Citation Nr: 20046271 Decision Date: 07/10/20 Archive Date: 07/10/20 DOCKET NO. 06-18 530 DATE: July 10, 2020 ORDER Entitlement to service connection for hypertension, as secondary to the service-connected diabetes mellitus, is granted. Entitlement to service connection for a stomach disorder, to include diabetic gastroparesis and gastroesophageal reflux disease (GERD) is denied. Entitlement to a disability rating higher than 10 percent for allergic rhinitis and sinusitis is denied. Entitlement to a disability rating higher than 10 percent for low back strain is denied. Entitlement to a disability rating higher than 10 percent for degenerative changes, of the left shoulder (left shoulder disability) prior to December 20, 2004 is denied. Entitlement to a disability rating higher than 20 percent for left shoulder disability since December 20, 2004 is denied. Entitlement to a disability rating higher than 10 percent for residuals of a right knee medial meniscectomy with post traumatic arthritis (right knee disability) prior to July 14, 2014 is denied. Entitlement to a disability rating higher than 20 percent for right knee disability since July 14, 2014 is denied. Entitlement to a separate 10 percent disability rating for right knee disability, based on symptomatic removal of semilunar cartilage, is granted. Entitlement to a disability rating higher than 10 percent for degenerative changes of the right hand (right hand arthritis) is denied. Entitlement to a disability rating higher than 10 percent for degenerative changes of the left hand (left hand arthritis) is denied. REMANDED 12. Entitlement to an effective date earlier than November 28, 2007 for the assignment of a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Resolving all reasonable doubt in the Veteran’s favor, there is an approximate balance of positive and negative evidence as to whether his hypertension is aggravated by his service-connected diabetes mellitus. 2. The Veteran’s stomach disorder, diagnosed as GERD was not present in service and is not otherwise related to service or service-connected disability. 3. The Veteran’s allergic rhinitis/sinusitis has not resulted in three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge, or crusting and no evidence of nasal obstruction or polyps. 4. The Veteran’s low back strain has been manifested by painful, but noncompensable degree of limitation of motion; the disorder was not manifested by muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal, by ankylosis, or by incapacitating episodes of intervertebral disc syndrome (IDS) requiring bed rest as defined under VA law. 5. Prior to December 20, 2004 the Veteran’s left shoulder disability was manifested by painful motion with forward flexion and abduction above shoulder level; it did not involve functional limitation approximating ankylosis or impairment of the humerus, clavicle, or scapula. 6. Since December 20, 2004 the Veteran’s left shoulder disability has been manifested by painful motion with forward flexion and abduction at shoulder level; it does not involve functional limitation of the arm to midway between side and shoulder level, or functional limitation approximating ankylosis, or impairment of the humerus or scapula. 7. Prior to July 14, 2014, the Veteran’s right knee disability was manifested by painful motion, with noncompensable levels of limited flexion and extension; there was no objective evidence of recurrent subluxation/lateral instability, ankylosis, impairment of the tibia or fibula, genu recurvatum, or symptomatic scarring. 8. Since July 14, 2014, the Veteran’s service-connected right knee disability was manifested by limitation of flexion at worst to 80 degrees, limitation of extension at worst to 10 degrees; there is no objective evidence of recurrent subluxation/lateral instability, ankylosis, impairment of the tibia or fibula, genu recurvatum, or symptomatic scarring. 9. The Veteran’s right knee disability is manifested by frequent episodes of joint pain related to a meniscectomy. 10. The Veteran’s right hand arthritis is manifested by painful limited motion; there is no clinical evidence of ankylosis, or symptoms analogous to amputation of the finger, or other demonstrated functional impairment of the hand. The rating criteria reasonably describe his disability level and symptomatology. 11. The Veteran’s left hand arthritis is manifested by painful limited motion; there is no clinical evidence of ankylosis, or symptoms analogous to amputation of the finger, or other demonstrated functional impairment of the hand. The rating criteria reasonably describe his disability level and symptomatology. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for a stomach disorder are not met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.310. 3. The criteria for a disability rating higher than 10 percent for allergic rhinitis/sinusitis are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.97, Diagnostic Code (DC) 6510. 4. The criteria for a disability rating higher than 10 percent for low back strain are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.71a, DC 5237-5243. 5. The criteria for a disability rating, higher than 10 percent for left shoulder disability prior to December 20, 2004 are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.71a, DC 5201-5203. 6. The criteria for a disability rating, higher than 20 percent for the left shoulder disability since December 20, 2004 are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.71a, DC 5201-5203. 7. The criteria for a disability rating higher than 10 percent for right knee disability prior to July 14, 2014 are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.71a, DCs 5260, 5261. 8. The criteria for a disability rating higher than 20 percent for right knee disability since July 14, 2014 are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.71a, DCs 5260, 5261. 9. The criteria for a separate 10 percent disability rating for symptomatic residuals of right knee meniscectomy with frequent episodes of joint pain are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.71a DC 5259. 10. The criteria for a disability rating higher than 10 percent for right hand arthritis are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.321(b)(1), 4.71a, DC 5003-5229. 11. The criteria for a disability rating higher than 10 percent for left hand arthritis are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.321(b)(1), 4.71a, DC 5003-5229. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1969 to November 1990. The case was most recently remanded by the Board in October 2016 for additional development. The Agency of Original Jurisdiction (AOJ) made an unsuccessful attempt to obtain the complete report for a July 2003 VA sinus examination. In March 2020, the Oklahoma VA Medical Center responded that the only record located was a July 2003 sinus imaging report that had already been associated with the claims file. Based upon the foregoing, the Board finds that there has been substantial compliance with the previous remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998); D’Aries v. Peake, 22 Vet. App. 97, 105 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). Service Connection The Veteran is seeking service connection for hypertension and a stomach disorder. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Certain chronic diseases are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). Continuity of symptomatology may also provide a basis for a grant of service connection for those diseases defined as “chronic” by VA. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 446 (1995) (en banc). In order to establish service connection for a claimed secondary disorder, there must be medical evidence of a current disability; evidence of a service-connected disability; and medical evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). Service connection may be granted for any disease initially 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, any reasonable doubt is resolved in favor of the Veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. hypertension The Veteran asserts that his hypertension is caused, or made worse, by his service-connected diabetes mellitus. For VA compensation purposes, the term “hypertension” means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. Multiple blood pressure readings are required to confirm the diagnosis of hypertension with 2 or more readings on at least 3 different days. 38 C.F.R. § 4.104, DC 7101, Note 1. A VA medical opinion was provided in April 2017. The examiner noted no evidence of renal impairment, well controlled diabetes, multiple other risk factors for hypertension, and only fair compliance with a treatment regime. The examiner concluded that the Veteran’s hypertension was less likely proximate to his diabetes. However, she then went on to note that the Veteran continued to participate in risk factors which worsened, and subsequently lessened the control of his diabetes and increased the risk of worsening his hypertension. She therefore concluded that it was at least as likely as not that the Veteran’s hypertension had been aggravated by the service-connected diabetes mellitus. This medical opinion establishes the required cause-and-effect correlation between the Veteran’s service-connected diabetes mellitus and the development/progression of his hypertension. Also, there is no adequate reason to reject the VA medical opinion that is favorable to the Veteran. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (in evaluating the evidence and rendering a decision on the merits, the Board is required to assess the credibility and probative value of proffered evidence in the context of the record as a whole); Evans v. West, 12 Vet. App. 22, 26 (1998). After carefully reviewing and weighing the competent medical evidence of record, the Board is satisfied that it is as likely as not that the Veteran’s hypertension is aggravated by his diabetes mellitus. Accordingly, the Board resolves all reasonable doubt in favor of the Veteran and finds that the requirements for secondary service connection for hypertension are met. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. stomach disorder The Veteran asserts that his stomach disorder, claimed as diabetic gastroparesis is caused, or made worse, by his diabetes mellitus. While he appears to have limited his argument to principles of secondary service connection, direct service connection was also considered by the AOJ during the course of this appeal. During VA examination in April 2017, the Veteran denied gastroparesis symptoms including abdominal distention, nausea, vomiting, undigested food, premature feeling of fullness after eating, hypoglycemia, or unexplained weight loss. The examiner concluded the Veteran did not meet the diagnostic criteria for gastroparesis, nor did it appear on any problem list and he was not on any medications for gastroparesis (e.g., reglan, erythromycin, or antiemetics). However, the Veteran did have reflux and was on medications to treat it. He also reported that his diabetes was managed with metformin and his blood sugars were stable. The examiner concluded the Veteran’s GERD was not proximately due to or aggravated by his service-connected diabetes mellitus. The examiner explained that the Veteran has multiple risk factors for GERD other than diabetes including NSAID use for his various joint pains, aging, certain medications (calcium channel blocker-amlodipine), and iron supplements. In addition, by the Veteran’s own report his reflux has been stable for years with the use of his Nexium. The examiner noted that although Nexium is listed among his medications, his non-VA primary care provider does not even list GERD on the problem lists since 2004 (the same year it lists diabetes type 2 controlled by diet). Thus, there is no evidence in medical records or by the Veteran’s report that his GERD has been aggravated, progressed or worsened. Based on the foregoing, the Board finds there is no probative and competent medical evidence of record to indicate that the Veteran’s service-connected diabetes mellitus plays any role in the development of his current GERD. The VA opinion is both probative and persuasive medical evidence as it is based upon a review of the claims file, sets out the most helpful and complete discussion of the medical questions. In providing the rationale, the VA examiner considered specific medical history including the onset and course of pertinent symptoms, the results of clinical evaluation, and the Veteran’s belief that his stomach problems are related to his service-connected diabetes mellitus. There are no favorable competent opinions of record, and no other medical evidence of record suggests such a relationship. The Board is also unable to attribute the post-service development of GERD to military service. The Veteran did not experience chronic stomach symptoms in service and the earliest post-service evidence (documentation) of pertinent symptoms or complaints is found in July 2000 Upper Gastrointestinal (UGI) test results which showed GERD to the mid esophagus. There is also no competent evidence linking the diagnosed GERD to service or evidence that suggests such a relationship. The April 2017 VA examiner concluded that the Veteran’s GERD was less likely than not related to service. As rationale he referenced service treatment records which were negative for chronic stomach condition and insufficient evidence of symptomatology for 14 years after service. In this case, any assertion by the Veteran that his diagnosed GERD is related to service or service-connected disability treads into the realm of medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). This is particularly true here, as there is no competent evidence of a stomach disorder in service and there is gap of more than decade between service and the first documentation of any stomach disorder. Those factors confound any lay opinion on the matter, and require medical experience, education and training. Because the claimed GERD was not present in service, and there is no competent medical evidence relating it to service or service-connected disability, the claim cannot be granted. 38 C.F.R. §§ 3.303, 3.310; Allen, supra; see also, Wallin, Reiber, supra. Accordingly, the preponderance of the evidence is against the claim and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b). Increased Ratings The Veteran is seeking increased disability ratings for multiple service-connected disabilities. Disability ratings are determined by comparing a veteran’s present symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A review of the recorded history of a disability is necessary to make an accurate rating. 38 C.F.R. §§ 4.2, 4.41. The regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). allergic rhinitis/sinusitis The Veteran is seeking a higher disability rating for his service-connected allergic rhinitis/sinusitis, currently rated as 10 percent disabling under DC 6510. The General Rating Formula for Sinusitis is used to evaluate disabilities assigned DCs 6510 through 6514. A 10 percent evaluation is assigned for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-capacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent evaluation is assigned for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-capacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent evaluation is assigned following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. An incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97. The current 10 percent rating is based on findings from a July 2003 VA examination report. The Veteran reported symptoms of post-nasal drip, crusting, frequent cough, and sinus headaches. He also reported infections that occur about every 4 months with 2 episodes so far in the current calendar year and allergies that are present year-round. Sinus imaging was compatible with acute superimposed upon chronic sinusitis. Subsequent records include sinus imaging from July 2005 which showed the maxillary, ethmoid and sphenoid sinuses were normal. There was one small sinus cell on the left but none on the right and no abnormalities of the paranasal sinuses. These records do not otherwise indicate instances of treatment, medication, hospitalizations, or complaints of any symptoms reasonably attributable to sinusitis or allergic rhinitis which support a higher rating. When examined by VA in December 2007, the Veteran reported early morning post-nasal drainage resulting in a productive cough and intermittent nasal obstruction mostly at night. He described sinus infections as purulent rhinorrhea, headaches and facial pain. He also reported occasional allergy symptoms of sneezing, itchy eyes nose and throat treated with an oral antihistamine. Examination showed septal deviation to the right superiorly with septal spur. The turbinates were very edematous with clear rhinorrhea but no masses, polyps, or, purulence. The oral cavity showed moist mucosa and no lesions, masses or ulcerations. There was no post-nasal drainage. The most recent VA examination report is dated in July 2014. The Veteran reported frequent sneezing and coughing episodes sometimes productive of thick phlegm that is clear or green. He noted that certain allergens such as dust and flowers exacerbate his symptoms and that he took over-the-counter nasal spray and tablets about once a week to treat the symptoms. He had not been seen by a medical provider for treatment for the last 15 years. The examiner noted there were no current findings, signs or symptoms of chronic sinusitis. The Veteran had no non-incapacitating episodes or incapacitating episodes requiring a prolonged course of antibiotics in the past 12 months. Examination of the nose was essentially within normal limits with no evidence of nasal obstruction or polyps. The Veteran’s sinusitis/allergic rhinitis did not impact his ability to work. Therefore, based on the above, the medical evidence does not support a higher disability rating. The evidence does not show that the Veteran’s allergic rhinitis/sinusitis resulted in any incapacitating episodes requiring prolonged antibiotic treatment or three or more non-incapacitating episodes. In addition, the Veteran had no history of sinus surgery. In fact, in the most recent radiology report, there was no evidence of sinusitis. For these reasons, an evaluation higher than 10 percent is not warranted. The Board has also considered the potential assignment of a higher rating under DC 6522, which addresses allergic rhinitis. 38 C.F.R. § 4.97. Under this criteria a 10 percent evaluation is appropriate when there are no polyps, but when there is greater than 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. A 30 percent rating is appropriate when, in addition to these symptoms, there are also polyps. The medical evidence details various symptoms and complications, including nasal congestion, sneezing, itchy eyes, and post-nasal drip. Despite these symptoms the objective medical evidence does not reveal that the Veteran has had nasal polyps, as is required for a higher rating under DC 6522. Accordingly, the preponderance of the evidence is against the claim, and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b). low back strain The Veteran is seeking a higher disability rating for his service-connected low back strain rated as 10 percent disabling under DC 5237. The criteria for rating disabilities of the spine are listed under DCs 5235 to 5243. The code for intervertebral disc syndrome (DC 5243), permits rating under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever results in the higher rating when all disabilities are combined. 38 C.F.R. § 4.71a. The Veteran’s low back strain is rated as 10 percent disabling for forward flexion of the thoracolumbar spine is greater than 60 degrees, but not greater than 85 degrees; or, when the combined range of motion of the thoracolumbar spine greater than 120 degrees, but not greater than 225 degrees; or when there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is appropriate where there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation for forward flexion of the thoracolumbar spine of 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71. Any associated neurological abnormalities (e.g., bowel or bladder impairment) are evaluated separately under the appropriate diagnostic code. See Note 1, General Rating Formula for Disease and Injuries of the Spine, 38 C.F.R. § 4.71a. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent rating is warranted for incapacitating episodes having a total duration of at least one week, but less than two weeks in the past 12 months; and a 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. A 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks in the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks, but less than six weeks in the past 12 months; and a 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. Normal forward flexion of the thoracolumbar segment of the 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 rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. See Note 2, General Rating Formula for Disease and Injuries of the Spine, 38 C.F.R. § 4.71a, Plate V. Relevant evidence includes clinical findings from a July 2003 VA examination report. The Veteran reported constant low back pain that traveled down the right leg and occasional left leg numbness. He reported flare-ups during the early morning and when he is inactive. The pain goes away on its own when he moves around and with medications. He walked slowly with a normal gait and did not require any braces, crutches or canes. Range of motion testing showed forward flexion to 70 degrees, extension to 20 degrees, right lateral flexion to 30 degrees, left lateral flexion to 35 degrees and rotation to 30 degrees bilaterally with objective evidence of pain on motion. A February 2003 MRI report showed degenerative disc at L5-S1 with associated facet joint arthropathy, bilateral neural foraminal stenosis at L5, and mild degeneration of the intervertebral disc at L2-L3. Neurology examination was grossly within normal limits. During VA examination in December 2004, the Veteran reported continued back pain that was especially worse when lying down, bending over or moving around. Range of motion testing showed forward flexion limited to 60 degrees, with pain, but the examiner also noted the Veteran’s obese belly contributed to his inability to completely flex forward. Extension was to 20 degrees, lateral flexion was to 20 degrees bilaterally, and rotation was to 20 degrees bilaterally. The Veteran denied any prolonged periods of incapacitation in the last year. Subsequently dated treatment records show no indication of a worsening in range of motion or incapacitating episodes. There are also no neurological symptoms noted, no days of prescribed bed rest for intervertebral disc syndrome, and no findings or history to suggest any bladder or bowel dysfunction. When examined by VA in July 2014, the Veteran reported pain exacerbated by bending forward and prolonged sitting and flare ups when he has to change positions. Range of motion testing showed forward flexion to 80 degrees, backward extension to 25 degrees, lateral flexion to 25 degrees bilaterally, and rotation to 25 degrees bilaterally. There was no additional loss of range of motion after repetitive-use testing. Additional factors contributing to disability included less movement than normal and pain on movement. There was evidence of right lumbosacral paravertebral tenderness to palpation but no muscle spasm or guarding. The examiner could not determine functional loss/impairment during flare-ups, without resorting to mere speculation because the Veteran was not having a flare up at the time of examination. Muscle strength testing was 5/5 throughout both legs with no atrophy. Reflexes were normal at the knee but hypoactive at both ankles. Sensory examination showed decreased sensation to light touch at the feet and toes. Straight leg raising test was negative with no radicular pain or other signs or symptoms due to radiculopathy. There was no ankylosis and no other neurologic abnormalities or findings such as bowel or bladder problems/pathologic reflexes. The Veteran did not have IDS or incapacitating episodes and used a 4-prong cane for support for his right knee and low back condition. The examiner noted the Veteran would be limited in those occupations that require heavy/unassisted lifting, repetitive rotation of the back, carrying, pushing, or pulling heavy objects; vibrational stresses, overhead work, and prolonged sitting. He was also limited in prolonged standing and walking and would need allowance for rest periods every 30 minutes. The Veteran was most recently examined in April 2017 and reported back pain and stiffness that worsens with immobility, standing or changing positions. He described flareups as more of the same low back pain with deep ache in one area and functional loss/impairment with leaning forward, sitting, standing, or turning when lying down. He takes naproxen on average 4 times a week when his low back pain is the worse. Range of motion testing showed forward flexion to 90 degrees, backward extension to 25 degrees, lateral flexion to 30 degrees bilaterally and rotation to 30 degrees bilaterally with no additional loss of function or range of motion after repetitive testing. There was pain with passive range of motion testing and tenderness to palpation at the lumbar region paraspinal muscles bilaterally but no pain with weightbearing. Because the examiner was not present following repeated use or during a flare up, they were unable to assess for any additional limitations in range of motion. There was no muscle spasm or guarding. Additional factors contributing to disability included interference with sitting, standing, lifting, bending, and twisting. Muscle strength was normal at 5/5 and symmetrical with no atrophy. Reflexes were normal at 2+ and sensation was normal. Straight leg raising test was negative with no radicular pain nor any other signs or symptoms due to radiculopathy. There is no ankylosis and no other neurologic abnormalities or findings such as bowel or bladder problems/pathologic reflexes and the Veteran did not have IDS or incapacitating episodes that required prescribed bed rest in the past 12 months. Lumbar imaging showed mild grade 1 anterolisthesis, disc narrowing and degenerative changes. The examiner noted the Veteran would be limited in those occupations that require heavy/unassisted lifting, repetitive rotation of the back, carrying, pushing, or pulling heavy objects; vibrational stresses, overhead work, and prolonged sitting. He was also limited in prolonged standing and walking and would need allowance for rest periods every 30 minutes. Based upon a review of the evidence of record, the Board concludes that the 10 percent rating is appropriate and fully contemplates the Veteran’s low back strain. In fact, he demonstrated normal or near normal ranges of motion with no additional loss of motion or function after repetitive use testing. There was also no evidence of muscle spasm, guarding, localized tenderness, or vertebral body fracture. The Board acknowledges that the Veteran was only able to flex his lumbar spine to 60 degrees during VA examination in 2004. However, he generally manifested normal or near normal range of motion of the spine at all other examinations during the claims period. See VA examinations dated in July 2003, July 2014 and April 2017. In this case, the Board finds that his inability to flex the lumbar spine past 60 degrees at that time was due to an acute exacerbation and was not truly indicative of sustained worsening or of a particular stage in which his low back strain deteriorated. See 38 C.F.R. § 4.2 (regarding the duty to interpret medical findings comprehensively). The Board has also considered the impact of functional loss on the Veteran’s lumbar range of motion, but the clinical findings do not suggest that it would change to the degree required for a higher rating due to pain, or after repetitive use, or with weight bearing, or during flare-ups. The Veteran has also been able to take care of his activities of daily living and even with repetitive use there was no significant loss of motion. Given that his complaints do not prevent him from achieving substantial range of lumbar spine motion, they do not support a finding of additional functional loss beyond that contemplated by the assigned 10 percent evaluation. See 38 C.F.R. § 4.71, DC 5237; 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Correia v. McDonald, 28 Vet. App. 158 (2016), and Sharp v. Shulkin, 29 Vet. App. 26 (2017). Additionally, an increased evaluation is not warranted under the criteria for IDS, as the Veteran has not reported incapacitating episodes which required bed rest prescribed by a physician. The Board acknowledges the Veteran’s account of chronic back pain, but what is lacking is objective documentation that any physician prescribed the bed rest or that the Veteran was treated by a physician for any period approaching a total duration of even one week during a 12-month period. Thus, an increased evaluation under this diagnostic code is not for assignment. See 38 C.F.R. § 4.71a, DC 5243. The Board has also considered whether separate evaluations are for assignment for any objective neurologic manifestations of the Veteran’s low back strain. However, in this case, there is no evidence of radiculopathy and no significant sensory, reflex or muscular deficits. With the exception of hypoactive reflexes in 2014, the Veteran had normal muscle strength, and negative straight leg raising throughout the appeal period. Accordingly, the evidence does not support the award of a separate evaluation for any objective neurological manifestations. The preponderance of the evidence shows the Veteran’s impairment due to his low back strain is most consistent with a 10 percent disability rating. left shoulder The Veteran’s left shoulder disability is currently rated as 20 percent disabling under DC 5003-5201, effective April 20, 2015. Prior to that date, it was rated as 10 percent disabling. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. 38 C.F.R. § 4.69. The evidence establishes the Veteran is right-handed, so his left shoulder disability is rated for impairment of the minor upper extremity. Arthritis due to trauma, substantiated by X-ray findings, is rated as degenerative arthritis, which will be rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DCs 5003 and 5010. Under DC 5201 limitation of motion of the major or minor arm at shoulder level is rated as 20 percent disabling. Limitation of motion of the minor arm midway between the side and shoulder level also warrants a 20 percent rating. When motion is limited to 25 degrees from the side, a 30 percent rating is warranted for the minor arm. 38 C.F.R. § 4.71a. The normal range of motion of the shoulder is forward elevation (flexion) from zero to 180 degrees; abduction from zero to 180 degrees; and internal and external rotation to 90 degrees. Lifting the arm to shoulder level is lifting it to 90 degrees. Id., Plate I. prior to December 20, 2004 During VA examination in July 2003, the Veteran reported intermittent left shoulder pain that had no relationship to any activity. He did not use any braces, had no problems with short-term overhead work and had not undergone surgery. Range of motion testing showed flexion to 175 degrees, extension to 40 degrees, and abduction to 160 degrees with crepitus. External rotation was to 80 degrees, and internal rotation to 60 degrees. Applying the facts in this case to the criteria set forth above, the Board finds that a rating in excess of 10 percent for the Veteran’s left shoulder disability were not met. The VA examination during the timeframe in question show he was able to achieve at least 165 degrees of abduction, i.e., he was capable of reaching the arm to a point well above shoulder level. Active forward elevation of the left shoulder was to 175 degrees. In order to be entitled to the next higher evaluation of 20 percent, under DC 5201, limitation of motion of the arm must be to shoulder level. This was not demonstrated. The preponderance of the evidence shows the Veteran’s impairment due to his left shoulder disability prior to December 20, 2004 is most consistent with a 10 percent rating. since December 20, 2004 The current 20 percent evaluation is assigned from December 20, 2004 the date of outpatient treatment records which showed 90 degrees of forward flexion and abduction and external rotation to 35 degrees. In addition, during VA examination about that same time, the Veteran reported left shoulder pain, weakness, fatigability, lack of endurance and difficulty raising his arms to dress himself. He denied flare-ups as his shoulder hurts all the time but lifting caused more pain than normal. On examination there was some guarding of movement and a well-healed scar on the tip of his left deltoid from a muscle biopsy. There was pain on palpation of the left shoulder and some weakness. Left shoulder flexion was to 160 degrees, abduction to 60 degrees, and external and internal rotations were both to 50 degrees, all with pain. During VA examination in July 2014, the Veteran reported constant left shoulder aches. Range of motion showed flexion to 130 degrees with pain at 120 and abduction to 90 degrees with pain. There was no additional loss of range of motion after repetitive-use testing. Additional factors causing functional loss included less movement than normal and pain on movement. Muscle strength was normal at 5/5 for both abduction and flexion with no evidence of atrophy or ankylosis. There was no evidence of rotator cuff conditions, instability, recurrent dislocation or labral pathology and no impairment of the clavicle or scapula. The Veteran did not use any assistive devices and the left shoulder impacted his ability to work in occupational activities that required reaching, arm use above shoulder level, repetitive lifting, pushing, carrying more than 25 pounds or working at a high rate of speed. Any sedentary employment would require modifications such as use of headsets to answer telephones and forearm rests for use of computer keyboards. The examiner could not determine functional loss/impairment flare-ups, without resorting to mere speculation because the Veteran was not having a flare up at the time of examination. Subsequently dated VA outpatient records show that while the Veteran continued to report chronic pain, the clinical findings from these records are not materially different from those reported on the prior VA examinations and show no indication of a worsening in range of motion or functional impairment. When examined by the VA in April 2017, the Veteran reported intermittent left shoulder pain and flareups described as 12/10 on the pain scale. Range of motion showed flexion to 110 degrees and abduction to 160 degrees. External and internal rotation were both to 70 degrees. Pain was noted on exam but did not result in/cause functional loss. There was pain on passive range of motion but no evidence of pain with weight bearing, localised tenderness, or crepitus. Additional factors contributing to disability included problems with lifting, pushing, and pulling. Because the examiner was not present following repeated use of the shoulder over time or during flare-ups, they were unable to assess for any additional limitations in range of motion. Muscle strength was slightly weakened at 4/5 for both abduction and flexion with no evidence of atrophy or ankylosis. There were no rotator cuff conditions or evidence of shoulder instability/labral pathology, or impairment of the clavicle, scapula, or humerus. Imaging studies showed arthritis and the examiner noted the Veteran’s left shoulder would limit occupational activities that required reaching, arm use above shoulder level, lifting, pushing, carrying or working at a high rate of speed. During his most recent VA examination in November 2019, the Veteran reported moderately severe left shoulder pain that flares up nightly. Left shoulder range of motion was normal with flexion to 180 degrees, abduction to 180 degrees and external and internal rotation to 90 degrees with no additional loss of function or motion after repetitive testing. There was no pain noted on examination and no objective evidence of pain on passive range of motion testing. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time or during flare-ups. The examiner noted that there was no rational basis to make a notation regarding any additional losses of function or motion during a flare up or when it comes to repeated use over time. Muscle strength was slightly weakened at 4/5 for both abduction and flexion with no evidence of atrophy or ankylosis. There were no rotator cuff conditions or evidence of shoulder instability/labral pathology, or impairment of the clavicle, scapula, or humerus. Imaging studies showed arthritis and the examiner noted the Veteran was a retired electrician and security officer and that his left shoulder would limit occupational activities that required reaching out, pushing or pulling. Based on the preceding evidence, the criteria for a rating greater than 20 percent for the Veteran’s left shoulder disability are not met. The VA examinations of record show he can achieve at least 60 degrees of abduction, i.e., he was capable of reaching the arm slightly below shoulder level. He was also capable of at least 90 degrees of forward elevation of the arm. In order to be entitled to a higher evaluation, limitation of motion of the arm must be limited to no more than 25 degrees from the side. This has not been demonstrated. Although, the Veteran reports that activity is the precipitating factor for increased pain, there is no evidence to suggest that repetitive use or flare-ups would limit shoulder flexion to the degree required for a higher rating due to pain, or after repetitive use, or with weight bearing, or during flare-ups. Further, the Veteran has not needed any assistive devices at any time due to his left shoulder disability and has been able to take care of his activities of daily living. So, while his complaints have been taken into consideration, there is no evidence that his left shoulder disability suffers significant or additional functional loss beyond that contemplated by the assigned 10 and 20 percent evaluations. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 207; see also Mitchell, 25 Vet. App. at 32; Correia, 28 Vet. App. at 158; Sharp, 29 Vet. App. at 26. The preponderance of the evidence shows the Veteran’s impairment due to his left shoulder disability since December 20, 2004 is most consistent with a 20 percent rating. The Board also finds that no other diagnostic code pertaining to the shoulder would provide any higher disability evaluation. There is no evidence of ankylosis of the scapulohumeral articulation, impairment of the humerus, or impairment of the clavicle or scapula as contemplated by DCs 5200, 5202, and 5203. 38 C.F.R. § 4.71a. Accordingly, a preponderance of the evidence is against the claim, and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b). right knee The Veteran’s right knee disability is currently rated as 20 percent disabling under DC 5003-5261, effective July 14, 2014. Prior to that date, it was rated as 10 percent disabling. Arthritis due to trauma, substantiated by X-ray findings, is rated as degenerative arthritis, which will be rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DCs 5003 and 5010. Under DC 5260 where flexion is limited to 45 degrees, a 10 percent rating is assigned. When flexion is limited to 30 degrees, a 20 percent rating is assigned; and when flexion is limited to 15 degrees, a 30 percent rating is assigned. 38 C.F.R. § 4.71a. Separate ratings may be assigned for disability of the same joint under DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg). See VAOPGCPREC 9-04. Specifically, where a veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Under DC 5261, where extension is limited to 10 degrees, a 10 percent rating is assigned. When extension is limited to 15 degrees, a 20 percent rating is assigned; when limited to 20 degrees, a 30 percent disabling is assigned; when limited to 30 degrees, a 40 percent rating is assigned and when extension is limited to 45 degrees, a 50 percent rating is assigned. Id. Normal range of motion in the knee is 0 degrees of extension and 140 degrees of flexion. See 38 C.F.R. § 4.71a, Plate II. prior to July 14, 2014 Relevant evidence includes a July 2003 VA examination report. At that time the Veteran reported constant pain and occasional swelling, with popping and snapping using stairs. He also reported flareups once or twice a month that last from a couple of hours to a day. On examination the right knee had well-healed scars and crepitations on range of motion. Right knee flexion was to 120 degrees and extension to 5 degrees. The Veteran did not have any evidence of ligamentous instability and McMurray’s and drawer sign were negative. He had pain on patella-femoral compression but there was no evidence of muscle atrophy. During VA examination in December 2004, the Veteran reported constant right knee pain weakness, stiffness, swelling, fatigability and lack of endurance. He denied redness, instability, giving way and locking. Prolonged walking or standing, cold weather, and stairs caused daily flare-ups that last several hours and are alleviated by rest and medication. He does not use any braces, crutches or canes, but sometimes uses a walker when his knee is stiff especially in the morning. Examination of the knee revealed some well-healed scars and a limp of the right leg. The Veteran had pain on palpation of the medial joint line but no pain on patellofemoral compression. Knee flexion was limited to 125 degrees and extension was more painful and limited to about 3 degrees. Subsequently dated VA outpatient records show that while the Veteran continued to report chronic pain, he maintained a conservative treatment plan for his right knee disability, including pain medication and injections. Moreover, the clinical findings from these records are not materially different from those reported on the prior VA examinations and show no indication of a worsening in range of motion or functional impairment. Based on the preceding evidence, the criteria for a rating greater than 10 percent for the Veteran’s right knee disability are not met. The results from the VA examinations do not show limitation of flexion (to 30 degrees) or extension (to 10 degrees) sufficient to warrant an increased 20 percent evaluation or separate 10 percent under DCs 5260 or 5261, respectively. 38 C.F.R. § 4.71a. In fact, if strictly rated under range-of-motion diagnostic codes, the worst recorded findings from the 2003 VA examination (120 degrees flexion to 5 degrees extension) would be rated as noncompensable. However, according to VA policy, the presence of arthritis with painful limitation of motion supports a 10 percent rating under DCs 5003 and 5010. See VAOPGCPREC 9-98. The preponderance of the evidence shows the Veteran’s impairment due to his right knee disability prior to July 14, 2014 is most consistent with a 10 percent rating. from July 14, 2014 The 20 percent evaluation is based, in part on findings from a July 2014 examination. The Veteran reported constant pain made worse by walking, sitting and standing. He was unable to squat or kneel secondary to his reduced range of motion and feeling that the right knee might give way. Flare-ups results in decreased ability to stand, sit or walk for more than 15-30 minutes. On examination right knee flexion was to 100 degrees with pain at 90 and extension to 15 degrees with pain at 35. The Veteran was able to perform repetitive use testing with no additional functional loss or range of motion. There was no additional loss of motion with repetitive-use testing, but additional factors contributing to disability included less movement than normal, weakened movement, excess fatigability, pain on movement, deformity, disturbance of locomotion, and interference with sitting. The examiner could not determine functional loss/impairment during flare-ups, without resorting to mere speculation because the Veteran was not having a flare up at the time of examination. Muscle strength was normal at 5/5 with no evidence of atrophy or ankylosis. Joint stability testing was normal and there was no history of patellar subluxation/dislocation or additional conditions. The examiner noted the Veteran’s history of right knee surgery in 1971, with intermediate degrees of residual weakness, pain and limitation of motion, but no meniscus (semilunar cartilage) conditions. The examiner also noted a genu varus deformity of the right lower extremity secondary to the osteoarthritis of the right knee. The Veteran used a 4-prong cane to support for his right knee and low back conditions. He would be limited in those occupational requirements that include frequent or prolonged periods of walking, lifting/carrying heavy items, using stairs/ramps, squatting or kneeling. A sedentary work-place environment may need to allow for extending the knee rather sitting with the knee flexed. During VA examination in April 2017, the Veteran reported swelling and deep aching right knee pain. The right knee is hard to bend in the morning and the swelling worsens as the day progresses. He described flareups as worsening pain medially or behind knee and functional loss/impairment due to prolonged walking/standing, using stairs and squatting. Range of motion testing was normal with flexion to 140 degrees and extension to 0 degrees. Pain was noted but did not result in/cause functional loss. The Veteran was able to perform repetitive-use testing with no additional loss of function or range of motion and no pain on passive range of motion testing or with weight bearing. There was pain on non weight bearing and on palpation medial to patella as well as evidence of crepitus. Because the examiner was not present following repeated use of the knee over time or during a flare up, they were unable to assess for any additional limitations in range of motion. Muscle strength was normal at 5/5 for knee flexion and extension with no evidence of atrophy or ankylosis. Joint stability testing was negative with no evidence of recurrent subluxation, lateral instability, or recurrent effusion. There was no evidence of recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, tibial and/or fibular impairment, or meniscus (semilunar cartilage) condition. The examiner did not the Veteran had a meniscal tear with frequent episodes of joint pain due to meniscectomy in the 1970s. There was also a scar to the medial to the right patella measuring 6cm x 2cm that was not painful or unstable. The examiner noted the Veteran would be limited in occupations that required frequent or prolonged periods of walking, lifting or carrying heavy items, ascending and descending stairs or ramps, or squatting. Any sedentary workplace environment may need modifications to allow him to extend his knee rather sitting with it flexed. Based on the preceding evidence, the criteria for a rating greater than 20 percent for the Veteran’s right knee disability are not met. The results from the VA examinations do not show limitation of extension (to 20 degrees) or flexion (to 45 degrees) sufficient to warrant an increased 30 percent evaluation or a separate 10 percent evaluation under DCs 5261 or 5260 respectively. 38 C.F.R. § 4.71a. With respect to both timeframes, the clinical findings from the VA examination reports do not suggest that range of motion would change to the degree required for higher ratings after repetitive use, due to pain, with weight bearing, or during flare-ups. The Veteran has been able to take care of his activities of daily living and even with repetitive use there is no significant loss of motion. Given that his complaints do not prevent him from achieving substantial measured range of motion of the knee they do not support a finding of additional functional loss for higher ratings. The Veteran’s complaints have been taken into consideration, but there is no evidence that his knee disability suffers significant or additional functional loss beyond that contemplated by the assigned 10 and 20 percent evaluations. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 207; see also Mitchell, 25 Vet. App. at 32; Correia, 28 Vet. App. at 158; Sharp, 29 Vet. App. at 26. The preponderance of the evidence shows the Veteran’s impairment due to his right knee disability from July 14, 2014 is most consistent with a 20 percent rating. separate 10 percent under DC 5259 The Board has also considered a separate rating for impairment of the meniscus under either DC 5258 or DC 5259. A maximum 20 percent rating under DC 5258 can be assigned for dislocated semilunar cartilage (meniscus) with frequent episodes of locking, pain, and effusion into the joint. Under DC 5259 symptomatic removal of the meniscus, warrants a maximum 10 percent rating. 38 C.F.R. § 4.71a. The record shows that the Veteran underwent a right knee meniscectomy during service and his documented complaints of crepitus, swelling, popping, and snapping show that it remains symptomatic. Therefore, he is entitled to a separate 10 percent rating for symptomatic status post right knee meniscectomy under DC 5259. Id. The only other possibilities for a higher disability rating are not applicable to the Veteran’s case or do not offer a higher disability rating. 38 C.F.R. § 4.71a, DCs 5256, 5257, 5262, 5263. Finally, with regard to surgical scars, the clinical evidence does not show that any surgical scars are painful, tender, deep, unstable, cause limitation of motion, or are otherwise symptomatic such that a separate compensable rating would be warranted. 38 C.F.R. § 4.118, DC 7803, 7804, or 7805. After resolving any reasonable doubt in favor of the Veteran, the Board finds that the preponderance of the evidence supports a separate 10 percent disability rating for the portion of his service-connected right knee disability manifested by symptomatic meniscus removal under DC 5259. 38 C.F.R. § 3.102. hands The Veteran is seeking higher disability ratings for his service-connected bilateral hand arthritis rated as 10 percent disabling. Arthritis due to trauma, substantiated by X-ray findings, is rated as degenerative arthritis, which will be rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DCs 5003 and 5010. The diagnostic codes pertaining to ankylosis or limitation of motion of single or multiple digits of the hand are found at 38 C.F.R. § 4.71a, DCs 5216 to 5230. The preamble to these diagnostic codes provides, in relevant part, that: (1) For the index, long, ring, and little fingers (digits II, III, IV, and V), zero degrees of flexion represents the fingers fully extended, making a straight line with the rest of the hand. The position of function of the hand is with the wrist dorsiflexed from 20 to 30 degrees, the metacarpophalangeal and proximal interphalangeal joints flexed to 30 degrees, and the thumb (digit I) abducted and rotated so that the thumb pad faces the finger pads. Only joints in these positions are considered to be in favorable position. For digits II through V, the metacarpophalangeal (MCP) joint has a range of zero to 90 degrees of flexion, the proximal interphalangeal (PIP) joint has a range of zero to 100 degrees of flexion, and the distal (terminal) interphalangeal (DIP) joint has a range of zero to 70 or 80 degrees of flexion. See 38 C.F.R. § 4.71a, Table “Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand.” The Veteran’s bilateral hand arthritis is currently rated as10 percent disabling under DC 5229 for limitation of motion of the index or long finger with a gap of one inch (2.5 cm) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or with extension limited by more than 30 degrees. 38 C.F.R. § 4.71a. The 10 percent rating is the maximum rating assignable whether or not the limitation of motion of the individual digit is on the major or minor hand. Disability ratings in excess of 10 percent require limitation of motion or ankylosis of the thumb, or ankylosis of multiple digits. See, 38 C.F.R. § 4.71a, DCs 5216-5228. The VA examination of July 2003 shows the Veteran reported pain in the knuckles of both hands and morning stiffness in the fingers of both hands that resolves during the course of the day. He had no synovitis of the hand joints and his grip strength was normal. He could approximate the all the fingers to the thumb and range of motion was within normal limits. During VA examination in December 2004, the Veteran’s complaints of pain and stiffness of both hands remained unchanged. He also reported swelling and daily flareups brought on by cold weather and overuse. Examination showed mild swelling to the proximal interphalangeal joints of both hands but normal grip and normal muscle strength of 5/5. There was no gross limitation of range of motion of the hands. When examined by VA in July 2014, the Veteran reported increased pain, stiffness, and episodes of locking when picking up small items or reaching into his pocket. The locking lasts about 5-10 seconds and then releases. He denied any functional loss of movement or strength but reported flare-ups that impact function of the hand in that he has stop any activity for several seconds. There was painful motion for the fingers and thumbs bilaterally but no gap between the thumb pad and fingers. There was a gap of less than 1 inch (2.5 cm) between the fingertips and the proximal transverse crease of the palm affecting the index and long fingers of both hands. The Veteran was able to perform repetitive-use testing with no additional limitation of motion for any fingers or thumb. There was tenderness on palpation of both hands. Muscle strength testing was 5/5 for hand grip with no ankylosis. The examiner could not determine functional loss/impairment during flare-ups, without resorting to mere speculation because the Veteran was not having a flare up at the time of examination. The Veteran was most recently examined in April 2017. He reported bilateral hand pain throughout the fingers along with swelling of the 3rd and 4th fingers bilaterally specifically at the proximal and middle phalangeal joints. He also reported daily locking and stiffness and flare-ups of increased stiffness and deeper pain. Range of motion was normal for all fingers except for extension of the little finger DIP to 5 degrees. There was no gap between the pad of the thumb and the fingers or between the fingers and the proximal transverse crease of the hand on maximal finger flexion. There was no evidence of pain on examination and no additional loss with repetitive motion testing. Because the examiner was not present during a flare up, they were unable to assess for any additional limitations in range of motion. Muscle strength testing was 5/5 for hand grip with no ankylosis. The Veteran’s bilateral hand arthritis impacted functional impairment due to restrictions with lifting, carrying, typing, and work that requires fine motor skills. The Veteran’s currently assigned 10 percent disability ratings are the maximum available under DC 5229. The Board has considered whether the Veteran would be entitled to a higher or separate rating under any other diagnostic code. Range of motion testing throughout the appeal period did not meet the criteria of a compensable rating. However, the Veteran demonstrated painful motion, thus meeting the criteria for a 10 percent evaluation. 38 C.F.R. § 4.59. The only other possibilities for a higher disability rating would be under DCs 5225 or 5226 for ankylosis and under DC 5154 for amputation of the long finger. However, the Veteran’s bilateral hand arthritis disability has not shown to be manifested by any ankylosis and there are no other pertinent physical findings. The Board has considered the evidence to determine whether any additional functional loss due to pain and weakness on use results in impairment/disability equivalent to amputation. Functional impairment comparable to amputation is simply not shown. As such, higher rating pursuant to DCs 5154, 5225, and 5226 are not warranted. The Board has also considered whether the Veteran is entitled to an increased rating for his bilateral hand arthritis on an extraschedular basis. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321 (b)(1); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical). The Court has set out a sequential three-step analysis, based on the language of 38 C.F.R. § 3.321 (b)(1), to determine whether to refer a case for extraschedular consideration. Thun v. Peake, 22 Vet. App. 111 (2008). Step one is to determine whether the schedular rating adequately contemplates a claimant’s disability picture. If the criteria reasonably describe the disability level and symptomatology, then the claimant’s disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral to the Under Secretary for Benefits or the Director, Compensation Service for consideration of an extraschedular rating is required. If, however, the schedular criteria do not contemplate the claimant’s level of disability and symptomatology and are therefore found to be inadequate, step two is to determine whether the claimant’s disability picture is exceptional, with such related factors as marked interference with employment or frequent periods of hospitalization, as to render impractical the application of the regular schedular criteria. If the claimant’s disability picture meets this second step, then the third and last step is to refer the case to the Under Secretary for Benefits or the Director, Compensation Service to determine whether an extraschedular rating is warranted. In this case, the manifestations of the Veteran’s bilateral hand arthritis are fully contemplated by the schedular rating criteria. He has largely described his functional limitations in terms of fine motor skills such as being able to pick up small items. However, this type of movement is contemplated by the schedular criteria, as the ability to grip and handle objects is largely determined by the index finger’s ability to flex towards the palm, which is exactly what is measured in DC 5229. The pain elicited by such movements is contemplated in the 10 percent rating under DC 5229. See 38 C.F.R. § 4.59. As the Veteran’s symptomology is contemplated by the schedular criteria, extraschedular consideration is not warranted. The Board finds that all symptoms identified by the Veteran have been specifically contemplated by the criteria for the 10 percent rating that he is already receiving. There are no symptoms attributable to his service-connected bilateral hand arthritis that are left uncompensated or unaccounted for by the assignment of schedular rating. There is no need to consider the second step of the inquiry, namely whether there are “related factors” such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board’s “threshold” finding that the rating criteria were adequate to evaluate the claimant’s disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). As such, referral for extraschedular consideration is not warranted. The preponderance of evidence is against the claim and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND The Veteran is seeking an effective date earlier than November 28, 2007. In light of the grants of service connection for hypertension and a separate 10 percent evaluation for a right knee meniscectomy residuals, the Board finds this issue cannot be adjudicated until the AOJ effectuates the grant of service connection for hypertension and assigns the initial evaluation and an effective date as well as assigns an effective date for the separate 10 percent rating for the right knee meniscectomy residuals. The matters are REMANDED for the following action: (Continued on the next page)   1. Assign an initial rating and effective date for the now service-connected hypertension as well as an effective date for the separate 10 percent evaluation for the service-connected right knee meniscectomy residuals. 2. Then, readjudicate the issue of an earlier effective date for TDIU. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.R. Bryant 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.