Citation Nr: 1631155 Decision Date: 08/04/16 Archive Date: 08/11/16 DOCKET NO. 10-08 356 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for numbness and tingling in the arms and hands as secondary to degenerative joint disease of the cervical spine. 2. Entitlement to service connection for sleep apnea. 3. Entitlement to an initial disability evaluation in excess of 10 percent for service-connected right knee laxity (right knee laxity). 4. Entitlement to an initial disability evaluation in excess of 10 percent for service-connected degenerative joint disease (DJD) of the right knee (right knee DJD). 5. Entitlement to a disability evaluation in excess of 10 percent for service-connected residuals of fracture and dislocation of the right elbow (right elbow disability). 6. Entitlement to a compensable disability evaluation for service-connected residuals of fracture of the left elbow (left elbow disability). 7. Entitlement to an initial compensable disability evaluation for service-connected hypertension (HTN). 8. Entitlement to an initial disability evaluation in excess of 20 percent for service-connected DJD of the lumbar spine with sciatica (lumbar spine disability). 9. Entitlement to a disability evaluation in excess of 10 percent for service-connected DJD of the cervical spine (cervical spine disability). 10. Entitlement to a disability evaluation in excess of 30 percent for service-connected dysthymia. 11. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Ralph J. Bratch, Esq. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from April 1977 to December 1994. These matters initially came to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St Petersburg, Florida. In March 2009, the RO granted service connection for the lumbar spine disability, and assigned a 20 percent rating, effective July 11, 2008; granted service connection for right knee DJD, and assigned a noncompensable rating, effective July 11, 2008; denied an increased rating for dysthymia disorder; and decreased the disability rating for the right elbow disability from 10 percent to noncompensable, effective July 11, 2008. In November 2009, the RO granted an increased rating of 30 percent for dysthymia disorder, effective July 11, 2008. The RO also found clear and unmistakable error in the March 2009 decision regarding the reduction of disability rating for the right elbow disability and the assignment of a noncompensable rating for right knee DJD. The RO reinstated the 10 percent rating for the right elbow, effective July 11, 2008 and assigned a 10 percent rating for right knee DJD, effective July 11, 2008, as well as a separate 10 percent rating for right knee laxity, effective July 11, 2008. In November 2010, the RO denied a request to reopen the claim for service connection for HTN. In May 2012, the RO denied service connection for numbness and tingling in the arms and hands as secondary to degenerative joint disease of the cervical spine; and denied increased ratings for the cervical spine and left elbow disabilities. The Veteran filed a notice of disagreement (NOD) with this decision in September 2012. In August 2014, the RO issued a statement of the case (SOC), and in August 2014 the Veteran submitted a VA Form 9, Appeal to the Board of Veterans' Appeals (VA Form 9). In October 2012, the Veteran testified before the undersigned Veterans Law Judge at a Board hearing at the RO. A transcript of the hearing is of record. In March 2013, the Board reopened and granted the claim for service connection for HTN, and remanded the issues of entitlement to service connection for sleep apnea; and increased disability evaluations for service-connected dysthymia, a right elbow disability, right knee DJD, right knee laxity, and a lumbar spine disability for further development. In September 2013, the RO implemented the Board's grant of service connection for HTN and assigned a noncompensable evaluation, effective April 23, 2010. The Veteran filed a NOD in October 2013, and disagreed with the assignment of the noncompensable evaluation. In August 2014, the RO issued a SOC, and in August 2014 the Veteran submitted a VA Form 9. In November 2014, the Board remanded this matter noting that on VA Form 9's, received in June 2014 and August 2014, the Veteran indicated that he wished to continue with all of the issues included in the May 2014 supplemental SOC (SSOC) and the August 2014 SOCs, and requested a Board videoconference hearing before a VLJ. The Veteran had a hearing scheduled in December 2015. In November 2015, the Veteran, through his attorney, withdrew that hearing request. The issues of service connection for numbness and tingling in the arms and hands as secondary to degenerative joint disease of the cervical spine and sleep apnea, along with higher evaluations for the cervical spine disorder, dysthymia, and the TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran has been shown to require the use of continuous blood pressure medication throughout the appeal period. 2. For the time period prior to May 4, 2010, the Veteran was not shown to have right knee extension limited to less than 5 degrees or flexion limited to less than 120 degrees, with no more than slight subluxation/lateral instability being demonstrated. 3. For the time period from May 4, 2010, the date of the Veteran's right total knee arthroplasty (TKA) surgery, until May 31, 2011, following the surgery, a 100 percent disability evaluation is warranted. 4. For the time period from June 1, 2011, the right TKA has been manifested by intermediate degrees of residual weakness, pain, and limitation of motion (LOM), with no more than slight lateral instability. 5. The evidence of record does not show that the Veteran's right elbow disability is manifested by forearm flexion limited to 100 degrees, forearm extension limited to 45 degrees, or any other elbow impairment which would warrant greater than a 10 percent rating. 6. The evidence of record does not show that the Veteran's left elbow disability is manifested by forearm flexion limited to 100 degrees, forearm extension limited to 45 degrees, or any other elbow impairment which would warrant greater than a 10 percent rating. 7. The Veteran's lumbar strain with degenerative joint disease with sciatica is not manifested by forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine; there were also no incapacitating episodes of intervertebral disc disease demonstrated at any time during the appeal. 8. For the time period from July 11, 2008, the Veteran was shown to have mild neurological impairment from right lower extremity radiculopathy. CONCLUSIONS OF LAW 1. The criteria for a 10 percent rating, and no more, for hypertension have been met throughout the appeal period. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7101 (2015). 2. The criteria for a rating in excess of 10 percent for right knee degenerative joint disease, based upon limitation of motion, prior to May 4, 2010, were not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261, 5262 (2015). 3. The criteria for an evaluation in excess of 10 percent for right knee degenerative joint disease, based upon subluxation/lateral instability, were not met at any time throughout the course of the appeal. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.71a, Diagnostic Code 5257 (2015). 4. The criteria for a 100 percent disability evaluation based upon a right knee TKA for the period from May 4, 2010 to May 31, 2011, have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2015). 5. The criteria for a 30 percent evaluation for residuals of right TKA based upon loss of motion, from June 1, 2011, have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.21, 4.59, 4.68, 4.71a, Diagnostic Codes (DCs) 5055, 5260, 5261, 5262 (2015). 6. The criteria for greater than a 10 percent rating for residuals of fracture and dislocation of the right elbow have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5205, 5206, 5207, 5208, 5209, 5212 (2015). 7. The criteria for a 10 percent rating, and no more, for residuals of fracture and dislocation of the left elbow have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5205, 5206, 5207, 5208, 5209, 5212 (2015). 8. The criteria for an evaluation in excess of 20 percent for degenerative joint disease of the lumbar spine with sciatica, based upon limitation of motion and/or incapacitating episodes, have not been met at any time. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.1 4.2, 4.3, 4.7, 4.10, 4.40, 4.45. 4.71a, Diagnostic Codes Diagnostic Codes 5003, 5242, 5235-5243 (2015). 9. The criteria for a 10 percent evaluation for right lower extremity radiculopathy, and no more, have been met from July 11, 2008. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Assist and Notify VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2015). Notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. §3.159(b) must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Such notice also must include notice that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004). As a portion of the Veteran's appeal for higher initial ratings arise from disagreement with the initial evaluations following the grants of service connection for degenerative joint disease (DJD) and laxity of the right knee, degenerative joint disease of the lumbar spine, and hypertension, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the United States Court of Appeals for Veterans Claims (Court) have held that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also 38 C.F.R. § 3.159(b)(3)(i). As it relates to the claims for increased evaluations for right and left elbow disorders, the RO, in June 2009 and March 2012 letters, respectively, informed the Veteran about the information and evidence not of record that was necessary to substantiate the claim; the information and evidence that VA would seek to provide; the information and evidence the Veteran was expected to provide; and the information on disability ratings and effective dates required by Dingess. The Board finds that there has been substantial compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service treatment records, VA treatment records, private treatment records, and lay evidence, to include testimony from the Veteran. No additional pertinent evidence has been identified by the claimant. As to the necessity for examinations, as it relates to the left and right elbow disorders the Veteran was afforded VA examinations in October 2008, May 2012, and April 2014. As it relates to the right knee disorder, the Veteran was afforded VA examinations in October 2008 and April 2014. The Board finds that the combination of the Veteran's private and VA treatment records, his VA examinations, and the private evaluations submitted by the Veteran are an adequate basis for the decisions in this decision. See Correia v. McDonald, 13-3238, 2016 WL 3591858 (Vet. App. July 5, 2016). As it relates to the lumbar spine disorder, the Veteran was afforded VA examinations in October 2008 and April 2014. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations of record are adequate for rating purposes, because they were performed by a medical professional, were based on a thorough examination of the Veteran, and reported findings pertinent to the rating criteria. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008); see Barr v. Nicholson, 21 Vet. App. 303 (2007) (holding that VA must provide an examination that is adequate for rating purposes). Thus, the Board finds that further examinations are not necessary. As it relates to the issues of a higher evaluation for hypertension, while the Veteran has not been afforded a VA examination, the record contains numerous blood pressure readings along with the testimony of the Veteran that he is currently on continuous blood pressure medications. There is significant evidence demonstrating the severity of the Veteran's current hypertension to properly rate this disability. Accordingly, the Board finds that referral for a VA medical examination is not warranted. The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claim, including by submission of statements and arguments from his attorney and through testimony at this hearing. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide the appeal. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating this claim. Evaluations Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997); 38 C.F.R. § 4.59 (2015). Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). 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, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is assigned where x-ray evidence shows involvement of two or more major joints or 2 or more minor joint groups. Where there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, a 20 percent evaluation is assigned. Note (1) to Diagnostic Code 5003 states that the 20 and 10 percent ratings based on x-ray findings, above, will not be combined with ratings based on limitation of motion. Id. Hypertension With regard to hypertension, the rating schedule provides a 10 percent evaluation when diastolic pressure is predominantly 100 or more, or when systolic pressure is predominantly 160 or more, or for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted when diastolic pressure is predominantly 110 or more, or; systolic pressure is predominantly 200 or more. A 40 percent evaluation requires diastolic pressure of predominantly 120 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. The Veteran maintains that the symptomatology associated with his hypertension warrants an increased evaluation. A review of the record demonstrates that the Veteran has been prescribed medication for his hypertension throughout the appeal period. Treatment records associated with the file reveal continuous use of blood pressure medication throughout the appeal period. At his October 2012 hearing, the Veteran testified that he was on blood pressure medication and that when he was placed on blood pressure medication he was having very high readings. The Veteran indicated that his blood pressure medication had been gradually increased over time. After considering the totality of the evidence, the Board finds a disability rating of 10 percent is warranted. The Veteran has continuously been on blood pressure medication throughout the appeal period. The record indicates a reported history of high blood pressure readings which would appear to indicate a history of diastolic pressure predominantly 100 or more. Resolving any doubt in the Veteran's favor, a 10 percent rating is warranted as the weight of evidence demonstrates continuous medication necessary for control with a history of diastolic pressure 100 or more. The private medical evidence from North Florida Pain Center and Family Medical Center contains a thorough record for this condition, with blood pressure readings documented on numerous visits. There is no evidence of diastolic pressure predominantly 100 or more or, systolic pressure predominantly 160 or more. An evaluation of 20 percent is not warranted at any time as the weight of the evidence does not demonstrate diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more at any time. Thus, as there is no evidence of hypertensive vascular disease with diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more, a disability rating in excess of 10 percent is not warranted. Right Knee Limitation of motion of the knee is addressed in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 provides for a zero percent rating where flexion of the leg is limited to 60 degrees; 10 percent rating where flexion is limited to 45 degrees; 20 percent rating where flexion is limited to 30 degrees; and 30 percent rating where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a zero percent rating where extension of the leg is limited to 5 degrees; 10 percent rating where extension is limited to 10 degrees; 20 percent rating where extension is limited to 15 degrees; a 30 percent rating where extension is limited to 20 degrees; a 40 percent rating where extension is limited to 30 degrees; and a 50 percent rating where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. The knee is considered a major joint. 38 C.F.R. § 4.45(f). The normal range of motion of the knee is from zero to 140 degrees. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5257 provides for assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability; a 20 percent rating when there is moderate recurrent subluxation or lateral instability; and a 30 percent rating when there is severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). The General Counsel subsequently clarified that for a knee disability rated under DC 5257 to warrant a separate rating for arthritis based on x-ray findings and limitation of motion, limitation of motion under DC 5260 or DC 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. A separate rating for arthritis could also be based on x-ray findings and painful motion under 38 C.F.R. § 4.59. VAOPGCPREC 9-98 (1998); 63 Fed. Reg. 56,704 (1998). The General Counsel further held that separate ratings could also be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Prosthetic replacement of a knee joint, for one year following implantation of the prosthesis warrants a 100 percent rating. With chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent evaluation will be assigned. With intermediate degrees of residual weakness, pain or limitation of motion, the knee replacement is rated by analogy to 38 C.F.R. Part 4, DCs 5256, 5261, or 5262. 38 C.F.R. § 4.71, DC 5055. The minimum rating assigned will be 30 percent. Under DC 5256, favorable ankylosis of the knee, ankylosis in flexion between 10 degrees and 20 degrees warrants a 40 percent evaluation; ankylosis in flexion between 20 degrees and 45 degrees warrants a 50 percent evaluation; and extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more warrants a 60 percent evaluation. 38 C.F.R. § 4.71a, DC 5256. In conjunction with his claim, the Veteran was afforded a VA examination in October 2008. With regard to the right knee, the Veteran complained of pain and stiffness on a daily basis with instability and crepitus. He denied any significant swelling, heat, redness, recurrent subluxation/dislocation, or flare ups. He stated that he could stand for approximately one minute but had no difficulty with walking for prolonged periods of time. He wore a neoprene brace over the right lower extremity. Physical examination revealed no effusion. He has mild tenderness to palpation over the infrapatellar space and a mildly antalgic gait. Range of motion was from -5 to 120 degrees, active and passive, pain onset at 120 degrees. Repetitive testing was unchanged from baseline at the right knee. Anterior and posterior drawer test were applied to the right knee, with mild laxity in the ACL on the right, with no evidence of PCL instability. Varus and valgus maneuvers were applied in neutral and 30 degrees flexion position in the right knee with no evidence of MCL or LCL instability in the right knee. McMurray's testing was negative for medial or lateral meniscus entrapment in the right knee. A diagnosis of right knee strain was rendered. At the time of a March 2010 outpatient visit, the Veteran reported that his knee had become worse with aching after activity. He stated that it would occasionally lock up at times. He indicated that limited walking due to aching pain occurred on a daily basis. Examination revealed that the Veteran reported the most pain along the medial aspect of the right knee. He did have a slight varus alignment with walking. There were marginal osteophytes along the medial femoral condyle with localized tenderness. There was crepitation with range of motion and 1+ effusion. He did have some laxity with the Drawer test. A diagnosis of posttraumatic arthritis of the right knee with an old ACL tear was rendered. On May 4, 2010, the Veteran underwent a right total knee replacement. At his October 2012 hearing, the Veteran testified as to having had a total knee replacement in May 2010. He reported that he constantly had to get up and move and stretch his right leg. He stated that his right knee never recovered muscle wise. He indicated that he had fallen once or twice. He noted having trouble going up and down stairs. The Veteran stated that walking on uneven terrain was very difficult. He testified that it was better than before he had his knee replaced. At the time of an April 2014 VA examination, the Veteran was noted to have undergone a right knee arthroplasty in 2010. The Veteran indicated that the knee replacement did not help with the pain but stated that he did not experience swelling. He stated that he could walk up to a half mile. Range of motion was from 0 to 110 degrees. There was no additional loss of motion with repetitive use. There were no signs of effusion, medial lateral joint line tenderness, anserine bursa tenderness, erythema, or anterior or posterior drawer signs. The scar was well-healed and nontender, with no erythema or keloid formation. The examiner indicated that the Veteran underwent the right knee replacement, and the record showed that he was doing well with his new right knee prosthesis. He noted that, in general, prosthesis enabled patients to function normally and alleviate the weakness and pain they had experience prior to the replacement. The examination was noted to be unremarkable and the range of motion was excellent. He indicated that the objective observation was not consistent with the Veteran's statement regarding his right knee prosthesis. Evaluation from July 11, 2008, to May 4, 2010 As it relates to flexion of the right knee, the Veteran was not shown to have flexion to less than 60 degrees at the time of any VA examination or outpatient visit during the time period in question. As the Veteran has been shown to have limitation of motion, although noncompensable for rating purposes, in conjunction with his arthritis, a 10 percent disability evaluation, and no more, would be warranted under 5260. Therefore, a rating in excess of 10 percent for limitation of flexion is not warranted. Likewise, the Veteran has been shown to have limited to no less than -5 degrees. As such, a compensable disability evaluation would not be warranted for extension under 5261. See also VAOPGCPREC 9-98; VAOPGCPREC 9-2004. As it relates to instability, the Veteran was assigned a 10 percent disability based upon instability for the time period in question. An evaluation in excess of 10 percent, which accounts for slight instability, has not been demonstrated. During the time period in question there was no demonstration of moderate instability nor were there findings of moderate instability prior to the May 4, 2010 surgery. The Veteran did not report having moderate instability at any time. The evidence includes clinical findings of only slight instability. The Board finds that the weight of the evidence does not demonstrate that a rating in excess of 10 percent for instability of the right knee prior to May 4, 2010 is not warranted. There is no evidence of right knee ankylosis or impairment of the tibia and fibula so as to warrant a higher rating under DC 5256 or DC 5262. The remaining diagnostic codes pertaining to impairment of the knee (i.e., DC 5259 for removal of symptomatic semilunar cartilage and DC 5263 for genu recurvatum) provide no rating higher than 10 percent; therefore a higher rating is not available under either of those codes. Under DC 5259, a maximum 10 percent rating is prescribed for removal of symptomatic semilunar cartilage. 38 C.F.R. § 4.71a . Under DC 5258, a maximum 20 percent rating is assigned when there is evidence of semilunar dislocated cartilage with frequent episodes of locking, pain and effusion into the joint. In this case, a higher or separate 10 percent rating is not warranted under either DC 5258 or DC 5259 because the evidence shows no removal of symptomatic semilunar cartilage and no dislocated semilunar cartilage, and the reported symptom of pain in the right knee joint is already contemplated in the ratings assigned. Evaluation for Time Period from May 4, 2010, to May 31, 2011 In this case, the appeal period regarding an increased rating for the right knee disability encompasses the period of time during which the Veteran underwent total right knee replacement as the claim was filed prior to this time. In accordance with DC 5055, following a total knee replacement, a 100 percent disability evaluation is assigned for the one year period following the replacement. As the surgery was performed on May 4, 2010, the evidence demonstrates that a 100 percent disability evaluation is warranted until May 31, 2011. Evaluation for Time Period From June 1, 2011 to Present As noted above, with chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent evaluation will be assigned. With intermediate degrees of residual weakness, pain or limitation of motion, the knee replacement is rated by analogy to 38 C.F.R. Part 4, DCs 5256, 5261, or 5262. 38 C.F.R. § 4.71, DC 5055. The minimum rating is 30 percent. Diagnostic Code 5055 provides that with intermediate levels of disability, ratings should be provided under DCs 5256 (for ankylosis); 5260 (for limitation of flexion or 5261 (for limitation of extension). The Veteran has retained significant ranges of knee motion and does not have ankylosis. The reported ranges of motion would not approximate the criteria for more than a noncompensable rating for limitation of flexion and a noncompensable rating for limitation of extension, even with consideration of any additional limitation of motion or function of the knee due to pain or other symptoms, such as weakness, fatigability, or incoordination (see 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca). Moreover, the VA examiner indicated that the Veteran was doing well after his right knee surgery. The Board finds that the evidence supports no more than the minimum rating of 30 percent for the right knee disability, residuals of right knee TKA, from June 1, 2011. VA has interpreted the rating criteria to mean separate ratings for knee disabilities rated on the basis of limitation of motion and instability are appropriate where indicated by clinical findings. See VAOPGCPREC No. 23-97 (July 1, 1997), 62 Fed. Reg. 63,604 (1997). Although, DC 5055 does not explicitly provide for ratings based on instability, the General Counsel 's reasoning would indicate that a separate rating for instability was permissible. The Board finds the right knee met the requirements for a separate rating for instability as of June 1, 2011. The rating criteria provide for a 10 percent rating for slight instability; 20 percent for moderate; and, 30 percent for severe. 38 C.F.R. § 4.71a, DC 5257. The objective findings on clinical examination show mild instability, which has been demonstrated throughout the appeal. Hence, a 10 percent rating is more nearly approximated. The combined rating for the limitation of motion and instability residuals is 40 percent. See 38 C.F.R. § 4.25. Hence, the amputation rule does not come into play, as the rating for a below-the-knee amputation is 40 percent, and for above-the-knee, 60 percent. See 38 C.F.R. §§ 4.68, 4.71a, DCs 5162, 5165. Elbows Under Diagnostic Code 5205 ankylosis of the elbow warrants a 40 percent evaluation if it is favorable, at an angle between 90 and 70 degrees for the dominant arm and 30 percent for the minor arm; warrants a 50 percent evaluation if it is intermediate, at an angle more than 90 degrees or between 70 and 50 degrees for the dominant arm and a 40 percent for the minor arm; and warrants a 60 percent evaluation if it is unfavorable, at an angle of less than 50 degrees or with complete loss of supination or pronation for the dominant arm and 50 percent for the minor arm. Diagnostic Code 5206 concerns limitation of forearm flexion. Limitation of flexion of the forearm is rated 0 percent when limited to 110 degrees for both the dominant and minor arm; 10 percent when limited to 100 degrees for both arms, 20 percent when limited to 90 degrees for both arms, 30 percent when limited to 70 degrees for the major arm and 20 percent for the minor arm, 40 percent when limited to 55 degrees for the major arm and 30 percent for the minor arm, and 50 percent when limited to 45 degrees for the major arm and 40 percent for the minor arm. 38 C.F.R. § 4.71, DC 5206 (2011). Diagnostic Code 5207 concerns limitation of forearm extension. Limitation of extension of the forearm is rated 10 percent when limited to 45 and 60 degrees for both arms, 20 percent when limited to 75 degrees for both arms, 30 percent when limited to 90 degrees for the major arm and 20 percent for the minor arm, 40 percent when limited to 100 degrees for the major am and 30 percent for the minor arm, and 50 percent when limited to 110 degrees for the major arm and 40 percent for the minor arm. Under Diagnostic Code 5208 limitation of forearm flexion to 100 degrees with extension to 45 degrees in the minor and major arm warrants a 20 percent evaluation. Under Diagnostic Code 5209 joint fracture, with marked cubitus varus or cubitus valgus deformity or with ununited fracture of head of radius, warrants a 20 percent rating for the major and minor arm and other impairment of flail joint warrants a 60 percent rating for the major arm and 50 percent rating for the minor arm. Under Diagnostic Code 5210 nonunion of the radius and ulna with flail false joint of the minor arm warrants a 50 percent rating for the major arm and 40 percent rating for the minor arm. Under Diagnostic Code 5211 impairment of the ulna of the arm with malunion and bad alignment warrants a 10 percent rating for both arms; with nonunion in lower half warrants a 20 percent rating for both arms; with nonunion in upper half with false movement without loss of bone substance or deformity warrants a 30 percent rating for the major arm and 20 percent rating for the minor arm; and nonunion in upper half with false movement with loss of bone substance (1 inch (2.5 cms.) or more) and marked deformity warrants a 40 percent rating for the major arm and 30 percent rating for the minor arm. Under Diagnostic Code 5212 impairment of the radius with malunion and bad alignment warrants a 10 percent rating for both arms; with nonunion in upper half warrants a 20 percent rating for both arms; without loss of bone substance or deformity warrants a 30 percent disability evaluation for the major arm and 20 percent for the minor arm; with loss of bone substance (1 inch (2.5 cms.) or more) and marked deformity warrants a 40 percent evaluation for the major arm and 30 percent for the minor arm. Under Diagnostic Code 5213, limitation of supination of the minor arm to 30 degrees or less warrants a 10 percent rating; limitation of pronation of the minor arm with motion lost beyond last quarter of arc for both arms, the hand does not approach full pronation, warrants a 20 percent rating for both arms; with motion lost beyond middle of arc warrants a 30 percent rating for the major arm and 20 percent for the minor arm; and with the hand fixed near the middle of the arc moderate pronation of the arm warrants a 20 percent rating for both arms, with the hand fixed in full pronation in the minor arm warrants a 30 percent rating for the major arm and 20 percent for the minor arm, and with the hand fixed in supination or hyperpronation warrants a 40 percent rating for the major arm and 30 percent for the minor arm. Under 38 C.F.R. § 4.71a, Plate I (2015), normal flexion of the elbow is 0 to 145 degrees, normal forearm pronation is 0 to 80 degrees, and normal forearm supination is 0 to 80 degrees. Normal extension and flexion of the elbow is from 0 to 145 degrees. 38 C.F.R. § 4.71, Plate I (2015). In conjunction with his claim for increased evaluations, the Veteran was afforded a VA examination in October 2008. As it related to the elbows, the examiner indicated that the Veteran complained of pain and stiffness, much more significant in the right than the left elbow, with swelling in the right elbow and no swelling in the left elbow. He also reported having occasional flare-ups in both elbows whenever there were changes in barometric pressure occurring several times per month, wherein he had increased, from mild to moderate, intensity of pain lasting for several hours, mildly alleviated by Naproxen. The Veteran complained of an inability to extend at the right elbow and reported increased pain in the left elbow with forced extension, forced flexion, and pronation/supination movements. As it related to the right elbow, the Veteran had flexion from -10 to 140 degrees, active and passive, with pain onset at -10 degrees. Forearm supination was 0 to 85 degrees, active and passive, pain onset 85 degrees, and forearm pronation 0 to 80 degrees, active and passive, pain onset at 60 degrees. Repetitive testing was unchanged from baseline at the right elbow. At the left elbow, flexion was from 0 to 145 degrees, active and passive, pain onset at 0 and 145 degrees. Forearm supination 0 to 85 degrees, active and passive, with pain onset at 85 degrees. Forearm pronation was from 0 to 80 degrees, active and passive, pain onset at 80 degrees. Repetitive testing was unchanged from baseline at the left elbow. Diagnoses of residuals of a right elbow fracture and left elbow strain were rendered. At the time of a May 2012 VA examination, the Veteran was noted to be right hand dominant. Physical examination of the left elbow revealed flexion from 0 to 145 degrees. There was no objective evidence of painful motion. There was no change in range of motion following repetitive testing. There was no localized tenderness or pain on palpation. Muscle strength was 5/5 on flexion and extension. There was no ankylosis. There was no flail joint, joint fracture and/or impairment of supination/pronation. There was no joint replacement. The examiner observed that prior x-rays had revealed minimal deformity of the left radial head consistent with residuals from an old fracture. At his October 2012 hearing, the Veteran testified that he had nerve damage to his right elbow. He reported that they had to remove the radial head and the bone only went up so far and cut off. He stated that he had been told to keep moving it to prevent it from locking up. In conjunction with his claim, the Veteran was afforded an additional VA examination in April 2014. At that time, a diagnosis of status post bilateral elbow fracture was rendered. The Veteran was noted to be right-hand dominant. Flare-ups were noted to not impact the function of the elbow. The examiner indicated that the Veteran had no functional loss or impairment of either elbow. There was also no localized tenderness or pain on palpation of the joints/soft tissue of the elbow/forearm. Muscles strength was 5/5 on flexion and extension. There was no ankylosis. The Veteran did not have flail joint, joint fracture, and/or impairment of supination or pronation. Degenerative arthritis was present in the right elbow. For the right elbow, the Veteran had active and passive range of motion for flexion from 0 to 135 degrees. The Veteran had extension limited to 10 degrees after repetitive use with active motion but to 0 degrees with passive motion. Pronation was from 0 to 80 degrees, with no additional loss of motion on repetitive use, and supination was from 0 to 85 degrees, with no additional loss of motion with repetitive use. For the left elbow, active motion for flexion was from 0 to 135 degrees, while passive motion was from 0 to 145 degrees. Pain was noted at 0 degrees with repetitive use. Pronation was from 0 to 80 degrees while supination was from 0 to 85 degrees with no additional loss of motion with repetitive use. As it relates to the right elbow, on each occasion on which his range of motion was tested, the flexion of the Veteran's right elbow was to no less than 135 degrees. Such limitation does not warrant a rating higher than 10 percent under Diagnostic Code 5206. The flexion of the Veteran's right elbow would have to be limited to 90 degrees in order to warrant a rating higher than 10 percent under Diagnostic Code 5206. Similarly, the Veteran is not entitled to a rating in excess of 10 percent under the diagnostic criteria pertaining to limitation of extension. The Veteran has been shown to have extension limited to more than -10 degrees. Such extension does not warrant a compensable rating. Extension of the Veteran's right elbow would have to be limited to 75 degrees to warrant a 20 percent rating. Thus, the Veteran is not entitled to a higher rating for his right elbow disability under either Diagnostic Code 5206 or Diagnostic Code 5207. While the Board is sympathetic to the Veteran's reports of pain, objective testing did not reveal that any pain on use or during flare-ups, abnormal movement, fatigability, incoordination, or any other such factors resulted in the right elbow being limited in motion to the extent required for a 20 percent rating for limitation of flexion or extension of the right elbow. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). There is no evidence of flexion of the forearm limited to 100 degrees and extension to 45 degrees to warrant a 20 percent rating under Diagnostic Code 5208. 38 C.F.R. § 4.71a, Diagnostic Code 5208. Under Diagnostic Code 5209, the evidence does not show flail joint of the right elbow. There is also no evidence of impairment of supination and pronation that would warrant a higher evaluation under Diagnostic Code 5213. 38 C.F.R. § 4.71a, Diagnostic Code 5213. Further, in considering the applicability of other diagnostic codes, Diagnostic Codes 5205 (ankylosis of the elbow), 5210 (nonunion of the radius and ulna, with flail false joint), 5211 (impairment of the ulna), and 5212 (impairment of the radius) are not applicable in this instance, as the medical evidence does not show that the Veteran has any of those conditions. As to the left elbow, the Board notes that the Veteran has continuously reported having pain in the left elbow, with some impairment of motion being demonstrated. As a result, the Board will resolve reasonable doubt in favor of the Veteran and assign a 10 percent disability evaluation throughout the appeal period. An evaluation in excess of 10 percent is not warranted as on each occasion on which range of motion was tested, the flexion of as left elbow was to no less than 135 degrees. Such limitation does not warrant a rating higher than 10 percent under Diagnostic Code 5206. The flexion of the Veteran's elbow would have to be limited to 90 degrees in order to warrant a rating higher than 10 percent under Diagnostic Code 5206. Similarly, the Veteran is not entitled to a rating in excess of 10 percent under the diagnostic criteria pertaining to limitation of extension. The Veteran was shown to have full extension. Such extension does not warrant a compensable rating. Extension of the Veteran's elbow would have to be limited to 75 degrees to warrant a 20 percent rating. Thus, the Veteran is not entitled to a higher rating for his left elbow disability under either Diagnostic Code 5206 or Diagnostic Code 5207. While the Board is sympathetic to the Veteran's reports of pain, objective testing did not reveal that any pain on use or during flare-ups, abnormal movement, fatigability, incoordination, or any other such factors resulted in the left elbow being limited in motion to the extent required for a 20 percent rating for limitation of flexion or extension of the left elbow. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995) There is no evidence of flexion of the forearm limited to 100 degrees and extension to 45 degrees to warrant a 20 percent rating under Diagnostic Code 5208. 38 C.F.R. § 4.71a, Diagnostic Code 5208. Under Diagnostic Code 5209, the evidence does not show flail joint of the left elbow. There is also no evidence of impairment of supination and pronation that would warrant a higher evaluation under Diagnostic Code 5213. 38 C.F.R. § 4.71a, Diagnostic Code 5213. Further, in considering the applicability of other diagnostic codes, Diagnostic Codes 5205 (ankylosis of the elbow), 5210 (nonunion of the radius and ulna, with flail false joint), 5211 (impairment of the ulna), and 5212 (impairment of the radius) are not applicable in this instance, as the medical evidence does not show that the Veteran has any of those conditions. Lumbar Spine Diseases and injuries to the spine are to be evaluated under diagnostic codes 5235 to 5243 as follows: 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 Unfavorable ankylosis of the entire spine: 100 percent Unfavorable ankylosis of the entire thoracolumbar spine: 50 percent Unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine: 40 percent Forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine: 30 percent Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis: 20 percent Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height: 10 percent Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, General Rating Formula for Disabilities and Diseases of the Spine (2015). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes is as follows: With incapacitating episodes having a total duration of at least six weeks during the past 12 months 60 percent With incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months 40 percent With incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months 20 percent With incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months 10 percent Note (1): For purposes of evaluations under 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating for Formula and Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a, Diagnostic Code 5235-5243. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123 . Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. See nerve involved for diagnostic code number and rating. Tic douloureux, or trifacial neuralgia, may be rated up to complete paralysis of the affected nerve. 38 C.F.R. § 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral the rating should include the application of the bilateral factor. 38 C.F.R. § 4.124a. Under 38 C.F.R. § 4.124a, Diagnostic Code 8520, which provides criteria for rating impairment of the sciatic nerve, a 10 percent evaluation is warranted for mild incomplete paralysis. A 20 percent rating requires moderate incomplete paralysis, and a 40 percent rating requires moderately severe incomplete paralysis of the sciatic nerve. The next higher evaluation of 60 percent requires severe incomplete paralysis of the sciatic nerve with marked muscular atrophy. An 80 percent evaluation requires complete paralysis of the sciatic nerve, in which the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. The Veteran maintains that the symptomatology associated with his lumbar spine disorder is worse than the disability evaluation which is currently assigned. In conjunction with his claim, the Veteran was afforded a VA examination in October 2008. The Veteran reported that he had had problems with persistent pain in the right lower extremity with sciatica with moderate to severe pain on a daily basis involving the lumbar paraspinal regions. He complained of pain and stiffness in the lumbar paraspinal region with occasional unsteady gait secondary to instability in the right knee. He denied any bowel or bladder incontinence but did have a history of erectile dysfunction as well as numbness and weakness subjectively in a sciatic distribution of the right lower extremity. He denied any dizziness or visual disturbance. His pain typically was rated as 4 to 6 out of 10 on a daily basis, without medications, and was approximately 2/10 with pain medications. He denied use of a lumbar support and denied any incapacitating episodes in the past 12 months. On examination of the spine, the Veteran had no paraspinal muscle spasm tenderness or weakness noted in the thoracolumbar spine. He had forward flexion from 0 to 60 degrees, active and passive pain, onset at 60 degrees; extension 0 to 15 degrees, active and passive, pain throughout; left lateral flexion 0 to 15 degrees, active and passive, pain throughout; right lateral flexion 0 to 15 degrees, active and passive, pain throughout; left lateral rotation 0 to 20 degrees, active and passive, with pain throughout; and right lateral rotation 0 to 20 degrees, active and passive, with pain throughout. Repetitive testing was unchanged from baseline at the thoracolumbar spine. Neurological examination revealed he had normal tone and bulk throughout; his strength was 5/5, proximally and distally, and symmetrical through all four extremities. Reflexes were hypoactive but symmetrical at the patella and ankles, and the toes and were down going, bilaterally. Sensory examination revealed minimally diminished sensation in the L4 L5 distribution in the right foot, with otherwise intact sensation to vibration, light touch, pain and temperature distally, in all four extremities Lasegue's sign was negative bilaterally. A diagnosis of lumbar spine degenerative joint disease with radiculopathy was rendered. Private treatment records from the North Florida Pain Clinic reveal normal ranges of motion for the lumbar spine with at most intermittent findings of radiculopathy to the right lower extremity. At his October 2012 hearing, the Veteran testified that he had been receiving cortisone injections for his back since May 2011which had helped with the pain. He reported that this was helping with his sciatica. The Veteran also reported having muscle spasms. He also noted taking neurological and pain medications. He indicated that the pain would go down his legs. He reported using a TENS unit two to three times per week. In April 2014, the Veteran was afforded an additional VA examination. The Veteran reported that he had constant back pain, was not able to sleep on his back, was not able to lift heavy objects, and could walk 1/2 mile. He indicated that he could do the laundry, dishes, cleaning, and mowing. He stated that he needed his pain pills. At the time of the examination, the Veteran did not report having flare-ups. Range of motion testing revealed flexion from 0 to 90 degrees, with pain at 90 degrees. Extension was from 0 to 30 degrees. Left and right lateral flexion and left and right lateral rotation were from 0 to 30 degrees. There was pain after motion but there was no additional loss of motion after repetitive use. There was no localized tenderness on palpation of the joints. There was also no abnormal gait or abnormal spinal contour. Muscle strength was noted to be 5/5 in the lower extremities, with no muscle atrophy. Reflexes were normal for the knee and ankle. Sensory examination was normal in the upper anterior thigh, thigh/knee, lower leg/ankle, and feet and toes. Straight leg raising was negative. The examiner indicated that the Veteran did not have radiculopathy on either the left or right side. The Veteran did not have ankylosis. There were also no bowel or bladder problems and the Veteran did not have any incapacitating episodes or intervertebral disc syndrome. The examiner stated that the Veteran had no objective evidence of radiculopathy and had no neurological dysfunction. With regard to the Veteran's degenerative joint disease with sciatica, the Board finds that the weight of the lay and medical evidence demonstrates that an evaluation in excess of 20 percent is not warranted on the basis of limitation of motion or incapacitating episodes. Forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine has not been demonstrated throughout the course of the appeal. Moreover, as noted above, at the time of the most recent VA examination, performed in April 2014, the Veteran had forward flexion to 90 degrees, with no ankylosis being reported. There have also been no reports or findings of incapacitating episodes/physician prescribed bed rest, as defined in the regulation, totaling 4 weeks over any 12 month period at any time. The competent evidence reflects consideration of the Veteran's complaints of pain, weakness, and fatigability by medical professionals. Both VA examiners found no additional limitation of motion after repetition. Even when considering any additional limitation of motion caused by pain, fatigue, weakness and flare-ups, neither the actual range of motion nor the functional limitation warrants an evaluation in excess of 20 percent for limitation of motion based upon the appropriate codes governing limitation of motion for this time period. In sum, the weight of the lay and medical evidence demonstrates that an evaluation in excess of 20 percent is not warranted for at any time based upon range of motion or incapacitating episodes. 38 C.F.R. § 4.71a. Resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran has had mild neurological impairment of the right lower extremity resulting from his service-connected lumbar spine disorder throughout the appeal period. The Veteran was noted to have mild radiculopathy in his right lower extremity at the time of the October 2008 VA examination. Treatment records associated with the record also reveal the Veteran reporting intermittent right lower extremity neuropathy. Although the Board notes that the April 2014 examiner indicated that the Veteran did not have radiculopathy, the Board finds that the overall symptomatology and findings demonstrate that the Veteran has mild right lower extremity radiculopathy. The weight of the lay and medical evidence demonstrates that an evaluation in excess of 10 percent is not warranted as the Veteran has not been shown to have moderate incomplete paralysis of the right lower extremity at any time. Extraschedular Consideration In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2015). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R.§ 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. 38 C.F.R. § 3.321(b)(1). Turning to the first step of the extraschedular analysis, the Veteran's right knee disability has been manifested by painful motion associated with degenerative changes and a total knee replacement. The schedular rating criteria contemplate such symptomatology. The schedular rating criteria specifically provides ratings for such noncompensable limitation of motion due to painful arthritis (Diagnostic Codes 5003, 38 C.F.R. § 4.59), and contemplate ratings based on limitation of motion (Diagnostic Codes 5055, 5256, 5260, 5261), including motion limited to orthopedic factors such as pain, weakness, and stiffness (38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca), as well as instability and subluxation (Diagnostic Code 5257). Turning to the elbows, the schedular rating criteria contemplate such symptomatology. The schedular rating criteria specifically provides ratings for such noncompensable limitation of motion due to painful arthritis (Diagnostic Codes 5003, 38 C.F.R. § 4.59), and contemplate ratings based on limitation of motion, including motion limited to orthopedic factors such as pain, weakness, and stiffness (38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca), as well as other impairments of the elbow. As to the lumbar spine disability with resulting radiculopathy, this directly corresponds to the schedular criteria for the assigned disability evaluations, which also incorporates various orthopedic factors that limit motion or function of the spine. See 38 C.F.R. §§ 4.40 , 4.45, 4.59; DeLuca. Moreover, the resulting right lower extremity radiculopathy is also contemplated by the schedular criteria. For this reason, the Board finds that the assigned schedular ratings are adequate to rate the Veteran's degenerative joint disease with resulting radiculopathy. As to the hypertension disability rating, the Board finds that the symptomatology and impairment caused by the Veteran's hypertension, throughout the appeal period, is fully contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria provide for disability ratings based on the predominant diastolic blood pressure and predominant systolic blood pressure shown during the rating period, as well as any history of diastolic blood pressure predominantly 100 or more with continuous medication required for control. In this case, the Veteran's hypertension requires continuous medication for control and is manifested by a history of diastolic pressure of 100 or more. In this case, comparing the Veteran's disability level and symptomatology of the right knee disorder, the left and right elbow disorders, the low back disorder with resultant radiculopathy, and hypertension to the rating schedule, the degree of disability throughout the entire periods under consideration is contemplated by the rating schedule and the assigned ratings are therefore adequate. Because the schedular rating criteria are adequate to rate the Veteran's right knee, low back, and left and right elbow disabilities, and hypertension, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). Further, and according to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be entitled to "consideration [under 38 C.F.R. § 3.321(b)] for referral for an extra-schedular evaluation based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular evaluations." Referral for an extraschedular rating under 38 C.F.R. § 3.321(b) is to be considered based upon either a single service-connected disability or upon the "combined effect" of multiple service-connected disabilities when the "collective impact" or "compounding negative effects" of the service-connected disabilities, when such presents disability not adequately captured by the schedular ratings for the service-connected disabilities. In this case, the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. In this case, there is neither allegation nor indication that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. Comparing the Veteran's disability level and symptomatology of the right knee and left and right elbow and low back disorders and the hypertension to the rating schedule, the degree of disability throughout the entire period under consideration is contemplated by the rating schedule and the assigned ratings are, therefore, adequate. Absent any exceptional factors associated with the right knee low back, and left and right elbow disabilities and hypertension, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). As to a total disability evaluation based upon individual unemployability (TDIU), this issue will be addressed in the remand portion of this decision. ORDER A 10 percent rating, and no more, for hypertension from April 23, 2010 is granted. A rating in excess of 10 percent for right knee degenerative joint disease, based upon limitation of motion, prior to May 4, 2010, is denied. An evaluation in excess of 10 percent for right knee degenerative joint disease, based upon subluxation/lateral instability, is denied. A 100 percent disability evaluation based upon a right knee TKA for the period from May 4, 2010 to May 31, 2011, is granted. A 30 percent evaluation for residuals of right TKA based upon loss of motion, from June 1, 2011, is granted. An evaluation in excess of 10 percent for residuals of fracture and dislocation of the right elbow is denied. A 10 percent disability evaluation for residuals of fracture and dislocation of the left elbow, and no more, is granted. An evaluation in excess of 20 percent for lumbar spine degenerative joint disease is denied. A 10 percent disability evaluation for right lower extremity radiculopathy from July 11, 2008, is granted. REMAND As it relates to the claim of service connection for obstructive sleep apnea, the Board notes that while the Veteran was afforded a VA examination in April 2014, with the examiner indicating that the Veteran's current sleep apnea was not related to his period of service, the Veteran, through his attorney, has raised the issue of service connection for sleep apnea on a secondary basis, to include as secondary to medications taken for his current service-connected disorders and also as a result of obesity resulting from an inability to exercise due to his service-connected disabilities. Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, at 448 (1995) (holding that service connection on a secondary basis requires evidence sufficient to show that the current disability was caused or aggravated by a service-connected disability). To establish secondary service connection, the law states that there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between a service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). There has been no opinion expressed as to the relationship, if any, between the Veteran's current sleep apnea, and his service-connected disabilities, to include medications taken for those disabilities and/or an inability to exercise resulting in obesity, which may have led to his chronic sleep apnea. As it relates to the claims of service connection for numbness and tingling in the arms and hands as secondary to degenerative joint disease of the cervical spine, the Board notes that at the time of a May 2012 VA examination, it was indicated that the Veteran did not have cervical radiculopathy. However, a review of numerous medical records from the North Florida Pain Center, including treatment records dated subsequent to the examination reveals numerous diagnoses of cervical radiculopathy. While the Veteran was noted to not have radiculopathy at the time of an April 2014 cervical spine VA examination, there were no EMG/NCV studies performed to confirm the absence or presence of radiculopathy. Given the conflicting findings, the Veteran should be afforded an additional VA examination to determine the etiology of any current numbness/tingling in the hands and arms, to include as possibly resulting from the Veteran's service-connected cervical spine disorder and/or his service-connected elbow disorders. Also, if cervical radiculopathy is found to be present, this may have an impact on the Veteran's current cervical spine evaluation. Given the foregoing, the Veteran should be afforded an additional VA examination. As to the Veteran's claim for an increased evaluation for dysthymia, the Veteran's attorney, in his December 2015 written argument, indicated that the symptomatology associated with the Veteran's dysthymia was worse than that currently assigned, he pointed to a deterioration in the Veteran's social interactions, including his relationship with his wife. He maintains that the Veteran currently meets the criteria for a 70 percent disability evaluation. VA is obligated to afford a veteran a contemporaneous examination where there is evidence of an increase in the severity of the disability. VAOPGCPREC 11-95 (1995). As it relates to the claim for a TDIU, given the above actions, resulting in increased disability evaluations for several service-connected disorders, and the remanding of several issues, which may have an impact upon the TDIU claim, the TDIU claim is not ripe for appellate review. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). The Board acknowledges that the ultimate issue of whether a TDIU should be awarded is not a medical issue, but rather is a determination for the adjudicator. See Moore v. Nicholson, 21 Vet. App. 211, 218 (2007) (ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator), rev'd on other grounds sub nom, Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). Although VA must give full consideration, per 38 C.F.R. § 4.15, to "the effect of combinations of disability," VA regulations place responsibility for the ultimate TDIU determination on VA, not a medical examiner's opinion. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); 38 C.F.R. § 4.16(a); see also Smith v. Shinseki, 647 F.3d 1380, 1385-86 (Fed. Cir. 2011) (VA is not required to obtain an industrial survey from a vocational expert before making a TDIU determination but may choose to do so in an appropriate case). Nonetheless, the record is not clear regarding the Veteran's level of education, special training, or work history. Accordingly, further development is necessary prior to analyzing this TDIU claim on the merits. In order to assist the Board in adjudicating this claim, a VA examination should be obtained on remand to assist in determining whether the Veteran's service-connected disabilities impact his ability to work. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be requested to provide the names and addresses of all health care providers who have treated him for any hand/arm problems, cervical spine, psychiatric difficulties, or sleep apnea, since April 2014. After obtaining any written authorization, where necessary, obtain and associate with the record copies of those treatment records identified by the Veteran. Records from all identified VA facilities should be obtained and associated with the record. 2. The Veteran should be scheduled for a VA examination to determine the nature and etiology of any current obstructive sleep apnea. All indicated tests and studies should be performed and all findings should be reported in detail. The entire record must be made available to the examiner. The examiner is requested to offer the following opinions: a. Is it at least as likely as not (50 percent probability or greater) that any current sleep apnea, if found, is caused by any service-connected disorder, to include medications taken for those disorders, and/or an inability to exercise due to the service-connected disorders, which led to obesity, resulting in sleep apnea? b. If not, is it at least as likely as not (50 percent probability or greater) that any current obstructive sleep apnea is aggravated (permanently worsened) by any service-connected disorder, to include medications taken for that disorder, and or an inability to exercise due to the service-connected disorders resulting in obesity, leading to sleep apnea? If aggravation is found, to the extent that is possible, the examiner is requested to provide an opinion as to approximate baseline level of severity of the nonservice-connected disorder before the onset of aggravation. Complete detailed rationale is requested for each opinion that is rendered. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of any current numbness/tingling of the hands and the current severity of any current cervical spine disorder. All indicated tests and studies, to include EMG/NCV testing, should be performed and all findings should be reported in detail. The entire record must be made available to the examiner and the examiner should note such review in his/her report. As it relates to the numbness/tingling in the hands and arms, the examiner should provide the following opinions: a. Is it at least as likely as not (50 percent probability or greater) that any current numbness/tingling in the hands/arms, if found, had its onset in service or is otherwise related to the Veteran's service? b. Is it as likely as not (50 percent probability or greater) that any current numbness/tingling in the hands/arms is caused by the service-connected cervical spine disorder or the residuals of the left and right elbow fractures? c. If not, is it at least as likely as not (50 percent probability or greater) that any current numbness/tingling in the hands/arms is aggravated (permanently worsened) by the service-connected cervical spine or right/left elbow disorders? If aggravation is found, to the extent that is possible, the examiner is requested to provide an opinion as to approximate baseline level of severity of the nonservice-connected disorder before the onset of aggravation. When rendering the above opinions, the examiner is to address the numerous findings of cervical radiculopathy noted in the North Florida Pain Treatment Center Records. As to the cervical spine disorder, the examiner should report the Veteran's ranges of cervical spine motion in degrees and note the presence or absence of ankylosis of the spine. The examiner should determine whether the cervical spine disability is manifested by weakened movement, excess fatigability, or incoordination. Such inquiry should not be limited to muscles or nerves. These determinations should be expressed in terms of the additional degree of range of motion loss due to any pain, weakened movement, excess fatigability, incoordination, or flare-ups. The examiner should report whether intervertebral disc disease has required periods of doctor prescribed bed rest in the last 12 months and, if so, the frequency and duration of such periods. The examiner should also note any nerves affected by paralysis, partial paralysis, neuralgia, or neuritis, and, for affected nerves, express an opinion as to the severity of such symptoms in terms of being slight, moderate, moderately severe, severe, or complete. 4. The Veteran should be afforded a VA psychiatric examination to determine the severity of his dysthymia. All appropriate tests and studies, including psychological testing, should be performed and all findings should be reported in detail. The entire record must be made available to the examiner and the examiner should note such review in the report. 5. Then, afford the Veteran an appropriate VA examination and opinion regarding the Veteran's employability. The examiner should obtain from the Veteran full and current employment history and provide an opinion as to the functional and occupational effect of the Veteran's service-connected disabilities. The examiner should consider the Veteran's education and previous work experience, but should not consider age or the effect of any non-service-connected disabilities on the ability to obtain or maintain employment. 6. Thereafter, readjudicate the remaining issues on appeal. If any benefit sought on appeal remains denied, issue an additional Supplemental Statement of the Case. After the Veteran and his attorney have had an adequate opportunity to respond, return the appeal to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ K. Parakkal Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs