Citation Nr: 1806241 Decision Date: 01/31/18 Archive Date: 02/07/18 DOCKET NO. 94-05 741 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to a higher initial rating for degenerative arthritis of the left wrist, evaluated as 0 percent disabling from February 6, 1992, through March 10, 2013, and as 10 percent disabling on and after March 11, 2013. 2. Entitlement to a higher initial rating for degenerative arthritis of the left elbow, evaluated as 0 percent disabling from February 11, 1992, through March 10, 2013, and as 10 percent disabling on and after March 11, 2013. 3. Entitlement to a higher initial evaluation for a left knee disability, to include left knee osteoarthritis and status post left total knee replacement, evaluated as 10 percent disabling from September 27, 1993, through September 26, 2011, and as 30 percent disabling on and after November 1, 2012. 4. Entitlement to a higher initial rating for neuralgia of the left radial nerve, evaluated as 0 percent disabling from February 6, 1992, through June 13, 2005, and as 20 percent disabling on and after June 14, 2005. 5. Entitlement to a higher initial rating for neuralgia of the left median nerve, evaluated as 0 percent disabling from February 6, 1992, through June 13, 2005, and as 10 percent disabling on and after June 14, 2005. 6. Entitlement to an effective date prior to June 14, 2005, for the grant of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Sean A. Ravin, Attorney at Law WITNESS AT HEARING ON APPEAL Dr. E.T. ATTORNEY FOR THE BOARD Elizabeth Jalley, Counsel INTRODUCTION The Veteran had active duty service from October 1961 to August 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 2013, March 2014, and December 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The March 2013 rating decision granted the claims of entitlement to service connection for disabilities of the left wrist and the left elbow. It assigned 0 percent (noncompensable) ratings for each of these disabilities effective from June 13, 2012, and 10 percent ratings for each of these disabilities effective from March 11, 2013. A notice of disagreement with the disability ratings and effective dates was received in September 2013, a statement of the case was issued in March 2014, and a substantive appeal was received in May 2014. In the course of this appeal, the Board, in its August 2016 decision and remand, granted an effective date of February 6, 1992, for the left wrist disability and an effective date of February 11, 1992, for the left elbow disability. In its December 2016 decision that effectuated the Board's decision, the RO assigned a 0 percent rating for the left wrist disability from February 6, 1992, through March 10, 2013. The RO assigned a 0 percent rating for the left elbow disability from February 6, 1992, through March 10, 2013. The claims of entitlement to earlier effective dates for disabilities of the left wrist and the left elbow have thus been resolved by the Board and are no longer on appeal. The August 2016 Board decision remanded the claims of entitlement to increased ratings for the left wrist and left elbow disabilities for additional development, and these issues have been returned to the Board for further appellate review. The March 2014 rating decision effectuated a March 2014 Board grant of entitlement to service connection for a left knee disability. It assigned a 10 percent rating effective June 14, 2005, a 100 percent rating effective September 27, 2011, and a 30 percent rating effective November 1, 2012. A notice of disagreement with the disability ratings and effective dates (other than the period that has been assigned the 100 percent rating) was received in May 2014, a statement of the case was issued in September 2014, and a substantive appeal was received in November 2014. The August 2016 Board decision also granted entitlement to an effective date of September 27, 1993, for the grant of entitlement to service connection for the left knee disability. In its December 2016 decision that effectuated the Board's decision, the RO assigned a 10 percent rating from September 27, 1993. The claim of entitlement to an earlier effective date for a left knee disability has thus been resolved by the Board and is no longer on appeal. The August 2016 Board decision remanded the claim of entitlement to an increased rating for the left knee disability for additional development, and this issue has been returned to the Board for further appellate review. The March 2014 Board decision also awarded a separate 20 percent rating for neuralgia of the left radial nerve and a separate 10 percent rating for neuralgia of the left median nerve. Unless the Chairman of the Board orders reconsideration (or pursuant to those exceptions identified in 38 C.F.R. § 20.1100(b)), all Board decisions are final on the date stamped on the face of that decision. 38 C.F.R. § 20.1100(a) (2017); see also 38 U.S.C. § 7103(a) (2012). The Veteran did not appeal the Board's decision to the Court. See 38 U.S.C. § 7266 (2012) (a person adversely affected by a final decision of the Board has 120 days to file Notice of Appeal to the Court). Thus, the March 2014 Board decision is final with respect to the award of the 20 percent rating for neuralgia of the left radial nerve and the 10 percent rating for neuralgia of the left median nerve; it is also final with respect to the implementation of that award by the RO in a March 2014 rating decision. 38 U.S.C. §§ 511 (a), 7103(a), 7104(a), 7252, 7261, 7266 (2012); 38 C.F.R. §§ 3.160 (d)(2), 20.1100 (2017). For this reason, the Board's actions were premature when it addressed those issues in the body of its August 2016 remand and in the instruction paragraphs contained therein. Although the RO inadvertently furnished the Veteran the September 2014 statement of the case that addressed the ratings, which was not in accordance with the laws and regulations that govern final board decisions and appeals thereof, the Board nonetheless moved forward with the appeal concerning these discrete issues when it accepted the May 2014 notice of disagreement and November 2014 VA Form 9 substantive appeal (following the issuance of the September 2014 statement of the case) and formally remanded the appeal of those same issues. As a remedy, in order to accord the Veteran due and fair process, and in accordance with 38 C.F.R. § 20.2 and 20.102(b), the Board expands its jurisdictional authority to include these issues at this time, and thus they are listed on the cover page of this decision. Given that the Board's present adjudication of these issues does not result in a reduction of the Veteran's benefits, the Board finds that there is no prejudice to the Veteran in assuming jurisdiction of these increased rating issues. The December 2016 rating decision also effectuated the Board's August 2016 grant of entitlement to a TDIU and assigned an effective date of June 14, 2005. The Veteran filed a notice of disagreement with the effective date that was assigned by the RO. The Veteran was issued a statement of the case in October 2017, and the Veteran's substantive appeal was received in December 2017. In April 2016, a vocational rehabilitation consultant and psychologist testified on the Veteran's behalf with respect to the TDIU issue before the undersigned Veterans Law Judge (VLJ) at the Central Office in Washington, DC. A copy of the hearing transcript has been associated with the claims file. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. Throughout the appeals period, the Veteran's left wrist disability has been manifested by pain, but not by ankylosis. 2. From February 11, 1992, through March 16, 2010, and on and after June 13, 2012, the Veteran's left elbow disability has manifested in painful motion but has not manifested in limitation of flexion to 90 degrees or less. 3. From March 17, 2010, through June 12, 2012, the Veteran's left elbow disability manifested in limitation of flexion to 90 degrees. 4. From September 27, 1993, through September 26, 2011, the Veteran's left knee disability was manifested by objective evidence of painful movement, extension that was limited to no more than zero degrees and flexion that was limited to no less than 90 degrees, even in contemplation of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement, repetitive motion, or flare-ups, and does not result in dislocation of semilunar cartilage, ankylosis, impairment of the tibia or fibula, or genu recurvatum. 5. On and after November 1, 2012, the Veteran's left knee disability, status post total knee replacement, is manifested by residual pain and limitation of motion, but not by severe pain or weakness; ankylosis; limitation of extension to 30 degrees or more; or nonunion of the tibia and fibula with loose motion, requiring a brace. 6. Throughout the appeals period, the Veteran's neuralgia of radial nerve has been manifested by no more than mild, incomplete paralysis. 7. Throughout the appeals period, the Veteran's neuralgia of median nerve has been manifested by no more than mild, incomplete paralysis. 8. As of September 27, 1993, the Veteran's service-connected disabilities have been shown to prevent him from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. From February 6, 1992, through March 10, 2013, the criteria for a rating of 10 percent, but no higher, for a left wrist disability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5214, 5215 (2017). 2. On and after March 11, 2013, the criteria for a rating in excess of 10 percent for a left wrist disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5214, 5215 (2017). 3. From February 11, 1992, through March 16, 2010, the criteria for a rating of 10 percent, but no higher, for a left elbow disability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5206, 5207, 5208 (2017). 4. From March 17, 2010, through June 12, 2012, the criteria for a rating of 20 percent, but no higher, for a left elbow disability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5206, 5207, 5208 (2017). 5. From June 13, 2012, through March 10, 2013, the criteria for a rating of 10 percent, but no higher, for a left elbow disability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5206, 5207, 5208 (2017). 6. On and after March 11, 2013, the criteria for a rating in excess of 10 percent for a left elbow disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5206, 5207, 5208 (2017). 7. From September 27, 1993, through September 26, 2011, the criteria for a rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261 (2017). 8. On and after November 1, 2012, the criteria for a rating in excess of 30 percent for the Veteran's left total knee replacement have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5055, 5256, 5261, 5262 (2017). 9. From February 6, 1992, through June 13, 2005, the criteria for a rating of 20 percent, but no higher, for neuralgia of the radial nerve have been met. 38 U.S.C. §§ 1155 , 5107 (2012); 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Code 8714 (2017). 10. On and after June 14, 2005, the criteria for a rating in excess of 20 percent for neuralgia of the radial nerve have not been met. 38 U.S.C. §§ 1155 , 5107 (2012); 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Code 8714 (2017). 11. From February 6, 1992, through June 13, 2005, the criteria for a rating of 10 percent, but no higher, for neuralgia of the median nerve have been met. 38 U.S.C. §§ 1155 , 5107 (2012); 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Code 8714 (2017). 12. On and after June 14, 2005, the criteria for a rating in excess of 10 percent for neuralgia of the median nerve have not been met. 38 U.S.C. §§ 1155 , 5107 (2012); 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Code 8714 (2017). 13. On and after September 27, 1993, the criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 1507, 5110, 7105 (2012); 38 C.F.R. § 3.400, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) imposes on VA a duty to provide notice of how to substantiate a claim and to assist in evidentiary development. VA's duty to notify as to the original claims for service connection and TDIU were satisfied. See 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). VCAA notice is not required as to the downstream elements of the assignment of the initial disability ratings and an earlier effective date for TDIU. See VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). All relevant, obtainable evidence has been associated with the claims file to fulfill VA's duty to assist. 38 U.S.C. § 5103A. I. Increased Ratings Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (2012); 38 C.F.R. § Part 4 (2017). Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7 (2017). Evidence to be considered in the appeal of an initial assignment of a disability rating is not limited to that reflecting the then-current severity of the disorder. Fenderson v. West, 12 Vet. App. 119 (1999). "Staged ratings," or different percentage evaluations for separate periods based on the facts found, may also be awarded. Id. at 126-127. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, degenerative arthritis, when substantiated by x-rays, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Evaluation of a disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain, weakness, fatigability, incoordination, or pain on movement. 38 C.F.R. §§ 4.40, 4.45. See, in general, DeLuca v. Brown, 8 Vet. App. 202 (1995). However, pain itself does not constitute functional loss. In order to constitute functional loss, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance." Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). Joints that are actually painful, unstable, or malaligned due to healed injury are entitled to at least the minimum compensable rating. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). A. Left Wrist From February 6, 1992, through March 10, 2013, the Veteran was in receipt of a noncompensable (0 percent) rating for his service-connected degenerative arthritis of the left wrist. On and after March 11, 2013, he has been in receipt of a 10 percent rating for that disability. These ratings have been assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5003. The evidence of record reflects that the Veteran has had pain in his left wrist throughout the appeals period. (See October 1993 VA examination report.) The Board therefore finds that a 10 percent rating is warranted throughout the appeals period pursuant to 38 C.F.R. § 4.59. The Board finds that a rating in excess of 10 percent is not warranted at any point. Disabilities of the wrist are rated under Diagnostic Codes 5214 (ankylosis) and 5215 (limitation of motion). "Ankylosis" is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary p. 93 (30th ed. 2003). In the case at hand, higher ratings cannot be assigned under either diagnostic code, as the Veteran does not have ankylosis (Diagnostic Code 5214), and the diagnostic code for limitation of motion (Diagnostic Code 5215) does not allow for a rating in excess of 10 percent. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the assignment of a rating in excess of 10 percent, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Therefore, entitlement to a rating in excess of 10 percent must be denied. The Board notes that, in his September 2017 Informal Hearing Presentation, the Veteran's representative noted that no retrospective opinion on the severity of the Veteran's left wrist disability from 1992 to the present had been obtained. He noted that the Agency of Original Jurisdiction (AOJ) had been directed to obtain such an opinion in the Board's August 2016 remand. However, given that the Board is granting a 10 percent rating effective from 1992, the only way that the Veteran may receive an even higher rating is by a showing of ankylosis. There is no suggestion of ankylosis at any point during this appeal, and the Veteran has not contended otherwise. Therefore, the Board finds a remand for the purpose of obtaining a retrospective opinion with respect to the severity and ranges of motion of the left wrist from 1992 to the present would serve no useful purpose and would only delay resolution of this claim. B. Left Elbow From February 11, 1992, through March 10, 2013, the Veteran was in receipt of a noncompensable (0 percent) rating for his service-connected degenerative arthritis of the left elbow. On and after March 11, 2013, he has been in receipt of a 10 percent rating for that disability. These ratings have been assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5003. The evidence of record reflects that the Veteran has had pain in his left wrist throughout the appeals period. (See March 1992 VA examination report.) The Board therefore finds that a 10 percent rating is warranted throughout the appeals period pursuant to 38 C.F.R. § 4.59. The Board has considered whether a rating in excess of 10 percent is warranted at any point of the appeals period. Disabilities of the elbow and forearm are rated under 38 C.F.R. § 4.71, Diagnostic Codes 5205 through 5213. The Board notes that the Veteran is right-handed, so his left elbow is his minor elbow for rating purposes. The evidence of record reflects that the Veteran has not had ankylosis of the elbow at any point during the appeals period, so a higher rating is not warranted under Diagnostic Code 5205. The February 2017 VA examination report expressly finds that there is no flail joint (Diagnostic Code 5209), nonunion of radius and ulna (Diagnostic Code 5210), ulna impairment (Diagnostic Code 5211), radius impairment (Diagnostic Code 5212), or supination or pronation impairment (Diagnostic Code 5213). There is no indication that the Veteran has had any of these disabilities at any point during the appeals period. Therefore, increased ratings under Diagnostic Codes 5209 through 5213 are not warranted. The remaining diagnostic codes, Diagnostic Codes 5206 through 5208, compensate for limitation of flexion and/or extension. For reference, normal range of motion of the elbow is 145 degrees flexion and 0 degrees extension. Diagnostic Code 5206 involves limitation of flexion. Under this diagnostic code, limitation of flexion of the minor extremity to 110 degrees warrants a 0 percent rating. Limitation of flexion to 100 degrees warrants a 10 percent rating. Flexion limited to 90 degrees warrants a 20 percent rating. Flexion limited to 55 degrees warrants a 30 percent rating. Flexion limited to 45 degrees warrants a 40 percent rating. Diagnostic Code 5207 pertains to limitation of extension. Extension of the minor extremity limited to 45 degrees warrants a 10 percent rating. Extension limited to 75 degrees warrants a 20 percent rating. Extension limited to 100 degrees warrants a 30 percent rating. Extension limited to 110 degrees warrants a 40 percent rating. Diagnostic Code 5208 assigns a 20 percent rating when there is both limitation of flexion of the minor forearm to 100 degrees and limitation of extension to 45 degrees. In adjudicating this claim, the Board has considered the contention from the Veteran's accredited representative in the September 2017 Informal Hearing Presentation, specifically that a remand for a retrospective opinion that complies with the Board's August 2016 remand directives is necessary. The August 2016 remand directed that "the VA examiner must also provide retrospective medical opinions as to the current severity of the service-connected degenerative arthritis of the left elbow, and the ranges of motion of the opposite joint (right elbow) from 1992 to the present." [Emphasis omitted.] Further review of the voluminous claims file, however, reveals that left elbow range of motion measurements appear throughout the appeals period. A representative sampling of these measurements has been included below. Therefore, the Board finds that a remand for an examiner to provide information that is already of record would unnecessarily delay adjudication of this claim and serve no useful purpose. Turning to the evidence of record, the March 1992 VA examination report focuses on the left upper extremity. It notes that the Veteran had sharp pain going from the left elbow across the dorsum of the forearm and into just under the third metacarpal head. The examiner noted that musculoskeletal range of motion was normal unless otherwise noted, and the examiner did not note left elbow abnormality. January 1996 and February 1997 records of examinations conducted in connection with a Social Security Administration (SSA) evaluation note normal ranges of motion in the left elbow. The May 2000 VA examination report notes full range of motion without discomfort. The June 2005 VA examination report notes that range of motion was normal with minimal discomfort on examination. The March 17, 2010 VA examination report notes that the Veteran has elbow range of motion from 0 to 90 degrees, with pain at the end of range of flexion. There was no change with repetition. There was tenderness over the olecranon process, but there was no swelling or increased joint warmth. The June 13, 2012, VA elbow and forearm conditions examination report notes flexion 145 degrees with no objective evidence of painful motion. Extension was full with no evidence of painful motion. There was no decrease in range of motion on repetitive use. There was no localized tenderness or pain on palpation of joints/soft tissue of the elbow. The March 2013 VA elbow and forearm conditions examination report notes flexion to 145 degrees with objective evidence of painful motion beginning at 140 degrees. There was no limitation of extension with pain at 0 degrees or at any degree of hyperextension. There was no additional limitation of motion following repetitive use testing. He had functional loss due to weakened movement and pain on movement. There was localized tenderness or pain on palpation of joints/soft tissue. He reported that flare-ups are triggered by resting his elbow on the arm of a chair, table top, etc., and that symptoms are relieved by removing pressure from the elbow. The flare-ups consist of shooting pain from the elbow to the shoulder and wrist. They occur two to three times per day and last a few minutes. They result in loss of less than 10 percent range of motion. The February 2017 VA elbow and forearm conditions examination report notes left elbow flexion to 145 degrees and extension to 0 degrees. No pain was noted on examination. There was no additional limitation of motion on repetitive use. It was noted that pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over a period of time. It was noted that this functional weakness was caused by pain. However, the examiner was unable to describe this functional loss in terms of reduction of range of motion, and the Veteran was unable to replicate a loss in range of motion. The Veteran denied flare-ups. He reported functional impairment as follows: "Cutting grass and vibrating, that goes up both arms, both elbows, both wrists, both shoulders." The examiner also noted that passive range of motion testing and nonweight-bearing range of motion testing were medically inappropriate because they additionally stress the left elbow joint in a non-functional way and may cause unnecessary pain and harm to the Veteran. The Board finds that a rating in excess of 10 percent is not warranted prior to March 17, 2010, based on normal ranges of flexion and extension prior to that date. The Board further finds that a 20 percent rating is warranted from March 17, 2010, through June 12, 2012, based on the finding of flexion limited to 90 degrees during the March 2010 examination. The 10 percent rating resumes on June 13, 2012, based on the normal ranges of flexion and extension on that date. With respect to evidence of functional impairment on flare-ups, the March 2013 VA examination report estimates a loss of less than 10 percent of range of motion two to three times per day for a few minutes each. Because there is no indication that the Veteran's elbow disability has gotten better since 1992, the Board will resolve reasonable doubt in the Veteran's favor and apply this standard (a loss of 10 percent range of motion on flare-up) to estimate additional functional impairment throughout the appeals period. At no point during the appeals period does this result in loss of range of motion that would satisfy the criteria for a higher rating. In short, the Veteran is entitled to a 10 percent rating for his service-connected left elbow disability from February 11, 1992, through March 16, 2010, and on and after June 13, 2012. He is entitled to a 20 percent rating for his left elbow disability from March 17, 2010, through June 12, 2012. With respect to the denial even higher ratings, the Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise, and even higher ratings are not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). C. Left Knee The Veteran has also claimed entitlement to a higher initial evaluation for a left knee disability, to include left knee osteoarthritis and status post left total knee replacement. This disability has been evaluated as 10 percent disabling from September 27, 1993, through September 26, 2011, and as 30 percent disabling on and after November 1, 2012. Prior to the total knee replacement, the Veteran was in receipt of a 10 percent rating for his left knee disability under 38 C.F.R. § 4.59. Disabilities of the knee and leg are evaluated pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5256 through 5263. In the absence of ankylosis, the Board finds that a rating in excess of 10 percent is not warranted under Diagnostic Codes 5256. No separate ratings are warranted for subluxation or lateral instability under Diagnostic Code 5257, as the VA examination reports, SSA evaluations, and medical treatment records reflect stable ligaments. (See, e.g., September 1994 VA medical record, March 2010 VA joints examination report.) In the absence of dislocation of the semilunar cartilage prior to the Veteran's knee surgery, the Board finds that the criteria for an increased or separate rating under Diagnostic Code 5258 are not satisfied. A rating in excess of 10 percent is not available under Diagnostic Code 5259, for symptomatic removal of semilunar cartilage, as he has regularly been found not to have residual signs or symptoms due to meniscectomy. In the absence of tibia and fibula impairment or of genu recurvatum, increased ratings are not warranted under Diagnostic Codes 5262 or 5263. Diagnostic Codes 5260 and 5261 pertain to limitation of flexion and extension of the knee. VA's General Counsel has stated that separate ratings under Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 2004). A 10 percent rating is warranted under Diagnostic Code 5260 for limitation of flexion to 45 degrees. A 20 percent rating is warranted for limitation of flexion to 30 degrees. A 10 percent rating is warranted under Diagnostic Code 5261 for limitation of extension to 10 degrees. A 20 percent rating is warranted for limitation of extension to 15 degrees. A review of the ranges of motion that are listed in VA examination reports, SSA reports, and treatment records reveals that, even when considering factors such as pain, weakness, fatigability, incoordination, or pain on movement, the Veteran's flexion does not approach the 30 degrees that is required for a 20 percent rating under Diagnostic Code 5260. Review of the record from prior to the date of his surgery reflects a maximum limitation of flexion to 90 degrees with pain at the end of the range and no change on repetition. (See March 2010 VA joints examination report.) Nor does his extension approach the 15 degrees that is required for a 20 percent rating under Diagnostic Code 5261, as extension during this period has shown to be full. Nor does the Veteran have both a limitation of flexion to 45 degrees and a limitation of extension to 10 degrees to warrant two separate 10 percent ratings under Diagnostic Codes 5260 and 5261. Therefore, increased ratings based on limitation of motion are not warranted at any point prior to September 26, 2011. From the date of his surgery, the Veteran's left knee disability is rated under 38 C.F.R. 4.71a, Diagnostic Code 5055, prosthetic replacement of a knee joint. That diagnostic code assigns a minimum rating of 30 percent. A 60 percent rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. For intermediate degrees of residual weakness, pain, or limitation of motion, Diagnostic Code 5055 directs a rating by analogy under Diagnostic Codes 5256 (ankylosis), 5261 (limitation of extension), or 5262 (impairment of the tibia and fibula). Diagnostic Code 5055 also assigns a 100 percent rating for the one year following implantation of the prosthesis. In the case at hand, the Veteran has received his temporary 100 percent rating from September 27, 2011, through October 31, 2012, and he does not contend that he satisfied the criteria for a 100 percent rating for any period that is contemplated by this appeal. On and after November 1, 2012, the directed ratings by analogy under Diagnostic Codes 5256, 5261, and 5262 are permitted because these diagnostic codes allow for ratings in between the minimum 30 percent rating and the maximum 60 percent rating that is permitted under Diagnostic Code 5055. Any intermediate ratings that are assigned under Diagnostic Codes 5256, 5261, or 5262 would be assigned in place of any rating that would have been assigned under Diagnostic Code 5055. Assigning concurrent ratings under Diagnostic Code 5055 and Diagnostic Codes 5256, 5261, or 5262 is impermissible, as it would violate the prohibition against pyramiding. See 38 C.F.R. § 4.14 (2017). Under Diagnostic Code 5256, a rating in excess of 40 percent is warranted for ankylosis in flexion between 10 and 20 degrees; a 50 percent rating is warranted for ankylosis in flexion between 20 and 45 degrees; a 60 percent rating is warranted for extremely unfavorable ankylosis or ankylosis in flexion at an angle of 45 degrees or more. The evidence reflects that the Veteran does not have ankylosis and that his left knee has not been ankylosed at any point during the appeals period. Therefore a rating in excess of 30 percent under Diagnostic Code 5256 is not warranted. Under Diagnostic Code 5261, limitation of extension to 30 degrees warrants a 40 percent rating, while limitation of extension to 45 degrees warrants a 50 percent rating. Even when considering factors such as pain, weakness, fatigability, incoordination, or pain on movement, the Veteran's range of motion has not approached 30 degrees of extension. The March 2013 VA knee and lower leg examination report notes extension ending at 5 degrees with no additional loss of range of motion on repetitive use testing, while the February 2017 VA knee and lower leg conditions examination report notes full extension. While the examiner does note that pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over a period of time, there is no indication that such limitation includes limitation of extension to 30 degrees or greater. Therefore, the Board finds that entitlement to a rating in excess of 30 percent is not warranted under Diagnostic Code 5261. Under Diagnostic Code 5262, nonunion of the tibia and fibula, with loose motion, requiring a brace, warrants a 40 percent rating. As noted above, the Veteran does not have impairment of the tibia and fibula, and therefore a rating for nonunion of the tibia and fibula is not warranted. With respect to the rating criteria of Diagnostic Code 5055, the records from following the Veteran's left knee replacement surgery reflect that the Veteran does not have severe pain or weakness. (See March 2013 and February 2017 VA examination reports.) Therefore, a rating of 60 percent is not warranted under Diagnostic Code 5055. In short, entitlement to a rating in excess of 10 percent at any point from September 27, 1993, through September 26, 2011, is not warranted. In addition, a rating in excess of 30 percent is not warranted at any point on and after November 1, 2012. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. D. Left Radial and Median Nerves The Veteran has also claimed entitlement to higher initial ratings for neuralgia of the left radial and median nerves. Neuralgia of the left radial nerve is currently evaluated as 0 percent disabling from February 6, 1992, through June 13, 2005, and as 20 percent disabling on and after June 14, 2005. These ratings are assigned pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8714. Neuralgia of the left median nerve is currently evaluated as 0 percent disabling from February 6, 1992, through June 13, 2005, and as 10 percent disabling on and after June 14, 2005. These ratings are assigned pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8715. Following review of the record, the Board finds that the 20 percent rating for neuralgia of the left radial nerve and the 10 percent rating for neuralgia of the left median nerve should be effective from February 6, 1992, the effective date on which service connection was granted for each of these claims. The Board further finds that higher ratings are not warranted for these disabilities at any point during the appeals period. With respect to the period prior to June 14, 2005, the evidence of record consistently shows that the Veteran has reported neurologic symptoms affecting the left upper extremity, but diagnostic testing during this period has shown that the radial and median nerves were within normal limits. (See e.g., April 1992 Nerve Conduction Studies, Upper Extremity, Rehabilitation Medicine Service; April 2002 VA peripheral nerves examination report.) As discussed in the March 2014 Board decision, sensory examination on the most recent VA examination showed decreased sensation in the left hand and fingers. The March 2013 VA examiner specifically identified mild incomplete paralysis of the left radial and median nerves (indicative of symptoms that are wholly sensory), which warrant separate ratings of 20 percent and 10 percent, respectively. See 38 C.F.R. § 4.124a , Diagnostic Codes 8714, 8715. Likewise, the February 2017 VA examination report specifically identified mild incomplete paralysis of the radial and median nerves. Higher ratings are not warranted as the examiner noted that the most severe symptom was intermittent pain. The Veteran reported severe, constant pain, mild paresthesias and/or dysthesias, and mild numbness of the left upper extremity. Muscle testing was mostly normal, with the sole exception being a finding of 4/5 on wrist extension. Reflexes and sensory examination were both normal. Based on the above, the Board finds that the current ratings of 20 percent for the radial nerve and 10 percent for the median nerve are appropriate. The examiners' assessments were based on symptoms reported by the Veteran and findings upon physical examination of the Veteran. The Board has considered whether providing separate ratings would constitute pyramiding as one of the symptoms of the left radial and median nerves overlaps (i.e. flexion of wrist weakened). However, a majority of the symptoms do not. The VA examiner did not specifically attribute particular symptoms to each nerve but only indicated that they were mild in severity. While the Board recognizes that there may be an overlap with one of the symptoms, there are other symptoms unique to each of the nerves. Resolving the benefit of the doubt in the Veteran's favor, the Board assumes that the symptoms are separate and do not overlap. Therefore, no pyramiding is involved by the granting of separate ratings for the individual nerves. In assigning these ratings, the Board acknowledges the argument presented by the Veteran's accredited representative in the September 2017 Informal Hearing Presentation, that the Veteran "should be equally compensated for both [the radial and the median nerve] disabilities as they have the exact same symptoms and origin." The Board notes, however, that the applicable diagnostic codes themselves (Diagnostic Codes 8714 and 8715) assign different ratings for mild disability of the radial and median nerves. The Board, as the finder of fact, has determined that both of these disabilities manifest in mild, incomplete paralysis. A disability rating is reached by applying the relevant findings of fact to the applicable diagnostic codes. The representative is, in effect, asking the Board to reverse engineer a finding that the Veteran's median nerve disability manifests in moderate, incomplete paralysis based on his belief that the Veteran's radial and median nerves deserve to be compensated at the same rates. Such a practice would be improper, and thus the Board declines to assign a 20 percent rating for mild, incomplete paralysis of the left median nerve. Furthermore, the Board observes that, if it were to accept the representative's contention that the Veteran's radial and median nerve disabilities "have the exact same symptoms," the Board would arguably be prohibited from assigning separate ratings for these disabilities at all, as to do so would violate the prohibition against pyramiding. See 38 C.F.R. § 4.14. To summarize, the Board finds that a rating of 20 percent, but no higher, is warranted for neuralgia of the left radial nerve pursuant to Diagnostic Code 8714. The Board also finds that a rating of 10 percent, but no higher, is warranted for neuralgia of the left median nerve pursuant to Diagnostic Code 8715. Both of these ratings are effective from February 6, 1992, which is the effective date for the grants of service connection for these disabilities. With respect to the question of whether even higher ratings are warranted, the Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, the claims are not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, even higher ratings must be denied. II. Earlier Effective Date for TDIU In general, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400 (2017). In the case at hand, the Board granted entitlement to a TDIU in its August 2016 decision. The August 2016 Board decision determined that the TDIU claim had arisen from an August 2006 claim. The effective date of June 14, 2005, was assigned by the RO in its December 2016 rating decision that effectuated the Board's August 2016 decision. The Veteran has appealed the effective date that was assigned by the RO. The Board notes that, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. Total disability will be considered to exist where there is impairment of mind or body sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340 , 4.16. Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16 (a). Total disability ratings for compensation may be assigned where the schedular rating is less than total when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, the disability shall be ratable at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). Factors to be considered are the veteran's education, employment history, and vocational attainment. Ferraro v. Derwinski, 1 Vet. App. 326 (1991). For the purpose of establishing one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from the common etiology or a single accident; (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; (4) multiple injuries incurred in action; or, (5) multiple disabilities incurred as a prisoner of war. The Court has held that in determining whether the veteran is entitled to a total disability rating based upon individual unemployability neither nonservice-connected disabilities nor advancing age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether a veteran can find employment. Id. In a claim for TDIU, the Board may not reject the claim without producing evidence, as distinguished from mere conjecture, that the veteran's service-connected disabilities do not prevent him or her from performing work that would produce sufficient income to be other than marginal. See Friscia v. Brown, 7 Vet. App. 294 (1995). In the case at hand, all of the disabilities for which the Veteran has been granted service connection have arisen on or after February 6, 1992. The Board's August 2016 TDIU grant had been based on an August 2006 date of TDIU claim, and the RO's December 2016 assignment of the June 14, 2005, effective date had been based on the August 2006 date of claim. The current claim, however, has arisen as part and parcel of the Veteran's claims of entitlement to higher initial ratings for his service-connected disabilities. Because all of the Veteran's service connection claims have been raised on or after February 6, 1992, all of his service-connected disabilities may be considered for purposes of determining entitlement to an earlier effective date for a TDIU pursuant to Rice. Effective from February 6, 1992, service connection has been in effect for the following disabilities: (1) residuals of a left shoulder injury, with minimal degeneration, healed, post arthrotomy and arthroscopy, at 10 percent; (2) degenerative arthritis of the left wrist, at 10 percent; (3) neuralgia of the ulnar nerve of the left forearm (characterized as neurological residuals, left forearm), at 20 percent; (4) neuralgia of the left radial nerve, at 20 percent; and (5) neuralgia of the left median nerve, at 10 percent. When combined pursuant to 38 C.F.R. § 4.25, the overall disability rating is 53, which rounds to 50 percent. These disabilities arise from a common etiology, and thus count as a single disability for purposes of determining entitlement to a TDIU. However, because they do not combine to a 60 percent rating, they do not meet the schedular criteria. Effective from February 11, 1992, service connection has been in effect for the above disabilities, as well as for (1) degenerative arthritis of the left elbow, at 10 percent. When combined pursuant to 38 C.F.R. § 4.25, the overall disability rating is 58, which rounds to 60 percent. These disabilities arise from a common etiology, and thus count as a single disability for purposes of determining entitlement to a TDIU. Because the disabilities of common etiology alone equal 60 percent, the Veteran has met the schedular criteria of 38 C.F.R. § 4.16(a) as of February 11, 1992. The Board must now consider whether the competent evidence demonstrates that the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disabilities prior to June 14, 2005. As noted above, in its August 2016 decision, the Board granted entitlement to a TDIU effective June 14, 2005. Between February 11, 1992, and June 14, 2005, service connection has been granted for the following disabilities: (1) hypertensive heart disease, at 10 percent effective March 21, 1992; (2) bronchitis and COPD, at 0 percent effective August 5, 1992; (3) residuals of a fracture to the right ring finger, at 0 percent effective August 17, 1992; (4) corneal erosion, at 10 percent effective July 16, 1993; (5) a tender scar on the left forearm, at 10 percent effective July 16, 1993; (6) fracture of the left heel, at 0 percent effective July 16, 1993; (7) fracture of the right heel, at 0 percent effective July 16, 1993; (8) allergic rhinitis, at 0 percent effective July 16, 1993; and (9) left knee osteoarthritis, status post total knee replacement, at 10 percent effective September 27, 1993. The Board finds that the evidence of record supports a grant of entitlement to TDIU effective September 27, 1993, but no earlier. The Board notes that the Veteran is currently unemployed and has been since 1991. In the February 1998 VA 21-8940 Form, the Veteran contends that he is unemployable due to hypertension, as well as disabilities of the left arm, elbow, lungs, shoulder, knee, and ankle. He stated that he was previously self-employed as a sub-contractor performing HVAC appliance repair. Prior to that job, he performed apartment maintenance and facilities maintenance. The Veteran indicated that he received four + years of college and, as of February 1992, had received training in HVAC technology. In a June 1997 decision, SSA found that the Veteran was disabled for employment and had been since January 1992 due to his osteoarthritis and other disorders of the respiratory system. The SSA decision was based on an examination of the Veteran and a review of the Veteran's medical records. A vocational assessment was conducted by a vocational rehabilitation consultant and psychologist in September 2015. The consultant reviewed the Veteran's claims file, to include the prior medical opinions, and examined the Veteran. The consultant noted that the Veteran last worked on a full-time basis in 1989 as an apartment supervisor. The job required him to lift 20-50 pounds, and was considered medium skilled. The consultant stated that the Veteran then attempted some part-time work and eventually stopped working altogether in 1991. The consultant opined that, at least as of July 1993, the Veteran was incapable of sustaining and maintaining substantial, gainful work activity based on his education, training, past work experience, and current level of symptoms. The consultant reasoned that the combination of the Veteran's orthopedic/neurological problems pertaining to his service-connected impairments greatly affected his ability to work in a substantial manner. The Veteran indicated that at times "his medication did not handle the pain" well. He basically was functioning at a medium work level, using mainly his dominant hand to perform the work. The consultant noted that all of the prior medical opinions determined that the Veteran could not return to his prior work considering his service-connected disabilities, but opined that the Veteran could return to some type of sedentary work. In this regard, the consultant found that the Veteran does not have any training or transferability of skills to sedentary work. In sedentary work, the Dictionary of Occupational Titles indicates that one would usually sit six out of eight hours, but walk two out of eight hours. Even within an office setting, one must be able to ambulate to get supplies, etc. The consultant found that none of the prior medical opinions took into consideration the Veteran's complaints of ongoing and persistent pain. He has pain in his feet, leg, left shoulder, forearm, and hand. For instance, regarding the June 2012 VA medical opinion, the consultant noted that the medical opinion was provided by a nurse practitioner who did not take into consideration the Veteran's complaints of pain in the various areas, which would affect his ability to perform his past work or any other. In April 2016, the Veteran's representative and the consultant who provided the September 2015 medical opinion testified before the undersigned at a Board hearing. Specifically, the consultant testified that she had experience in providing evaluations for SSA and the Board in TDIU cases. The consultant indicated that she was aware of the requirements for establishing a TDIU and reviewed the Veteran's claims file. The consultant indicated that the Veteran did not have any skills, education, or history that were consistent with or transferrable to sedentary employment. The consultant opined that the Veteran was totally disabled and individually unemployable due to his service-connected disabilities. The Board finds the private medical opinion and testimony to be competent and credible evidence with respect to the claim of entitlement to an effective date prior to June 14, 2005, for the TDIU grant. The opinions that were presented in this evidence are supported by the Veteran's lay statements and the medical treatment records. The Veteran's work experience and education is related to maintenance, and the medical opinions support that the Veteran is unable to be employed in this occupation due to his service-connected disabilities. The Veteran indicated on his VA 21-8940 Form that his education was related to maintenance, which does not qualify the Veteran to obtain and maintain substantially gainful employment in a sedentary position, especially when his prior work experience is in a non-sedentary position. The September 2015 private medical opinion is also supported by a March 2013 VA examination, which was discussed in detail in the August 2016 Board decision, which does document that the Veteran would experience limitations in a physical position, such as his prior position. The Board notes that this evidence supports a finding of entitlement to a TDIU effective from September 27, 1993, but no earlier. This effective date corresponds with the effective date of the grant of service connection for the Veteran's left knee disability. The evidence of record, in particular the rehabilitation counselor's April 2016 Board hearing testimony, places great emphasis on the difficulties the Veteran has with walking and standing due to symptomatology related to his heels and knee. When combined with the considerable impairment that is caused by the Veteran's left upper extremity disabilities, the Board finds that the Veteran's service-connected disabilities precluded him from securing and maintaining substantially gainful employment consistent with his educational and vocational experiences as of September 27, 1993. The Board has considered whether a TDIU is warranted prior to that date. However, given that the impairment that is caused by lower extremity symptomatology is integral to the opinions that weigh in favor of the Veteran's claim, the Board finds that entitlement to an effective date prior to September 27, 1993, is not warranted. Therefore, entitlement to an effective date of September 27, 1993, but no earlier, for a TDIU is granted. The Board is cognizant of VA's duty to maximize benefits. See Bradley v. Peake, 22 Vet. App. 280 (2008). Relevant to this appeal, a claim for a TDIU may include the "inferred issue" of entitlement to special monthly compensation even where the veteran has not expressly placed entitlement to special monthly compensation at issue. Akles v. Derwinski, 1 Vet. App. 118, 121 (1991); see Buie v. Shinseki, 24 Vet. App. 242 (2010) (requiring VA to assess all of the claimant's disabilities to determine whether entitlement to special monthly compensation under 38 U.S.C. § 1114 (s) is established whenever a veteran with a total disability rating is subsequently awarded service connection for any additional disability or disabilities even in the absence of an express claim for special monthly compensation). Special monthly compensation at the housebound rate is payable where a veteran has a single service-connected disability rated as 100 percent and: (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or, (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). Prior to June 14, 2005, the special monthly compensation requirements have not been met, as the TDIU rating is not being awarded based exclusively on the symptoms of any single service-connected disability. Instead, the Veteran is being awarded TDIU based on the combined effects of all of his service-connected disabilities on his employability. Thus, the Veteran does not satisfy the single 100 percent rating requirement for special monthly compensation under 1114(s). Special monthly compensation at the housebound rate prior to June 14, 2005, is not warranted. ORDER From February 6, 1992, through March 10, 2013, entitlement to a rating of 10 percent, but no higher, for degenerative arthritis of the left wrist is granted, subject to the laws and regulations governing the award of monetary benefits.. On and after March 11, 2013, entitlement to a rating in excess of 10 percent for degenerative arthritis of the left wrist is denied. From February 11, 1992, through March 16, 2010, entitlement to a rating of 10 percent, but no higher, for degenerative arthritis of the left elbow is granted, subject to the laws and regulations governing the award of monetary benefits. From March 17, 2010, through June 12, 2012, entitlement to a rating of 20 percent, but no higher, for degenerative arthritis of the left elbow is granted, subject to the and laws and regulations governing the award of monetary benefits. From June 13, 2012, through March 10, 2013, entitlement to a rating of 10 percent, but no higher, for degenerative arthritis of the left elbow is granted, subject to the laws and regulations governing the award of monetary benefits. On and after March 11, 2013, entitlement to a rating in excess of 10 percent for degenerative arthritis of the left elbow is denied. Entitlement to a higher initial evaluation for a left knee disability, to include left knee osteoarthritis and status post left total knee replacement, evaluated as 10 percent disabling from September 27, 1993, through September 26, 2011, and as 30 percent disabling on and after November 1, 2012, is denied. From February 6, 1992, through June 13, 2005, entitlement to a rating of 20 percent, but no higher, for neuralgia of the left radial nerve is granted, subject to the laws and regulations governing the award of monetary benefits. On and after June 14, 2005, entitlement to a rating in excess of 20 percent for neuralgia of the left radial nerve is denied. From February 6, 1992, through June 13, 2005, entitlement to a rating of 10 percent, but no higher, for neuralgia of the left median nerve is granted, subject to the laws and regulations governing the award of monetary beneifts. On and after June 14, 2005, entitlement to a rating in excess of 10 percent for neuralgia of the left median nerve is denied. Entitlement to an effective date of September 27, 1993, but no earlier, for TDIU is granted, subject to the laws and regulations governing the award of monetary benefits. ______________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs