Citation Nr: 1742167 Decision Date: 09/25/17 Archive Date: 10/04/17 DOCKET NO. 10-16 964 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for irritable bowel syndrome. 2. Entitlement to a compensable initial rating prior to August 24, 2016 and in excess of 10 percent thereafter for right knee status post arthroscopy torn medial meniscus. 3. Entitlement to an initial rating in excess of 10 percent for degenerative arthritis of the lumbar spine. 4. Entitlement to a compensable initial rating for left ankle strain. 5. Entitlement to a compensable initial rating for lateral epicondylitis of the right elbow. 6. Entitlement to a compensable initial rating for lateral epicondylitis of the left elbow. 7. Entitlement to an initial rating in excess of 20 percent for a cervical spine disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Henriquez, Counsel INTRODUCTION The Veteran had active duty from November 1992 to May 1993, from September 1995 to April 1996, from October 2001 to May 2002, and from July 2005 to March 2009. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In December 2013 and August 2016, the Board remanded the claims for further development. In a May 2014 rating decision, the RO increased the Veteran's evaluation for his cervical spine disability from 10 percent to 20 percent, effective March 20, 2009. In a March 2017 Decision Review Officer Decision, the RO increased the Veteran's evaluation for his right knee status post arthroscopy torn medial meniscus to 10 percent, effective August 24, 2016. The Board has recharacterized the claims on appeal accordingly. The issue of entitlement to an initial rating in excess of 20 percent for a cervical spine disability is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's irritable bowel syndrome is not shown to be manifested by severe symptoms with more or less constant abdominal distress. 2. For the initial rating period prior to August 24, 2016, the Veteran's right knee disability was not manifested by ankylosis, recurrent subluxation or lateral instability, dislocated cartilage, flexion limited to 45 degrees, extension limited to 10 degrees, impairment of the tibia or fibula, or genu recurvatum; the right knee was also not additionally limited by pain, weakness, lack of endurance, or incoordination on repetition; and normal x-ray findings were shown. 3. From August 24, 2016, Veteran's right knee disability is not manifested by objective evidence of flexion limited to 30 degrees or less; extension limited to 15 degrees or more; recurrent subluxation or objective evidence of slight lateral instability; dislocated semilunar cartilage with frequent locking, pain, or effusion into the joint; or impairment of the tibia or fibula. 4. The Veteran's degenerative arthritis of the lumbar spine is not shown to result in limitation of flexion to 60 degrees or less, combined range of motion to 120 degrees or less, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis or incapacitating episodes. 5. The Veteran's left ankle strain has not resulted in moderate limitation of motion; limitation of motion objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion; or the involvement of two or more major joints. 6. The Veteran's lateral epicondylitis of the right elbow is not manifested by limitation of flexion of less than 100 degrees, limitation of extension greater than 45 degrees, and no pain on motion. 7. The Veteran's lateral epicondylitis of the left elbow is not manifested by limitation of flexion of less than 100 degrees, limitation of extension greater than 45 degrees, and no pain on motion. CONCLUSIONS OF LAW 1. The criteria for an initial rating greater than 10 percent for irritable bowel syndrome have not been met at any time during the appeal period. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 4.114, Diagnostic Code 7319 (2016). 2. The criteria for compensable initial rating prior to August 24, 2016, for right knee status post arthroscopy torn medial meniscus and in excess of 10 percent thereafter, are not met. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2016). 3. The criteria for an initial rating in excess of 10 percent for degenerative arthritis of the lumbar spine have not been met. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. §§ 4.71a, Diagnostic Code 5237 (2016). 4. The criteria for an initial compensable rating for left ankle strain have not been met. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 4.71 Diagnostic Codes 5003, 5024, 5271 (2016). 5. The criteria for a compensable initial evaluation for lateral epicondylitis of the right elbow have not been met. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5024 (2016). 6. The criteria for a compensable initial evaluation for lateral epicondylitis of the left elbow have not been met. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5024 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). General Criteria - Increased Rating Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 for that rating. 38 C.F.R. § 4.7. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). The Board notes that, when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2016); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). 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. See 38 C.F.R. § 4.7. It is important to note that the August 2016 VA examinations of the right knee, left ankle and bilateral elbows comply with the holding in Correia v. McDonald, 28 Vet. App. 158 (2016). In Correia, the United States Court of Appeals for Veterans Claims (Court) interpreted 38 C.F.R. § 4.59 as requiring examinations to include joint testing in both active and passive motion, in weight-bearing and non-weight bearing, and, when possible, of the opposite joint. Id. at 169-70; see also Barr, 21 Vet. App. 312 (holding that when VA provides an examination, it must be adequate). However, with respect to the lumbar spine claim, there is no opposite joint for the thoracolumbar spine; therefore, the Correia requirement is not at issue. Irritable Bowel Syndrome The Veteran's irritable bowel syndrome is currently is evaluated as 10 percent disabling under 38 C.F.R. § 4.114, Diagnostic Code 7319 (irritable colon syndrome). See 38 C.F.R. § 4.114, Diagnostic Code 7319 (2016). A 10 percent rating is assigned under Diagnostic Code 7319 for moderate irritable colon syndrome with frequent episodes of bowel disturbance with abdominal distress. A maximum 30 percent rating is assigned for severe irritable colon syndrome with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. Id. A November 2008 letter was received from a private physician, Dr. G. B. Dr. G. B. stated that he evaluated the Veteran in October 2008 for reported symptoms of intermittent watery diarrhea of three years duration and intermittent fecal incontinence. Physical examination was unremarkable. An upper GI series revealed a normal small bowel transit time of one hour. Dr. G. B. stated that the Veteran's symptoms were due to chronic hypermotility which is a chronic condition. The Veteran was recommended to consume a low fat high fiber diet and to avoid carbonated beverages. He was also prescribed Lomotil. On VA examination in June 2009, the Veteran complained of colicky abdominal pain. He stated that he has incontinence of his bowels once a month. He has eight to 12 bowel movements a day. He did not have any bleeding. His bowel movements were loose. He took Atropine three times a day but it did not seem to help his symptoms. On physical examination, there was slight generalized abdominal distension and guarding without rebound. There were no masses and no hernia. Peristalsis was hyperactive. There were no femoral nodes or femoral bruits. The diagnosis was irritable bowel syndrome, five years duration, normal evaluation procedures, on treatment without beneficial effect. On VA examination in February 2014, the Veteran reported that he had an average of 7 loose (partially formed) bowel movements per day. He initially stated that he had 12 but stated that this was perhaps an overestimation. He denied taking any medication currently for the disorder. He did not have any bleeding. He denied any further workup or change in his diagnosis. He could not identify any pattern or trigger to his symptoms. He was able to sit in the examiner's office for 2 hours without needing to use the bathroom. He did not have episodes of bowel disturbance with abdominal distress or exacerbations or attacks of the intestinal condition. He did not have weight loss attributable to an intestinal condition. He did not have malnutrition, serious complications or other general health effects attributable to the intestinal condition. He did not have a benign or malignant neoplasm or metastases related to his condition. The above evidence shows that throughout the rating period, the symptoms of the Veteran's irritable bowel syndrome most closely approximate the criteria for a 10 percent rating under Code 7319. Although the VA examination reports document the Veteran's reports of having several bowel movements per day, the evidence does not show he experienced constant abdominal distress with such problems. Specifically, the February 2014 VA examination report shows that the Veteran denied episodes of bowel disturbance with abdominal distress or exacerbations. Thus, the Board finds that the evidence does not show severe irritable bowel syndrome with more or less constant abdominal distress. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial rating in excess of 10 percent irritable bowel syndrome, and the claim is denied. Right Knee The Veteran's right knee is currently rated under Diagnostic Code 5260 for limited flexion. It is rated noncompensably prior to August 24, 2016 and as 10 percent disabling thereafter. 38 C.F.R. § 4.71a. Diagnostic Code 5260 concerns limitation of leg flexion. A noncompensable evaluation is assigned where flexion is limited to 60 degrees. A 10 percent rating is warranted where flexion is limited to 45 degrees. A 20 percent evaluation is for application where flexion is limited to 30 degrees. Finally, a 30 percent rating applies where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5261, pertaining to limitation of leg extension, is also of relevance here. Under that Code section, a noncompensable evaluation is assigned where extension is limited to 5 degrees. A 10 percent rating is warranted where extension is limited to 10 degrees. A 20 percent evaluation is for application where extension is limited to 15 degrees. A 30 percent rating applies where extension is limited to 20 degrees. A 40 percent rating is warranted where extension is limited to 30 degrees. Finally, a 50 percent evaluation is warranted where extension is limited to 45 degrees. Id. 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, or a 30 percent evaluation for severe knee impairment with recurrent subluxation or lateral instability. Id. The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Traumatic arthritis is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion for the specific joint or joints involved. 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. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Precedent opinions of the VA's General Counsel have held that dual ratings may be given for a knee disorder, with one rating for instability (Diagnostic Code 5257) and one rating for arthritis with limitation of motion (Diagnostic Codes 5003 and 5010). VAOPGCPREC 9-98 (63 Fed. Reg. 56,704 (1998)) and 23-97 (62 Fed. Reg. 63,604 (1997)). Another such opinion held that separate ratings under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension) may be assigned for disability of the same joint. VAOPGCPREC 9-2004 (69 Fed. Reg. 59988 (2004)). On VA examination in June 2009, the Veteran complained of sharp right knee pain. There was no history of locking, and no further giving out. He stated that he would experience a grinding sensation with clicking and popping. He did not use any braces or orthopedic assistive devices. On physical examination, his gait was antalgic. There was palpable crepitus on range of motion testing. He did not exhibit any increased pain, fatigue, weakness, lack of endurance, or incoordination on repetitive motion testing. Range of motion was from 0 to 140 degrees without pain. There was no swelling. The knee was stable to varus and valgus stress. McMurray's test and Lachman's test were negative. Anterior and posterior drawer were both negative. Strength testing of the knee was 5/5. On VA examination in February 2014, the Veteran reported pain on the medial and lateral aspect of the right knee that was aggravated by activities, prolonged walking and using stairs. He denied numbness, tingling and locking. He had occasional popping. He did not report any flare-ups that impacted the function of the knee. Right knee flexion was to 140 degrees or greater with evidence of painful motion at 140 degrees or greater. There was no limitation of motion of the right knee extension which was to 0 degrees. There was no evidence of painful motion on right knee extension. The Veteran was able to perform repetitive use testing with three repetitions. Post test, right knee flexion was to 140 degrees or greater. There was no limitation of motion of the right knee extension which was to 0 degrees. There was no additional limitation in range of motion of the knee and lower leg following repetitive-use testing. Joint stability tests were normal. There was no evidence or history of recurrent patellar subluxation/dislocation. The Veteran did not have "shin splints," stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran did not have any residual signs and/or symptoms due to meniscectomy. There was no total knee replacement. Diagnostic tests did not reveal any degenerative or traumatic arthritis of the right knee. On VA examination of the right knee in August 2016, the Veteran reported having aching right kneecap pain. He stated that he had flare-ups of increased right knee pain with increased squatting and kneeling. Forward flexion of the knee was from 0 to 140 degrees. Extension was from 140 degrees to 0 degrees. There was pain on flexion. There was evidence of pain with weight bearing. There was objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions. There was no additional loss of function or loss of range of motion after three repetitions. Pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time. Flexion was from 0 to 140 degrees and extension was from 140 to 0 degrees. There was disturbance of locomotion and interference with sitting due to pain. There was no ankylosis of the right knee. Joint stability tests were normal. The Veteran did not have recurrent patellar dislocation, "shin splints," stress fractures, chronic exertional compartment syndrome or any other tibial or fibular impairment. Right knee x-rays showed medial compartment joint space narrowing and confirmed a diagnosis of osteoarthritis. Upon review of the evidence, the Board finds, first, that the evidence does not support an initial compensable rating prior to August 24, 2016, for the Veteran's right knee status post arthroscopy torn medial meniscus. The VA examination reports during this period show that the Veteran had full extension and flexion of the knee. Moreover, the Veteran did not demonstrate right knee disability which could reasonably be described as contemplating ankylosis, instability, dislocated or symptomatic removal of cartilage, limitation of either flexion or extension, impairment of the tibia and fibula, or genu recurvatum. Therefore, the Board concludes that a compensable rating is not warranted for right knee status post arthroscopy torn medial meniscus for the initial rating period prior to August 24, 2016, pursuant to Diagnostic Codes 5256-5263 Further, no x-ray evidence confirmed arthritis at any time prior to August 24, 2016, rendering a higher rating under Diagnostic Codes 5003 and 5010 inapplicable for that period. The Board further finds that from August 24, 2016, the Veteran's right knee disability does not warrant a rating in excess of 10 percent. Specifically, the Board finds that the evidence does not suggest, even when functional loss due to pain is considered, that the Veteran's right knee disability is so disabling as to approximate the level of impairment required for the assignment of a rating in excess of 10 percent for flexion or extension of the knee. The Veteran has shown flexion to no worse than 140 degrees on repetitive motion testing, as shown at the August 2016 VA examination. At the August 2016 examination, the Veteran had full extension with pain on motion. As for instability, the August 2016 VA examination report found no instability. Thus, no separate or higher ratings are warranted for the Veteran's right knee disability from August 24, 2016. See 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5260, 5261. Thus, while the Veteran experiences pain, the Board finds that the 10 percent evaluation assigned for the knee adequately portrays any functional impairment, pain, and weakness that the Veteran experiences as a consequence of use of his right knee. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). Therefore, a higher evaluation from August 24, 2016 for the right knee disability based on functional loss is not warranted. See DeLuca, supra. Moreover, the Board has also considered other diagnostic codes from August 24, 2016, to determine if a higher evaluation is warranted. However, evaluation of the relevant evidence of record reflects that the record contains no evidence of ankylosis, malunion or nonunion of the tibia and fibula, or genu recurvatum. Thus, Diagnostic Codes 5256, 5262, and 5263 do not apply. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a compensable initial rating prior to August 24, 2016, and in excess of 10 percent thereafter for right knee status post arthroscopy torn medial meniscus, and the claim is denied. Lumbar Spine The Veteran's service-connected degenerative arthritis of the lumbar spine is rated as 10 percent disabling. 38 C.F.R. § 4.71a, Code 5237. Under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), a 10 percent evaluation is warranted where there is forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; combined range of motion of the thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees; 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. A 20 percent evaluation is warranted where there is forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; combined range of motion of the thoracolumbar spine not greater than 120 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. 38 C.F.R. § 4.71a, General Rating Formula. A 40 percent evaluation is warranted where there is forward flexion of the thoracolumbar spine limited to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent evaluation is warranted where there is unfavorable ankylosis of the entire thoracolumbar spine. Id. A 100 percent evaluation is warranted where there is unfavorable ankylosis of the entire spine. Id. Normal range of motion of the thoracolumbar spine is forward flexion to 90 degrees, extension from zero to 30 degrees, left and right lateral flexion from zero to 30 degrees, and left and right lateral rotation from zero to 30 degrees. The combined range of motion refers to the sum of the forward flexion, extension, left and right lateral flexion, and left and right rotation. See 38 C.F.R. § 4.71a, General rating Formula for diseases and Injuries of the Spine, Note (2). See also 4.71, Plate V (2016). Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are separately evaluated under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a, at Note (1). If intervertebral disc syndrome (IVDS) is present, a lumbosacral spine disability may also be rated under Diagnostic Code 5243. 38 C.F.R. § 4.71a, Diagnostic Code5243 (2016). Diagnostic Code 5243 provides that IVDS is to be rated either under the General Rating Formula or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (Formula for Rating IVDS), whichever method results in the higher rating when all disabilities are combined. Id.; see also 38 C.F.R. § 4.25 (2016). The Formula for Rating IVDS provides a 10 percent disability rating with incapacitating episodes having a total duration of at least one week, but less than two weeks, during the past 12 months; a 20 percent disability rating with incapacitating episodes having a total duration of at least two weeks, but less than four weeks, during the past 12 months; a 40 percent disability rating with incapacitating episodes having a total duration of at least four weeks, but less than six weeks, during the past 12 months; and a 60 percent disability rating with incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS. Note (1) to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 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. On VA examination in June 2009, the Veteran reported daily low back pain that was achy in nature. Physical examination of the lumbar spine revealed negative straight leg raising while sitting and while supine. Distal sensation was intact. Forward flexion was from 0 to 70 degrees with complaints of pain at 70 degrees. Extension was from 0 to 20 degrees with complaints of pain at 20 degrees. Right and left flexion was from 0 to 20 degrees with complaints of pain on the right side greater than the left at 20 degrees. Right and left rotation was from 0 to 30 degrees with complaints of pain at 30 degrees. The Veteran did not exhibit any increased fatigue, weakness, lack of endurance, or incoordination on repetitive motion testing. He did experience increased pain. There were no palpable muscle spasms. There were no bowel or bladder changes. There was no urinary or fecal incontinence. He had flare-ups approximately twice per week that caused him to seek self-imposed bedrest for approximately one hour. On VA examination of the lumbar spine in in February 2014, the Veteran reported that since having back surgery in 2007, his symptoms had improved significantly. He denied radicular pain, numbness, and tingling from his back. Flare-ups did not impact the function of the lumbar spine. Forward flexion of the spine was to 80 degrees with evidence of pain at 80 degrees. Extension was to 20 degrees with evidence of pain at 20 degrees. Right lateral flexion was to 30 degrees or greater with objective evidence of pain at 30 degrees or greater. Left lateral flexion was to 30 degrees or greater with evidence of pain at 30 degrees or greater. Right lateral rotation was to 30 degrees or greater with evidence of painful motion at 30 degrees or greater. Left lateral rotation was to 30 degrees or greater with evidence of painful motion at 30 degrees or greater. The Veteran was able to perform repetitive use testing with 3 repetitions. Post-test forward flexion was to 80 degrees. Extension was to 20 degrees. Right lateral flexion was to 30 degrees or greater. Left lateral flexion was to 30 degrees or greater. Right lateral rotation was to 30 degrees or greater. Left lateral rotation was to 30 degrees or greater. There was no additional limitation in range of motion of the thoracolumbar spine following repetitive-use testing. There was less movement than normal, pain on movement and interference with sitting, standing or weight bearing. There was no localized tenderness or pain to palpation for joints/soft tissue of the thoracolumbar spine. There was no muscle spasm of the thoracolumbar spine resulting in abnormal gait or abnormal spinal contour. There was no guarding of the thoracolumbar spine resulting in abnormal gait or abnormal spinal contour. There was no muscle atrophy. There was no radicular pain or any other signs or symptoms due to radiculopathy. There was no ankylosis of the spine. There were no neurologic abnormalities related to the thoracolumbar spine such as bowel or bladder problems. The Veteran did not have intervertebral disc syndrome of the thoracolumbar spine. He did not use any assistive devices. He did not have a vertebral fracture with loss of 50 percent or more of height. Diagnostic testing revealed degenerative arthritis of the spine. As noted above, the evidence does not show flexion of the thoracolumbar spine to 60 degrees or less. Similarly, the evidence does not show combined range of motion of 120 degrees or less. Additionally, muscle spasm severe enough to result in abnormal gait or abnormal spinal contour has not been shown. Accordingly, a rating in excess of 10 percent is not warranted under the General Rating Formula. Consideration has also been given to whether separate evaluations are warranted for neurologic manifestations of the Veteran's service-connected disability. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). The record shows no bowel or bladder dysfunction, or other objective neurological impairment as a result of the Veteran's lumbar spine disability. Accordingly, the evidence does not support a separate rating for neurologic manifestations. In addition, consideration has been given as to whether a higher disability evaluation could be assigned under the Formula for Rating IVDS. 38 C.F.R. § 4.71a, Diagnostic Code 5243. On VA examination in June 2009, the Veteran reported self-imposed bedrest rather than physician prescribed bedrest. Moreover, the February 2014 VA examination report reflects that the Veteran does not have intervertebral disc syndrome. Therefore, a higher rating under the Rating Formula for IVDS is not appropriate. Consideration has been given to functional impairment due to the Veteran's service-connected disability. The Board acknowledges the subjective complaints of pain made throughout the course of the Veteran's claim, as well as the objective evidence of pain on movement and reduced movement during range of motion testing at the VA examinations in June 2009 and February 2014. The Board acknowledges these findings, however, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). The Board acknowledges the Veteran's subjective complaints and finds his assertions both competent and credible. However, the objective evidence as demonstrated in the VA examination reports reflects that the Veteran's disability picture most closely approximates the criteria for an initial 10 percent rating and that a rating in excess of 10 percent based on functional loss is not warranted. 38 C.F.R. §§ 4.40, 4.45 (2016); Deluca v. Brown, 8 Vet. App. 202, 204-06 (1995). As such, the Board finds that the preponderance of the evidence weighs against an initial rating excess of 10 percent for the Veteran's service-connected degenerative arthritis of the lumbar spine. Left Ankle Strain The Veteran's left ankle, status post partial tear anterior tibial fibular ligament, is rated as noncompensably disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5024, which evaluates impairment from tenosynovitis. Diagnostic Code 5024 in turn calls for the disability to be rated on limitation of motion, as arthritis, degenerative. Degenerative arthritis is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5003. Pursuant to DC 5003, degenerative arthritis established 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. 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 the 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, involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations shall be rated as 20 percent disabling, and involvement of two or more major joints or two or more minor joint groups without occasional incapacitating exacerbations shall be rated as 10 percent disabling. The 20 percent and 10 percent ratings based on X-ray findings without limitation of motion will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2016). The ankle is considered a major joint. 38 C.F.R. § 4.45(f) (2016). Limitation of motion of the ankle is rated 38 C.F.R. § 4.71a, Diagnostic Code 5271. Pursuant to Diagnostic Code 5271, a 10 percent rating is warranted when there is moderate limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2016). A 20 percent evaluation is warranted when there is marked limitation of motion. Id. The normal ranges of motion of the ankle are 20 degrees of dorsiflexion and 45 degrees of plantar flexion. 38 C.F.R. § 4.71a, Plate II (2016). When the criteria for a compensable rating under a diagnostic code are not met and the rating schedule does not provide for a 0 percent rating, a noncompensable (0 percent) rating will be assigned when the required symptomatology is not shown. 38 C.F.R. § 4.31. On VA examination in June 2009, the Veteran complained of left ankle pain. He did not use any orthopedic devices. He reported that he had difficulty going up and down stairs and ladders. He did not have any surgery. Most of the pain was located in the anterior and lateral part of the ankle. On physical examination, he was able to hold the left ankle and foot in 90 degrees at neutral position without difficulty. Dorsiflexion was from 0 to 5 degrees without pain. Plantar flexion was from 0 to 45 degrees without pain. The Veteran did not exhibit any increased fatigue, weakness, lack of endurance, or incoordination on repetitive motion testing. He did not experience any pain with repetitive motion testing. No swelling was present. Distal sensation was intact. The left ankle was stable to anterior drawer. It was stable to inversion and eversion. There was some tenderness to palpation along the anterior and lateral aspects of both ankles. There was no pain in the forefoot with torsion. Distal pulses were good. Strength was 5/5. The diagnosis was recurrent ankle sprains. On VA examination in February 2014, the Veteran stated that he has pain in the left ankle generally when he rolls it. He did not report any flare-ups of the ankle. Left ankle plantar flexion was 45 degrees or greater with no objective evidence of painful motion. Left ankle plantar dorsiflexion was to 20 degrees or greater with no evidence of painful motion. Post-test, plantar flexion was to 45 degrees or greater. Dorsiflexion was to 20 degrees or greater. There was no additional limitation in range of motion of the ankle following repetitive use testing. There was swelling of the ankle. There was localized tenderness or pain on palpation of the joints/soft tissue of the ankle. Joint stability tests were normal. There was no ankylosis of the ankle. There were no "shin splints," stress fracture, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus or talus, or the talectomy. On VA examination in August 2016, the Veteran reported pain on his outer left ankle that is worsened by impact activities. Range of motion testing of the left ankle was normal. Dorsiflexion was from 0 to 20 degrees. Plantar flexion was from 0 to 45 degrees. No pain was noted on examination. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was evidence of pain with weight bearing. There was no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions. There was no additional loss of function or range of motion after three repetitions. Pain, weakness, fatigability, and incoordination significantly limited functional ability with repeated use over a period of time. Pain caused this functional loss. Dorsiflexion was from 0 to 20 degrees and plantar flexion was from 0 to 45 degrees. There was no ankylosis of the left ankle. There was no joint instability. Diagnostic testing did not reveal degenerative or traumatic arthritis of the left ankle. Beginning with Diagnostic Code 5271, a 10 percent rating contemplates moderate limitation of motion. The Veteran's VA examinations have not suggested that his left ankle disability results in moderate limitation of motion. As noted above, normal range of motion of the ankle is dorsiflexion to 20 degrees and plantar flexion to 45 degrees. At worst, the Veteran was shown to have dorsiflexion limited to 5 degrees during his June 2009 VA examination, but his more recent examinations showed normal motion with no pain. His plantar flexion was also normal to 45 degrees at all three VA examinations in 2009, 2014 and 2016. Even following repetition, there was still no objective evidence of pain and no additional limitations in motion. Considering that the Veteran's dorsiflexion has been shown to be worse than half of normal motion in one isolated instance in 2009, while normal with no pain in 2014 and 2016 and as his plantar flexion has been normal, the Board is unable to conclude that the Veteran's left ankle disability results in "moderate" limitation of motion. Furthermore, no medical professional has provided any opinion indicating that the Veteran had moderate limitation of motion. Therefore, the Board concludes that an initial compensable rating under Diagnostic Code 5271 is not warranted. As for Diagnostic Code 5003, when limitation of motion 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 the 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, involvement of two or more major joints or two or more minor joint groups without occasional incapacitating exacerbations shall be rated as 10 percent disabling. In this case, the VA examinations of record did not show swelling, muscle spasm, or satisfactory evidence of painful motion. The evidence also does not show involvement of two or more major joints. Therefore, an initial compensable rating under this diagnostic code is not warranted at any time since the award of service connection. In reaching the conclusion that an initial compensable rating is not warranted, the Board has considered whether the Veteran's painful motion contributes to the actual limitation of motion such that an increased rating is warranted. Here, even when taking into account the pain on use experienced by the Veteran, the Board finds that an increased rating for limitation of motion is not warranted. See 38 C.F.R. § 4.40. The examination takes into account the Veteran's functional impairment resulting from his service-connected left ankle disability. The examination and treatment records do not show that the Veteran had muscle atrophy or other evidence of disuse due to his service-connected left ankle disability such that an initial compensable rating is warranted. Accordingly, the criteria for an initial compensable rating for limitation of motion for the Veteran's service-connected left ankle strain have not been met. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5024, 5271. For these reasons, the Board finds that the criteria for an initial compensable rating have not been met. Right Elbow and Left Elbow The Veteran's right and left elbow disabilities are each rated at zero percent or noncompensably disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5024, which evaluates impairment from tenosynovitis. Diagnostic Code 5024 in turn calls for the disability to be rated on limitation of motion, as arthritis, degenerative. Degenerative arthritis is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under Diagnostic Code 5206, limitation of flexion of either the major or minor forearm to 100 degrees warrants a 10 percent rating; limitation of flexion of either forearm to 90 degrees warrants a 20 percent rating; limitation of flexion of the major forearm to 70 degrees warrants a 30 percent rating; limitation of flexion of the major forearm to 55 degrees warrants a 40 percent rating; and limitation of flexion of the major forearm to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5206. Under Diagnostic Code 5207, limitation of extension of either the major or minor forearm to 45 or 60 degrees warrants a 10 percent rating; limitation of extension of either forearm to 75 degrees warrants a 20 percent rating; limitation of extension of the major forearm to 90 degrees warrants a 30 percent rating; limitation of extension of the major forearm to 100 degrees warrants a 40 percent rating; and limitation of extension of the major forearm to 110 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5207. Also, under Diagnostic Code 5213, a 10 percent rating requires impairment of supination to 30 degrees or less for either the major or minor forearm and a 20 percent rating for limitation of pronation, when pronation is lost beyond the middle or last quarter of the arc in either major or minor forearm. The normal range of motion of the elbow is flexion to 145 degrees and extension to 0 degrees. Normal pronation is from zero to 80 degrees and normal supination is from zero to 85 degrees. 38 C.F.R. § 4.71, Plate I. 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. 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, no 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 20 percent evaluation will be assigned with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbation. A 10 percent evaluation will be assigned with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. 38 U.S.C.A. § 4.71 a, Diagnostic Code 5003 (2016). On VA examination in June 2009, the Veteran complained of bilateral elbow pain on a daily basis. The pain was located in the lateral epicondyle area. He was not taking any prescription treatment for the pain. He reported painless clicking and popping but no swelling, locking or giving out. Physical examination was the same for both elbows. They exhibited tenderness to palpation along the lateral epicondyles. There was positive long finger sign. Distal sensation was intact. Range of motion was from 0 to 145 degrees without pain. The Veteran did not exhibit any increased pain, fatigue, weakness, lack of endurance or incoordination on repetitive motion testing. No swelling was present. There was no crepitus. The diagnosis was recurrent bilateral elbow lateral epicondylitis. On VA examination of the elbows in February 2014, the Veteran reported pain in his bilateral elbows that would spread to his mid forearm, right greater than left. His dominant hand was his right hand. He did not report any flare-ups that impact the function of his elbow and/or forearm. Right elbow flexion was to 145 degrees or greater with no objective evidence of painful motion. There was no limitation of motion with right elbow extension. There was no objective evidence of painful motion on right elbow extension. Left elbow flexion was to 145 degrees or greater with no objective evidence of painful motion. There was no limitation of motion with left elbow extension. There was no objective evidence of painful motion on left elbow extension. Bilateral elbow pronation was from 0 to 60 degrees without pain times three. Bilateral elbow supination was from 0 to 70 degrees without pain times three. The Veteran was able to perform repetitive use testing with three repetitions. Post-test, right elbow flexion was to 145 degrees with no limitation of extension. Post-test, left elbow flexion was to 145 degrees with no limitation of extension. There was no additional limitation in range of motion of the elbows and forearms following repetitive use testing. There was no functional loss and/or functional impairment of the elbows and forearms. There was no localized tenderness or pain on palpation of joints/soft tissue of either elbow or forearm. Muscle strength testing was normal in both elbows. There was no ankylosis of either elbow. There was no flail joint, joint fracture and/or impairment of supination or pronation. On VA examination in August 2016, the Veteran complained of persistent bilateral elbow pain which was worsened by repetitive use. Bilateral x-rays of the elbows taken in August 2016 were normal. The Veteran reported that there were flare ups of bilateral elbow pain in cold weather. Range of motion of the right elbow was normal. Flexion was from 0 to 145 degrees. Extension was from 145 to 0 degrees. Forearm supination was from 0 to 85 degrees. Forearm pronation was from 0 to 80 degrees. Pain was not noted on examination. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was evidence of pain with weight bearing. There was no objective evidence of crepitus. Range of motion of the left elbow was normal. Flexion was from 0 to 145 degrees. Extension was from 145 to 0 degrees. Forearm supination was from 0 to 85 degrees. Forearm pronation was from 0 to 80 degrees. Pain was not noted on examination. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was evidence of pain with weight bearing. There was no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions, with both elbows. There was no additional loss of function or range of motion after three repetitions with both elbows. With both elbows, there was pain with grasping and pulling. There was no ankylosis of either elbow. The Veteran did not have flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation of either elbow. Based on the evidence of record, the Board finds that compensable initial ratings are not warranted for the right elbow and left elbow disabilities. The VA examinations of record do not show that the Veteran's right elbow and left elbow had limitation of flexion of the forearm to 100 degrees or less or limitation of extension of the forearm to 45 degrees or more, or supination of 30 degrees or less. Therefore, compensable ratings are not warranted under Diagnostic Codes 5206, 5207, or 5213. The evidence also fails to show that the Veteran's right elbow and left elbow had objective evidence of pain on motion. The VA examination reports show that following repetitive use, the range of motion of both the right and left elbows was not additionally limited by pain, fatigue, weakness or lack of endurance. As discussed above, under Diagnostic Code 5024, the Veteran's right and left elbow disabilities are rated on limitation of motion of affected parts, as arthritis, degenerative. However, in this case, diagnostic tests have not confirmed the presence of arthritis. The Board has considered the factors noted in DeLuca and has considered the clinical findings; however, even with such consideration, the evidence does not reflect that the Veteran's symptoms were synonymous with pain on motion warranting compensable evaluations. The Board has considered whether the Veteran is entitled to higher ratings under other rating criteria. There is no evidence of joint fracture, with marked cubitus varus or cubitus valgus deformity or with ununited fracture of head of radius. Therefore, a higher rating for either elbow is not warranted under Diagnostic Code 5209. In conclusion, the Board finds that compensable initial ratings are not warranted for the right and left elbow disabilities. Consequently, the benefit-of-the-doubt rule is not applicable, and the claim must be denied. ORDER Entitlement to an initial rating in excess of 10 percent for irritable bowel syndrome is denied. Entitlement to a compensable initial rating prior to August 24, 2016, and in excess of 10 percent thereafter for right knee status post arthroscopy torn medial meniscus is denied. Entitlement to an initial rating in excess of 10 percent for degenerative arthritis of the lumbar spine is denied. Entitlement to a compensable initial rating for left ankle strain is denied. Entitlement to a compensable initial rating for lateral epicondylitis of the right elbow is denied. Entitlement to a compensable initial rating for lateral epicondylitis of the left elbow is denied. REMAND The Veteran's claim of entitlement to an initial rating in excess of 20 percent for a cervical spine disability warrants further development. In August 2016, the Board remanded the claim in order to obtain additional VA treatment records and further VA examination of the cervical spine. Additional VA treatment records were obtained and an examination of the cervical spine was conducted in August 2016. However, the record does not reflect RO consideration of this additional evidence. A supplemental statement of the case (SSOC) must be furnished to the Veteran and his representative when additional pertinent evidence is received after a statement of the case (SOC) is issued. 38 C.F.R. § 19.31 (2016). Therefore, a remand is necessary for initial RO review of this evidence. Accordingly, the case is REMANDED for the following action: The case should be reviewed by the AOJ on the basis of all additional evidence, particularly since the issuance of the March 2014 SSOC, to include the report of an August 2016 VA cervical spine examination. If any benefit sought is not granted, the Veteran and his representative should be furnished a SSOC and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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). ______________________________________________ Jennifer Hwa Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs