Citation Nr: 20005658 Decision Date: 01/23/20 Archive Date: 01/23/20 DOCKET NO. 09-39 249 DATE: January 23, 2020 ORDER Entitlement to a disability rating in excess of 10 percent prior to April 23, 2015 and in excess of 20 percent thereafter for service-connected chronic right elbow lateral epicondylitis, impairment of flexion is denied. Entitlement to a disability rating in excess of 10 percent, but no higher, from March 21, 2019 for impairment of supination and pronation due to right elbow lateral epicondylitis is granted, subject to the laws and regulations of monetary payments. Entitlement to a compensable disability rating for limitation of forearm extension due to right elbow lateral epicondylitis is denied FINDINGS OF FACT 1. The Veteran is left hand dominant. 2. Prior April 23, 2015, the Veteran’s right forearm had range of motion more than 90 degrees flexion. 3. From April 23, 2015, the Veteran’s right forearm had range of motion more than 110 degrees. 4. From March 21, 2019, the Veteran’s right forearm had limitation of pronation of more than 30 degrees and pain upon range of motion testing. 5. From March 21, 2019, the Veteran’s right forearm had limitation of extension of 40 degrees and no pain upon range of motion testing. CONCLUSIONS OF LAW 1. Prior to April 23, 2015, the criteria for a disability rating in excess of 10 percent for right elbow epicondylitis, limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5206. 2. From April 23, 2015, the criteria for a disability rating in excess of 20 percent for right elbow epicondylitis, limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5206. 3. From March 21, 2019, the criteria for a disability rating of 10 percent for right elbow epicondylitis, limitation of pronation and supination have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5213. 4. From March 21, 2019, the criteria for compensable disability rating for right elbow epicondylitis, limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5207. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1978 to June 1981 and from April 1986 to January 2005.This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an October 2008 decision by a Department of Veterans Affairs (VA) Regional Office (RO). A videoconference hearing was held in June 2012 before the undersigned, and a transcript of this hearing is of record. In April 2016, the Board granted a compensable rating of 10 percent for the Veteran’s service-connected right elbow epicondylitis. In September 2017, the United States Court of Appeals for Veterans Claims (Court) set aside the Board’s April 2016 decision and remanded for further development. In April 2019, the RO granted a 20 percent disability rating for chronic right elbow lateral epicondylitis, effective April 23, 2015; a separate 10 percent evaluation for impairment of supination and pronation due to right elbow lateral epicondylitis, effective May 21, 2019; and a separate non-compensable evaluation for limitation of forearm, effective March 21, 2019. Because these rating decisions are not a total grant of benefits, the claim for an increased rating remains before the Board. A.B. v Brown, 6 Vet. App. 35, 39 (1993). Chronic Right Elbow Epicondylitis The Veteran contends that his service-connected right elbow disability is more disabling than currently evaluated. The Veteran filed his claim for an increased rating on April 3, 2008; therefore, the appellate period is from April 3, 2007, one year prior to the Veteran’s application for increased benefits. As noted above the Veteran is currently service-connected for right elbow epicondylitis, impairment of supination and pronation, and limitation of motion of the forearm, which each stemmed from his chronic right elbow epicondylitis. Each service-connected disability related to the Veteran’s right elbow epicondylitis is discussed below. a. Applicable Law Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Governing law provides that the evaluation of the same manifestation under different diagnoses, known as pyramiding, is to be avoided. See Esteban v. Brown, 6 Vet. App. 259 (1994); see also 38 C.F.R. § 4.14 (2015). When rating the Veteran’s service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. (1991). In general, the degree of impairment resulting from a disability is a factual determination and the Board’s primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, staged ratings are appropriate in any initial rating/increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. 38 C.F.R. § 4.40. However, in Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system. Rather, pain may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Id. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is 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. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must provide opinions regarding flare-ups based upon estimates derived from information procured from relevant sources, including lay statements, when a flare-up is not observable at the time of examination. The most recent VA examination of the back and knees in March 2019 is responsive to the guidance provided in Correia and Sharp, and is adequate in that regard. The assignment of a particular Diagnostic Code is “completely dependent on the facts of a particular case.” Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual’s relevant medical history, diagnosis, and demonstrated symptomatology. Any change in Diagnostic Code must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Board accordingly will consider whether another rating code is more appropriate than the one used by the RO. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The Veteran’s lay statements and testimony are considered competent evidence when describing his symptoms of disease or disability that are non-medical in nature. Barr v. Nicholson, 21 Vet. App. 303 (2007), Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); and Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). His lay statements and testimony regarding the severity of his symptoms must be viewed in conjunction with the objective medical evidence of record and the pertinent rating criteria. And the ultimate probative value of his lay testimony and statements is determined not just by his competency, but also his credibility to the extent his statements and testimony concerning this is consistent with this other evidence. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). See also 38 C.F.R. § 3.159(a)(1) and (a)(2). The rating criteria distinguish between the major (dominant) extremity and the minor (non-dominant) extremity. The Veteran is shown to be left-handed, so the criteria for the minor extremity are applicable. The rating criteria of Diagnostic Code 5206 (limitation of flexion) are as follows for the minor extremity. A rating of 0 percent is assigned for flexion limited to 110 degrees. A rating of 10 percent is assigned for flexion limited to 100 degrees. A rating of 20 percent is assigned for flexion limited to 90 degrees. A rating of 20 percent is assigned for flexion limited to 70 degrees. A rating of 30 percent is assigned for flexion limited to 55 degrees. A rating of 40 percent is assigned for flexion limited to 45 degrees. The rating criteria of Diagnostic Code 5207 (limitation of extension) are as follows for the minor extremity. A rating of 10 percent is assigned for extension limited to 45 or 60 degrees. A rating of 20 percent is assigned for extension limited to 75 or 90 degrees. A rating of 30 percent is assigned for extension limited to 100 degrees. A rating of 40 percent is assigned for extension limited to 110 degrees. The rating criteria of Diagnostic Code 5208 are as follows. A rating of 20 percent is assigned for limitation of flexion to 100 degrees and limitation of flexion to 45 degrees. The rating criteria of Diagnostic Code 5213 (impairment of supination and pronation) are as follows for the minor extremity. A rating of 10 percent is assigned for limitation of supination to 30 degrees or less. A rating of 20 percent is assigned for loss of pronation with motion lost beyond the last quarter of the arc, with the hand not approaching full pronation; or, for bone fusion with the hand fixed near the middle of the arc. A rating of 20 percent is assigned for limitation of pronation with motion lost beyond the middle of the arc; or, for bone fusion with the hand fixed in full pronation. A rating of 30 percent is assigned for bone fusion with the hand fixed in supination or hyperpronation. A note following these Diagnostic Codes indicates that in all the forearm and wrist injuries, Codes 5205 through 5213, multiple impaired finger movements due to tendon tie-ups, muscle or nerve injury, are to be separately rated and combined not to exceed rating for loss of use of the hand. 38 C.F.R. § 4.71a. Under VA rating criteria, normal range of motion of the elbow is flexion from 0 to 145 degrees, forearm pronation from 0 to 80 degrees and forearm supination from 0 to 85 degrees. 38 C.F.R. § 4.71a, Plate I. b. Evidence The Veteran underwent a July 2008 VA elbow examination. During the examination the Veteran reported chronic aching and soreness of the right elbow at a level of 4 to 5 out of 10. He stated it was worse with movement or lifting, and he occasionally felt a momentary stabbing sensation. He reported occasional weakness, and instability. He also reported fatigability and lack of endurance. The Veteran denied stiffness, swelling, heat, redness, locking, dislocation and subluxation. The Veteran noted that sometimes he needed to change tasks when he had elbow discomfort. The Veteran stated he was left-hand dominant and used his left hand more, even though he was actually ambidextrous. Upon examination, there was no edema, effusion or instability of the right elbow. There was a negative upright prayer sign and a positive reverse prayer sign. Range of motion of the right elbow was as follows: flexion to 138 degrees and then to 140 without pain. Passive range of motion of the right elbow was to 142 degrees without pain. After repetitive motion, flexion was to 144 degrees. There was no additional limitation of joint function in the right elbow after three repetitions. With supination of the right forearm, range of motion was to 85 degrees with active and passive range of motion, and after three repetitive movements. With pronation, active and passive range of motion was to 80 degrees and also after three repetitive movements. The examiner indicated that there was no limitation of joint function after three repetitive movements of the right elbow, and there was no point tenderness to the medial or lateral epicondyle on physical examination. The examiner found there was no evidence for any right elbow lateral epicondylitis on examination. In January 2013 the Veteran underwent another VA examination, the examiner diagnosed epicondylitis. The Veteran complained of occasional stabbing pain in the elbow, and pain in the distal aspect of the right hand along the lateral aspect near the little finger and the lateral aspect of the wrist. He had pain in the lateral aspect of the elbow, which radiated up to his shoulder. The Veteran reported problems when shooting or using a fishing pole and could not perform push-ups because of elbow and wrist symptoms. The Veteran was left-handed. The Veteran stated that with flare-ups, he had a stabbing pain which caused decreased use of the elbow, which could limit his ability to carry things. It was painful to use his elbow when he had that pain and had dropped things as a result. Range of motion of the right elbow was as follows: flexion to 140 degrees, and right elbow extension to 0 degrees (i.e., no limitation of extension), with no objective evidence of painful motion. After repetitive-use testing, range of motion was from 0 to 135 degrees. The examiner indicated that that after this testing, there was less movement than normal, and excess fatigability, but no objective evidence of pain, weakness or incoordination. There was pain to palpation of the elbow. Muscle strength was full (5/5) in flexion and extension. There was no ankylosis of the elbow. Pronation of the right forearm was from 0 to 55 degrees, and supination was from 0 to 55 degrees; both were unchanged after three repetitions, and there was stiffness, but no pain, weakness, excess fatigability or incoordination. A January 2013 X-ray study of the right elbow was normal and showed no degenerative or traumatic arthritis. The examiner indicated that that the functional impact of the elbow condition was difficulty with overhead lifting and lifting items weighing more than 60 pounds, pain on repetitive motion. The position of the arm/forearm caused limitations, and the Veteran reported that using a computer mouse was sometimes difficult, but more for his wrist. The examiner found mild tenderness along the medial epicondyle bilaterally with palpation, and no lateral tenderness currently (although the Veteran said this was intermittent). The Veteran had a VA examination of the elbow in April 2015. The Veteran said his right elbow disability was more painful than at the January 2013 VA examination. He stated that he was left-handed. He reported flare-ups of the elbow disability, with a stabbing pain that caused decreased use of the elbow, and which could limit his ability to carry things. He said the pain had sometimes caused him to drop things. He said it was difficult to use a mouse and keyboard with his right hand; using these items or fishing caused increased right-hand pain. Flare-ups occurred once or twice daily and lasted for less than a minute. The Veteran stated that the right elbow disability prevented him from lifting weights and made it difficult to use a paint brush or roller. On examination, range of motion of the right elbow was from 0 to 135 degrees, extension was from 135 to 0 degrees, forearm supination was from 0 to 0 to 80 degrees, and pronation was from 0 to 85 degrees. The examiner indicated that range of motion did not contribute to functional loss, and there was no pain noted on examination. There was lateral epicondylar pain to palpation. There was no objective evidence of crepitus. After repetitive use testing, range of motion was unchanged, but there was additional functional loss, namely pain. Muscle strength was full (5/5) on flexion and extension, and there was no muscle atrophy. The examiner indicated that the left forearm muscle was slightly larger than that of the right forearm, but that this was likely because he is left handed. The examiner indicated that there was some flattening of the right thenar eminence. The examiner indicated that there was no ankylosis in the right elbow, and there was no flail joint, joint fracture, ununited fracture, malaligned fracture or impairment of supination or pronation. It was noted that he occasionally used a brace and right elbow strap. Due to the Veteran’s elbow conditions, there was not functional impairment to the degree that that no effective functions remained other than that which would be equally well served by an amputation with prosthesis. An X-ray study of the elbow did not show degenerative or traumatic arthritis. The examiner indicated that his right elbow disability impacted his occupational tasks in that reaching for items, moving a box, or putting something on a shelf caused increased pain with an electric-type sensation which caused him to stop what he was doing, which slowed down his productivity at work. The diagnosis was lateral epicondylitis. The Veteran underwent a March 2019 VA elbow and forearm examination. The examiner diagnosed the Veteran with right lateral and medial epicondylitis. During the examination the Veteran reported pain in the right elbow that was constant and located in the medial more than the lateral elbow, which could radiate up the right neck area or into the right medial hand area intermittently. The Veteran reported the elbow pain felt like an electric type of pain. The Veteran reported constant pain at the 6 out of 10 in severity. The right elbow pain was worse when lifting more than 50 pounds, trying longer than a couple hours, moving the right elbow that caused a twinge, and using the mouse and keyboard from time to time. The Veteran reported no significant changes in symptoms for the right elbow conditions since the last examination. The examiner found the Veteran was left hand dominant. The Veteran reported flare-ups in his right elbow. The Veteran described his flare-ups occurring 2 to 3 times a week. During a flare, the pain increased to 7 out of 0. The Veteran stated that he would stop doing activity until flare subsided. The Veteran noted that snowplowing with the use of controls on the snow blower, prolonged driving, and fishing could cause the flares. The Veteran reported that he had not gone fishing since the end of the summer and that he had to give his right arm after prolonged driving. Upon range of motion testing, the Veteran’s right elbow had 0 to 120 flexion, 120 to 0 flexion, 0 to 80 forearm supination, and 0 to 90 forearm pronation. The Veteran’s loss of range of motion contribute to functional loss. The examiner noted that for any activities that would require full or near full motion, the activities would be limited. The examiner noted pain on examination that caused functional loss in flexion, forearm supination, and forearm pronation. The examiner found evidence of localized tenderness or pain on palpitation of the joint or associated soft tissues in the medial and lateral epicondyle areas. There was no evidence of crepitus or ankylosis. The Veteran was able to perform repetitive use testing with at least three repetitions without additional functional loss. The examiner found that pain, fatigue, weakness, lack of endurance, and incoordination significantly limit functional ability with repeated use over a period of time. The examiner described the limitation in terms of 40 to 70 degrees flexion, 70 to -40 extension, 0 to 80 degrees forearm supination, and 0 to 90 forearm pronation. The examiner noted that the examination was not conducted during a flare-up. The examiner found that pain, fatigue, weakness, lack of endurance, and incoordination significantly limit functional ability with flare-ups. The examiner described the limitation during a flare-up in terms of range of motion of 40 to 70 degrees flexion, 70 to -40 extension, 0 to 80 degrees forearm supination, and 0 to 90 forearm pronation. The Veteran had additional contributing factors of the right elbow disability of interference with sitting. The examiner noted that when resting his right elbow on an arm support he would have to pull the arm away from time to time. The examiner found the Veteran had pain on passive range motion testing for the right elbow flexion, extension, and pronation. The examiner noted the Veteran in the seated, non-weight bearing position, with both hands resting on his lap, he had pain of 2 out 10 in his right elbow. The examiner noted the opposing joint was damaged. VA outpatient treatment records reflect treatment for “tennis elbow.” A November 2008 VA treatment note reflects that the Veteran currently worked in supply as a civilian and had held that position since 2004. The Veteran stated he was an avid fisherman. A February 2009 VA physical therapy note reflects that the Veteran had been referred for “tennis elbow” of the right arm. He reported having pain for a few years with a current increase. He reported difficulty using the arm for activities such as driving and holding items. He reported current pain at a level of 6/10, which increased with activity and decreased with rest. The Veteran pain was located mainly in the lateral aspect of the right elbow, but sometimes radiated up his arm and down into the little finger. He denied any numbness or tingling. He worked full time at a university as a supply technician, and his job involved being on his feet, as well as lifting and driving. He was left-handed. On examination, there was pain with palpation of the right elbow on the lateral aspect over the epicondyle, as well as the proximal third of the forearm. Active range of motion of the right upper extremity was full. There was pain with gentle stretching of the right upper extremity into elbow extension, wrist flexion, and ulnar deviation. Manual muscle test of the right elbow, forearm and wrist was 5/5. He was given an elbow brace. In April 2009, it was noted that the Veteran’s pain was decreased, and his strength had increased, and he had an improved ability to perform functional activities with his right arm. c. Limitation of Flexion The Veteran’s lateral epicondylitis is rated 20 percent from April 23, 2015 and 10 percent prior to April 23, 2015 under Diagnostic Code 5206. Initially, the Board finds that the evidence in the record demonstrates that the Veteran is left handed, and therefore, the Veteran’s right elbow disability is a “minor” upper extremity. The Board finds that prior to April 23, 2015, a disability in excess of 10 percent for limitation of flexion due to right elbow lateral epicondylitis is not warranted. The evidence of record demonstrates that the Veteran’s most significant symptom, both by subjective complaint and by clinical observation, had been pain, with some limitation of flexion, but such limitation has been, at worst, to 138 degrees, which does not approximate the level of impairment (90 degrees) required for a 20 percent disability rating under Diagnostic Code 5206. Although there is evidence that the Veteran had pain, fatiguability, weakness, and lack of endurance, the evidence does not indicate that such functional impairment caused an additional loss of 40 degrees of flexion. As such, a disability rating in excess of 10 percent rating for limitation of motion prior to April 23, 2015, is not warranted. From April 23, 2015, the Board finds that a disability rating in excess of 20 percent for limitation of forearm flexion due to right elbow lateral epicondylitis is not warranted. During this period the evidence indicates that the Veteran’s most significant symptom, both by subjective complaint and by clinical observation, had been pain, with some limitation of flexion, but such limitation has been, at worst, to 120 degrees, which does not approximate the level of impairment (55 degrees) required for a 30 percent disability rating under Diagnostic Code 5206. Although there is evidence that the Veteran had pain, fatiguability, weakness, and lack of endurance, the evidence does not indicate that such functional impacts caused an additional loss of 65 degrees of flexion. The Board notes that the Veteran indicated that he had flare-ups that caused limitation of motion. The March 2019 VA examiner found that during a flare-up the Veteran’s flexion would be limited to 70 degrees. There is no other indication that a flare-up caused 55-degree loss of motion. As such, a rating in excess of 20 percent for limitation of flexion from April 23, 2015, is not warranted. d. Impairment of Supination and Pronation The Veteran’s impairment of supination and pronation is rated 10 percent from May 21, 2019. The Board notes that the September 2019 rating decision that granted the award for service-connection for impairment of supination and pronation based on a March 21, 2019 VA examination. However, it appears that there was an error, in which the rating decision indicated May rather than March as the effective date. This is further evidenced by the noncompensable award for impairment extension effective March 21, 2019, on the same examination which provided the bases for impairment of supination and pronation award. As such, the Board grants a 10 percent disability rating from March 21, 2019 for impairment of supination and pronation in keeping with the March 21, 2019 examination and September 2019 RO rating decision. The Board finds that prior to March 21, 2019, service connection for impairment of supination or pronation is not warranted. Although, there is some evidence of limitation of motion prior March 21, 2019, the loss of range of motion did not rise to a limitation of 30 degrees or more; pronation lost beyond the last quarter of the arc, which the hand did not approach full pronation; or motion lost beyond middle of the arch. Further, VA examinations in April 2015 and January 2013, found no pain on range of motion testing in regard to supination and pronation. From March 21, 2019, the Board finds that a disability rating of 10 percent for impairment of supination and pronation is warranted. The Board notes that the March 21, 2019 VA examination indicated pain upon range of motion testing for the pronation and supination of the Veteran’s right forearm. In light of the Veteran's demonstrated chronic pain of the right elbow joint, with limitation of pronation and supination due to his service-connected disability, the Board finds that this disability is entitled to a 10 percent rating for the joint under Diagnostic Code 5213. 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59. The 10 percent rating effectively compensates him for additional limitation of function due to pain consistent with DeLuca. A disability rating in excess of 10 percent is not warranted. The evidence in the record does not indicate that the Veteran’s pronation was lost beyond the last quarter of the arc, which the hand did not approach full pronation; or motion lost beyond middle of the arch. Further, the evidence does not indicate loss of bone due to fusion. The Board notes that the Veteran’s current disability rating of 10 percent effective March 2019 is based on pain upon range of motion, rather than actual loss; and there is no indication that during a fare-up the Veteran’s range of motion pronation was lost beyond the last quarter of the arc, which the hand did not approach full pronation; or motion lost beyond middle of the arch. As such a disability rating in excess of 10 percent is not warranted. e. Limitation of Forearm Extension The Veteran was service-connected for limitation of forearm extension due to chronic right elbow epicondylitis based on the March 21, 2019 VA examination. The Veteran was rated noncompensable for limitation of forearm extension. Prior to March 21, 2019, the record does not indicate any limitation of right forearm extension. The Board finds that a compensable disability rating for a limitation of extension is not warranted. A compensable percent disability rating requires loss of extension of 45 degrees. The March 2019 examination found that the Veteran did not have any right forearm limitation of extension. However, during repetitive use testing and during flare-ups the Veteran had a limitation of 40 degrees extension. The March 2019 examiner did not indicate any pain upon extension. As there is no medical evidence of the Veteran’s extension is limited to more than 40 degrees or additional functional loss, a higher disability rating is not warranted. f. Other Considerations The Board has considered other diagnostic codes but finds that a higher rating is not warranted. In this regard, the Veteran’s elbow is not ankylosed, he does not have flail joint or false flail joint, and he does not have malunion or nonunion of the radius or ulna. Thus, Diagnostic Codes 5205, 5209, 5210, 5211, and 5212 are not applicable and cannot serve as a basis for a higher rating. Similarly, as the evidence fails to demonstrate flail joint of the elbow, with joint fracture, with marked cubitus varus or cubitus valgus deformity or with ununited fracture of the head of the radius, an increased rating is not warranted under Diagnostic Code 5209. In conclusion, the Board finds that a disability rating in excess of 10 percent prior to April 23, 2015, and in excess of 20 percent disability rating thereafter for chronic right elbow lateral epicondylitis impairment of flexion is not warranted. A disability rating in excess of 10 percent evaluation for impairment of supination and pronation due to right elbow lateral epicondylitis from March 21, 2019 is not warranted. Finally, a compensable evaluation for limitation of extension of the forearm is not warranted. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Robert Batten The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.