Citation Nr: 1745549 Decision Date: 10/12/17 Archive Date: 10/19/17 DOCKET NO. 09-17 623 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to a higher initial rating for limitation of motion of the lumbar spine, rated as 10 percent disabling prior to February 16, 2017 and 20 percent disabling thereafter. 2. Entitlement to a higher initial raring for degenerative disc disease of the cervical spine, rated as 10 percent disabling prior to December 13, 2013 and 20 percent disabling thereafter. 3. Entitlement to an initial rating higher than 10 percent for chronic right wrist tendonitis. 4. Entitlement to a higher initial rating for a left knee disability, rated as 10 percent disabling for osteoarthritis and 10 percent disabling for instability. 5. Entitlement to an initial rating higher than 10 percent for right elbow degenerative joint disease. 6. Entitlement to an initial rating higher than 10 percent for right hand tendonitis and degenerative joint disease of the major thumb, index, and long fingers. 7. Entitlement to an initial compensable rating for right hand tendonitis and degenerative joint disease of the major ring and little fingers. 8. Entitlement to an initial rating higher than 10 percent for piriformis syndrome of the left leg claimed as chronic left leg pain, left hip pain, and left foot pain. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Riley, Counsel INTRODUCTION The Veteran served on active duty from January 1981 to August 2006. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. Jurisdiction over the claims file is currently held by the RO in Houston, Texas. The Board observes that the Veteran moved to Alexandria, Virginia in March 2015 and requested the RO in Roanoke, Virginia take jurisdiction over the claims file. The record does not indicate that a transfer of jurisdiction has taken place. The Veteran testified at an October 2015 hearing before the undersigned Veterans Law Judge (VLJ) at the Board's Central Office in Washington, D.C. A transcript of the hearing is of record. In February 2016, the Board remanded the case for further action by the originating agency. It has now returned to the Board for further appellate action. When the case was previously before the Board in February 2016, the Veteran was represented by The American Legion. In May 2017, the Veteran informed the Board he had submitted a request for a change in representation (to the Disabled American Veterans (DAV)) using VA's online eBenefits system. This request was received within the 90 day period provided by 38 C.F.R. § 20.1304(a) (2016). In response, the Board contacted the Veteran in a July 2017 letter and notified him that his representation with The American Legion was revoked. The Board also requested the Veteran submit an enclosed VA Form 21-22 (Appointment of Veterans Service Organization as Claimant's Representative) which is required to appoint a new representative. No response to this request was received. The Veteran is therefore currently unrepresented. In the February 2016 remand, the Board referred several new claims to the Agency of Original Action (AOJ) for appropriate action. These claims, raised in the Veteran's October 2015 hearing testimony, are entitlement to an increased rating for right knee osteoarthritis, entitlement to service connection for residuals of anthrax shots, to include facial numbness, and claims to reopen service connection for sleep apnea and neurological impairment of the bilateral upper extremities, to include carpal tunnel syndrome. The claims file does not indicate that any action has been taken on these matters and the Board does not have jurisdiction over them. They are therefore again referred to the AOJ for appropriate action, to include forwarding the Veteran a VA standard form in paper or electronic form, if necessary. 38 C.F.R. § 3.155(b)(1)(ii) (2016); see also 79 Fed. Reg. 57660 (Sep. 25, 2014) (all claims governed by VA's adjudication regulations must be filed on standard forms prescribed by VA, regardless of the type of claim or posture in which the claim arises.) The issues of entitlement to increased initial ratings for piriformis syndrome of the left leg and left knee osteoarthritis and instability are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. Prior to February 16, 2017, the Veteran's degenerative disc disease of the lumbar spine manifested painful limitation of motion with flexion limited to 76 degrees, a combined range of motion limited to 182 degrees, and a normal lumbar spinal contour without muscle spasm, guarding, or ankylosis. 2. From February 16, 2017, the Veteran's limitation of motion of the lumbar spine (previously characterized as degenerative disc disease ) manifests forward flexion to 60 degrees and a combined range of motion to 180 degrees without ankylosis. 3. The Veteran's lumbar spine disability does not manifest episodes of incapacitation with periods of acute signs and symptoms requiring bed rest prescribed by a physician. 4. The Veteran's radiculopathy of the right lower extremity most nearly approximates moderate incomplete paralysis from September 7, 2007 to September 24, 2008 and mild incomplete paralysis thereafter. 5. The Veteran's radiculopathy of the left lower extremity most nearly approximates mild incomplete paralysis from September 1, 2006 to January 16, 2013 and moderately severe incomplete paralysis thereafter. 6. Prior to December 13, 2013, the Veteran's degenerative disc disease of the cervical spine manifested painful motion with full flexion to 45 degrees and a combined range of motion of 340 degrees without muscle spasm or guarding resulting in an abnormal gait, abnormal spinal contour, ankylosis, or neurological impairment. 7. From December 13, 2013, the Veteran's degenerative disc disease of the cervical spine manifests painful limited motion with flexion to 30 degrees and a combined range of motion of 200 degrees without muscle spasm or guarding resulting in an abnormal gait, abnormal spinal contour, ankylosis, or neurological impairment. 8. The Veteran's cervical spine disability does not manifest manifests episodes of incapacitation with periods of acute signs and symptoms requiring bed rest prescribed by a physician. 9. The Veteran's right wrist tendonitis manifests pain and limitation of motion without ankylosis. 10. The Veteran's right elbow disability manifests pain with noncompensable limitation of motion without ankylosis, impairment of flail joint, or impairment of the radius, ulna, supination, or pronation. 11. The Veteran's right hand tendonitis and degenerative joint disease of the major thumb, index, and long fingers manifests pain and limitation of motion without ankylosis. 12. The Veteran's right hand tendonitis and degenerative joint disease of the major ring and little fingers manifests pain and limitation of motion without ankylosis. 13. The manifestations of the Veteran's service-connected disabilities are not so exceptional or unusual that the normal provisions of the rating schedule do not adequately compensate the Veteran for these service-connected disabilities, nor do they present an exceptional or unusual disability picture such as marked interference with employment or frequent periods of hospitalization. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for degenerative disc disease of the lumbar spine prior to February 16, 2017 are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.45, 4.71a, Diagnostic Codes 5235-5243 (2016). 2. The criteria for a rating in excess of 20 percent for limitation of motion of the lumbar spine (previously degenerative disc disease) from February 16, 2017 are not met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.45, 4.71a, Diagnostic Codes 5235-5243. 3. The criteria for a separate initial rating of 20 percent, but not higher, for radiculopathy of the right lower extremity from September 7, 2007 to September 24, 2008 are met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 4. The criteria for a separate rating of 10 percent, but not higher, for radiculopathy of the right lower extremity from September 25, 2008 are met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 5. The criteria for a separate initial rating of 10 percent, but not higher, for radiculopathy of the left lower extremity from September 1, 2006 to January 16, 2013 are met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 6. The criteria for a separate rating of 40 percent, but not higher, for radiculopathy of the left lower extremity from January 16, 2013 are met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 7. The criteria for an initial rating in excess of 10 percent for degenerative disc disease of the cervical spine prior to December 13, 2013 are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.45, 4.71a, Diagnostic Codes 5235-5243 (2016). 8. The criteria for a rating in excess of 20 percent for degenerative disc disease of the cervical spine from December 13, 2013 are not met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.45, 4.71a, Diagnostic Codes 5235-5243. 9. The criteria for an initial rating in excess of 10 percent for chronic right wrist tendonitis are not met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Codes 5003, 5024, 5214, 5215. 10. The criteria for an initial rating in excess of 10 percent for right elbow degenerative joint disease are not met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5205-5213. 11. The criteria for an initial rating in excess of 10 percent for right hand tendonitis and degenerative joint disease of the major thumb, index, and long fingers are not met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Codes 5003, 5228-5230. 12. The criteria for an initial compensable rating for right hand tendonitis and degenerative joint disease of the major ring and little fingers are not met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Codes 5003, 5024, 5228-5230. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist 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; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). VA has also complied with the Board's February 2016 remand instructions. In response to the remand, updated treatment records from various VA facilities were obtained and added to the claims file. The Veteran was also provided VA examinations in April 2016 and February 2017 to determine the current severity of the disabilities on appeal. The examination reports include a recitation of the Veteran's history, including the Veteran's own statements regarding his symptoms and loss of function. The VA examiner performed range of motion measurements of the relevant joints, noted any objective evidence of pain, and conducted the same tests again after repetitive motion. With respect to the Court of Appeals for Veterans Claims' (Court's) recent decision in Correia v. McDonald, 28 Vet. App. 158 (2016), the Board notes that remanding the claims for additional examinations would serve no useful purpose in this case. The Court held that 38 C.F.R. § 4.59 requires VA examinations to include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if appropriate, with range of motion measurements of an opposite undamaged joint. In this case, the Veteran did not have any pain with weight-bearing when testing the disabilities addressed below, the April 2016 VA examinations were essentially normal for many of the disabilities, and there is no evidence either in the medical record or from the Veteran's statements that testing in passive motion would result in evidence to support a higher rating. Thus, remanding for additional examinations under Correia would serve no useful purpose and only cause further delay in the final disposition of these claims. The claims on appeal were readjudicated in a March 2017 supplemental statement of the case (SSOC) and rating decision and VA has therefore complied with the Board's February 2016 remand instructions. Schedular Increased Rating Claims Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability ratings. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). 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). However, where, as here, the question for consideration is the propriety of the initial disability rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Lumbar Spine Service connection for degenerative disc disease of the lumbar spine was granted in the September 2007 rating decision on appeal. An initial noncompensable evaluation was awarded effective September 1, 2006. In an April 2009 rating decision, an increased 10 percent evaluation was assigned also effective September 1, 2006. Most recently, in March 2017, the Veteran's service-connected disability was recharacterized as limitation of motion of the lumbar spine and an increased 20 percent rating was assigned from February 16, 2017. The Veteran's lumbar spine disability is therefore currently rated as 10 percent disabling prior to February 16, 2017 and 20 percent disabling thereafter. The Veteran contends that an increased rating is warranted as his back disability is productive of more severe orthopedic and neurological impairment. The Veteran's back disability is rated under Diagnostic Code 5237 as lumbosacral strain and the general rating formula for diseases and injuries of the spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5237-5242. The Veteran's service-connected disability includes degenerative disc disease and the criteria pertaining to intervertebral disc syndrome are also for application. Intervertebral disc syndrome is evaluated under the general formula for diseases and injuries of the spine or under the formula for rating intervertebral disc syndrome based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Under the general rating formula for rating diseases and injuries of the spine, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. A 10 percent evaluation is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees, but not greater than 235 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. A 20 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted if forward flexion of the thoracolumbar spine is to 30 degrees or less or if there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. In applying regulations that rate disabilities based on range of motion, VA should obtain examinations in which the examiner determines whether the disability is 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, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. 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. During the period prior to February 16, 2017, the Veteran's back disability is rated as 10 percent disabling. Limitation of the lumbar spine was most limited during this period at an April 2016 VA Medical Center (VAMC) physical therapy consultation. The physical therapist recorded the Veteran's range of motion in terms of the percentage limited from normal. For example, forward flexion was limited by 15 percent at the April 2016 consultation. Normal forward flexion of the thoracolumbar spine is to 90 degrees, and flexion limited by 15 percent therefore measures to 76 degrees. See 38 C.F.R. § 4.71a, Plate V (Range of Motion of the Cervical and Thoracolumbar Spine). The Veteran's combined range of motion was similarly limited to 182 degrees. These findings are contemplated by the currently assigned initial 10 percent rating under the general rating formula. The Veteran's VA examinations and other treatment records are also consistent with an initial 10 percent evaluation during this period. The Veteran manifested full lumbar spine motion upon VA examination in November 2006 and in a VAMC treatment record dating from January 2008, when the Veteran established VA as his primary care provider. Some loss of motion was observed during a January 2008 VAMC physical therapy session, but forward flexion was again limited to 76 degrees with a combined range of motion to 204 degrees. These findings are contemplated by the currently assigned 10 percent rating. VA examinations conducted in December 2013 and April 2016 also document improved range of motion that is not consistent with an increased rating, and there is no objective evidence of lumbar muscle spasm, guarding, or an abnormal lumbar contour to warrant an increased disability evaluation. Additionally, the Veteran manifested pain at the endpoint of range of motion testing and the November 2006, December 2013, and April 2016 VA examiners all concluded there was no additional loss of motion or function with repetitive testing due to weakened movement, excess fatigability, incoordination, or pain. The Veteran's low back pain was characterized as mild by VAMC physicians in June 2010 and January 2013, and his numerous treatment records clearly show that his chief complaints during the claims period were related to neurological impairment of the low back and not orthopedic symptoms of the disability. The Veteran's lay statements during the claims period report functional loss mostly in the context of neurological impairment and with restrictions to bending at the waist. Limitation of bending is contemplated in the currently assigned 10 percent rating based on overall painful limited motion. Thus, even with consideration of functional factors, the Board finds that the orthopedic impairment of the low back disability most nearly approximated the criteria associated with the current 10 percent prior to February 16, 2017. For the period beginning February 16, 2017, the Veteran is in receipt of an increased 20 percent rating for his back disability. Review of the evidence establishes that the disability does not most nearly approximate the criteria for an increased evaluation under the general rating formula. Range of motion was most limited at the February 2016 VA examination when the Veteran manifested forward flexion to 60 degrees and a combined range of motion to 180 degrees. Again, there was no additional loss of motion or functional impairment after repetitive movement. The Veteran manifested moderate low back pain with no evidence of spasms, guarding, or abnormal lumbar contour. Regarding functional factors, the Veteran reported experiencing three to four flare-ups of pain per week, each lasting a few hours, and the February 2016 examiner could not estimate the additional loss of motion with flares without speculation. However, as noted above, the Veteran did not manifest any additional loss of motion or function after repetitive testing and his reports of functional impairment are contemplated by the increased 20 percent evaluation. Thus, even with consideration of all relevant functional factors, it is clear that the Veteran's range of motion does not most nearly approximate forward flexion limited to 30 degrees as required for an increased 40 percent evaluation under the general rating formula. Furthermore, there is no evidence of ankylosis and the Veteran has clearly maintained useful motion of his thoracolumbar spine throughout the claims period. A rating in excess of 20 percent is therefore not warranted for the period beginning February 16, 2017 under the general rating criteria. Turning to whether an increased rating is warranted using the criteria pertaining to intervertebral disc syndrome, under 38 C.F.R. § 4.71a, Diagnostic Code 5243, a 10 percent evaluation is assigned with incapacitating episodes having a total duration of at least once a week but less than two weeks during the past 12 months. A 20 percent evaluation is assigned in cases of intervertebral disc syndrome with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past twelve months. A 40 percent evaluation contemplates incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past twelve months. An "incapacitating episode" is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bedrest prescribed by a physician and treatment by a physician. In this case, there is no objective evidence of incapacitating episodes of low back pain requiring bedrest prescribed by a physician. The Veteran reported in an April 2017 statement that his physician often advised "rest" following episodes of increased low back and left leg pain, but his treatment records are completely negative for findings of doctor-prescribed bedrest. In May 2008, when the Veteran was seen for an exacerbation of low back pain, reportedly due to an injury incurred while moving from Georgia to Texas and sitting in a recliner, he was told to continue with his current medications and appointments for a lumbar MRI and nerve conduction study were arranged. Other VA treatment records document treatment of low back pain with medication and physical therapy. A VA medical officer also concluded in April 2016 that the Veteran's low back disability had not been treated with bedrest prescribed by a physician. Therefore, the record does not establish that the Veteran has experienced incapacitating episodes as defined by VA that most nearly approximate an increased rating under Diagnostic Code 5243 at any time during the claims period. Thus, the evidence establishes that the Veteran's orthopedic impairment associated with the service-connected lumbar spine disability most nearly approximates the currently assigned 10 percent evaluation prior to February 16, 2017 and a 20 percent evaluation thereafter. While an increased rating is not warranted for the orthopedic component of this disability, the general rating formula does provide for separate ratings for neurologic manifestations of a back disability. Disability involving a neurological disorder is ordinarily rated in proportion to the impairment of motor, sensory, or mental function. When the involvement is wholly sensory, the rating should be for the mild, or, at most, the moderate degree. 38 C.F.R. §§ 4.120, 4.124a. The Veteran is not currently in receipt of any separate disability ratings for neurological impairment associated with the service-connected low back condition. The Board finds that separate ratings are warranted for neurological deficits of both the right and left lower extremities. The right lower extremity warrants a separate 20 percent evaluation for moderate impairment of the sciatic nerve from September 7, 2007 to September 25, 2008 with a 10 percent rating thereafter. The left lower extremity warrants a separate 10 percent evaluation prior to January 16, 2013 and an increased 40 percent evaluation thereafter. The above ratings are all assigned under Diagnostic Code 8520 for incomplete paralysis of the sciatic nerve. Incomplete paralysis of the sciatic nerve warrants a 60 percent evaluation if it is severe with marked muscular atrophy, a 40 percent evaluation if it is moderately severe, a 20 percent evaluation if it is moderate or a 10 percent evaluation if it is mild. Complete paralysis of the sciatic nerve where the foot dangles and drops, no active movement is possible of the muscles below the knee, and flexion of the knee weakened or (very rarely) lost warrants a maximum 80 percent evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Regarding the right lower extremity, the Board finds that the Veteran manifested neurological impairment that most nearly approximated moderate incomplete paralysis of the right sciatic nerve from September 7, 2007 to September 25, 2008. The record contains no lay or medical evidence of radiating pain to the right leg until September 7, 2007, when the Veteran reported experiencing right lower extremity pain to his private physician. The Veteran reported the pain began one month earlier and was diagnosed as lumbosacral radiculitis down the right leg. A private neurological examination in October 2007 showed a positive straight leg raise on the right, decreased pinprick sensation of the right lower extremity, and a right-sided lumbar disc herniation impinging on the right nerve root upon MRI. The Veteran continued to receive treatment for right leg radiculopathy, including private and VAMC physical therapy. During a September 25, 2008 VAMC pain consultation, the Veteran reported that his right leg pain had improved with physical therapy and the examining physician characterized the condition as radiculopathy, "now resolved." During the period between September 7, 2007 and September 25, 2008, the Veteran's symptoms of neurological impairment manifested radiating pain, positive straight leg raising, and sensory deficits. There is no indication of motor impairment and the Veteran's reflexes in the right leg were consistently normal. Furthermore, a June 2008 nerve conduction test at the VAMC was negative for evidence of right lumbosacral radiculopathy. The Board therefore finds that an initial 20 percent evaluation, consistent with moderate incomplete paralysis of the right sciatic nerve, is warranted from September 7, 2007 to September 25, 2008. After September 25, 2008, a 10 percent rating for mild incomplete paralysis is appropriate, as only intermittent complaints of right leg pain or numbness are noted in the record. In February 2009, a VA neurologist noted intermittent complaints of right leg pain, but also observed that objective neurological examination was completely normal. The Veteran called his VAMC physician in October 2010, complaining of right foot numbness, but he never sought treatment or made further reference to this symptom. Three years later, in January 2013, a VAMC physical therapist noted that the Veteran's previous right leg radiating pain had improved with therapy and there were no indications of right leg neurological impairment upon examination. The Veteran testified in October 2015 that he experienced radiating pain down both legs, but there are no objective findings of right leg radiculopathy after September 2008. A 10 percent evaluation is accordingly assigned for subjective neurological impairment of the right lower extremity from September 25, 2008. Turning to the left lower extremity, the Board finds that a separate initial 10 percent rating is warranted from September 1, 2006 to January 16, 2013 with an increased 40 percent evaluation assigned thereafter. Prior to January 16, 2013, the Veteran's left leg radiculopathy manifested radiating pain and loss of sensation. During this period, the Veteran was primarily concerned with the pain in his right leg, but experienced the recurrence of left leg radiating pain in July 2007. He received physical therapy for left leg pain on several occasions, but objective neurological examination was typically normal aside from a decrease in sensation over the left lower extremity in July 2008. The Board notes that the Veteran was found to have decreased deep tendon reflexes with downward pointing toes during a January 2006 service examination indicating some motor dysfunction of the left leg, but these symptoms appear to have resolved and there was no objective evidence of neurological impairment of the left leg upon VA examination in November 2006. In fact, there are no other complaints of left leg radiating pain until July 2007, when the Veteran reported the return of occasional left leg pain to a private physical therapist. The Board therefore finds that the January 2006 findings of decreased reflexes are not truly indicative of the impairment related to the left lower extremity during the period prior to January 16, 2013 and a separate rating of 10 percent, but not higher, is warranted under Diagnostic Code 8520 for mild incomplete paralysis of the left sciatic nerve. For the period beginning January 16, 2013, an increased 40 percent rating is assigned under Diagnostic Code 8520 for worsening of the left leg radiculopathy that most nearly approximates moderately-severe. In January 2013, a VAMC physical therapist characterized the Veteran's disability as moderate to severe with radiating symptoms to the left lower extremity. Neurological examination at that time was normal, but the Veteran complained of constant numbness in the left leg with frequent "jabs" of radiating sharp pain. VA examinations were also normal for neurological impairment in December 2013, April 2016, and February 2017, though the Veteran had some numbness and tingling of the left foot during an April 2016 physical therapy session at the Alexandria VA outpatient clinic. Based on the characterization of the disability as moderate to severe by the January 2013 physical therapist and the Veteran's consistent reports of radiating pain down the left leg, the Board finds that a 40 percent rating, but not higher, is warranted for moderately severe incomplete paralysis of the left sciatic nerve from January 16, 2013. In sum, the Veteran's service-connected low back disability warrants an initial 10 percent evaluation for orthopedic impairment prior to February 16, 2017 and a 20 percent evaluation thereafter. The associated radiculopathy of the right lower extremity warrants a separate initial 20 percent rating from September 7, 2007 to September 25, 2008 and a 10 percent rating thereafter. Radiculopathy of the left lower extremity also warrants a separate initial rating of 10 percent from September 1, 2006 to January 16, 2013 and a 40 percent rating thereafter. The Board has considered whether there is any other schedular basis for granting a higher rating other than those discussed above, but has found none. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against any increased schedular ratings other than those granted above. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Cervical Spine Service connection for degenerative disc disease of the cervical spine was awarded in the September 2007 rating decision on appeal with an initial noncompensable evaluation assigned effective September 1, 2006. An increased 20 percent evaluation was granted in an October 2014 rating decision effective from December 13, 2013. Most recently, in January 2017, the RO assigned an increased initial rating of 10 percent from September 1, 2006 to December 12, 2013. The Veteran's cervical spine disability is therefore rated as 10 percent disabling prior to December 13, 2013 and 20 percent disabling thereafter. The Veteran's cervical spine disability is currently rated under Diagnostic Code 5242 as degenerative arthritis of the spine and the general rating formula for diseases and injuries of the spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5237-5242. However, when rating degenerative arthritis of the spine, a rating for degenerative arthritis under Diagnostic Code 5003 is also for consideration. 38 C.F.R. § 4.71a. Prior to December 13, 2013, a 10 percent rating is in effect for the cervical spine disability under Diagnostic Code 5003 which provides that degenerative arthritis generally 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. The Veteran's service-connected disability also includes degenerative disc disease and the criteria pertaining to intervertebral disc syndrome are for application. Intervertebral disc syndrome is evaluated under the general formula for diseases and injuries of the spine or under the formula for rating intervertebral disc syndrome based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The general rating formula provides a 10 percent disability rating for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 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. A 20 percent disability rating is assigned for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 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. A 30 percent disability rating is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent disability rating is assigned for unfavorable ankylosis of the entire cervical spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Prior to December 13, 2013, the Veteran's cervical spine disability is rated as 10 percent disabling based on degenerative arthritis. If a Veteran manifests limitation of motion that is noncompensable under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent 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. In this case, the record establishes that the Veteran experienced painful motion of the cervical spine, but manifested full range of motion during objective testing prior to December 13, 2013. Range of motion was full upon VA examination in November 2006, with forward flexion to 45 degrees and a combined range of motion to 300 degrees with pain at the endpoint of testing. Range of motion was also full upon examination at the VAMC in September 2008 and November 2013. A June 2009 MRI confirmed the presence of multilevel degenerative disc disease, but the Veteran's neck pain was characterized as asymptomatic at a February 2010 VAMC neurosurgery consultation and June 2010 rehabilitation consultation. Additionally, only "occasional" cervical pain was reported at a May 2011 VA nerve conduction study of the upper extremities. With respect to functional factors, the Veteran reported that he experienced pain with bending of his neck and guarding when turning to the right. There was no additional loss of motion following repetitive testing at the November 2006 VA examination and the Veteran reported pain only at the endpoint of movement. In short, it is clear that the Veteran experienced some painful motion of the cervical spine during the period prior to December 13, 2013, but demonstrated full range of motion that is noncompensable under the general rating criteria even with consideration of all relevant functional factors. The current 10 percent rating, and not higher, is therefore appropriate under Diagnostic Code 5003 for painful motion of the joint. An increased rating is also not warranted under the other criteria of the general rating formula. Guarding and a muscle spasm of the neck were noted in November 2013 at the VAMC, but it is clear that the Veteran did not experience an abnormal gait or abnormal spinal contour as a result. The spasm and guarding were also noted in the context of an acute exacerbation of symptoms, and were not present during the wholly normal findings of the cervical spine in November 2006, September 2008, February 2010 and June 2010. The Board therefore finds that the Veteran's cervical spine disability, characterized as asymptomatic on several occasions and manifesting only "occasional" pain, does not more nearly approximate an increased 20 percent rating during the period prior to December 13, 2013 under the general rating formula. From December 13, 2013, the Veteran's cervical spine disability is rated as 20 percent disabling under the general rating formula. Limitation of motion was most restricted during this period at the December 2013 VA examination when forward flexion was measured to 30 degrees with a combined range of motion to 200 degrees. This finding is contemplated by the current 20 percent rating which provides for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees and a combined range of motion not greater than 170 degrees. 38 C.F.R. § 3.71a, Diagnostic Code 5003. With regard to functional factors, there was no pain during range of motion testing and the VA examiner found there was no additional loss of motion or function with repetitive testing. The same conclusion was reached by the April 2016 VA examiner who also found no additional pain or loss of motion with repetitive movement. VAMC treatment records document complaints of increased neck and shoulder/clavicle pain dating from February 2014, but the Veteran's health care providers attributed this pain to acute injuries and nonservice-connected thoracic dextroscoliosis and associated rib and shoulder dysfunction, sternoclavicular joint strain, and shoulder arthritis. The Veteran's complaints of loss of function have pertained to his shoulder/clavicle pain, with a loss of ability to work overhead and having to miss several days of work and stop exercising noted in December 2014 due to the nonservice-connected disabilities. The Board notes that the Veteran had full range of cervical motion at the December 2014 VAMC rehabilitation consultation and the examiner found that the Veteran was "quite functionally limited due [to] shoulder pain." The Veteran also testified in October 2015 that his neck pain was elicited by looking in the right direction for an extended period and ran down his shoulder blade to his back, further indicating that his shoulder and clavicle were the source of his limited function. Therefore, even with consideration of functional factors, the Board cannot conclude that forward flexion of the cervical spine most nearly approximates 15 degrees as required for an increased 40 percent evaluation. It is also clear that the Veteran retained useful motion of his spine throughout the claims period, and an increased rating based on ankylosis is not possible. Thus, the Veteran's cervical spine disability most nearly approximates the current 20 percent evaluation under the general rating formula and an increased evaluation is not warranted. Turning to whether an increased rating is warranted using the criteria pertaining to intervertebral disc syndrome, the Veteran does not allege and the record does not show that he has ever experienced incapacitating episodes of cervical pain requiring bedrest prescribed by a physician. The functional impairment described by the Veteran throughout the claims period pertains to limitation of motion and pain with extended movement. He has never reported requiring bedrest to recover from an episode of cervical pain and his medical records are negative for treatment of this nature. An increased rating is accordingly not warranted under the criteria for rating intervertebral disc syndrome. The Board has also considered whether separate ratings are appropriate based on neurological impairment of the upper extremities due to cervical degenerative disc disease. The Veteran has made some complaints of numbness and tingling in his bilateral upper extremities during the claims period and a VA orthopedist found that his symptoms of shooting pain and numbness in the upper extremity were likely related to degenerative changes of the cervical spine. The Board finds that this evidence is outweighed by the other competent evidence of record which establishes the Veteran's symptoms are due to other orthopedic disabilities of the wrists and/or other neurologic etiologies. The Veteran complained of shooting pain and numbness in his arms throughout the claims period, increased with typing on his keyboard at work. Although a VA orthopedist attributed these symptoms to the Veteran's cervical disability, no other health care provider or VA examiner has identified any evidence of cervical radiculopathy. Neurological examination of the upper extremities was normal at VA examinations in November 2006, and April 2016. These VA examiners also determined that there was no objective evidence of cervical neurological impairment of the upper extremities. The Veteran was diagnosed with degenerative disease of the cervical spine without neurologic compromise following a VAMC neurosurgery consultation and there was no electrophysiologic evidence of neurological impairment of the arms during a May 2011 VAMC nerve conduction study. The provider at that time also noted the Veteran did not complain of radicular pain down his arms. The Veteran reported "substantial relief" from hand and wrist pain in September 2012 following tendon sheath injections from a VAMC orthopedist, indicating that his upper extremity pain was not associated with the cervical spine. Treatment records also show diagnoses of possible ulnar neuropathy in February 2010 and carpal tunnel syndrome in June 2011. The Board further notes that while the Veteran is competent to report experiencing pain in his neck, shoulder blade, and in his upper extremities, he is not competent to attribute that pain to his cervical spine disability, particularly in light of the other possible etiologies and conditions identified as the source of his symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1131, 1336 (Fed. Cir. 2006). Therefore, separate ratings are not warranted for radiculopathy in this case as the weight of the evidence establishes that the Veteran does not have neurological impairment of upper extremities associated with the service-connected cervical spine disability. Right Wrist Service connection for chronic right wrist tendonitis was awarded in the September 2007 rating decision on appeal. An initial noncompensable evaluation was assigned effective September 1, 2006. In an October 2014 rating decision, an increased 10 percent evaluation was assigned effective August 15, 2011. Most recently, in January 2017, an increased 10 percent evaluation was granted during the period dating from September 1, 2006 to August 14, 2011. The Veteran's right wrist disability is therefore rated as 10 percent disabling throughout the entire claims period. The Veteran's right wrist tendonitis is currently rated as 10 percent disabling under Diagnostic Codes 5024-5215 for limitation of motion of the wrist. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Diagnostic Code 5024 pertains to tenosynovitis and provides for rating the service-connected disability based on limitation of motion of the affected part as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5024. Degenerative arthritis is evaluated under Diagnostic Code 5003 and provides a rating of 10 percent for noncompensable limitation of motion of an involved joint confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Limitation of motion of the wrist is rated under Diagnostic Code 5215 and provides for maximum 10 percent ratings for limited palmar flexion and limited dorsiflexion in the major and minor wrists. 38 C.F.R. § 4.71a, Diagnostic Code 5215. The Veteran is already in receipt of a 10 percent rating for limitation of motion due to his right wrist tendonitis and a higher initial evaluation is therefore not possible under Diagnostic Codes 5003, 5024, or 5215. A higher rating is possible under Diagnostic Code 5214 for ankylosis of the wrist, but the record clearly shows that the Veteran's right wrist is not ankylosed. VA examiners who physically examined the Veteran's wrist in November 2006, December 2013, and April 2016 concluded that the Veteran did not have ankylosis. The VA examinations and VAMC treatment records show some findings of reduced motion and complaints of pain with use, especially with activities that require heavy lifting or repetitive twisting of the wrist. However, even with consideration of all relevant functional factors, it is clear that the Veteran has retained useful motion of his right wrist throughout the claims period. Additionally, as the Veteran is already in receipt of the highest available rating based on restriction of motion, the provisions regarding pain in 38 C.F.R. §§ 4.40 and 4.45 do not apply. Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Thus, the assignment of an increased rating for the service-connected right wrist disability based on ankylosis under Diagnostic Code 5214 is not appropriate and the claim for a higher initial rating is denied. Right Elbow Service connection for right elbow degenerative joint disease was granted in the September 2007 rating decision on appeal. An initial noncompensable evaluation was assigned effective September 1, 2006. An increased 10 percent evaluation was awarded in a January 2017 rating decision, also effective September 1, 2006. The Veteran's right elbow disability is therefore rated as 10 percent disabling throughout the entire claims period. The right elbow degenerative joint disease is currently rated as 10 percent disabling under Diagnostic Code 5003-5206. They hyphenated diagnostic code in this case indicates arthritis of the right elbow rated as limitation of motion of the forearm. Diagnostic Code 5003 provides a rating of 10 percent for noncompensable limitation of motion of an involved joint confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. A rating higher than 10 percent is not possible under Diagnostic Code 5003 without involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. Id. The Board finds that an initial rating in excess of 10 percent is not warranted for the service-connected right elbow disability. The Veteran's service-connected condition is limited to the individual right elbow joint and a 20 percent rating is not warranted under Diagnostic Code 5003. Additionally, while the Veteran complained of intermittent elbow pain with lifting heavy weight or performing activities that require repetitive flexion, range of motion of the right elbow has been normal throughout the claims period. VA examinations performed in November 2006, December 2013, and April 2016 have demonstrated full motion of the right elbow with no limitations due to pain or after repetitive testing. The December 2013 and April 2016 VA examiners both found there was no objective evidence of a right elbow disability after physical examination. Diagnostic Code 5206 and 5207 provide for ratings in excess of 10 percent for limitation of elbow flexion that most nearly approximates 90 degrees and limitation of extension that most nearly approximates 75 degrees for the major (dominant) forearm. 38 C.F.R. § 4.71a, Diagnostic Codes 5206-5207. The Veteran's limitation of motion clearly does not approximate this criteria and an increased rating based on loss of motion is not warranted. The Board has also considered whether higher ratings are appropriate based on impairment to function and use of the right elbow in accordance with 38 C.F.R. §§ 4.10, 4.40 and 4.45. See DeLuca, supra. In this case, the Veteran has reported experiencing increased elbow pain with heavy lifting, repetitive tasks, and keyboard use. The Board finds this impairment is contemplated by the existing rating assigned the service-connected right elbow. While the Veteran gave a history of right elbow pain during the November 2006, December 2013, and April 2016 VA examinations, he was able to perform repetitive testing without additional loss of function or strength during the examinations. None of the VA examiners or the Veteran's treating physicians have identified a significant limitation to functional ability due to pain, weakness, fatigability or incoordination. The Veteran reported experiencing flare-ups of symptoms, but has never manifested loss of muscle strength, atrophy, or other objective indications of functional impairment indicative of a higher disability rating. Furthermore, the Veteran has never received medical treatment for complaints related to the right elbow, though he has been treated at the VAMC on several occasions for symptoms associated with a nonservice-connected left elbow disability. The Board has considered the Veteran's reports of pain and impairment, but based on the absence of any additional loss of function or motion following repetitive testing, the presence of only mild to moderate arthritis on X-ray in March 2016, and the absence of any objective evidence of a significant impairment to function, the Board finds that an increased rating based on functional factors is not warranted. The Board has also considered whether an increased rating is warranted under the other criteria pertaining to rating the elbow or forearm. The Veteran has clearly maintained useful motion of his right elbow and does not manifest ankylosis of the joint. There is also no medical or lay evidence of impairment to the radius or ulna or impairment of supination. Finally, there is no indication that the disability manifests marked a flail joint with cubitus varus or cubitus valgus deformity or an ununited fracture of the head of the radius. The Board has considered the statements of the Veteran, but finds that his lay reports of elbow pain and limitations to lifting and repetitive tasks are contemplated by the currently assigned evaluation based on painful motion of the elbow. Thus, an increased rating is not warranted. The Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for an initial rating in excess of 10 percent for the right elbow. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Right Hand Entitlement to service connection for right hand tendonitis and degenerative joint disease was granted in the September 2007 rating decision on appeal with an initial noncompensable evaluation assigned effective September 1, 2006. In a January 2017 rating decision, the RO assigned separate ratings for right hand tendonitis and degenerative joint disease involving two groups of fingers. The thumb, index, and long fingers were assigned an increased 10 percent evaluation effective September 1, 2006 and the ring and little fingers were assigned a noncompensable evaluation also effective September 1, 2006. The Veteran's right tendonitis is therefore currently assigned two ratings: one evaluated as 10 percent disabling throughout the claims period and the other as noncompensably disabling. As a preliminary matter, the Board notes that the Veteran's service-connected right hand and finger disabilities involve symptoms and impairment that is orthopedic in nature. The applicable diagnostic codes rate the right hand tendonitis and degenerative joint disease on the basis of limitation of motion and function associated with the service-connected tendonitis and arthritis. To the extent the Veteran contends that he experiences neurological impairment of the bilateral upper extremities (described as tingling and shooting pain from the bilateral fingers to the elbows), this symptomatology is contemplated by the referred claim to reopen service connection for neurological impairment in the bilateral extremities. The Board will fully address and consider all the Veteran's complaints with respect to the service-connected orthopedic disabilities, but will not rate the Veteran's claimed neurological impairment. The Board will first address the claim for an initial rating in excess of 10 percent for tendonitis and arthritis of the thumb, index, and long fingers. This disability is rated under Diagnostic Code 5003-5228 as degenerative arthritis and limitation of motion of the thumb. As noted above, Diagnostic Code 5003 allows for the assignment of a 10 percent rating for each major joint or group of minor joints affected by limitation of motion that is noncompensable under the relevant diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of motion of the fingers is rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5228-5230. Limitation of motion of the thumb is rated under Diagnostic Code 5228 which provides for a 10 percent rating when there is a gap of one to two inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A 20 percent rating is assigned when there is a gap of more than two inches between the thumb pad and fingers, with the thumb attempting to oppose the fingers. Id. Limitation of motion in the index or long finger is rated under Diagnostic Code 5229 which provides for a 10 percent rating when there is a gap of one inch or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. A gap of less than one inch is noncompensable. Id. The Board finds that increased ratings are not warranted in this case based on the limitation of motion criteria under Diagnostic Codes 5228 or 5229. With respect to the thumb, the Veteran has never demonstrated a gap of greater than one inch between the thumb pad and the fingers. In fact, range of motion of the fingers of the right hand has been normal throughout the entire claims period, including during VA examinations in November 2006, December 2013, and April 2016. The Veteran complained of intermittent pain in his right hand during the November 2006 VA examination, but had no demonstrable loss of motion and was asymptomatic upon VA examination in December 2013 and April 2016. There are no other orthopedic complaints of pain in the right thumb, index, and long fingers in the medical record and the Veteran is already in receipt of the maximum rating of 10 percent under Diagnostic Code 5229. Most recently, during the April 2016 VA examination, the Veteran stated that he was not pursuing a claim for his right hand service-connected disability and the condition was characterized as "subsided." Thus, even with consideration of all relevant functional factors, it is clear that a rating in excess of 10 percent is not warranted for the right thumb, index, and long fingers as the Veteran does not manifest compensable limitation of motion. Turning to the other service-connected fingers, the right ring and little fingers, limitation of motion in these fingers is noncompensable. 38 C.F.R. § 4.71a, Diagnostic Code 5230. The schedular criteria do not provide a compensable rating based on limitation of motion of these fingers, regardless of the extent of the limitation. A compensable rating for a ring or little finger disability requires amputation, or the functional equivalent thereof. 38 C.F.R. § 4.41a, Diagnostic Code 5155, 5156. The Veteran clearly does not manifest the functional equivalent of amputation; range of motion of the fingers was full throughout the claims period, and while he demonstrated pain and snapping of the right ring finger during an April 2011 VAMC orthopedic consultation, these symptoms were the result of an acute injury incurred while boxing and resolved with no other complaints or treatment. The Veteran is therefore in receipt of the highest possible schedular rating for the service-connected right tendonitis and degenerative joint disease of the right ring and little fingers. The Board has considered the other criteria pertaining to the fingers, but notes that higher ratings under Diagnostic Codes 5216-5227 require a finding of ankylosis. There is no evidence that the Veteran has had ankylosis in any of his digits at any time during the appeal period. The record documents the Veteran's complaints of joint pain and limited motion, but it is clear he has retained some useful motion of his fingers. Therefore, ankylosis is not present and Diagnostic Codes 5216-5227 are not for application. The Board finds that while the Veteran has some pain and functional impairment from his service-connected tendonitis and arthritis of the fingers of the right hand, he is in receipt of the maximum ratings possible for this disability. Increased initial ratings are accordingly not warranted and the claims are denied. Extraschedular Ratings In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board may not assign an extra-schedular rating in the first instance, but must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). In this case, the issue of extraschedular ratings was raised in the Veteran's April 2017 statement arguing that his service-connected back, neck, and left leg pain have resulted in marked interference with employment or frequent periods of hospitalization. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that renders the available schedular evaluations for the service-connected disabilities inadequate. A comparison between the level of severity and symptomatology of the Veteran's orthopedic disabilities and accompanying neurological conditions with the established criteria shows that the rating criteria reasonably describe his disability level and symptomatology. As noted in the analysis regarding the Veteran's schedular ratings, his disabilities are productive of painful limited motion and radiating pain with sensory loss of the lower extremities. These symptoms result in impairment to functional use for activities such as sitting, standing, bending, lifting, and performing repetitive movements. These manifestations are all contemplated in the schedular criteria pertaining to disabilities of the musculoskeletal system and peripheral nerves and the applicable DCs. See 38 C.F.R. §§ 4.71a, 4.124a. The Board also finds that the criteria of Thun step two is not established. See Johnson v. Shinseki, 26 Vet. App. 237, 247 (2013) (en banc) (error in Thun step one analysis is harmless where Board makes an adequate finding that Thun step two is not satisfied). The Veteran's disabilities do not present an exceptional disability picture with related factors such as marked interference with employment or frequent hospitalization. 38 C.F.R. § 3.321(b)(1). Regarding his employment, the Veteran has attended school or worked throughout most of the claims period, aside from the time immediately after his separation from service when he was looking for employment. He participated in VA's Vocational and Rehabilitation program and began full-time employment as an Information Technologies data management specialist in approximately April 2010 and has continued this employment throughout the claims period. The Veteran has several workplace accommodations for his disability including an adjustable standing/sitting desk and an ergonomic chair. His description of his work duties, keyboarding, typing, and sitting, indicates that the job is sedentary in nature and does not require a significant amount of physical activity. In his April 2017 statement, he reported that he often uses sick leave or works from home due to pain and limitation of function associated with his disabilities. Review of the Veteran's medical records shows that he reported missing three days of work in the last month during the December 2013 and February 2017 VA examinations due to back and left leg pain. However, the Veteran's treatment records also show that he has missed time from work due to nonservice-connected disabilities, such as his rib and clavicular dysfunction beginning in early 2014 and odynophagia in October 2014. A rating for a service-connected disability presupposes there will be consequent occupational impairment. See 38 C.F.R. §§ 4.1, 4.15. According to 38 C.F.R. § 4.1, generally, the degrees of disability specified [in the Rating Schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illness proportionate to the severity of the several grades of disability. Marked interference with employment means to an extent above and beyond that contemplated by the regular schedular rating criteria. The Veteran's disability impacts his ability to perform repetitive movements with his hands, sit and stand for extended periods of time, and lift heavy objects. The impact on his occupational functioning from this type of impairment is not "exceptional" as characterized by Thun and it is contemplated by the currently assigned schedular evaluations. The Veteran's disabilities certainly result in some limitations to his employment activities, particularly with respect to his service-connected right hand, wrist, and elbow conditions with significant time spent typing, but there is simply no evidence that such limitations rise to the level of marked interference with employment or present an exceptional disability picture, especially in light of the Veteran's continuous employment in a specialized technical field. With respect to the Veteran's arguments regarding "frequent hospitalization," the Board finds no evidence of any inpatient treatment for the service-connected disabilities on appeal. He stated in April 2017 that his exacerbations of low back and cervical pain reduce his mobility such that the only way to seek treatment would be via ambulance as he is unable to drive himself to his health care providers. The Veteran also noted that there is little treatment he can receive from an emergency department for his condition aside from medication and a referral to his primary care doctor. The Board has considered the Veteran's statements that his loss of functional ability is comparable to frequent hospitalization, but disagrees. Review of the objective medical records shows that his low back and cervical disabilities are productive of some loss of motion due to pain and neurological impairment of the lower extremities. The Veteran has sought and received treatment throughout the claims period for his service-connection conditions, to include pain medication and physical therapy, but there is no objective evidence of symptoms or impairment that are of sufficient severity to require or approximate hospitalization. In fact, the most recent VA examinations of the Veteran's disabilities in April 2016 and February 2017 demonstrated largely normal range of motion with few signs of orthopedic disability in the right hand, elbow, and wrist. In short, the weight of the competent evidence establishes that the Veteran's service-connected disabilities do not present an exceptional disability picture, to include frequent hospitalization or a functional equivalent. With consideration of all of the above, the Board finds that referral for consideration of an extraschedular rating is not warranted in this case. The Veteran's service-connected disabilities are productive of symptoms and impairment that is specifically contemplated in the rating criteria and clearly do not present an "exceptional disability picture." As a final matter, the Board also finds that the record does not raise a claim for a total disability rating due to individual employability resulting from service-connected disability (TDIU). A request for TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but is rather part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, when entitlement to TDIU is raised during the appeal of a rating for a disability, it is part of the claim for benefits for the underlying disability. Id at 454. In this case, the record is negative for evidence that the Veteran is unemployable. He is not in receipt of Social Security disability benefits, and has continued to work full time throughout the claims period. The record establishes that his disabilities result in some impairment to employment activities, but the relevant rating criteria contemplate these impairments and the Veteran does not allege that he is unable to perform his duties due to service-connected disabilities such that he is unemployable. Therefore, remand of a claim for TDIU is not necessary as there is no evidence of unemployability due to the service-connected conditions on appeal. ORDER Entitlement to an initial rating higher than 10 percent for limitation of motion of the lumbar spine (previously degenerative disc disease) prior to February 16, 2017 is denied. Entitlement to a rating higher than 20 percent for limitation of motion of the lumbar spine from February 16, 2017 is denied. Entitlement to a separate initial rating for radiculopathy of the right lower extremity rated as 20 percent disabling, but not higher, from September 7, 2007 to September 24, 2008 is granted. Entitlement to a separate rating for radiculopathy of the right lower extremity rated as 10 percent disabling, but not higher, from September 25, 2008 is granted. Entitlement to a separate initial rating for radiculopathy of the left lower extremity rated as 10 percent disabling, but not higher, from September 1, 2006 to January 16, 2013 is granted. Entitlement to a separate rating for radiculopathy of the left lower extremity rated as 40 percent disabling, but not higher, from January 16, 2013 is granted. Entitlement to an initial rating higher than 10 percent for degenerative disc disease of the cervical spine prior to December 13, 2013 is denied. Entitlement to a rating higher than 20 percent for degenerative disc disease of the cervical spine from December 13, 2013 is denied. Entitlement to an initial rating higher than 10 percent for chronic right wrist tendonitis is denied. Entitlement to an initial rating higher than 10 percent for right elbow degenerative joint disease is denied. Entitlement to an initial rating higher than 10 percent for right hand tendonitis and degenerative joint disease of the major thumb, index, and long fingers is denied. Entitlement to an initial compensable rating for right hand tendonitis and degenerative joint disease of the major ring and little fingers is denied. REMAND The Board regrets further delay in this case, but finds that a remand is necessary with respect to the claims for entitlement to increased initial ratings for a left knee disability and piriformis syndrome of the left leg. Additional VA examinations are necessary in light of the Court's decision in Correia v. McDonald, 28 Vet. App. 158 (2016). The Veteran's knees and left foot were most recently examined by VA in April 2016; unfortunately, the examination report does not meet the specifications of Correia. The examination report contains range of motion testing for what is presumably active motion, but not in passive motion, weight-bearing, and nonweight-bearing. At the April 2016 VA examinations, the Veteran was found to experience pain with weight-bearing of the left knee and left foot, and the examination reports are internally inconsistent. For example, the VA examiner reported that the Veteran's left knee was stable, but also indicated that stability testing was not performed. Therefore, additional examinations are necessary under 38 C.F.R. § 3.159 (c)(4) to ensure compliance with the decision in Correia and VA's duty to assist. The Board also notes that although the Veteran reported for a VA examination of his left leg piriformis syndrome in April 2016, the examination was not performed. The April 2016 VA examiner documented the Veteran's statements that "I don't have any muscle injury, [I] only have pain in my left leg, [I] don't have any explanation for muscle injury." The Veteran is service-connected for piriformis syndrome of the left leg, a condition whereby the piriformis muscle of the buttock can aggravate the sciatic nerve and cause impairment down the lower extremity. This condition is currently rated as 10 percent disabling under Diagnostic Code 5318 pertaining to muscle injuries of Muscle Group XVIII and impairment of the pelvic girdle group including the pyriformis muscle. The Veteran stated that he did not have a "muscle injury," but his disability is rated by analogy based on the symptoms and manifestations of the condition. As additional examinations are necessary for the left knee and foot, VA should attempt to provide another VA examination of the Veteran's piriformis muscle and all associated impairment. Accordingly, the case is REMANDED for the following action: 1. Obtain copies of the Veteran's records of treatment from the VA South Texas Healthcare System (HCS) dated from March 11, 2016 and records from the Washington, D.C. VAMC dated from March 30, 2016. All records received pursuant to this request must be associated with the claims file. 2. Schedule the Veteran for a VA examination to determine the current severity of his left knee disability with osteoarthritis and instability. The claims file must be made available to and reviewed by the examiner. The examination must include range of motion studies of both knees. In reporting the range of motion findings, the examiner must comment on the extent of any painful motion, functional loss due to pain, weakness, excess fatigability, and additional disability during flare-ups. Both knees must be tested for pain on both active and passive range of motion with weight bearing and nonweight bearing. See Correia v. McDonald, supra. The examiner should further address whether, and if so to what extent, there is ankylosis of either knee. The examiner should also provide an opinion concerning the degree of severity (whether mild, moderate, or severe) of any instability or subluxation of the knees. The examiner should also determine if the knees lock and if so the frequency of the locking. The examiner should also determine the functional impairment due to the right and left knee disabilities. The complete bases for all medical opinions must be provided. 3. Schedule the Veteran for a VA muscle examination to determine the nature and severity of his piriformis syndrome of the left leg, to include examinations of the left hip, leg, and foot. The claims file must be made available to and reviewed by the examiner in conjunction with the examination. Based on a physical examination of the Veteran's left hip, leg, and foot and Muscle Group XVIII, the examiner is asked to determine: a) the degree of injury to all muscle groups involved, to include whether there is more than one muscle group involved in the same anatomical region, and the functions affected; b) whether the disability associated with each affected muscle group would be considered slight, moderate, moderately severe, or severe, to include commenting on the presence or absence of the cardinal signs and symptoms of muscle disability, including loss of power, weakness, lowered threshold of fatigue, fatigue pain, impairment of coordination, and uncertainty of movement; c) whether the service-connected piriformis syndrome manifests any neurological impairment, to include sensory or motor impairment in the left lower extremity. The examiner should provide an opinion with respect to any symptoms due to nerve root impingement as to whether they are mild, moderate, moderately severe, or severe. The Veteran is currently in receipt of a disability rating for radiculopathy of the left lower extremity associated with a lumbar spine disability. If the examiner identifies neurological impairment of the left leg due to piriformis syndrome, if possible, the symptoms of each neurological disorder of the left lower extremity should be differentiated from one another. If this is not possible, the examiner should so state and provide a full explanation for all expressed opinions. The complete bases for all medical opinions must be provided. 4. Then, readjudicate the claims on appeal. If the benefits sought are not fully granted, issue a SSOC to the Veteran before returning the case to the Board. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. 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). ______________________________________________ M. H. Hawley Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs