Citation Nr: 1756943 Decision Date: 12/08/17 Archive Date: 12/15/17 DOCKET NO. 10-31 061 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Medical and Regional Office (RO) Center in Wichita, Kansas THE ISSUES 1. Entitlement to a higher initial disability rating (or evaluation) for a cervical spine disability, in excess of 0 percent (noncompensable) prior to March 19, 2012, and in excess of 20 percent thereafter. 2. Entitlement to a higher initial disability rating (or evaluation) for degenerative arthritis of the thoracolumbar spine, in excess of 10 percent prior to March 19, 2012, and in excess of 20 percent thereafter. 3. Entitlement to a higher initial disability rating (or evaluation) for degenerative arthritis of the right hip, in excess of 10 percent prior to March 19, 2012, and in excess of 20 percent thereafter. 4. Entitlement to a higher initial disability rating (or evaluation) for degenerative arthritis of the right knee in excess of 10 percent. 5. Entitlement to a higher initial disability rating (or evaluation) for degenerative arthritis of the right shoulder in excess of 20 percent. 6. Entitlement to a higher initial disability rating (or evaluation) for degenerative arthritis of the left shoulder in excess of 20 percent. 7. Entitlement to a higher initial disability rating (or evaluation) for degenerative arthritis of the right foot in excess of 10 percent. 8. Entitlement to a higher initial disability rating (or evaluation) for degenerative arthritis of the left foot in excess of 10 percent. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD E. Blowers, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from May 1978 to August 1978, from December 2002 to September 2003, from October 2003 to August 2004, and from April 2006 to September 2008. The Veteran also had unverified periods of service in the National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision of the RO in Wichita, Kansas. This case has a long procedural history. Relevant to the instant matter, in a September 2016 decision, the Board, in pertinent part, remanded the remaining issues on appeal for new VA orthopedic examinations and opinions. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Failure of the Board to ensure compliance with remand instructions constitutes error and warrants the vacating of a subsequent Board decision. See Stegall v. West, 11 Vet. App. 268, 271 (1998). As will be elaborated upon below, the Board finds that its September 2016 directives were adequately complied with on remand; therefore, the Board finds the issues on appeal are ripe for adjudication. The Veteran testified from Wichita, Kansas, at a November 2011 Board videoconference hearing before the undersigned Veterans Law Judge (VLJ), who was seated in Washington, D.C. The hearing transcript has been associated with the record. The instant matter is a Veterans Benefits Management System (VBMS) appeal. The Board has reviewed both the VBMS and the "Virtual VA" files so as to insure a total review of the evidence. Since the issuance of the last supplemental statement of the case (SSOC), additional evidence has been received by the Board for which a waiver of initial RO consideration was provided. 38 C.F.R. § 20.1304 (2017). The Veteran has appealed from the initial ratings assigned for multiple service-connected disabilities. In Fenderson v. West, 12 Vet. App. 119, 125-26 (1999), the United States Court of Appeals for Veterans' Claims (Court) addressed a similar appeal and directed that such appeal of the initial rating assigned following a grant of service connection was specifically not a claim for an increased disability rating. The Court also directed that separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. FINDINGS OF FACT 1. For the entire initial rating period on appeal, from September 30, 2008, the service-connected cervical spine disability more nearly approximated painful limitation of forward flexion to 15 degrees or less, without ankylosis or incapacitating episodes having a total duration of at least four weeks in the previous 12 months. 2. For the entire initial rating period on appeal, from September 30, 2008, the service-connected degenerative arthritis of the thoracolumbar spine more nearly approximated painful limitation of motion of the thoracolumbar spine, with flare-ups of pain, resulting in forward flexion of 30 degrees or less, with no ankylosis of the thoracolumbar spine or incapacitating episodes having a total duration of at least six weeks in the previous 12 months. 3. Prior to March 19, 2012, the service-connected degenerative arthritis of the right hip was not productive of ankylosis, fracture, malunion, or nonunion of the femur, or flail hip joint, and did not manifest limitation of flexion to 45 degrees, limitation of extension to 5 degrees, or limitation of abduction with motion lost beyond 10 degrees. 4. From March 19, 2012, the service-connected degenerative arthritis of the right hip was not productive of ankylosis, fracture, malunion, or nonunion of the femur, or flail hip joint, and did not manifest limitation of flexion to 30 degrees or limitation of extension to 5 degrees. 5. For the entire initial rating period on appeal, from September 30, 2008, the Veteran's service-connected degenerative arthritis of the right knee has more nearly approximated full extension of the knee, painful limitation of flexion, with flare-ups of pain, in excess of 45 degrees, and no ankylosis, subluxation, lateral instability, dislocation or removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. 6. For the entire initial rating period on appeal from September 30, 2008, the service-connected degenerative arthritis of the right shoulder did not manifest as recurrent dislocation of the humerus at the scapulohumeral joint, malunion of the humerus, fibrous union of the humerus, nonunion of the humerus, loss of head of the humerus, or ankylosis of scapulohumeral articulation; and painful limitation of motion, even when considering flare-ups of pain, was not limited to midway between the side and shoulder level. 7. For the entire initial rating period on appeal from September 30, 2008, the service-connected degenerative arthritis of the left shoulder did not manifest as recurrent dislocation of the humerus at the scapulohumeral joint, malunion of the humerus, fibrous union of the humerus, nonunion of the humerus, loss of head of the humerus, or ankylosis of scapulohumeral articulation; and painful limitation of motion, even when considering flare-ups of pain, was not limited to midway between the side and shoulder level. 8. For the entire initial rating period on appeal from September 30, 2008, the service-connected degenerative arthritis of the right foot did not manifest as claw foot (pes cavus), malunion or nonunion of the tarsal or metatarsal bones, or overall symptomatology of at least a moderately severe level. 9. For the entire initial rating period on appeal from September 30, 2008, the service-connected degenerative arthritis of the left foot did not manifest as claw foot (pes cavus), malunion or nonunion of the tarsal or metatarsal bones, or overall symptomatology of at least a moderately severe level. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, for the entire initial rating period on appeal from September 30, 2008, the criteria for a 30 percent disability rating for the service-connected cervical spine disability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.1, 4.3, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5237 (2017). 2. Resolving reasonable doubt in the Veteran's favor, for the entire initial rating period on appeal from September 30, 2008, the criteria for a 40 percent disability rating for the service-connected degenerative arthritis of the thoracolumbar spine have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.1, 4.3, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5243 (2017). 3. Prior to March 19, 2012, the criteria for an initial disability rating in excess of 10 percent for the service-connected degenerative arthritis of the right hip have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.1, 4.3, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5250-55 (2017). 4. From March 19, 2012, the criteria for an initial disability rating in excess of 20 percent for the service-connected degenerative arthritis of the right hip have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.1, 4.3, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5250-55 (2017). 5. The criteria for a higher initial disability rating in excess of 10 percent for the service-connected degenerative arthritis of the right knee have not been met or more nearly approximated for any period. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.1, 4.3, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5256-63 (2017). 6. The criteria for a higher initial disability rating in excess of 20 percent for the service-connected degenerative arthritis of the right shoulder have not been met or more nearly approximated for any period. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.1, 4.3, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5200-03 (2017). 7. The criteria for a higher initial disability rating in excess of 20 percent for the service-connected degenerative arthritis of the left shoulder have not been met or more nearly approximated for any period. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.1, 4.3, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5200-03 (2017). 8. The criteria for a higher initial disability rating in excess of 10 percent for the service-connected degenerative arthritis of the right foot have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.1, 4.3, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5278, 5283-84 (2017). 9. The criteria for a higher initial disability rating in excess of 10 percent for the service-connected degenerative arthritis of the left foot have not been met or more nearly approximated for any period. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.1, 4.3, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5278, 5283-84 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and to Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2017). The Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. As the higher initial disability rating issues arise from the Veteran's disagreement with the initial rating following the grant of service connection, no additional notice is required regarding this downstream element of the service connection claim. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the Court have similarly held that regarding the downstream element of the initial rating that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (noting that, once an initial VA decision awarding service connection and assigning a disability rating and effective date has been made, 38 U.S.C.A. § 5103(a) notice is no longer required); 38 C.F.R. § 3.159(b)(3) (no VCAA notice required because of filing of notice of disagreement (NOD)). Regarding the duty to assist in this case, VA provided multiple VA orthopedic examinations during the course of this appeal. Most recently, per the September 2016 remand directives, VA provided new VA orthopedic examinations in January 2017, with an addendum opinion being provided by the VA examiner in March 2017. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). However, unless the claimant challenges the adequacy of the examination or opinion, the Board may assume that the examination report and opinion are adequate and need not affirmatively establish the adequacy of the examination report or the competence of the examiner. Sickels v. Shinseki, 643 F.3d 1362, 1365-66 (Fed. Cir. 2011); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-1291 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged). Indeed, even when the adequacy is challenged, the Board may assume the competency of any VA medical examiner, including even nurse practitioners, as long as, under 38 C.F.R. § 3.159(a)(1), the examiner is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Cox v. Nicholson, 20 Vet. App. 563 (2007). In a June 2017 statement, the Veteran basically advanced the following: 1) that he received only a "partial examination"; 2) that the VA examiner failed to perform the testing directed by the Board; and 3) that the VA examiner "misrepresented" the Veteran's symptoms. The Federal Circuit has held that a claimant challenging the expertise of a VA physician must "set forth the specific reasons . . . that the expert is not qualified to give an opinion." Bastien v. Shinseki, 599 F.3d 1301, 1307 (Fed. Cir. 2010). That has not happened in this case. While the Veteran has expressed disagreement with the VA examiners' findings and how the examinations were performed, neither the representative nor the Veteran has provided a specific reasons to call into question the professional competence of the VA examiner; therefore, the VA examiner is presumed competent. See Rizzo, 580 F.3d at 1290-1291. Regarding the Veteran's specific arguments, review of the VA examination reports reflects that the VA examiner conducted all relevant testing, including range of motion testing. While the VA examiner initially did not render an opinion as to any additional loss of range of motion during a flare-up, VA subsequently received the requested opinion in a March 2017 addendum opinion. Further, considering all the evidence of record, including past VA orthopedic examinations, the Board finds the symptoms and functional limitations noted in the January 2017 examination reports to be consistent with the other evidence of record, and the Board does not find the Veteran's contention that symptoms were misrepresented by the VA examiner to be credible. Taken together, the multiple VA orthopedic examinations conducted during the course of this appeal reflect that, overall, the VA examiners reviewed the record, conducted in-person examinations, and rendered the requested opinions. As such, the examinations are adequate for VA rating purposes. All relevant documentation, including service records, Social Security Administration (SSA) records, and VA and private treatment (medical) records, has been secured and all relevant facts have been developed. There remains no question as to the substantial completeness of the record as to the initial orthopedic rating issues on appeal. 38 U.S.C. §§ 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.159, 3.326(a). Disability Rating Law and Regulation Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2017). Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2017). Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2017). It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 9-98. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert, 1 Vet. App. at 57. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. 303. Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The United States Court of Appeals for Veterans Claims (Court) has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). The Board notes that it has reviewed all of the available VA, private, and in-service treatment records from the relevant rating period on appeal. While there are extensive VA and private treatment records documenting the Veteran's orthopedic symptoms, the records do not convey any additional relevant symptoms beyond those discussed above. Spinal Disability Rating Criteria Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes (IVDS Rating Formula). Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. As to the low back, the General Rating Formula provides a 10 percent disability rating for forward flexion of the lumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range-of-motion of the lumbar 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 rating is provided for forward flexion of the lumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range-of-motion of the lumbar 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. A 40 percent disability rating is provided for forward flexion of the lumbar spine 30 degrees or less, or favorable ankylosis of the entire lumbar spine, while a 50 percent disability rating is assigned for unfavorable ankylosis of the entire lumbar spine. Finally, a 100 percent disability rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. As to the neck, 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 4 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 rating is provided 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 provided 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 provided for unfavorable ankylosis of the entire cervical spine, while a 100 percent disability rating is assigned for unfavorable ankylosis of the entire spine. Id. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2) (See also Plate V) provides that, for VA compensation purposes, normal forward flexion of the lumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range-of-motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range-of-motion of the lumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range-of-motion. Normal forward flexion of the cervical spine is 0 to 45 degrees, extension is 0 to 45 degrees, left and right lateral flexion are 0 to 45 degrees, and left and right lateral rotation are 0 to 45 degrees. The normal combined range of motion of the cervical spine is 340 degrees. Id. Note (3) provides that, in exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range-of-motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range-of-motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range-of-motion is normal for that individual will be accepted. Note (4) instructs to round each range-of-motion measurement to the nearest five degrees. Note (5) provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire lumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. The diagnostic codes for the spine are as follows: 5235 Vertebral fracture or dislocation; 5236 Sacroiliac injury and weakness; 5237 Lumbosacral or cervical strain; 5238 Spinal stenosis; 5239 Spondylolisthesis or segmental instability; 5240 Ankylosing spondylitis; 5241 Spinal fusion; 5242 Degenerative arthritis of the spine (see also DC 5003); 5243 Intervertebral disc syndrome. The IVDS Rating Formula provides a 10 percent disability rating for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician. Id. In rating cervical and thoracolumbar spinal disabilities, the Board is to consider whether any separate compensable disability ratings may be awarded for additional disability stemming from the disabilities. During the course of this appeal, the Veteran was awarded service connection for peripheral neuropathy of the right lower and left upper extremities as related to the service-connected spinal disabilities. As the Veteran did not appeal the initial ratings assigned, the issues of higher initial disability ratings for the service-connected peripheral neuropathy of the right lower and left upper extremities are not before the Board at this time. Further, in November 2009, the Veteran was specifically denied service connection for peripheral neuropathy of the left lower and right upper extremities. As the Veteran did not appeal the denial of service connection, the issues of service connection/separate compensable disability ratings for peripheral neuropathy of the left lower and right upper extremities are not before the Board at this time. Higher Initial Rating for Cervical Spine Disability After a review of all the evidence of record, the Board finds that, for the entire initial rating period on appeal, from September 30, 2008, the service-connected cervical spine disability more nearly approximated painful limitation of forward flexion to 15 degrees or less, without ankylosis or incapacitating episodes having a total duration of at least four weeks in a 12 month period. Per the report of a March 2008 pre-discharge examination, in reviewing the overall musculoskeletal disability picture, the examiner noted that the Veteran did not need an assistive device to move, there were no incapacitating episodes of arthritis, the Veteran did not have difficulty standing or walking, and there was no joint deformity, giving way, instability, weakness, dislocation or subluxation, locking, effusion, or inflammation. There was pain and stiffness in the joints. In May 2008, the Veteran received a Medical Evaluation Board (MEB) examination. Per the examination report, the Veteran advanced having overall pain at a level of five to eight out of ten on the pain scale, with flare-ups of pain to ten out of ten on particularly bad days. Upon range of motion testing, the Veteran had cervical spine flexion to 40 degrees. The Board notes that the MEB report stated that this was the best of three tests. Further, there is no indication that this is the point at which pain set in. As such, the Board finds that, when considering limitation of motion due to pain, including due to flare-ups, flexion may have been limited to approximately 15 degrees or less. At the November 2011 Board videoconference hearing, the Veteran testified to being able to move the neck left and right to 45 degrees each way. The Veteran also testified to not being able to move the neck back, but that it "could go down." The Veteran further testified to having constant pain in the neck. The Veteran received a VA neck examination in March 2012. Per the examination report, the Veteran advanced having constant neck pain at a level of two to three out of ten on the pain scale, with nightly flare-ups reaching seven out of ten. Upon range of motion testing, flexion was to 30 degrees, with objective evidence of painful motion at 30 degrees. There was no change upon repetitive use testing. Other than radiculopathy, no other neurologic abnormalities were identified. Under functional impairment, the Veteran advanced that the neck pain made driving difficult. The Board notes that, when considering the flare-ups of pain, at that time flexion may have been limited to approximately 15 degrees or less. A new VA examination was performed in October 2015. Range of motion testing showed forward flexion to 30 degrees, with objective evidence of painful motion at 30 degrees. Upon examination the Veteran had no radiculopathy, ankylosis, or other neurologic abnormality. A surgical scar was noted; however, the scar was not painful or unstable, and did not take up an area greater than 39 square centimeters. Finally, another VA neck examination was conducted in January 2017. Per the examination report, the Veteran would experience flare-ups of pain. Range of motion testing showed forward flexion limited to 30 degrees; however, the VA examiner did not specifically note where objective evidence of painful motion set in. Upon examination, there was no radiculopathy, ankylosis, or incapacitating episodes. Under functional impairment, the VA examiner noted that the Veteran had difficulty standing or walking for prolonged periods, and the Veteran was unable to lift more than 10 pounds. Having reviewed all the evidence of record, both lay and medical, the Board finds that the evidence reflects that, for the entire initial rating period on appeal, from September 30, 2008, the service-connected cervical spine disability more nearly approximated painful limitation of forward flexion to 15 degrees or less, without ankylosis or incapacitating episodes having a total duration of at least four weeks in the previous 12 months. For all the reasons discussed above, and resolving all reasonable doubt in favor of the Veteran, the Board finds that, when considering flare-ups of pain, the evidence is at least in equipoise on the question of whether forward flexion was limited to 15 degrees or less, warranting a 30 percent disability rating. 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237; DeLuca. The Board has considered whether a disability rating in excess of 30 percent for the cervical spine disability is warranted. First, the evidence of record reflects no ankylosis of the spine, and a disability rating in excess of 30 percent is not warranted on that basis. Second, as to incapacitating episodes due to IVDS, none of the evidence received by VA has conveyed that the Veteran ever had incapacitating episodes with a total duration of four weeks or more during any 12 month period on appeal. As such, a disability rating in excess of 30 percent due to incapacitating episodes is not warranted. For these reasons, the Board finds that the preponderance of the evidence of record is against a finding that a disability rating in excess of 30 percent is warranted at any point during the relevant rating period for the cervical spine disability. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has considered whether the Veteran is entitled to a separate compensable rating for any objective neurologic, or other, disabilities related to the service-connected spinal disabilities. Peripheral neuropathy rating questions have been addressed above. While the evidence reflects that the Veteran has a surgical scar related to prior neck surgery, the evidence does not show that the scar is symptomatic to a compensable level. Additionally, the evidence does not convey any other objective neurologic disabilities related to the service-connected cervical spine disability. For these reasons, the Board does not find that the assignment of a separate compensable rating for any additional disabilities related to the service-connected cervical spine is warranted at this time. Higher Initial Rating for Degenerative Arthritis of the Thoracolumbar Spine Having reviewed all the evidence of record, the Board finds that, for the entire initial rating period on appeal, from September 30, 2008, the service-connected degenerative arthritis of the thoracolumbar spine more nearly approximated painful limitation of motion of the thoracolumbar spine, with flare-ups of pain, resulting in forward flexion of 30 degrees or less, with no ankylosis of the thoracolumbar spine or incapacitating episodes having a total duration of at least six weeks in the previous 12 months. Per the report of a March 2008 pre-discharge examination, in reviewing the Veteran's overall musculoskeletal disability picture, the examiner noted that the Veteran did not need an assistive aid to move, there were no incapacitating episodes of arthritis, the Veteran did not have difficulty standing or walking, and there was no joint deformity, giving way, instability, weakness, dislocation or subluxation, locking, effusion, inflammation, or flare-ups of joint disease. There was pain and stiffness in the joints. In examining the spine, the March 2008 examiner found no IVDS and no other neurologic disorders. In May 2008, the Veteran received a MEB examination. Per the examination report, the Veteran advanced having overall pain at a level five to eight out of ten on the pain scale, with flare-ups of pain to ten out of ten on particularly bad days. Upon range of motion testing, the Veteran had forward flexion to 85 degrees. The Board notes that this was the best of three tests, that no notation was made as to where objective evidence of painful motion set in, and no opinion was rendered as to additional loss of range of motion during a flare-up of pain. Per a subsequent August 2008 service treatment record, both active flexion and active extension of the lumbosacral spine was decreased. Further, the service treatment provider noted that there was pain on motion. Unfortunately, the exact range of motion was not recorded by the service examiner. The Veteran received a VA back examination in March 2012. Per the examination report, the Veteran advanced having low back pain at a level of two to three out of ten on the pain scale. Once per month a flare-up would occur that would raise the pain level to seven out of ten. Upon range of motion testing, the Veteran had flexion to 90 degrees or greater, with objective evidence of painful motion at 80 degrees. Upon examination, muscle strength was full and without atrophy. No other neurologic abnormalities were noted. The Veteran did not have IVDS or any incapacitating episodes. Functional impairment included difficulty walking, standing, sitting, driving, putting on clothing, and gardening. A new VA back examination took place in October 2015. Upon range of motion testing, the Veteran had forward flexion of 60 degrees, which appears to be where objective evidence of painful motion set in. No IVDS, ankylosis, radiculopathy, or other neurologic abnormalities were noted upon examination. Finally, another VA back examination was conducted in January 2017. Per the examination report, the Veteran had difficulty bending, lifting more than 10 pounds, or walking long distances. Range of motion testing again showed forward flexion of 60 degrees, which appears to be where objective evidence of painful motion set in. Upon examination, the Veteran was found to have no radiculopathy, ankylosis, incapacitating episodes, or other neurologic abnormalities. After a review of all the evidence, lay and medical, the Board finds that, for the entire initial rating period on appeal, from September 30, 2008, the service- connected degenerative arthritis of the thoracolumbar spine more nearly approximated painful limitation of motion of the thoracolumbar spine, with flare-ups of pain, resulting in forward flexion of 30 degrees or less, with no ankylosis of the thoracolumbar spine or incapacitating episodes having a total duration of at least six weeks in the previous 12 months, to warrant a 40 percent initial disability rating, but no higher. 38 C.F.R. § 4.71a. There is conflicting evidence as to where objective evidence of painful motion sets in on flexion, and less evidence as to the limitation of motion during a flare-up of pain. Multiple measurements have shown forward flexion limited to at least 60 degrees. Viewing the evidence in the light most favorable to the Veteran, the Board finds that, when considering flare-ups of pain, the evidence is at least in equipoise on the question of whether forward flexion was limited to 30 degrees or less during the initial rating period on appeal. For these reasons, the Board will resolve reasonable doubt in favor of the Veteran to find that, for the entire initial rating period on appeal from September 30, 2008, forward flexion of the lumbar spine was limited to 30 degrees or less due to painful limitation of motion with painful flare-ups, warranting a 40 percent disability rating. 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5239 and 5242; DeLuca. The Board has considered whether a disability rating in excess of 40 percent for the thoracolumbar spine disability is warranted. First, the evidence of record reflects no ankylosis of the spine, and a disability rating in excess of 40 percent is not warranted on that basis. Second, as to incapacitating episodes due to IVDS, none of the evidence received by VA has conveyed that the Veteran ever had incapacitating episodes with a total duration of six weeks or more during any 12 month period on appeal. As such, a disability rating in excess of 40 percent due to incapacitating episodes is not warranted. For these reasons, the Board finds that the preponderance of the evidence of record is against a finding that a disability rating in excess of 40 percent is warranted at any point during the relevant rating period on appeal for the service-connected thoracolumbar spine disability. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Board has considered whether the Veteran is entitled to a separate compensable rating for any objective neurologic, or other, disabilities related to the service-connected thoracolumbar spine disability. Questions concerning peripheral neuropathy have been addressed above. The Board finds that the evidence does not convey any other objective neurologic disabilities related to the service-connected thoracolumbar spine disability. As such, the Board does not find that the assignment of a separate compensable rating for any additional disabilities related to the service-connected thoracolumbar spine disability is warranted at this time. Hip Disability Rating Criteria Disorders of the hips are rated under Diagnostic Codes 5250 through 5255 of 38 C.F.R. § 4.71a. Hip flexion is measured from 0 degrees to 125 degrees; abduction is measured from 0 degrees to 45 degrees. 38 C.F.R. § 4.71a, Plate II. Diagnostic Code 5250 contemplates ankylosis of the hip. Favorable ankylosis in flexion at an angle between 20 degrees and 40 degrees, and slight adduction or abduction warrants a 60 percent rating; intermediate ankylosis warrants a 70 percent rating; and unfavorable ankylosis, which contemplates extremely unfavorable ankylosis, the foot not reaching ground, crutches necessitated, warrants a 90 percent rating. 38 C.F.R. § 4.71a. Under Diagnostic Code 5251 (limitation of extension of the thigh), a 10 percent rating is assigned with extension limited to 5 degrees. Under Diagnostic Code 5252 (limitation of flexion of the thigh), a 10 percent rating is assigned with flexion limited to 45 degrees; a 20 percent rating is assigned with flexion limited to 30 degrees; a 30 percent rating is assigned with flexion limited to 20 degrees; and a 40 percent rating is assigned with flexion limited to 10 degrees. Under Diagnostic Code 5253, pertaining to impairment of the thigh, a 10 percent rating is warranted for limitation of adduction of the thigh such that the legs cannot be crossed or there is limitation of rotation such that it is not possible to toe out more than 15 degrees; a 20 percent rating requires limitation of abduction with motion lost beyond 10 degrees. Id. An 80 percent disability rating will be assigned under Diagnostic Code 5254 when there is a flail joint of the hip. Diagnostic Code 5255 contemplates impairment of the femur. Malunion of the femur warrants a 10 percent rating with slight knee or hip disability, a 20 percent rating with moderate knee or hip disability, and 30 percent rating with marked knee or hip disability. Id. The terms "moderate" and "marked" are not defined in the VA Schedule. Rather than applying a mechanical formula, it is incumbent upon the Board to arrive at an equitable and just decision after having evaluated the evidence. 38 C.F.R. § 4.6 (2017). Terminology such as "moderate" and "marked" used by VA examiners and others, although an element of evidence to be considered by the Board, are not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2017). Initial Hip Disability Rating prior to March 19, 2012 Having reviewed all the evidence of record, the Board finds that, prior to March 19, 2012, the service-connected degenerative arthritis of the right hip was not productive of ankylosis, fracture, malunion, or nonunion of the femur, or flail hip joint, and did not manifest limitation of flexion to 45 degrees, limitation of extension to 5 degrees, or limitation of abduction with motion lost beyond 10 degrees. Per the report of a March 2008 pre-discharge examination, in reviewing the Veteran's overall musculoskeletal disability picture, the examiner noted that the Veteran did not need an assistive aid to move, there were no incapacitating episodes of arthritis, the Veteran did not have difficulty standing or walking, and there was no joint deformity, giving way, instability, weakness, dislocation or subluxation, locking, effusion, inflammation, or flare-ups of joint disease. There was pain and stiffness in the joints. Upon range of motion testing the Veteran had full range of motion in the right hip without any objective evidence of pain. In May 2008 the Veteran received a MEB examination. Per the examination report, the Veteran advanced having overall pain at a level five to eight out of ten on the pain scale, with flare-ups of pain to ten out of ten on particularly bad days. A subsequent August 2008 service treatment record reported that the Veteran had full range of motion in the right hip, with no pain until the end of the motion, or as the service examiner put it, "the extremes." The Veteran received a VA joint examination in January 2009. Per the examination report, the Veteran advanced having hip pain at a level of three to seven out of ten on the pain scale. The Veteran conveyed that the right hip pain made it difficult to get into and out of the bathtub. Range of motion testing showed hip flexion to 110 degrees, with objective evidence of painful motion at 110 degrees. Extension was to six degrees with objective evidence of painful motion at six degrees. Adduction was to 15 degrees, with objective evidence of painful motion at 15 degrees. Abduction was to 25 degrees, with no objective evidence of painful motion. External rotation was to 62 degrees and internal rotation was to 8 degrees, without objective evidence of painful motion on either. After a review of all the evidence, lay and medical, the Board finds that, prior to March 19, 2012, a disability rating in excess of 10 percent was not warranted for the service-connected degenerative arthritis of the right hip. Specifically, the evidence reflects that, prior to March 19, 2012, the service-connected degenerative arthritis of the right hip was not productive of ankylosis, fracture, malunion, or nonunion of the femur, or flail hip joint, and did not manifest limitation of flexion to 45 degrees, limitation of extension to 5 degrees, or limitation of abduction with motion lost beyond 10 degrees. As discussed above, without any of the aforementioned symptoms, a higher initial disability rating (or a separate compensable rating) is not warranted for the relevant rating period prior to March 19, 2012; therefore, because the preponderance of the evidence is against a disability rating in excess of 10 percent for the service-connected degenerative arthritis of the right hip prior to March 19, 2012, a higher initial disability rating must be denied as to this time period. 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Codes 5250-55. Initial Hip Disability Rating from March 19, 2012 Having reviewed all the evidence of record, the Board finds that, from March 19, 2012, the service-connected degenerative arthritis of the right hip was not productive of ankylosis, fracture, malunion, or nonunion of the femur, or flail hip joint, and did not manifest limitation of flexion to 30 degrees or limitation of extension to 5 degrees. The Veteran received a VA hip examination in March 2012. Per the examination report, the Veteran advanced having constant pain in the right hip at a level of three out of ten on the pain scale. During a weekly flare-up, the pain would be at an eight out of ten in severity. Upon range of motion testing, flexion was measured to 90 degrees, with objective evidence of painful motion at 85 degrees. Extension was greater than five degrees, with no objective evidence of painful motion. Examination revealed that abduction was not lost beyond 10 degrees, adduction was not limited such that the Veteran could not cross the legs, and rotation was not limited such that the Veteran could not toe-out more than 15 degrees. These findings did not change upon repetitive use testing. Muscle strength was full, and there was no ankylosis of the hip. Further, there was no malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. At the conclusion of the examination the VA examiner noted that the right hip disability limited walking, lifting, and using stairs. A new VA hip examination was performed in October 2015. Per the examination report, range of motion testing could not be performed at that time, as the Veteran was unable to lie flat on the table. Upon examination, no ankylosis was observed, and there was no malunion or nonunion of the femur, flail hip joint, or any other disability. Finally, the Veteran received a new VA hip examination in January 2017. Range of motion testing showed flexion limited to 115 degrees, which appears to be where painful limitation of motion set in, and full extension, abduction, and adduction. Adduction was limited such that the Veteran could not cross the legs. Both external and internal rotations were full. Muscle strength was full and there was no ankylosis. Further, there was no malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. After a review of all the evidence, lay and medical, the Board finds that, from March 19, 2012, a disability rating in excess of 20 percent was not warranted for the service-connected degenerative arthritis of the right hip. Specifically, the evidence reflects that, from March 19, 2012, the service-connected degenerative arthritis of the right hip was not productive of ankylosis, fracture, malunion, nonunion of the femur, or flail hip joint, and did not manifest limitation of flexion to 30 degrees or limitation of extension to 5 degrees. As discussed above, without any of the aforementioned symptoms, a higher initial disability rating (or a separate compensable rating) is not warranted for the relevant rating period from March 19, 2012; therefore, because the preponderance of the evidence is against a disability rating in excess of 20 percent for the service-connected degenerative arthritis of the right hip from March 19, 2012, a higher initial disability rating must be denied as to this time period. 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Codes 5250-55. Higher Initial Rating for Degenerative Arthritis of the Right Knee The appropriate diagnostic codes for rating limitation of motion of the knees are Diagnostic Codes 5260 and 5261. 38 C.F.R. § 4.71a. Normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. In VAOPGCPREC 9-2004, the VA General Counsel interpreted that when considering Diagnostic Codes 5260 and 5261 together with 38 C.F.R. § 4.71, a veteran may receive a rating for limitation in flexion only, limitation of extension only, or, if the 10 percent criteria are met for both limitations of flexion and extension, separate ratings for limitations in both flexion and extension under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension). Currently, the Veteran's right knee is rated as 10 percent disabling under Diagnostic Code 5003 for painful limitation of flexion due to degenerative arthritis that does not meet the compensable rating criteria under Diagnostic Code 5260. 38 C.F.R. § 4.71a. Under Diagnostic Code 5260, limitation of knee flexion is rated 30 percent disabling where flexion is limited to 15 degrees; 20 percent disabling where flexion is limited to 30 degrees; 10 percent disabling where flexion is limited to 45 degrees; and noncompensable where flexion is limited to 60 degrees. Id. Under Diagnostic Code 5261, limitation of knee extension is rated 50 percent disabling where extension is limited to 45 degrees; 40 percent disabling where extension is limited to 30 degrees; 30 percent disabling where extension is limited to 20 degrees; 20 percent disabling where extension is limited to 15 degrees; 10 percent disabling where extension is limited to 10 degrees; and noncompensable where extension is limited to 5 degrees. Id. Diagnostic Code 5257 contemplates "other impairment" of the knee including recurrent subluxation or lateral instability. Under Diagnostic Code 5257, where impairment is severe, moderate or slight, disability evaluations of 30, 20, and 10 percent are assigned, respectively. Id. Diagnostic Code 5262 contemplates impairment of the tibia and fibula, assigning a 40 percent rating for nonunion of the tibia and fibula, and 10, 20, and 30 percent ratings for slight, moderate or marked knee or ankle disabilities. Id. The words "slight," "moderate," "severe," and "marked" as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." Id. Under Diagnostic Code 5256, ankylosis of the knee that is in the favorable angle in full extension, or is in slight flexion between 0 degrees and 10 degrees, warrants a 30 percent disability rating. Ankylosis of the knee in flexion between 10 degrees and 20 degrees warrants a 40 percent disability rating. Ankylosis of the knee in flexion between 20 degrees and 45 degrees warrants a 50 percent disability rating. Extremely unfavorable ankylosis of the knee, in flexion at an angle of 45 degrees or more, warrants a 60 percent rating. A 60 percent rating is the maximum schedular disability rating available under Diagnostic Code 5256. Id. Diagnostic Codes 5258 and 5259 provide for disability ratings when semilunar cartilage is dislocated and/or removed. Id. Finally, a 10 percent disability rating is assigned under Diagnostic Code 5263 when genu recurvatum is identified. Id. Having reviewed all the evidence of record, the Board finds that, from September 30, 2008, the Veteran's service-connected degenerative arthritis of the right knee has more nearly approximated full extension of the knee, painful limitation of flexion, with flare-ups of pain, in excess of 45 degrees, and no ankylosis, subluxation, lateral instability, dislocation or removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. Per the report of a March 2008 pre-discharge examination, in reviewing the Veteran's overall musculoskeletal disability picture, the examiner noted that the Veteran did not need an assistive aid to move, there were no incapacitating episodes of arthritis, the Veteran did not have difficulty standing or walking, and there was no joint deformity, giving way, instability, weakness, dislocation or subluxation, locking, effusion, inflammation, or flare-ups of joint disease. There was pain and stiffness in the joints. Upon range of motion testing the Veteran had full range of motion of the right knee without any objective evidence of pain. In May 2008, the Veteran received a MEB examination. Per the examination report, the Veteran advanced having overall pain at a level five to eight out of ten on the pain scale, with flare-ups of pain to ten out of ten on particularly bad days. Upon range of motion testing, the Veteran had full extension and flexion limited to 105 degrees. The Veteran received a VA joint examination in January 2009. Per the examination report, the Veteran advanced having right knee pain that went from one to eight out of ten on the pain scale. Upon range of motion testing, the Veteran had flexion of 113 degrees with objective evidence of painful motion at 113 degrees. The knee was stable and had no swelling or tenderness. At the November 2011 Board videoconference hearing, the Veteran testified to having difficulty climbing and descending stairs. The Veteran also testified to having difficulty walking and needing a cane to ambulate. The Veteran received a VA knee examination in March 2012. Per the examination report, the Veteran advanced having knee pain at a level of five to six out of ten on the pain scale. Flare-ups of pain would occur approximately once per month and last five to six hours. Range of motion testing showed flexion to 120 degrees, with objective evidence of painful motion at 120 degrees. Extension was full with no evidence of painful motion. There was no change upon repetitive use testing. Muscle strength was normal and there was no instability, subluxation, or dislocation. The VA examiner reported that the Veteran did not have a meniscal disability. Under functional impairment, the VA examiner noted that the Veteran had pain while walking, squatting, kneeling, and using stairs. A new VA knee examination was performed in October 2015. Range of motion testing showed flexion to 120 degrees, with objective evidence of painful motion at 120 degrees. The Veteran had full extension without objective evidence of pain. Upon examination there was no ankylosis, instability, subluxation, tibial or fibular impairment, meniscal impairment, or any other physical findings. The Veteran was noted to use a knee brace in addition to a cane. Finally, the Veteran received another VA knee examination in January 2017. Per the examination report, the Veteran advanced that the knee pain was at a five or six out of ten on the pain scale at worst, with some flare-ups of pain, and that the pain occurred with walking, climbing stairs, kneeling, and squatting. Upon range of motion testing, the Veteran had full extension and flexion limited to 120 degrees, which appears to be the point at which painful limitation of motion sets in. There was no ankylosis, instability, meniscal problems, muscle atrophy, or other symptoms on examination. Having reviewed all the evidence of record, both lay and medical, the Board finds that, for the entire initial rating period on appeal, from March 19, 2012, the service-connected degenerative arthritis of the right knee has more nearly approximated full extension of the knee, painful limitation of flexion, with flare-ups of pain, in excess of 45 degrees, and no ankylosis, subluxation, lateral instability, dislocation or removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. As the evidence reflects that the Veteran does not have ankylosis of the right knee, recurrent subluxation or lateral instability, removal or dislocation of semilunar cartilage, tibia or fibula impairment, or genu recurvatum, a higher initial (or separate compensable) disability rating is not warranted under Diagnostic Codes 5256, 5257, 5258, 5259, 5262, or 5263. 38 C.F.R. § 4.71a. Further, as the evidence reflects that the Veteran has full extension in the right knee/leg, a higher initial (or separate compensable) disability rating is not warranted under Diagnostic Code 5261. Id. As no higher initial (or separate compensable) disability ratings can be assigned under the other rating criteria, the Board must consider whether a disability rating in excess of 10 percent is warranted under Diagnostic Code 5260 for painful limitation of flexion. Under Diagnostic Code 5260, for a 20 percent disability rating (the next highest) to be warranted, flexion would have to be limited to at least 30 degrees. Even considering the Veteran's painful limitation of motion, to include during a painful flare-up, the evidence simply does not reflect a limitation of flexion to that level. During the relevant period on appeal, at its worst, flexion was limited to 113 degrees. The Board has considered additional loss of range of motion due to flare-ups of pain; however, nothing in the record reflects that the flare-ups are so drastic as to reduce flexion to at least 30 degrees (an over 80 degree change). For these reasons, a rating of 20 percent or higher is not warranted in this case because, even when flare-ups of pain are considered, flexion of the right knee is not limited to 30 degrees or less. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260; DeLuca at 206-07. As the preponderance of the evidence is against the claim for a higher initial disability rating in excess of 10 percent for degenerative arthritis of the right knee, the claim for a higher initial disability rating must be denied. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256-63; DeLuca. Initial Ratings for Degenerative Arthritis of the Right and Left Shoulders Under Diagnostic Code 5200, ratings of 30, 40, and 50 percent may be assigned when there is ankylosis of scapulohumeral articulation. 38 C.F.R. § 4.71a. Under Diagnostic Code 5201, a 20 percent disability rating is warranted for limitation of motion of the major and minor arm at shoulder level, a 30 percent disability rating is warranted for limitation of motion of the major arm midway between side and shoulder level, while a 20 percent rating is warranted for the minor arm, and a 40 percent disability rating is warranted for limitation of motion of the major arm to 25 degrees from the side, while a 30 percent rating is warranted for the minor arm. Id. Under Diagnostic Code 5203, a 20 percent disability rating is warranted when there is nonunion of the clavicle or scapula with loose movement or dislocation of the clavicle or scapula. Id. Under Diagnostic Code 5202, a 20 percent disability rating is warranted when there is recurrent dislocation of the humerus at the scapulohumeral joint with infrequent episodes and guarding of movement only at the shoulder level, or malunion of the humerus with moderate deformity. A 30 percent disability rating is warranted when there is recurrent dislocation of the humerus at the scapulohumeral joint with frequent episodes and guarding of all arm movements, or malunion of the humerus with marked deformity. A 50 percent disability rating is warranted when there is fibrous union of the humerus of the major arm, a 60 percent disability rating is warranted when there is nonunion of the humerus (false flail joint) of the major arm, and an 80 percent disability rating is warranted when there is loss of head of the humerus (flail shoulder) of the major arm. Id. Most of the aforementioned ratings are 10 percent lower for the minor arm. Id. Having reviewed all the evidence of record, the Board finds that, for the entire initial rating period on appeal from September 30, 2008, the service-connected degenerative arthritis of the right and left shoulders did not manifest as recurrent dislocation of the humerus at the scapulohumeral joint, malunion of the humerus, fibrous union of the humerus, nonunion of the humerus, loss of head of the humerus, or ankylosis of scapulohumeral articulation; and painful limitation of motion, even when considering flare-ups of pain, was not limited to midway between the side and shoulder level. Per the report of a March 2008 pre-discharge examination, in reviewing the Veteran's overall musculoskeletal disability picture, the examiner noted that the Veteran did not need an assistive aid to move, there were no incapacitating episodes of arthritis, the Veteran did not have difficulty standing or walking, and there was no joint deformity, giving way, instability, weakness, dislocation or subluxation, locking, effusion, inflammation, or flare-ups of joint disease. There was pain and stiffness in the joints. Upon range of motion testing, the right shoulder had forward flexion limited to 160 degrees and abduction limited to 170 degrees, without objective evidence of pain, and full external and internal rotation. There was also full range of motion in the left shoulder without objective evidence of pain. In May 2008, the Veteran received a MEB examination. Per the examination report, the Veteran advanced having overall pain at a level five to eight out of ten on the pain scale, with flare-ups of pain to ten out of ten on particularly bad days. Range of motion testing of the right shoulder revealed 105 degrees of abduction, 140 degrees of forward flexion, 20 degrees of extension, and internal rotation to the level of the back pocket. As to the left shoulder, there was 120 degrees of abduction, 170 degrees of forward flexion, 30 degrees of extension, and internal rotation to the upper lumbar spine level. Upon examination muscle strength was full. The Veteran received a VA joint examination in January 2009. Per the examination report, the Veteran advanced having bilateral shoulder pain that went from five to eight out of ten on the pain scale. Examination showed no swelling, erythema, or tenderness of either shoulder. Upon range of motion testing of the right shoulder, the Veteran had forward flexion to 170 degrees, with objective evidence of painful motion at 170 degrees. Abduction was to 135 degrees, with objective evidence of painful motion at 135 degrees. External rotation was to negative 18 degrees with pain, and internal rotation was to 78 degrees without pain. Upon range of motion testing of the left shoulder, the Veteran had forward flexion to 180 degrees, with objective evidence of painful motion at 180 degrees. Abduction was to 145 degrees, with objective evidence of painful motion at 145 degrees. External rotation was at 0 degrees with objective evidence of painful motion at negative 5 degrees, and internal rotation was to 115 degrees without pain. At the November 2011 Board videoconference hearing, the Veteran testified to having painful limitation of motion in the both shoulders. When asked where pain set in, the Veteran lifted the arms to just above shoulder level. The Veteran received a VA shoulder examination in March 2012. Per the examination report, the Veteran advanced having right shoulder pain at a level of four out of ten on the pain scale, with monthly flare-ups at a level of five to seven out of ten, and left shoulder pain at a level of one to two out of ten on the pain scale, with monthly flare-ups at a level of four out of ten. Upon range of motion testing of the right shoulder, flexion was to 145 degrees, with objective evidence of painful motion at 145 degrees. Abduction was to 140 degrees, with objective evidence of painful motion at 140 degrees. Upon repetitive use testing, flexion was reduced to 130 degrees, and abduction was reduced to 110 degrees. Range of motion testing of the left shoulder showed flexion was to 155 degrees, with objective evidence of painful motion at 155 degrees. Abduction was to 160 degrees, with objective evidence of painful motion at 160 degrees. Upon repetitive use testing, flexion was reduced to 155 degrees, and abduction was reduced to 130 degrees. Examination revealed localized tenderness and guarding of the shoulders. Muscle strength was normal and there was no ankylosis. There was no history of recurrent dislocation of the glenohumeral joint, and there was no malunion or nonunion of the clavicle or scapula. Under functional impairment, the VA examiner stated that the Veteran could not lift 20 pounds, was unable to throw a ball, and had difficulty raising the arms above the head. A new VA shoulder examination was conducted in October 2015. Per the Veteran, when a flare-up occurred, the pain was severe and the Veteran could not lift the arms very high. Range of motion testing of the right shoulder showed painful limitation of flection to 100 degrees, painful limitation of abduction to 100 degrees, painful external rotation to 40 degrees, and painful internal rotation to 60 degrees. Range of motion testing of the left shoulder showed painful limitation of flection to 140 degrees, painful limitation of abduction to 120 degrees, painful external rotation to 60 degrees, and painful internal rotation to 60 degrees. Upon examination, the VA examiner noted that the Veteran had interference with the use of the arms over shoulder height. No ankylosis was present. At the conclusion of the examination the VA examiner opined that the Veteran would be unable to work with the arms at shoulder height for any amount of time. Finally, the Veteran received another VA shoulder examination in January 2017. Per the examination report, the Veteran advanced having constant pain in the right shoulder at a level of four out of ten on the pain scale. The Veteran also conveyed being unable to lift more than 20 pounds and having difficulty reaching overhead. Range of motion testing of the right shoulder showed that both flexion and abduction were limited to 145 degrees, which appears to be where pain set in, and both external and internal rotation showed full range of motion. As to the left shoulder, both flexion and abduction were limited to 155 degrees, which appears to be where pain set in, and both external and internal rotation showed full range of motion. Upon examination it was noted that the Veteran experienced flare-ups of pain. The Veteran had full muscle strength, and there was no ankylosis, instability, clavicle, scapula, acromioclavicular or sternoclavicular joint disabilities, impairment of the humerus, or any other relevant findings. Under functional impairment, it was noted that the Veteran would not be able to work at shoulder height for any amount of time. Upon review of all the evidence of record, the Board finds that the preponderance of the evidence is against the assignment of an increased disability rating in excess of 20 percent for the service-connected right and/or left shoulder disabilities at any point during the relevant period on appeal. The evidence shows that, from September 30, 2008, the service-connected right and left shoulder disabilitys did not manifest as recurrent dislocation of the humerus at the scapulohumeral joint, malunion of the humerus, fibrous union of the humerus, nonunion of the humerus, loss of head of the humerus, or ankylosis of scapulohumeral articulation. Pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5200 and 5202, a disability rating in excess of 20 percent would only be warranted if there were recurrent dislocation of the humerus, fibrous union of the humerus, nonunion of the humerus, loss of head of the humerus, and/or ankylosis of scapulohumeral articulation. 38 C.F.R. § 4.71a. The evidence of record does not reflect any such findings. Further, an increased disability rating is not warranted under Diagnostic Code 5203, as the evidence does not reflect impairment of the clavicle or scapula in the right or left shoulder, and the maximum schedular rating under Diagnostic Code 5203 is 20 percent. Id. The Board has also considered whether a higher initial rating is warranted under Diagnostic Code 5201 for painful limitation of motion. The Veteran is rated under Diagnostic Code 5201 in both shoulders for limitation of motion at the shoulder level (approximately 90 degrees out of 180 degrees). A higher initial rating would only be warranted, at least as to the major extremity, if motion were limited to midway between the side and shoulder level (approximately 45 of 180 degrees). Range of motion testing throughout the course of this appeal, VA and private medical records, and the Veteran's own statements, show that, even during painful flare-ups, the Veteran's limitation of motion does not manifest until the arms reach approximately shoulder level. The evidence does not reflect, and the Veteran does not contend, that, even during a painful flare-up, the right and left arms cannot be raised higher than midway between the side and shoulder level. As such, a disability rating of 30 percent or higher under Diagnostic Code 5201 is not warranted. Id. As the preponderance of the evidence is against the a higher initial disability rating in excess of 20 percent for the service-connected right and left shoulder disabilities, the claim for a higher disability rating in excess of 20 percent for the service- connected right shoulder disability from September 30, 2008 must be denied. 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Diagnostic Codes 5200-03. Initial Ratings for Degenerative Arthritis of the Right and Left Feet The Veteran's left and right foot arthritis is rated under Diagnostic Code 5284 for foot injuries. Diagnostic Code 5284 provides a 10 percent rating for impairment of moderate degree, a 20 percent rating for moderately severe impairment, and a 30 percent rating for severe impairment. 38 C.F.R. § 4.71a. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104 (2012); 38 C.F.R. §§ 4.2, 4.6. In addressing the question of whether higher initial disability ratings can be assigned for the right and left foot, the Board has considered the other available diagnostic codes for disabilities of the foot that offer disability ratings in excess of 10 percent. This includes Diagnostic Code 5278 for claw foot (pes cavus); however, as will be discussed below, the evidence of record does not reflect that the Veteran has a claw foot deformity. As such, a higher initial disability rating under Diagnostic Code 5278 is not warranted. 38 C.F.R. § 4.71a. Further, under Diagnostic Code 5283, a disability rating in excess of 10 percent may be granted when there is malunion or nonunion of the tarsal or metatarsal bones; however, again, as will be discussed below, the evidence of record does not reflect that the Veteran has tarsal or metatarsal involvement. As such, a higher initial disability rating under Diagnostic Code 5283 is not warranted. Id. The Board notes that a disability rating in excess of 10 percent can also be awarded under Diagnostic Code 5276 for flat foot (pes planus); however, in a November 2009 rating decision, the Veteran was explicitly denied service connection for pes planus of both the right and left foot. As the Veteran did not appeal this denial, the issue is not before the Board, and the Board will not consider whether a higher initial disability rating could be assigned under Diagnostic Code 5276. For the above reasons, the only remaining question before the Board is whether a higher initial disability rating is warranted under Diagnostic Code 5284. Having reviewed all the evidence of record, lay and medical, the Board finds that neither the Veteran's right foot nor left foot disabilities reflected moderately severe or severe symptomatology at any point during the relevant period on appeal. Per the report of a March 2008 pre-discharge examination, in reviewing the Veteran's overall musculoskeletal disability picture, the examiner noted that the Veteran did not need an assistive aid to move, there were no incapacitating episodes of arthritis, the Veteran did not have difficulty standing or walking, and there was no joint deformity, giving way, instability, weakness, dislocation or subluxation, locking, effusion, inflammation, or flare-ups of joint disease. There was pain and stiffness in the joints. In examining both feet, the examiner found no symptoms other than pain. Upon examination, both feet had no painful movement, swelling, tenderness, instability, weakness, abnormal weight bearing, hallux valgus or rigidus, pes cavus, muscle atrophy, or malunion or nonunion of the tarsal or metatarsal bones. The Veteran received a VA foot examination in January 2009. Per the examination report, the Veteran advanced having pain in both feet that would fluctuate between one and eight out of ten on the pain scale. The Veteran advanced using a cane and custom orthotics. The foot pain made it difficult to enter and exit the bathtub, but had no other impact on the activities of daily living. Upon examination of the feet they were found to be symmetrical with no evidence of swelling, tenderness, or erythema. Posterior tibial and dorsal pedal pulsations were normal, and there were full motor and sensory responses of the feet. The Veteran had full range of motion in both feet. At the November 2011 Board videoconference hearing, the Veteran testified to having the sensation of pins and needles in the feet; however, the Veteran was unsure if the pins and needles were due to the arthritis or diabetes mellitus. The Veteran also testified to having foot pain, particularly after walking. The Veteran received a VA foot examination in March 2012. Per the examination report, the Veteran advanced having pain and pins in needles in both feet. Flare-ups of pain would occur every other month, with the pain ranging anywhere from two to seven out of ten on the pain scale. Upon examination, the fourth toe of each foot was hammered, and the Veteran had nonsymptomatic hallux valgus. Under functional impact, it was noted that the foot symptoms limited the Veteran's walking. A new VA foot examination was conducted in October 2015. Per the report, the Veteran advanced having pain in both feet, particularly while walking. The Veteran conveyed that the foot pain prevented standing for more than five minutes or walking for more than one block. Again, the fourth toe on each foot was found to be hammered. Upon examination, the VA examiner found pain on movement, pain on weight bearing, instability of station, disturbance of locomotion, interference with standing, and lack of endurance. Finally, the Veteran received another VA foot examination in January 2017. Per the examination report, the Veteran advanced having pain when walking. Upon examination, it was noted that the fourth toe on each foot was hammered. Further, there was no hallux valgus, pes cavus, or malunion or nonunion of the tarsal or metatarsal bones. The Veteran did have pain in both feet, instability of station, disturbance of locomotion, and lack of endurance. It was noted that the Veteran would experience flare-ups of pain that would significantly limit the ability to walk and stand for any significant period of time. When considering the above symptoms, the Board finds that they are more in line with a "moderate" symptomatology in each foot, which warrants a 10 percent disability rating for each foot under Diagnostic Code 5284. 38 C.F.R. § 4.71a. While the Veteran has shown difficulty with a number of activities of daily life, such as walking and bathing, the evidence reflects that these difficulties have also been attributed to the Veteran's numerous other service-connected orthopedic disabilities. As such, the Board finds that, focusing only on the feet, the evidence reflects that the foot disabilities alone have little more than a moderate effect on the activities of daily living. Concerning the symptoms themselves, the foot disabilities have primarily manifested as pain, a feeling of pins and needles, instability of station, disturbance of locomotion, and lack of endurance. Having reviewed all the relevant evidence of record, including the VA foot examination reports, the VA and private medical records, and the Veteran's own lay statements, the Board finds that nothing in the record indicates that these symptoms have manifested to more than a moderate level as contemplated by the rating schedule. The evidence of record, both lay and medical, in the context of the history of this disability, reflects that for the entire initial rating period on appeal, from September 30, 2008, the service-connected degenerative arthritis of the right and left feet did not manifest as claw foot (pes cavus), malunion or nonunion of the tarsal or metatarsal bones, or overall symptomatology of at least a moderately severe level. As the preponderance of the evidence is against a disability rating in excess of 10 percent for the service-connected right foot disability and the service-connected left foot disability, the increased disability rating claim must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Codes 5278, 5283-84. Extraschedular Referral Consideration The Board has also considered whether an extraschedular rating is warranted for any of the service-connected orthopedic disabilities on appeal. Ratings shall be based as far as practicable upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular ratings are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). The Court has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances). Second, if the schedular rating does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Thun v. Peake, 22 Vet. App. 111 (2008). However, the Board gives no deference to the Director's adjudication and the Board is permitted to exercise jurisdiction over the question of entitlement to an extraschedular rating whether or not the Director of the Compensation and Pension Service finds an extraschedular rating warranted. See Kuppamala v. McDonald, 27 Vet. App. 447 (2015) (applying principles announced in Wages to 38 C.F.R. § 3.321(b) extraschedular adjudication, namely, Director of C&P decision is not evidence, and is not a policy decision, but is simply a decision or adjudication that is adopted by the RO and reviewed de novo by the Board); Cf. Wages v. McDonald, 27 Vet. App. 233 (2015) (holding that a decision of TDIU under 38 C.F.R. § 4.16(b) by the Director of C&P is not evidence, and is not a policy decision, but is simply a decision or adjudication that is adopted by the RO and reviewed de novo by the Board). With respect to the first prong of Thun, the Veteran's orthopedic disabilities primarily manifested as symptoms including painful limitation of motion with flare-ups, and difficulties with activities of such as standing, sitting, walking, bending, driving, dressing, bathing, sleeping, and using stairs. As discussed above, painful limitation of motion with painful flare-ups is specifically considered under the schedular rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202 (additional limitation of motion due to orthopedic factors are incorporated as part of the schedular rating criteria). Further, any functional limitations imposed by the Veteran's orthopedic disabilities are primarily the result of the pain, including flare-ups, caused by engaging in these activities; therefore, consistent with DeLuca, the effects of the Veteran's orthopedic pain and associated limitations on occupational and daily life are specifically contemplated by the schedular criteria. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the functional limitations and the effects on daily life. According to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be entitled to "consideration [under 38 C.F.R. § 3.321(b)] for referral for an extra-schedular evaluation based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular evaluations." Referral for an extraschedular rating under 38 C.F.R. § 3.321(b) is to be considered based upon either a single service-connected disability or upon the "combined effect" of multiple service-connected disabilities when the "collective impact" or "compounding negative effects" of the service-connected disabilities, when such presents disability not adequately captured by the schedular ratings for the service-connected disabilities. In this case, the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. Comparing the Veteran's disability level and symptomatology of the orthopedic disabilities to the rating schedule, the degree of disability throughout the entire period under consideration is contemplated by the rating schedule; therefore, the assigned ratings are adequate. Absent any exceptional factors associated with the orthopedic disabilities, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court stated that a claim for a total disability rating based on individual unemployability (TDIU) due to service-connected disability is part and parcel of an increased rating claim when such claim is raised by the record. In this case, while the Veteran has been in receipt of a combined 100 percent rating since the day after separation from service, he is not precluded from eligibility for a TDIU based on a single disability. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011). As such, the Board has considered whether an inferred claim for a TDIU under Rice has been raised. Per the above, the evidence conveys that the Veteran has not worked since separating from service. In this case, the evidence, both lay and medical, does not suggest that the Veteran's unemployability is solely due to the service-connected orthopedic disabilities. SSA records indicate that the Veteran is unable to work based on the service-connected cognitive disorder, which is not in appellate status. Further, a VA examiner at a July 2015 VA posttraumatic stress disorder (PTSD) examination assessed that, while the Veteran was totally occupationally and socially impaired, such impairment was half due to traumatic brain injury (TBI) residuals (including the service-connected migraine headaches), while the other half was due to the service-connected PTSD. In a July 2015 VA Form 21-8940, the Veteran advanced being unemployable due the service-connected PTSD, cognitive disorder, and TBI residuals. Further, neither the Veteran, nor any VA examiner, nor the other evidence of record indicates that any one of the Veteran's service-connected orthopedic disabilities would prevent obtaining or maintaining substantially gainful employment alone. For these reasons, the Board finds that neither the Veteran nor the evidence suggests that any of the service-connected orthopedic disabilities alone would warrant granting a TDIU to invoke a claim for TDIU based on any one service-connected disability, as required to meet the exception under Buie. Moreover, the Board notes that in its June 2015 decision it found that Buie and Rice did not apply. This finding was not challenged by the Veteran before the Court in the April 2016 JMR. ORDER For the entire initial rating period on appeal, from September 30, 2008, a higher initial disability rating of 30 percent for the service-connected cervical spine disability, but no higher, is granted. For the entire initial rating period on appeal, from September 30, 2008, a higher initial disability rating of 40 percent for the service-connected degenerative arthritis of the thoracolumbar spine, but no higher, is granted. Prior to March 19, 2012, a higher initial disability rating in excess of 10 percent for degenerative arthritis of the right hip is denied. From March 19, 2012, a higher initial disability rating in excess of 20 percent for degenerative arthritis of the right hip is denied. (CONTINUED ON NEXT PAGE) For the entire initial rating period on appeal, from September 30, 2008, a higher initial disability rating in excess of 10 percent for degenerative arthritis of the right knee is denied. For the entire initial rating period on appeal, from September 30, 2008, a higher initial disability rating in excess of 20 percent for degenerative arthritis of the right shoulder is denied. For the entire initial rating period on appeal, from September 30, 2008, a higher initial disability rating in excess of 20 percent for degenerative arthritis of the left shoulder is denied. For the entire initial rating period on appeal, from September 30, 2008, a higher initial disability rating in excess of 10 percent for degenerative arthritis of the right foot is denied. For the entire initial rating period on appeal, from September 30, 2008, a higher initial disability rating in excess of 10 percent for degenerative arthritis of the left foot is denied. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs