The examiner indicated that the Veteran had occasional episodes of bowel disturbance with abdominal distress. No evidence of malnutrition, serious complications, or other generalized health effects attributable to intestinal pathology was observed. There was no weight loss attributable to his intestinal condition. The examiner noted that the Veteran's ulcerative colitis did not impact his ability to work. Additionally, the Board notes that the Veteran's VA clinic records do not reflect any medical opinion of weight loss attributable to his service-connected colitis. Rather, he was counseled on the benefits of weight loss. His weight ranged from 255 to 270 pounds. After careful review, the Board finds that the preponderance of the evidence is against a rating in excess of 30 percent for the Veteran's ulcerative colitis with backwash ileitis, as the record demonstrates at most moderately severe symptoms with frequent exacerbations during the appeal period. As noted above, the Veteran has experienced frequent and loose bowel movements with occasional blood in the stools, as well as abdominal pain and cramping which is contemplated in the current rating. He has secondary anemia and arthritis, which have been separately rated. However, the VA examiners found no evidence of malnourishment, and the Veteran himself has not described malnourishment. There has been variation of weight, but no medical opinion of weight loss attributable to service-connected colitis or that any weight loss was indicative of malnourishment. Additionally, the preponderance of the lay and medical evidence establishes that the Veteran's overall ulcerative colitis symptoms are not "severe" with numerous attacks per year. The currently assigned rating contemplates moderately severe symptoms with frequent exacerbations. The May 2010 VA examiner described the Veteran's overall symptoms as being at most moderate in degree. The Veteran has self-described "mild" abdominal cramps with a frequency of symptoms requiring frequent bathroom visits, but not otherwise interfering with his ability to work. He has not described his health as only being fair during remissions. While there are complications of arthritis and anemia, there is no lay or medical evidence of general debility or other serious complications such as liver abscess. Given that the Veteran's complaints include diarrhea, constipation, and abdominal distress, the Board has considered whether it is more appropriate to rate his disability symptoms under Diagnostic Code 7319. However, the Veteran is already evaluated as 30 percent disabled under Diagnostic Code 7323, which is the maximum rating under Diagnostic Code 7319. As noted, ratings under Diagnostic Codes 7301 to 7329 will not be combined with each other. A single rating will be assigned under the Diagnostic Code that reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Thus, assigning separate disability ratings under these codes is precluded. The Board acknowledges that the Veteran is competent to report his intestinal symptoms. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Here, much of the lay evidence in this case was provided during VA examinations and at clinical visits. As noted above, the reports from these examinations show that the examiners considered the Veteran's lay statements in rendering their conclusions as to the severity of his ulcerative colitis. The Veteran himself is competent to describe the frequency, duration and severity of his symptoms, but he has not described "severe" symptoms. Having considered the Veteran's reports along with findings from his VA examinations, the Board notes that, with regard to questions requiring medical expertise such as ulcerative colitis causing malnutrition, general debility and/or other serious complications such as liver abscess, the opinions of medical professionals have been accorded greater probative weight than the Veteran's lay assertion as the Veteran is not shown to possess the requisite medical training and expertise to offer opinions on medical diagnosis and etiology. In sum, the Board finds that the most probative lay and medical evidence is consistent with moderately severe ulcerative colitis with frequent exacerbations. "Severe" ulcerative colitis with numerous attacks per year and malnutrition has not been shown. There is no doubt of material fact to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b). Right Ankle Arthritis The Veteran contends that he is entitled to a rating in excess of 10 percent for his service-connected right ankle arthritis. His symptoms are rated under Diagnostic Code 5003-5271. 38 C.F.R. § 4.71(a). (Hyphenated Diagnostic Codes are used when a rating under one Diagnostic Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Under Diagnostic Code 5003, degenerative arthritis substantiated by X-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. 38 C.F.R. § 4.71(a). Diagnostic Code 5271 provides that a 10 percent rating is warranted for moderate limitation of motion of the ankle. A 20 percent rating is warranted for marked limitation of motion. Id. Normal ankle motion is measured from 0 to 20 degrees of dorsiflexion and 0 to 45 degrees of plantar flexion. Id. at Plate II. The Board notes that the words "moderate" and "marked" are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. However, according to the Veterans Benefits Administration (VBA), an example of moderate limitation of ankle motion is less than 15 degrees of dorsiflexion or less than 30 degrees of plantar flexion, while an example of marked limitation is less than 5 degrees of dorsiflexion or less than 10 degrees of plantar flexion. See M-21, III.iv.4.A.3.I. The Veteran filed the instant claim for an increased rating in February 2010. At that time, VA outpatient records, including rheumatology clinic notes, showed a history of ongoing treatment for joint pain, including right ankle pain. SSA medical records also reflect treatment and physical therapy for musculoskeletal pain, to include arthritis. A January 2010 X-ray revealed a large dorsal osteophyte at the right talar head. The impression was mild osteoarthritis. On VA examination in May 2010, the Veteran reported joint pain on a scale of 8 out of 10, as well as on and off swelling. He reported that moderate activities caused more pain, and that he was unable to walk more than two blocks or climb more than one flight of stairs at a stretch; however, he was able to perform routine activities, including the usual duties of his occupation. He denied using any assistive devices. Range of motion testing revealed dorsiflexion to 20 degrees and plantar flexion to 40 degrees. No objective evidence of painful motion was noted, and the examiner indicated that there was no additional loss due to repetitive movements, pain, weakness, or fatigue. Gait was normal, and there was no evidence of ankylosis. On VA examination in January 2014, the Veteran reported on and off pain in his right ankle which required pain medication. Range of motion testing revealed plantar flexion limited to 40 degrees and dorsiflexion limited to 15 degrees, with no objective evidence of painful motion. He was able to perform repetitive-use testing without additional lost motion. No pain on palpation was observed, and ankle strength was normal. There was no evidence of laxity, ankylosis, shin splints, Achilles pathology, malunion of the os calcis or talus, or talectomy. The Veteran denied using assistive devices for his right ankle. Subsequent VA outpatient records reveal ongoing treatment for right ankle pain and swelling. For example, a July 2014 rheumatology clinic note reflected mild pain and swelling, as well as synovitis. After careful review, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the Veteran's right ankle arthritis. The evidence of record does not demonstrate limitation of right ankle motion to a "marked" degree, as is required for a higher, 20 percent rating, at any time during the appeal period. As noted above, VA examination reports indicate that, at worst, the Veteran's plantar dorsiflexion has been limited to 40 degrees, and his dorsiflexion limited to 15 degrees. These findings reflect no more than 5 degrees of lost motion, compared to normal range of motion. Moreover, the objective findings noted in the VA examination reports indicate no additional loss of motion due to repetitive movements, pain, weakness, or fatigue. These findings do not meet the definition set forth by VBA as demonstrating "marked" limitation of motion. While the Board is not confined to VBA's definition of "marked," the Board does not find that the extent of limitation of motion shown - 5 degrees loss of motion in plantar and dorsiflexion - meets or more nearly approximates "marked" limitation of motion. The Board has considered the Veteran's lay statements regarding painful motion and swelling, as well as the impact his right ankle arthritis has on his ability to walk and climb stairs. He is certainly competent to report these symptoms. See Layno, 6 Vet. App. at 469-70. However, the Board finds that these lay reports are consistent with no more than moderate impairment, even taking into account the types of functional impairment addressed in 38 C.F.R. §§ 4.40 and 4.45. The Veteran does not require assistive devices to ambulate, and he has not reported that his right ankle symptoms cause additional limitation of motion than what is reflected in the objective findings. The Board has considered other potentially applicable Diagnostic Codes in determining whether a higher rating is warranted; however, the Veteran's right ankle disability is not shown to involve any other factor or diagnosis that would warrant evaluation under any other provision of the rating schedule. The VA examination reports demonstrate that the Veteran has no history of ankylosis of the right ankle or subastragalar or talar joints, malunion of the os calcis or astragalus, or astragalectomy. Consequently, an evaluation under Diagnostic Codes 5270, 5272, 5273, or 5274 would not be appropriate. In sum, the Board finds that the most probative evidence more nearly approximates right ankle limitation of motion that is no more than moderate in degree. A rating in excess of 10 percent is therefore not warranted. There is no doubt of material fact to be resolved in his favor. 38 U.S.C.A. § 5107(b). Right Forearm Arthritis The Veteran contends that he is entitled to a compensable rating for his service-connected arthritis of the right forearm. His symptoms are rated under Diagnostic Code 5003. 38 C.F.R. § 4.71(a). As noted above, under Diagnostic Code 5003, degenerative arthritis substantiated by X-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. Id. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate Diagnostic Codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. In such cases, limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Diagnostic Codes 5206 and 5207 provide disability ratings based on limitation of motion of the forearm. Under Diagnostic Code 5206, a noncompensable rating is assigned for flexion of the major forearm limited to 110 degrees. A 10 percent rating is assigned for flexion of the major forearm limited to 100 degrees. A 20 percent rating is assigned for flexion of the major forearm limited to 90 degrees. A 30 percent rating is assigned for flexion of the major forearm limited to 70 degrees. A 40 percent rating is assigned for flexion of the major forearm limited to 55 degrees. A 50 percent rating is assigned for flexion of the major forearm limited to 45 degrees. Under Diagnostic Code 5207, a 10 percent rating is assigned for extension of the major forearm limited to 60 degrees or less. A 20 percent rating is assigned for extension of the major forearm limited to 75 degrees. A 30 percent rating is assigned for extension of the major forearm limited to 90 degrees. A 40 percent rating is assigned for extension of the major forearm limited to 100 degrees. A 50 percent rating is assigned for extension of the major forearm limited to 110 degrees. Limitation of supination of either forearm to 30 degrees or less warrants a 10 percent evaluation. Limitation of pronation of the forearm of the major upper extremity warrants a 20 percent evaluation if motion is lost beyond the last quarter of the arc and the hand does not approach full pronation. A 30 percent evaluation requires that motion be lost beyond the middle of the arc. Id. at Diagnostic Code 5213. Normal ranges of elbow motion are 0 degrees extension and 145 degrees flexion; and forearm pronation and supination are 80 and 85 degrees, respectively. Id. at Plate I. The Veteran filed the instant claim for an increased rating in February 2010. At that time, VA outpatient records, including rheumatology clinic notes, indicate a history of ongoing treatment for joint pain, including right forearm pain. SSA medical records also reflect treatment and physical therapy for musculoskeletal pain, to include arthritis. A January 2010 X-ray revealed mild osteoarthritis of the right ulnohumeral joint. On VA examination in May 2010, he reported almost daily joint pains, including pain in his wrists and elbows, on a pain scale of 8 out of 10. He also reported on and off swelling of his joints. He stated that moderate activities caused more pain. A physical examination of the wrists and elbows was within normal limits, with no obvious swelling, tenderness, redness, or warmth. Range of motion of the wrists and elbows was normal, and repetitive testing did not result in limited motion. The examiner noted that X-ray testing confirmed osteoarthritis in the right ulnohumeral joint. On VA examination in January 2014, the Veteran reported off and on right forearm pain, which he characterized as flare-ups. Range of motion testing revealed full range of motion of the right elbow, with no objective evidence of painful motion. Muscle strength was normal and no ankylosis was noted. X-ray testing confirmed a diagnosis of arthritis. After careful review, the Board finds that the evidence supports a 10 percent rating, but no higher, for symptoms relating to the Veteran's arthritis of the right forearm. The Veteran primarily reports right forearm/elbow pain and swelling, and there is X-ray evidence of mild osteoarthritis of the right forearm. In light of VA's policy of providing a minimum compensable rating for arthritis with painful motion under Diagnostic Code 5003 and 38 C.F.R. § 4.59, the Board finds that a 10 percent rating is assigned for the entire appeal period. However, the Board finds that the criteria for a rating greater than 10 percent have not been met for any time during the appeal period. Here, there is no lay or medical evidence of flexion limited to 90 degrees or extension limited to 75 degrees, as would be required for a higher, 20 percent rating under Diagnostic Codes 5206 and 5207. The most recent examination acknowledged flare-ups and painful motion but documented full objective range of motion of the right elbow. The prior VA examination in 2010 also showed no loss of motion, even upon repetitive testing. As discussed above, the Board has applied the provisions of 38 C.F.R. §§ 4.40 and 4.45 in the Veteran's favor by finding that the limitation of motion due to arthritis represents the extent of his motion loss due to use and pain. By review of the lay and medical evidence, the Board does not find a basis for a higher rating even when considering functional impairment on use. In sum, the Board finds that a 10 percent rating, but no higher, is warranted for the entire appeal period, based on X-ray findings of arthritis in the right forearm and elbow. Extraschedular Consideration The Board has also considered the provisions of 38 C.F.R. § 3.321(b)(1), which govern the assignment of extra-schedular disability ratings. However, in this case, the evidence of record is against a finding that the Veteran's service-connected disabilities are so exceptional or unusual as to warrant the assignment of an extraschedular rating. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disabilities are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service- connected disabilities with the established criteria found in the rating schedule for those disabilities. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id.; see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided under 38 C.F.R. § 3.321(b)(1) as "governing norms"( including marked interference with employment and frequent periods of hospitalization). The Board notes that, in Johnson v. McDonald, 762 F.3d 1362, 1366 (Fed Cir. 2014), the Federal Circuit Court stated that "[l]imiting referrals for extra-schedular evaluation to considering a Veteran's disabilities individually ignores the compounding negative effects that each individual disability may have on the Veteran's other disabilities." When considering whether referral is warranted based on the combined effects of a Veteran's service-connected disabilities, the Board first must compare the Veteran's symptoms with the assigned schedular ratings. Yancy v. McDonald, 27 Vet. App. 484 (2016). The evidence in this case does not show such an exceptional disability picture that renders inadequate the available schedular evaluations for the service-connected disability on appeal. A comparison between the level of severity and symptomatology of the Veteran's assigned ratings with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. As discussed above, the Veteran's service-connected right ankle and right forearm disabilities are productive of pain and limited motion. His service-connected ulcerative colitis is productive of moderately severe symptoms, to include bowel disturbance and abdominal distress with frequent exacerbations and secondary conditions of anemia and arthritis. The ratings assigned for the disabilities on appeal - as well as prior ratings assigned for arthritis and anemia - fully contemplate this symptomatology. The Veteran reports the need to be near a bathroom due to the frequency of his symptoms, but the rating assigned specifically contemplates him experiencing frequent exacerbations. Furthermore, the record does not disclose any compounding negative effects which the service-connected disabilities have on the other disabilities. In August 2014 and May 2016 briefs, the Veteran's representative has contended that the Veteran's service-connected conditions are considerably worse when the entire disability picture is considered. However, neither the Veteran nor his representative have specified how exactly this is the case. As discussed above, the Veteran has been assigned separate schedular ratings for ulcerative colitis as well as complications of arthritis and anemia. When considering the entire record, it cannot be said that the available schedular evaluations for the disabilities on appeal are inadequate. The Board observes also that, even if the available schedular evaluations for the disabilities at issue are inadequate (which they manifestly are not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." There is no indication that the Veteran has required frequent periods of hospitalization, and although his disabilities have some effect on his employability, there is nothing in the record to indicate that these disabilities cause impairment with employment over and above that which is already contemplated in the assigned schedular ratings. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Indeed, the most recent VA examination report indicates that he is currently employed on a full-time basis. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected disabilities, under the provisions of 38 C.F.R. § 3.321(b)(1), have not been met. ORDER Entitlement to a rating in excess of 30 percent for ulcerative colitis with backwash ileitis is denied. Entitlement to a rating in excess of 10 percent for arthritis of the right ankle is denied. Entitlement to a 10 percent rating, but no higher, for arthritis of the right forearm is granted. REMAND After reviewing the evidence, the Board finds that the remaining issues on appeal must be remanded for additional evidentiary development. With respect to the claim for an increased rating for lumbar spine arthritis, the Board notes that the Veteran underwent a VA examination in January 2014. However, the examination report indicates that the Veteran refused range of motion testing due to the severity of his back pain. The Board finds that the appeal must be remanded for another VA examination so that range of motion testing can be performed. The Board acknowledges the Veteran's reports of severe pain; however, the Board reminds the Veteran that range of motion testing is critical in determining the severity of his musculoskeletal disability. To the extent possible, such testing should be performed to enable VA to properly rate his disability. With respect to the claim of entitlement to service connection for an eye condition, the Board finds that another VA examination is necessary in order to ascertain the nature and etiology of the reported symptoms. VA medical records reflect complaints of blurry vision and notations of suspected glaucoma. In May 2010, a VA examiner opined that these symptoms could not be related to the Veteran's ulcerative colitis, as the medical literature did not support such a claim. The Veteran has subsequently disagreed with this rationale, and the Board finds that additional explanation is needed. Moreover, an eye examination would be helpful in determining the nature of any current eye condition, as more than 6 years have elapsed since the last examination. Accordingly, the case is REMANDED for the following action: 1. Associate with the claims folder records of the Veteran's VA treatment since August 2014. 2. Have the Veteran scheduled for a VA examination to ascertain the current severity and manifestations of his service-connected arthritis of the lumbar spine. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed, and the entire claims file should be reviewed. Specifically, the examiner should provide ranges of motion for the lumbar spine, including information regarding whether there is any additional limitation of function due to or caused by fatigue, pain, weakness, lack of endurance, or incoordination. 3. Then, have the Veteran scheduled for a VA examination to determine the nature and likely etiology of his eye condition. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. After reviewing the entire record, the examiner identify all current eye disabilities and, for each diagnosed disorder, should opine as to whether it is at least as likely as not (50 percent probability or more) that such eye condition was proximately caused or aggravated beyond the normal progress of the disorder by the service-connected ulcerative colitis. The examiner should discuss the May 2010 VA examination report and accompanying opinions, as well as all recent VA optometry clinic notes and the Veteran's lay statements. A complete rationale should accompany each opinion provided and should be based on examination findings, historical records, and medical principles. 4. After completing all indicated development, readjudicate the claims remaining on appeal. If any benefit sought on appeal remains denied, furnish to the Veteran and his representative a Supplemental Statement of the Case. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ T. Mainelli Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs