Citation Nr: 1807731 Decision Date: 02/06/18 Archive Date: 02/14/18 DOCKET NO. 12-17 152 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for cervical radiculopathy of the right and left upper extremities. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to a compensable initial disability rating for right upper extremity carpal tunnel syndrome (CTS) prior to June 25, 2012, and a rating in excess of 10 percent thereafter. 4. Entitlement to a compensable initial disability rating for left upper extremity CTS. 5. Entitlement to a compensable initial disability rating for a lumbar spine disability prior to June 25, 2012, and a rating in excess of 10 percent thereafter. 6. Entitlement to an initial disability rating in excess of 20 percent for a cervical spine disability. 7. Entitlement to a compensable initial disability rating for a right shoulder disability prior to June 25, 2012, a rating in excess of 10 percent until January 10, 2017, and in excess of 20 percent thereafter. 8. Entitlement to a compensable initial disability rating for a right elbow disability prior to January 10, 2017, and a rating in excess of 10 percent thereafter. 9. Entitlement to a compensable initial disability rating for onychomycosis of the great toes. 10. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD R. Erdheim, Counsel INTRODUCTION The Veteran served on active duty from April 1987 to May 2010. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claims in September 2016. The Board is satisfied that there has been substantial compliance with the remand directives and the Board may proceed with review. Stegall v. West, 11 Vet. App. 268 (1998). The issue of entitlement to a TDIU has been raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). FINDINGS OF FACT 1. The Veteran does not have a current diagnosis of radiculopathy of the upper extremities or bilateral hearing loss. 2. Throughout the appeal period, the Veteran's right CTS has resulted in mild incomplete paralysis of the median nerve. 3. Throughout the appeal period, the Veteran's left CTS has resulted in mild incomplete paralysis of the median nerve. 4. Throughout the appeal period, the Veteran's lumbar spine disability has resulted in actual painful motion akin to forward flexion limited to less than 85 degrees. 5. Throughout the appeal period, the Veteran's cervical spine disability has not resulted in forward flexion of the cervical spine to 15 degrees or less or ankylosis. 6. Prior to January 10, 2017, the Veteran's right shoulder disability was manifested by painful noncompensable limitation of motion and arthritis. 7. Since January 10, 2017, the Veteran's right shoulder disability has been manifested by pain that limits range of motion to shoulder level on flare-up. 8. Throughout the appeal period, the Veteran's right elbow disability has been manifested by flexion limited to greater than 100 degrees and extension limited to less than 45 degrees. 9. Throughout the appeal period, the Veteran's onychomycosis of the great toes has covered less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and has necessitated no more than topical therapy required during the past 12-month period. 10. The Veteran's service-connected disabilities have not been shown to be of such severity so as to preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for radiculopathy of the upper extremities have not been met. 38 U.S.C. § 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2017). 2. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. § 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 3. Prior to June 25, 2012, the criteria for an increased 10 percent rating for right CTS have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.159, 4.124a, Diagnostic Code 8515 (2017). 4. Since June 25, 2012, the criteria for a rating in excess of 10 percent for right CTS have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.159, 4.124a, Diagnostic Code 8515 (2017). 5. The criteria for an increased 10 percent rating for left CTS have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.159, 4.124a, Diagnostic Code 8515 (2017). 6. Prior to June 25, 2012, the criteria for an increased 10 percent for a lumbar spine disability have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.159, 4.71a, DC 5242 (2017). 7. Since June 25, 2012, the criteria a rating in excess of 10 percent for a lumbar spine disability have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.159, 4.71a, DC 5242 (2017). 8. The criteria a rating in excess of 20 percent for a cervical spine disability have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.159, 4.71a, DC 5242 (2017). 9. Prior to January 10, 2017, the criteria for a 10 percent rating a right shoulder disability have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.159, 4.71a, DCs 5003, 5201 (2017). 10. Since January 10, 2017, the criteria for a rating in excess of 20 percent for a right shoulder disability have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.159, 4.71a, DCs 5003, 5201 (2017). 11. Prior to January 10, 2017, the criteria for a increased 10 percent rating for a right elbow disability have been met. 38 U.S.C. § 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.102, 3.303, 4.71(a), DC 5206 (2017). 12. Since January 10, 2017, the criteria for a rating in excess of 10 percent for a right elbow disability have not been met. 38 U.S.C. § 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.102, 3.303, 4.71(a), DC 5206 (2017). 13. The criteria for a compensable rating for onychomycosis of the great toes have not been met. 38 U.S.C. § 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.102, 3.303, 4.118, DC 7813 (2017). 14. The criteria for assignment of TDIU are not met. 38 U.S.C.A. § 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Direct service connection may be granted with medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303 (b) by evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307, (ii) present manifestations of the same chronic disease, and (iii) evidence of continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). If the claimed disability is not one listed under 38 C.F.R. § 3.309, credible lay evidence of continuous symptoms can support the claim. Bilateral Upper Extremity Radiculopathy The Board finds that service connection for bilateral upper extremity radiculopathy is not warranted, as that disability has not been diagnosed. Specifically, on January 2017 VA examination, the Veteran reported that the entire outer side of his left arm and forearm would tingle, with shooting pain into his fingertips. He didn't experience radiating pain from his neck or shoulder. He denied symptoms in his right arm. Physical examination was within normal limits. After completing physical examination and reviewing the treatment records, the examiner concluded that the Veteran did not suffer from radiculopathy of the upper extremities. This finding is consistent with the remaining VA examinations and treatment records that show normal neurological testing in the upper extremities, apart from the Veteran's already service-connected CTS. Accordingly, the Board finds that service connection for bilateral upper extremity radiculopathy must be denied. Bilateral Hearing Loss The Board finds that service connection for bilateral hearing loss is not warranted, as that disability has not been diagnosed. Specifically, on January 2017 VA examination, audiometric testing did not demonstrate the presence of hearing loss in either ear that would constitute a disability for VA purposes. See 38 C.F.R. § 3.385. The examiner further explained that in light of the Veteran's normal audiometric testing on examination, and based upon the medical literature, there was no evidence of noise-induced hearing loss related to acoustic trauma in service. The Board finds that the examiner's conclusion is consistent with the remainder of the medical evidence of record. Hearing loss that meets the requirement to be considered a disability for VA purposes has not been shown. Furthermore, the examiner provided a well-reasoned opinion as to why it was less likely than not that the Veteran's current mild hearing loss, that does not meet VA's criteria for a diagnosis, was not caused or aggravated by his service. Accordingly, the Board finds that service connection for bilateral hearing loss is not warranted. Increased Ratings Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Raters must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare-ups. 38 C.F.R. § 4.14. The guidance provided by the Court in DeLuca must be followed in adjudicating claims where a rating under the diagnostic codes governing limitation of motion should be considered. However, the Board notes that the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating 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. 38 C.F.R. § 4.59. With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45. For the purpose of rating disability from arthritis, the shoulders are each considered a major joint. 38 C.F.R. § 4.45. Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. 38 C.F.R. § 4.71a , Diagnostic Codes 5003 (degenerative arthritis) and 5010 (traumatic arthritis). Diagnostic Code 5010 (traumatic arthritis) direct that the evaluation of arthritis be conducted under Diagnostic Code 5003, which states that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5010. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Bilateral Carpal Tunnel Syndrome The Veteran's service-connected CTS of the right wrist is rated as noncompensable prior to June 25, 2012, and as 10 percent disabling thereafter, and his left CTS is rated as noncompensable, under 38 C.F.R. § 4.124a, DC 8515. Pursuant to Diagnostic Code 8515, incomplete paralysis of the median nerve affecting the major extremity that is mild, moderate, and severe warrants ratings of 10, 30, and 50 percent, respectively. Incomplete paralysis of the median nerve affecting the minor extremity that is mild, moderate, and severe warrants ratings of 10, 20, and 40 percent, respectively. A 70 percent rating is warranted for complete paralysis of the median nerve of the major extremity, with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. 38 C.F.R. § 4.124a, Diagnostic Code 8515. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The record reflects that the Veteran is right-handed. As such, his carpal tunnel syndrome of the right wrist affects his major extremity. 38 C.F.R. § 4.69. On April 2010 VA examination, the Veteran reported tingling and numbness in his left fingers at the tips. Physical examination was within normal limits of the wrist. Tinel's sign and Phalen's test were positive, bilaterally. On January 2013 VA examination, the Veteran reported moderate intermittent pain his right hand. He had undergone a carpal tunnel release procedure. Neurological testing demonstrated mild incomplete paralysis of the right median nerve, with no impairment to the nerves of the left hand. No other abnormalities were demonstrated. On January 2017 VA examination, there was no palmar sensory loss in the median distribution. Carpal tunnel syndrome in the left and right hand was noted to have resolved. In this case, the Board finds that prior to June 25, 2012, a 10 percent rating is warranted for both the right and left wrist CTS. Specifically, although the remaining neurological and musculoskeletal examinations reflected normal findings, Tinel's sign and Phalen's test were positive, bilaterally, on April 2010 VA examination. These tests demonstrate the presence of CTS. These results, coupled with the Veteran's report of numbness and tingling into the wrists, warrants a finding of mild incomplete paralysis of the nerve. A rating higher than 10 percent is not shown, however, as the remaining evidence of record, to include in 2017, have shown sensory, motor, and muscle examination that were all within normal limits. On 2013 VA examination, mild incomplete paralysis of the right wrist was demonstrated, only. Thus, the Board finds that moderate incomplete paralysis has not been shown. Lumbar Spine The Veteran's lumbar spine disability is evaluated under the General Rating Formula for Diseases and Injuries of the Spine. Under that criteria, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees, or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the lumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait pattern or spine contour such as scoliosis, reverse lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the lumbar spine 30 degrees or less, or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted when there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 2. On April 2010 VA examination, range of motion of the lumbar spine was within normal limits. There was no evidence of radiating movement. Straight leg testing was normal. Neurological examination was within normal limits. On January 2013 VA examination, the Veteran suffered from back pain that would come and go and was moderate in nature. Range of motion of the lumbar spine demonstrated flexion to 80 degrees, extension to 25 degrees, and lateral flexion and rotation within normal limits. Repetitive testing did not result in functional impairment. Muscle strength testing, reflex examination, and sensory examination were all normal. There was no radiculopathy. On January 2017 VA examination, the Veteran reported back pain. About twice a year, he would experience a back spasm when bending the wrong way. Range of motion of the spine was within normal limits, with some pain expressed in the last five to ten degrees of flexion. Neurological examination was normal, with no evidence of radiculopathy. In this case, the Board finds that a 10 percent rating is warranted prior to June 25, 2012, and throughout the appeal period. The Veteran reported on 2010 VA examination that he was experiencing pain in his lumbar spine when completing activities. While range of motion testing was within normal limits, the Veteran has shown actual painful motion of the spine as contemplated by 38 C.F.R. § 3.59, and thus the minimal compensable rating, or 10 percent, is warranted for that time period. However, a rating in excess of 10 percent is not warranted at any time during the appeal period, as the necessary limitation of motion was not show on 2013 or 2017 VA examination, nor has it been shown that his lumbar spine disability results in muscle spasm or guarding resulting in abnormal spinal contour. The Board has also considered whether a separate compensable rating for neurological impairment in either lower extremity is warranted at any time during the rating period in question; however, the medical evidence does not show such impairment during this period. Cervical Spine Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees, or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees, or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted 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 spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A maximum rating in this case of 30 percent is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. 38 C.F.R. § 4.71a , General Rating Formula for Diseases and Injuries of the Spine, Note 2. On April 2010 VA examination, the Veteran reported pain in his neck, shoulders, and arms that was constant. He underwent a discectomy in 2009, but has suffered from pain, discomfort, weakness, numbness, and tingling. On physical examination, range of motion of the cervical spine was limited in flexion to 20 degrees, extension was limited to 10 degrees, and right and left lateral flexion and rotation was limited to 10 degrees. There were no other functional limitations on repetitive use. Neurological examination was within normal limits. On January 2013 VA examination, the Veteran reported constant moderate neck pain and numbness and tingling down his left arm to his fingers. Range of motion of the cervical spine demonstrated flexion to 25 degrees, extension to 30 degrees, lateral flexion to 30 degrees, bilaterally, and rotation, to 40 degrees, bilaterally. There was no additional limitation on repetition, but there was functional loss by way of pain on movement and less movement than normal. There was guarding of movement that resulted in abnormal spinal contour. Neurological examination was normal and the examiner found no evidence of radiculopathy in the upper extremities. On January 2017 VA examination, the Veteran reported continuing pain in his neck, with tingling and weakness in his left arm. He reported that he could not look up. Range of motion showed flexion limited to 25 degrees, extension limited to 20 degrees, right and left lateral flexion limited to 30 degrees, and right and left rotation limited to 30 degrees. In this case, the Veteran's range of motion of the cervical spine has fallen within the criteria of a 20 percent rating. Limitation of motion less than 15 degrees, even when considering flare-ups or limitation on repetition, has not been demonstrated. Ankylosis of the spine has not been shown. Therefore, rating in excess of 20 percent is not warranted. Right Shoulder The Veteran's right shoulder disability is rated under Diagnostic Code 5003, which pertains to arthritis as outlined above. Diagnostic Code 5201which pertains to limitation of motion of the arm is also applicable. The rating criteria provide different ratings for the minor arm and the major arm. The Veteran has indicated (in various treatment records and on VA examination) that he is right-handed; therefore, the Board will apply the ratings and criteria for the major arm. 38 C.F.R. § 4.69. In considering the applicability of other diagnostic codes, the Board finds that DCs 5200, 5202, and 5203, which pertain to ankylosis of the shoulder, impairment of the clavicle and scapula, and recurrent dislocations of the scapulohumeral joint, do not apply. Specifically, VA examinations and the treatment records do not show the presence of any of these conditions during the appeal period. Accordingly, the criteria pertaining to those conditions are not applicable. 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202, 5203. Under Diagnostic Code 5201, for the major arm, a 20 percent rating is warranted for limitation of arm motion to shoulder level. A 30 percent rating is warranted for limitation midway between the side and shoulder level. A maximum 40 percent rating is warranted for limitation of arm motion to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Normal forward flexion of the shoulder is 0 to 180 degrees; abduction is 0 to 180 degrees; and internal and external rotation are from 0 to 90 degrees. 38 C.F.R. § 4.71a, Plate I. Forward flexion and abduction to 90 degrees amounts to shoulder level. On April 2010 VA examination, the Veteran reported moderate flare-ups of his right shoulder about once per week. It was hard to lift his arm above his head. On physical examination, there was no abnormal movement, effusion, weakness, subluxation, or guarding of the shoulder. Range of motion was within normal limits. On January 2013 VA examination, the Veteran reported pain, weakness, and decreased motion of the right shoulder. Range of motion of the shoulder was to 135 degrees on flexion, and 110 degrees on abduction. Internal and external rotation were to 80 out of 90 degrees. There was no additional limitation of motion on functional testing, but there was functional impairment by way of less movement than normal, weakened movement, and pain on movement. There were no other abnormalities of the shoulder joint such as a rotator cuff tear. There was evidence of arthritis of the joint. There was limitation on cross body abduction. On January 2017 VA examination, the Veteran reported that he would experience pain when lifting. He could not work with things overhead. Range of motion testing of the shoulder joint was normal, with evidence of pain in the final 10 degrees of flexion and abduction and in the final five degrees of external and internal rotation. There was mild tenderness to palpation at the right shoulder. There was positive Hawking's Impingement test suspected of a rotator cuff condition. In this case, the Board finds that prior to January 10, 2017, a 10 percent rating is warranted for arthritis of the right shoulder with noncompensable painful limitation of motion pursuant to 38 C.F.R. § 5003. However, a 20 percent rating is not warranted for this time period as there was no evidence of involvement of 2 or more major or minor joint groups resulting in occasional incapacitating exacerbations. Moreover, the range of motion did not result in limitation to shoulder level. Since January 10, 2017, the Veteran has been in receipt of a 20 percent rating for painful motion of the right shoulder similar to limitation of motion at shoulder level. The Board does not find evidence of limitation of motion limited to below shoulder level at any time during the appeal period, thus the criteria for an increased rating have not been met. Right Elbow Under Diagnostic Code 5206 for limitation of flexion of the forearm, a 0 percent rating is assigned when flexion of the major forearm is limited to 110 degrees; a 10 percent rating is assigned when flexion of the major forearm is limited to 100 degrees; a 20 percent rating is warranted for flexion of the major forearm limited to 90 degrees; a 30 percent rating is warranted for flexion of the major forearm limited to 70 degrees; a 40 percent rating is warranted for flexion of the major forearm limited to 55 degrees; and a 50 percent rating is warranted for flexion of the major forearm limited to 45 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5207 for limitation of extension of the forearm, a 10 percent rating is assigned when extension of the major forearm is limited to 45 or 60 degrees; a 20 percent rating is warranted for extension of the major forearm limited to 75 degrees; a 30 percent rating is warranted for extension of the major forearm limited to 90 degrees; a 40 percent rating is warranted for extension of the major forearm limited to 100 degrees; and a 50 percent rating is warranted for extension of the major forearm limited to 110 degrees. Diagnostic Code 5208 provides for a 20 percent evaluation where flexion of the forearm is limited to 100 degrees and extension to 45 degrees. Flexion of the elbow to 145 degrees is considered full and extension to 0 degrees is considered full. See Plate I. On April 2010 VA examination, the Veteran reported experiencing flare-ups of the right elbow once per day that was moderately severe. Physical examination of the right elbow was normal, with range of motion within normal limits. On January 2013 VA examination, the Veteran reported having elbow pain when leaning on his elbow. Range of motion of the elbow was normal on flexion, with extension limited to 5 degrees. There was no additional loss of degrees on repetitive testing, but there was less movement than normal. On January 2017 VA examination, the Veteran reported that if he bumped his right elbow the wrong way, it would feel like it was on fire. Range of motion was normal but for a loss of 5 degrees on flexion. There were no other abnormalities identified. In this case, prior to January 10, 2017, the Veteran suffered from painful limitation of motion of the right elbow, though such is noncompensable under the rating schedule. However, the Veteran reported pain on use of the right elbow that would result in functional impairment. The Board finds that such meets the criteria for a minimum compensable rating, in this case, 10 percent under DC 5206. However, a rating higher than 10 percent has not been demonstrated at any time during the appeal period, as the Veteran has not displayed the necessary loss of range of motion to result in the next higher rating, even when taking into consideration loss of use on repetition or during a flare-up. Onychomycosis of the Great Toes The Veteran's disability has been rated by analogy pursuant to DC 7813. Under that code, the skin disability is to be rated either as disfigurement of the head, face, and neck, scars, or dermatitis. In this case, dermatitis would be the most appropriate code. Under DC 7806, used to rate dermatitis or eczema, a 0 percent rating requires that less than 5 percent of the entire body or less than 5 percent of exposed areas affected and has required no more than topical therapy during a 12 month period. A 10 percent rating is assigned for dermatitis or eczema that involves at least 5 percent but less than 20 percent of the entire body, or at least 5 percent but less than 20 percent of exposed areas affected, or; requires intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than 6 weeks during the past 12-month period. Dermatitis or eczema that involves 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or requiring systemic therapy for a total duration of 6 weeks or more, but not constantly, during the past 12-month period, is rated as 30 percent disabling. A 60 percent rating is warranted for dermatitis or eczema with more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or requiring constant or near-constant systemic therapy during the past 12-month period. 38 C.F.R. § 4.118 . On April 2010 VA examination, the were no abnormal weightbearing of the feet or unusual show wear pattern. There was tenderness of the bottom of the foot, but normal motion of the right great toe. The Veteran's toe nail fungus did not result in exudation, ulcer formation, itching, shedding, or crusting. There was exfoliation and hyperpigmentation of less than six square inches, and of 0 percent of the exposed area. On January 2013 VA examination, there was no objective evidence of onychomycosis of the great toenails. The Veteran had not treated this condition in the previous year. On January 2017 VA examination, the Veteran's onychomycosis was noted to have resolved. Here, the Veteran's skin disability affecting the great toes has not resulted in greater than 5 percent coverage of the entire body or exposed affected areas, or necessitated intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs, at any time during the appeal period. Therefore, a compensable rating is not warranted. Disabling impairment related to the onychomycosis was not identified. TDIU Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides a rating of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, 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, this disability shall be ratable at 60 percent or more, and that, 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). In this case, the Veteran has met the schedular criteria for consideration of a TDIU throughout the appeal period. However, the Board finds that assignment of a TDIU is not warranted. The evidence reflects that on April 2010 VA examination, the Veteran was assessed not to suffer from an overall functional impairment related to his service-connected disabilities. He did have trouble driving when experiencing a flare of his right elbow. On January 2013 VA examination, the Veteran's lumbar spine was assessed to not impact the Veteran's ability to work. His cervical spine disability and right shoulder disability were assessed to not preclude light duty or sedentary employment. Strenuous physical employment would be limited. His range of motion of the shoulder and cervical spine were significantly limited. The Veteran's carpal tunnel syndrome and right elbow disability were assessed to have no occupational impact. On January 2017 VA examination, the Veteran reported that he had previously worked soldiering wires, and then worked as an engineer. He left in 2015 due to his depression and shakes. The examiner determined that activity involving physical stress or strain to the lower back such as straining to lift heavy objects or prolonged sitting or standing without breaks, would result in increased lower back discomfort. His right elbow disability was assessed to make lifting heavy objects result in increased discomfort. His right shoulder disability was impaired in that activities with arms stretched above head or fully behind the back would cause discomfort. The Veteran's tremors were found to not have a functional impact on his ability to work. On a January 2017 VA examination for the cervical spine, the Veteran reported that he had worked as an electrician after service, but had stopped working a few years previously due to many medical conditions, to include his neck. His neck condition did not preclude light duty or sedentary employment. The Veteran reports that he was last able to work full-time in May 2012. However, on his application for a TDIU submitted in 2013, he stated that his Parkinson's disease, for which he is not in receipt of service connection, is the disability that prevents his employment. The record also reflects that the Veteran did continue to work until 2015. The record further reflects that the Veteran has specialized training in electronics/engineering, and in one position worked as a supervisor. It does not appear as though the Veteran's field of employment would necessitate the type of manual labor that would be precluded by his service-connected musculoskeletal disabilities, as was opined on VA examination. In that regard, the Veteran has not put forth any statements or contentions as to how his field of employment would prevent substantially gainful employment in light of his service-connected disabilities. His service-connected tremors have been assessed to not impact his occupational functioning, and the evidence does not reflect that the remainder of his service-connected disabilities would preclude employment. Thus, when taking into consideration the VA examination opinions regarding the Veteran's occupational impairments, as well as the Veteran's employment history and specialized training and skills, and the Veteran's statements in support of his claim, the Board cannot conclude that the Veteran is precluded from gainful employment on account of his service-connected disabilities. The Board has considered the evidence located within the Veteran's Social Security Administration file, but, again, does not find persuasive evidence that the Veteran's service-connected disabilities prevent gainful employment under the TDIU criteria. The Board has also considered the Veteran's lay statements that his disabilities are worse than currently evaluated. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which this disability is evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective complaints of increased symptomatology. ORDER Service connection for cervical radiculopathy of the right and left upper extremities is denied. Service connection for bilateral hearing loss is denied. Prior to June 25, 2012, a 10 percent rating for right CTS is granted, subject to the rules and regulations governing the award of monetary benefits. Since June 25, 2012, a rating in excess of 10 percent for right CTS is denied. An increased 10 percent rating for left CTS of the upper extremity is granted, subject to the rules and regulations governing the award of monetary benefits. Prior to June 25, 2012, an increased 10 percent for a lumbar spine disability is granted, subject to the rules and regulations governing the award of monetary benefits. Since June 25, 2012, a rating in excess of 10 percent for a lumbar spine disability is denied. A rating in excess of 20 percent for a cervical spine disability is denied. Prior to January 10, 2017, a 10 percent rating a right shoulder disability is granted, subject to the rules and regulations governing the award of monetary benefits. Since January 10, 2017, a right in excess of 20 percent for a right shoulder disability is denied. Prior to January 10, 207, an increased 10 percent for a right elbow disability is granted, subject to the rules and regulations governing the award of monetary benefits. Since January 10, 207, a rating in excess of 10 percent for a right elbow disability is denied. A compensable rating for onychomycosis of the great toes is denied. A TDIU is denied. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs