Citation Nr: 21065700 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 11-32 687 DATE: October 27, 2021 ORDER Entitlement to an increased disability evaluation for degenerative joint disease of the left shoulder with tendinosis of the rotator cuff, currently rated as 20 percent disabling, is denied. Entitlement to an increased disability evaluation for bilateral plantar fasciitis with achilles tendonitis, initially rated as 30 percent disabling for the period prior to January 6, 2020, is denied. Entitlement to an increased disability evaluation for bilateral plantar fasciitis with achilles tendonitis, rated as 50 percent disabling since January 6, 2020, is denied. Entitlement to an increased disability rating for left hand arthritis, painful motion of the thumb, initially rated as 10 percent disabling, is denied. Entitlement to an increased disability evaluation for right hand arthritis, painful motion of the thumb, initially rated as 10 percent disabling, is denied. FINDINGS OF FACT 1. For the entire rating period on appeal, the Veteran's degenerative joint disease of the left shoulder with tendinosis of the rotator cuff (minor) is productive of pain on motion, with limitation of motion, but is not limited to 25 degrees from the side, with no additional functional loss. 2. For the rating period prior to January 6, 2020, the Veteran's bilateral plantar fasciitis with achilles tendonitis, is productive of manifested by marked deformity, accentuated pain on use, with swelling on use. 3. For the rating period since January 6, 2020, the Veteran's bilateral plantar fasciitis with achilles tendonitis, is productive of marked pronation, weight-bearing over or medial to the great toe, decreased longitudinal arch height on weight-bearing, inward bowing of the Achilles tendon, and marked deformity, without tenderness of the plantar surfaces. 4. Throughout the appeal period, the Veteran's left hand arthritis, painful motion of the thumb is manifested by on motion, without a gap of more than two inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, with no additional functional loss. 5. Throughout the appeal period, the Veteran's right hand arthritis, painful motion of the thumb is manifested by on motion, without a gap of more than two inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, with no additional functional loss. CONCLUSIONS OF LAW 1. The criteria for a disability evaluation in excess of 20 percent for degenerative joint disease of the left shoulder with tendinosis of the rotator cuff (minor) have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (2020). 2. The criteria for a disability evaluation in excess of 30 percent for bilateral plantar fasciitis with achilles tendonitis, for the rating period prior to January 6, 2020, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276 (2020). 3. The criteria for a disability evaluation in excess of 50 percent for bilateral plantar fasciitis with achilles tendonitis, for the rating period since January 6, 2020, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276 (2020). 4. The criteria for a rating in excess of 10 percent for left hand arthritis, painful motion of the thumb, are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5228 (2020). 5. The criteria for a rating in excess of 10 percent for right hand arthritis, painful motion of the thumb, are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5228 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 1987 to July 1991 and from November 1992 to June 2008. These matters come before the Board of Veterans' Appeals (Board) on appeal from July 2010, September 2011, and October 2011 rating decisions issued by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The July 2010 rating decision, in pertinent part, granted service connection for the Veteran's degenerative joint disease of the left shoulder; the September 2011 rating decision, in pertinent part, granted service connection for the Veteran's left foot plantar fasciitis, and the October 2011 rating decision, in pertinent part, granted service connection for the Veteran's right foot plantar fasciitis, left hand arthritis, and right hand arthritis. During the pendency of the appeal, in a July 2018 rating decision, the Veteran's plantar fasciitis was combined with achilles tendonitis and the Veteran was awarded an increased, 30 percent disability evaluation for his low back strain, effective July 1, 2009; the Veteran's arthritis of the right and left hand was recharacterized, such that the Veteran was awarded a 10 percent disability evaluation, per hand, reflecting the Veteran's painful motion of the thumb, effective July 1, 2009. In a June 2020 rating decision, the Veteran was granted an increased, 50 percent disability evaluation for his bilateral pes planus with achilles tendonitis, effective January 6, 2020. As the Veteran has not been granted the maximum benefits allowed, the claims of entitlement to increased disability ratings remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In August 2013, October 2016, November 2017, and March 2019, the Board remanded this appeal for further development. A supplemental statement of the case was most recently issued in June 2020. The Board finds that there was substantial compliance with its remand orders. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). Duties to Notify and Assist Neither the Veteran nor her representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Increased Rating Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In addition, when assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. When evaluating musculoskeletal disabilities, VA must consider whether a higher evaluation is warranted, where the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups. See 38 C.F.R. § § 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Nevertheless, pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Moreover, functional impairment must be supported by adequate pathology. Id.; Johnson v. Brown, 9 Vet. App. 7, 10 (1996) (both citing to 38 C.F.R. § 4.40). Notably, during the appeal period, changes were made to 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5201, and separate diagnostic criteria, Diagnostic Code 5269, for plantar fasciitis, was added to the rating schedule. Effective February 7, 2021, VA amended its regulations governing the schedule of rating musculoskeletal disabilities. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5201, 5269). Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). 1. Entitlement to an increased disability evaluation for degenerative joint disease of the left shoulder with tendinosis of the rotator cuff, currently rated as 20 percent disabling. The Veteran is currently rated for his service-connected degenerative joint disease of the left shoulder with tendinosis of the rotator cuff pursuant to the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5201. See 38 C.F.R. § 4.20. Diagnostic Code 5201 provides that limitation of motion of the arm at the shoulder level is rated 20 percent for the major shoulder and 10 percent for the minor shoulder; limitation of motion of the arm midway between the side and shoulder level is rated as 30 percent for the major shoulder and 20 percent for the minor shoulder; and limitation of motion of the arm to 25 degrees from the side is rated as 40 percent for the major shoulder and 30 percent for the minor shoulder. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The Board notes that effective February 7, 2021, the regulations pertaining to shoulders and arms were amended to state that Diagnostic Code 5201, governing limitation of the motion of the arm, includes flexion or abduction and to provide specific range of motion measurements; midway between side and shoulder level is defined as 45 degrees and at shoulder level is defined as 90 degrees. See 85 Fed. Reg. 76462 (Nov. 30, 2020) (effective 2/7/2021). The Board notes that this change does not impact the evaluation in this case. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 degrees to 180 degrees, abduction from 0 degrees to 180 degrees, external rotation from 0 degrees to 90 degrees, and internal rotation from 0 degrees to 90 degrees. See 38 C.F.R. § 4.71, Plate I (2019). In this case, documents of record establish that the Veteran is right-handed; the Veteran reported that her dominant hand is her right hand at the January 2018 and January 2020 VA examinations. See 38 C.F.R. § 4.69. The current evaluation contemplates pain on motion. In order to warrant a higher evaluation, there must be the functional equivalent of limitation of motion to shoulder level. See DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The Board finds that the Veteran's disability picture more nearly approximates the criteria for the currently assigned 20 percent disability rating for degenerative joint disease of the left shoulder with tendinosis of the rotator cuff (minor). According to the most recent, January 2020 VA examination report, the Veteran had active range of motion to 60 degrees flexion and 60 degrees abduction; external and internal rotation were each to 30 degrees. There was reduced strength of the left shoulder upon examination, as well as tenderness to palpation. The Veteran reported functional loss due to an inability to do overhead work or carry heavy objects as a result of pain, but the Veteran did not have additional loss of motion or functional loss upon repetitive use testing; the January 2020 VA examiner noted that the Veteran had pain. At the January 2018 VA examination, she had flexion to 100 degrees, abduction to 100 degrees, and external and internal rotation were each to 40 degrees. VA and private treatment records reflect treatment for left shoulder pain. The Board has considered whether additional functional impairment due to factors such as pain, weakness and fatigability demonstrate additional limitation of motion or function to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca at 206-07. The Board acknowledges that the Veteran reported at his VA examinations that she had difficulty lifting objects above his shoulder and pain with lifting due to her degenerative joint disease of the left shoulder with tendinosis of the rotator cuff; however, to the extent that the Veteran claims that her pain upon motion is the equivalent of limited motion, the Board finds that the Veteran's subjective complaints of pain have been contemplated in the current rating assignment, as the current rating is based on the objectively demonstrated reduced motion and impairment. See Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). The January 2020 VA examination report indicates that physical examination showed pain, without additional limitations upon repetitive use testing and flare-ups. In addition, the January 2018 VA examination report does not show that additional pain or limitation of motion on repetitive use testing, and or that the Veteran had pain on active motion/passive motion/in weight-bearing/nonweight-bearing which resulted in functional loss warranting the assignment of any higher evaluation for the left shoulder during the appeal period. See Correia v. McDonald, 28 Vet. App. 158 (2016). The Board finds that the criteria for a disability rating greater than 20 percent for the left shoulder have not been met or more nearly approximated for any part of the rating period on appeal. Although there is evidence of tenderness to palpation, there is no evidence of ankylosis, muscle atrophy, malunion of the humerus with deformity, or loss of head, nonunion, or fibrous union of the humerus during the rating period on appeal. Thus, a higher rating for the left shoulder, based on Diagnostic Codes 5200 and 5202, are not warranted. For the foregoing reasons, the preponderance of the evidence is against a disability rating in excess of 20 percent for the Veteran's degenerative joint disease of the left shoulder with tendinosis of the rotator cuff. Accordingly, the Veteran's claim for an increased disability evaluation is denied. 2. Entitlement to an increased disability evaluation for bilateral plantar fasciitis with achilles tendonitis, initially rated as 30 percent disabling. 3. Entitlement to an increased disability evaluation for bilateral plantar fasciitis with achilles tendonitis, rated as 50 percent disabling since January 6, 2020. The Veteran is in receipt of a 30 percent disability evaluation for her bilateral plantar fasciitis with achilles tendonitis for the rating period prior to January 6, 2020, pursuant to Diagnostic Code 5276. Effective January 6, 2020, the Veteran's bilateral plantar fasciitis with achilles tendonitis is rated as 50 percent disabling. Under Diagnostic Code 5276, a noncompensable disability evaluation is assigned for mild flat foot with symptoms relieved by a built-up shoe or arch support. A 10 percent rating is assigned for moderate flat foot with the weight-bearing line over or medial to the great toe, inward bowing of the tendon Achilles, and pain on manipulation and use of the feet. A 20 percent rating is assigned for unilateral severe flat foot with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated indications of swelling on use, and characteristic callosities. A 30 percent rating for unilateral flat foot requires a pronounced condition manifested by marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, not improved by orthopedic shoes or appliances. See 38 C.F.R. § 4.71a, Diagnostic Code 5276. The Board notes that, effective February 7, 2021, plantar fasciitis is now rated under Diagnostic Code 5269 of the Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); amended 86 Fed. Reg. 8142 (Feb. 4, 2021) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5269). Under Diagnostic Code 5269, a 30 percent disability rating is warranted for plantar fasciitis with no relief from both non-surgical and surgical treatment, bilateral. A 20 percent disability rating is warranted for plantar fasciitis with no relief from both non-surgical and surgical treatment, unilateral. A 10 percent disability rating is warranted for all other circumstances, unilateral or bilateral. Note (1): With actual loss of use of the foot, rate at 40 percent. Note (2): If a Veteran has been recommended for surgical intervention, but is not a surgical candidate, evaluate under the 20 percent or 30 percent criteria, whichever is appliable. 38 C.F.R. § 4.71a, Diagnostic Code 5269. Prior to January 6, 2020 The Board finds that the preponderance of the evidence is against a disability rating in excess of 30 percent for plantar fasciitis with achilles tendonitis for the rating period prior to January 6, 2020. At the July and August 2010 VA examinations, the Veteran reported experiencing pain, with accentuated pain on manipulation, but without callosities or swelling. At the January 2018 VA examination, the Veteran complained of pain that standing, which increased during a flare-up, including prolonged walking or standing, running, or jumping. She had accentuated pain on use of the feet, as well as swelling, without pain on manipulation or callosities. There was decreased longitudinal arch height, but there was no inward bowing, inward displacement, or spasm of the Achilles tendon, deformity (other than pes planus), pronation, or weight-bearing over or medial to the great toe. The Veteran reported using a cane to assist with ambulation. The Board finds that the Veteran's subjective complaints of pain have been contemplated in the current rating assignment, as the current rating is based on the objectively demonstrated pain on use. The Board acknowledges that the January 2018 VA examiner indicated that flareups are characterized by pain, lack of endurance, and interference with standing. However, her symptoms are not so severe as to be equivalent to symptoms required for a 50 percent disability rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca at 206-07. See also Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Therefore, the lay and medical evidence demonstrates that the Veteran's symptoms do not result in additional functional limitation to a degree that would support a rating in excess of the 30 percent disability rating assigned for the rating period prior to January 6, 2020. The Board notes that Diagnostic Code 5284, governing foot injuries - other, or any other foot Diagnostic Code is not applicable in the present case because the Veteran's service-connected condition, pes planus, is one of the foot condition specifically listed in 38 C.F.R. § 4.71a, and that to rate her plantar fasciitis under DC 5284 or any other foot Diagnostic Code would constitute an impermissible rating by analogy. Copeland v. McDonald, 27 Vet. App. 333, 338 (2015). In conclusion, the Board finds that the preponderance of the evidence is against a disability rating in excess of 30 percent for bilateral plantar fasciitis with achilles tendonitis for the rating period prior to January 6, 2020. Since January 6, 2020 After a review of the lay and medical evidence, the Board finds that the Veteran's service-connected bilateral plantar fasciitis with achilles tendonitis most closely approximates the criteria for a 50 percent disability rating for the rating period since January 6, 2020. At the January 2020 VA examination, she reported experiencing pain on use and tenderness of the plantar surfaces of both feet. However, examination did not show marked pronation, weight-bearing over or medial to the great toe, decreased longitudinal arch height on weight-bearing, inward bowing of the Achilles tendon, or marked deformity. Nevertheless, her achilles tendonitis compromised weight-bearing and required the use of orthotics, and there was pain on movement and weightbearing. Functional loss due to pain included an inability to stand and walk for more than 5 minutes. The Veteran did not report using an assistive device as a normal mode of locomotion. The Board finds that the Veteran's subjective complaints of pain have been contemplated in the current rating assignment. The VA examination reports indicate that the Veteran complained of pain, but physical examination did not demonstrate any additional limitations in response to pain; there was no weakness or fatigability beyond which was reflected in the examination report. See 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca at 206-07. See also Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Therefore, the lay and medical evidence demonstrates that the Veteran's symptoms do not result in additional functional limitation to a degree that would support a rating in excess of the 50 percent disability rating assigned for plantar fasciitis with achilles tendonitis, for the rating period since January 6, 2020. The Board observes that, in accordance with Diagnostic Code 5269, the Veteran is entitled to a 30 percent disability rating since February 7, 2021 because she does not have loss of use of her foot and she has no relief from both non-surgical and surgical treatment, bilateral. However, the Veteran has been rated at a 50 percent disability rating (above the schedular maximum for plantar fasciitis under Diagnostic Code 5269) since January 6, 2020; as a higher rating is not available under the revised Diagnostic Code, the Board will not disturb the Veteran's disability rating as the applied Diagnostic Code is more favorable. 4. Entitlement to an increased disability rating for left hand arthritis, painful motion of the thumb, initially rated as 10 percent disabling. 5. Entitlement to an increased disability evaluation for right hand arthritis, painful motion of the thumb, initially rated as 10 percent disabling. The Veteran is currently assigned a 10 percent rating, per hand, for her service-connected arthritis of the hands, painful motion of the thumb pursuant to the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5003 5228. See 38 C.F.R. § 4.20. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. The Board notes that the amended Diagnostic Code 5003, effective February 7, 2021, is substantively unchanged. To this point, the Board notes that Diagnostic Code 5003 was revised to reflect that this Diagnostic Code only applies to degenerative arthritis. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76460 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5003). Diagnostic Code 5003 provides that degenerative arthritis substantiated by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion. A 20 percent evaluation is warranted for x-ray evidence of involvement of 2 or more major or minor joints, with occasional incapacitating exacerbations. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. However, the Veteran has not reported experiencing any incapacitating exacerbations with regard to her left and right thumbs. Pursuant to Diagnostic Code 5228, a noncompensable disability rating is warranted for limitation of motion of the thumb with a gap of less than 1 inch (2.5 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a, Diagnostic Code 5228. A 10 percent disability rating is warranted for limitation of motion of the thumb with a gap of one to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. Id. A maximum schedular 20 percent disability rating is warranted for limitation of motion of the thumb with a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. Id. Note (4) under the criteria for Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand indicates the following regarding evaluation of ankylosis of the thumb: If both the carpometacarpal and interphalangeal joints are ankylosed, and either is in extension or full flexion, or there is rotation or angulation of a bone, the condition should be evaluated as amputation at metacarpophalangeal joint or through proximal phalanx. 38 C.F.R. § 4.71a, Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, Note 4. If both the carpometacarpal and interphalangeal joints are ankylosed, the condition should be evaluated as unfavorable ankylosis, even if each joint is individually fixed in a favorable position. If only the carpometacarpal or interphalangeal joint is ankylosed, and there is a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, the condition should be evaluated as unfavorable ankylosis. Finally, if only the carpometacarpal or interphalangeal joint is ankylosed, and there is a gap of two inches (5.1 cm.) or less between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, the condition should be evaluated as favorable ankylosis. Id. The Board finds that the weight of the evidence demonstrates that the symptoms of the Veteran's service-connected right and left hand arthritis, painful motion of the thumb, most closely approximate the diagnostic criteria for the currently assigned 10 percent rating per hand. With regard to limitation of motion, the Veteran has not demonstrated that her left and/or hands knees have compensable limitation of flexion. The Board observes that the Veteran, at her VA examinations, did not have a gap between the thumb pad and fingers; flexion to the metacarpal joint was to 90 degrees and flexion to the interphalangeal joint was to 80 degrees, bilaterally, at her January 2020 VA examination. Nevertheless, the Veteran reported that she experienced pain on flexion and extension, as well as opposition of the thumb to the fingers. Likewise, she had tenderness to palpation of hands. The Board acknowledges that the Veteran had flexion to the metacarpal joint to 80 degrees and flexion to the interphalangeal joint to 70 degrees, bilaterally, and a gap between the thumb pad and fingers of 2.5 centimeters on the right and 4 centimeters on the left, at the January 2018 VA examination. However, a 20 percent rating would require a gap of more than 2 inches between the thumb pad and fingers, which has not been demonstrated by the medical evidence of record. In the absence of this level of limited motion, a higher rating based on limitation of motion is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5228. Further, there is no evidence of ankylosis of the thumb at any time during the rating period on appeal. Thus, higher ratings for the left and/or right hands based on Diagnostic Code 5224 is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5224. Finally, with regard to functional loss, the Veteran's current evaluation contemplates pathology productive of painful motion. The evaluation is consistent with the functional equivalent of limitation of flexion to 2.5 and 5.1centimeters, as demonstrated on the January 2018 VA examination. The Board accepts the lay evidence that the Veteran experiences pain. Similarly, the Board accepts the evidence that she has limitation of flexion of the metacarpal and interphalangeal joints of the thumb. However, the limitation of motion due to pain is contemplated in the current evaluation that recognizes her painful motion. The January 2021 VA examiner noted that repetitive use testing did not reduce the Veteran's range of motion and that whether a flare-up would change the Veteran's range of motion could not be determined due to the many variables involved. Nevertheless, there is no indication that she has additional functional impairment, above and beyond the 10 percent level, per hand, for her service-connected left and right hand arthritis, painful motion of the thumb, which would support a higher rating for either hand. The Board acknowledges that the January 2021 VA examination report reflects reduced grip strength due to pain and muscle atrophy of the hands, but points out that this is not solely due to the Veteran's thumbs. See DeLuca, citing 38 C.F.R. §§ 4.40, 4.45, and 4.59. As discussed, the available medical findings do not show that painful motion, limitation of motion on repetitive use testing, or pain or limitation of motion on active motion/passive motion/in weight-bearing/nonweight-bearing resulted in functional loss warranting the assignment of any higher evaluation for the right and/or left hands during the entire appeal period. See Correia v. McDonald, 28 Vet. App. 158 (2016). Therefore, the Board finds that the evidence does not support a disability evaluation in excess of 10 percent, per hand, for the Veteran's service-connected left and right hand arthritis, painful motion of the thumbs, for the entire rating period on appeal. (CONTINUED ON NEXT PAGE) GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Brokowsky, Counsel 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.