Citation Nr: 21070507 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 18-05 091 DATE: November 24, 2021 ORDER Entitlement to a disability rating greater than 10 percent prior to May 10, 2021 for posttraumatic osteoarthritis of the left knee is denied. Entitlement to a disability rating greater than 20 percent from May 10, 2021 for posttraumatic osteoarthritis of the left knee is denied. Entitlement to a disability rating greater than 10 percent for posttraumatic osteoarthritis of the right knee is denied. Entitlement to a disability rating greater than 10 percent prior to May 10, 2021 for posttraumatic osteoarthritis of the left elbow is denied. Entitlement to a disability rating greater than 20 percent from May 10, 2021 for posttraumatic osteoarthritis of the left elbow is denied. Entitlement to a disability rating greater than 10 percent for posttraumatic osteoarthritis of the left wrist is denied. Entitlement to a total disability rating based upon individual unemployability (TDIU) prior to January 8, 2021 is denied. FINDINGS OF FACT 1. The preponderance of the evidence shows that prior to May 10, 2021, the Veteran's left knee disability did not manifest as limitation of flexion to 30 degrees or extension to 15 degrees, and; there is no evidence of arthritic changes involving two or more major joints or two or more minor joint groups. 2. The preponderance of the evidence shows that from May 10, 2021, the Veteran's left knee disability did not manifest as limitation of flexion to 15 degrees or extension to 20 degrees. 3. The preponderance of the evidence shows that the Veteran's right knee disability did not manifest as limitation of flexion to 30 degrees or extension to 15 degrees, and; there is no evidence of arthritic changes involving two or more major joints or two or more minor joint groups. 4. The preponderance of the evidence shows that prior to May 10, 2021, the Veteran's left elbow disability did not manifest as limitation of flexion to 90 degrees or 70 degrees, and; there is no evidence of arthritic changes involving two or more major joints or two or more minor joint groups. 5. The preponderance of the evidence shows that from May 10, 2021, the Veteran's left elbow disability did not manifest as limitation of flexion to 55 degrees. 6. The Veteran is in receipt of the maximum schedular rating under 38 C.F.R. § 4.71a, Diagnostic Code 5215, and; the preponderance of the evidence shows that the Veteran's left wrist disability did not manifest as favorable ankylosis of the wrist in 20 degrees to 30 degrees dorsiflexion or the functional equivalent of ankylosis, and; there is no evidence of arthritic changes involving two or more major joints or two or more minor joint groups. 7. Prior to January 8, 2021, the Veteran's service-connected disabilities did not preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a disability rating greater than 10 percent prior to May 10, 2021 for posttraumatic osteoarthritis of the left knee have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5010, 5260. 2. The criteria for a disability rating greater than 20 percent from May 10, 2021 for posttraumatic osteoarthritis of the left knee have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5010, 5260. 3. The criteria for a disability rating greater than 10 percent for posttraumatic osteoarthritis of the right knee have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5010, 5260. 4. The criteria for a disability rating greater than 10 percent prior to May 10, 2021 for posttraumatic osteoarthritis of the left elbow have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5010, 5206. 5. The criteria for a disability rating greater than 20 percent from May 10, 2021 for posttraumatic osteoarthritis of the left elbow have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5010, 5206. 6. The criteria for a disability rating greater than 10 percent for posttraumatic osteoarthritis of the left wrist have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5010, 5215. 7. The criteria for TDIU prior to January 8, 2021 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1982 to March 1991. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). A Board virtual hearing was held with the undersigned Veterans Law Judge in July 2020. A hearing transcript is associated with the claims file. The Board remanded these issues in September 2020 for further development and there has been substantial compliance with the remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). These matters are properly before the Board for adjudication. Since the September 2020 Board remand, the RO granted service connection for left wrist painful scar, right knee recurrent patellar instability, and left elbow limitation of extension. These claims for increased ratings based on instability/subluxation of the right knee, left wrist scar, and left elbow limitation of extension are in the AMA, were part of claims for service connection in the AMA, were promulgated after the case was re-certified to the Board, and are not part of this legacy appeal. The Board notes in that regard that issues cannot pend in the two systems simultaneously pursuant to 38 C.F.R. § 3.2500. The RO granted the Veteran entitlement to a TDIU from January 8, 2021. Pursuant to Harper v. Wilkie, an award of TDIU prior to January 8, 2021 is still pending in conjunction with the claim for an increased rating. See Harper v. Wilkie, 30 Vet. App. 356 (2018) (holding that once entitlement to a TDIU is put in issue as part of a claim for a higher initial rating and the RO grants a TDIU that does not span the entire period on appeal, the issue of entitlement to a TDIU for an earlier period is still on appeal). Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1991); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the United States Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § § 4.59 requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. §§ 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). Generally, hyphenated diagnostic codes are used when an unlisted disability is at issue. 38 C.F.R. § 4.27. Use of the second diagnostic code helps provide further detail regarding the origins of the unlisted disability, the bodily functions affected, the symptomatology, and anatomical location. Id. Additionally, the diagnostic code following the hyphen is the diagnostic code by which the disability is evaluated. Id. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). These amendments revised Diagnostic Codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021, and the criteria that is more favorable to the Veteran will be applied. Prior to the regulatory change, Diagnostic Code (DC) 5010 was evaluated under DC 5003 Arthritis, degenerative (hypertrophic or osteoarthritis). Degenerative arthritis when established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate Code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Code 5003. A 20 percent rating is applied where there is X-ray evidence of arthritic changes involving two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, DC 5003, 5010. As of February 7, 2021, under the amended criteria, DC 5010 assigns a disability rating pursuant to limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. The Veteran's posttraumatic osteoarthritis bilateral knee, posttraumatic osteoarthritis left elbow, posttraumatic osteoarthritis left elbow limitation of extension, and posttraumatic osteoarthritis left are currently rated under Diagnostic Codes (DCs) 5260, 5206, 5207, and 5215, respectively. Although the portion of the rating schedule that addresses the musculoskeletal system was revised effective February 7, 2021, these diagnostic codes were not changed. 1. Increased disability ratings for posttraumatic osteoarthritis of the left knee, and posttraumatic arthritis of the right knee are denied. The Veteran's posttraumatic osteoarthritis of the left knee and posttraumatic osteoarthritis of the right knee are evaluated pursuant to Diagnostic Codes 5010-5260. Generally, hyphenated diagnostic codes are used when an unlisted disability is at issue. 38 C.F.R. § 4.27. Use of the second diagnostic code helps provide further detail regarding the origins of the unlisted disability, the bodily functions affected, the symptomatology, and anatomical location. Id. Additionally, the diagnostic code following the hyphen is the diagnostic code by which the disability is evaluated. Id. Under Diagnostic Code 5260, limitation of knee flexion is rated 30 percent disabling where flexion is limited to 15 degrees; 20 percent disabling where flexion is limited to 30 degrees; 10 percent disabling where flexion is limited to 45 degrees; and noncompensable where flexion is limited to 60 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, limitation of knee extension is rated 50 percent disabling where extension is limited to 45 degrees; 40 percent disabling where extension is limited to 30 degrees; 30 percent disabling where extension is limited to 20 degrees; 20 percent disabling where extension is limited to 15 degrees; 10 percent disabling where extension is limited to 10 degrees; and noncompensable where extension is limited to 5 degrees. Id. VA's General Counsel has held that separate ratings may be warranted for limitation of flexion and extension when the criteria for compensable ratings are met for such limitation under DCs 5260 and 5261. VAOPGCPREC 9-2004. The Veteran underwent VA examinations in November 2014, January 2021, and June 2021. The November 2014 report indicates the Veteran experienced painful flare-ups. Range of motion testing measured right knee flexion ended at 125 degrees with objective evidence of painful motion at 125 degrees and no evidence of right knee limitation of extension or painful motion. Left knee range of motion for flexion and extension were normal with no evidence of painful motion. Repetitive use testing did not result in loss of range for either right or left knee. The examiner noted the Veteran had less movement than normal and pain on movement for the right leg. The report indicated no imaging studies of the knee were performed, no evidence of tenderness or pain to palpation of either knee, loss of muscle strength, joint instability, patellar subluxation or dislocation, shin splints, stress fractures, exertional compartment syndrome, tibial and/or fibular impairment, meniscal conditions, surgical procedures, of scars. The examiner opined that the Veteran's knee disabilities did not impact his ability to work. During the January 2021 examination, the Veteran reported flare-ups of the right and left knees during prolonged walking, kneeling, squatting, and ascending/descending stairs. The Veteran's bilateral knee flare-ups last a few days and are not alleviated by anything. Initial range of motion testing measured right knee flexion ending at 110 degrees and extension ending at zero degrees; left knee flexion ending at 105 degrees and extension ending at zero degrees. The examiner noted bilateral pain during flexion and extension that did not cause or result in functional loss. There was no evidence of localized tenderness, pain on palpation, pain with weight bearing, or crepitus of either knee. The Veteran performed repetitive use testing without additional loss of function or range of motion after three repetitions. The Veteran was not examined immediately after repetitive use over time or during a flare-up. The examiner stated the examiner was neither medically consistent or in consistent with statements describing functional loss with repetitive use over time or during a flare-up. He noted that pain caused functional and described right knee range of motion during repetitive use over time measured right knee flexion ending at 105 degrees and extension ending at zero degrees; and left knee flexion ending at 100 degrees and extension ending at zero degrees. The examiner noted pain caused functional and described right knee range of motion during flare-ups measured right knee flexion ending at 100 degrees and extension ending at zero degrees; and left knee flexion ending at 95 degrees and extension ending at zero degrees. The January 2021 examiner found no additional factors contributing to the bilateral knee disabilities, or muscle strength loss, muscle atrophy, instability, patellar subluxation or dislocation, shin splints, stress fractures, exertional compartment syndrome, tibial and/or fibular impairment, or meniscal conditions. The examiner noted that x-rays taken in July 2014 showed bilateral tricompartmental degenerative changes, greatest in medial compartments. The examiner determined the Veteran's disability prevented him from walking more than one block during flare-ups and caused fatigue, worsening pain, difficulty in activities such as squatting, kneeling, and walking which affected his daily routine. The Veteran underwent a VA examination in June 2021. He reported four moderate and transitory flare-ups causing right knee buckling. This led to falling and no alleviating factors were noted. The Veteran also stated he is unable to stand or walk prolonged times or distances; his right knee locks up, especially while descending stairs; and he has history of frequent effusion of the left knee. The examiner noted that abnormal range of motion reduced right knee ability to kneel, bend or squat and limited left knee ability to squat, kneel, or crawl. Initial range of motion testing measured right knee flexion ending at 75 degrees and extension ending at zero degrees; left knee flexion ending at 40 degrees and extension ending at zero degrees. The examiner noted no pain during flexion and extension, pain with weight bearing, nonweight-bearing, active motion, passive motion, or nonmovement, bilaterally. There was evidence of crepitus and moderate bilateral localized tenderness, pain on palpation at the lateral patella and hypertrophic tuberosity related to osteoarthritis. The Veteran performed repetitive use testing without additional loss of function or range of motion after three repetitions. The Veteran was not examined immediately after repetitive use over time or during a flare-up. The examiner noted that pain, fatigability, weakness, lack of endurance, and incoordination caused bilateral functional and estimated right knee range of motion during repetitive use over time measured flexion ending at 70 degrees and extension ending at zero degrees; and left knee flexion ending at 30 degrees and extension ending at zero degrees. The examiner noted the procured evidence did not suggest pain, fatigability, weakness, lack of endurance, and incoordination limited functional ability with flare-ups, bilaterally. Additional contributing factors to the Veteran's right knee disability include interference with sitting and standing; swelling; disturbance of locomotion; less movement than normal; and weakened movement. The examiner stated the right exhibited less movement than normal and weakened movement due to pain and swelling impacting ability to stand, sit, and walk. The examiner found right painful hypertrophic tibial tuberosity. The report indicated additional contributing factors to the left knee disability include interference with sitting and standing; swelling; swelling; disturbance of locomotion; deformity; less movement than normal; and weakened movement. In addition to painful hypertrophic tibial tuberosity, the left knee disability has a history of locking up and giving out causing falls. The examiner found no muscle atrophy, ankylosis, or tibial or fibular impairment, bilaterally. The report showed evidence of right knee recurrent subluxation, persistent instability, and patellar instability with no evidence of ligament tear or repair. The Veteran was prescribed a cane for right support. The Veteran had a right knee meniscal tear with frequent episodes of locking up and pain. There was no evidence of left knee meniscal conditions, however, the Veteran reported chronic pain and stiffness after a 1987 left knee arthroscopic debridement. The examiner noted 2007 and 2014 imaging tests showing tricompartmental degenerative changes bilaterally and patellar enthesopathy. The examiner opined the newly identified right knee instability and meniscal tear are related to service-connected diagnosis tibial tubercle hypertrophy. She also stated that the bilateral right knee disability prevented prolonged standing, sitting, walking, and is a fall risk due to the right knee instability. Based on the foregoing, the Veteran is not entitled to a disability rating greater than 10 percent prior to May 10, 2021 for posttraumatic osteoarthritis of the left knee; a disability rating greater than 20 percent from May 10, 2021 for posttraumatic osteoarthritis of the left knee; and a disability rating greater than 10 percent for posttraumatic osteoarthritis of the right knee is denied. Range of motion testing has consistently shown prior to May 10, 2021 left knee flexion measurements exceeding 30 degrees, and extension was not limited to 15 degrees; since May 10, 2021 left knee flexion exceeded 15 degrees, and extension was not limited to 20 degrees; and right knee flexion measurements exceeded 30 degrees and extension was not limited to 15 degrees. There is also no basis for the assignment of a separate compensable rating based on limitation of extension for right or left knee. Prior to May 10, 2021 left knee extension was not limited to 15 degrees; since May 10, 2021 left knee extension was not limited to 20 degrees; and right knee extension was not limited to 15 degrees. The Board has also considered whether higher ratings for the Veteran's right and/or left knee disability is appropriate under 38 C.F.R. §§ 4.40, 4.45, and 4.59, and concluded that such is not warranted. Pain on flexion and extension was noted on examination. However, limitation of prior to May 10, 2021 left knee flexion still measured well in excess of 30 degrees and extension measures in excess of 15 degrees; from May 10, 2021, left knee flexion measured well in excess of 15 degrees and extension measured in excess of 20 degrees; and right knee flexion measured well in excess of 30 degrees and extension measures in excess of 15 degrees. See 38 C.F.R. § 4.71a; DC 5260, 5261. The Court has also established that flare-ups must be considered. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Guidance on how to evaluate flare-ups has not been particularly clear. However, the Board finds overall wisdom in Mitchell. Flare-ups must be quantifiable and must result in limitation of motion or function beyond that contemplated by the already provided evaluation. In addition, because there is a regulation addressing stabilization of ratings, the flare-up must be of such length as to establish that the overall impairment is more severe than currently evaluated, rather than a brief snapshot in time. With that in mind, consideration has been given the reports of flare-ups during the January 2021 and June 2021 VA examinations. The January 2021 VA examiner found that pain reduced left and right knee range of motion by 5 degrees. This decrease applied to flexion and extension. This evidence, however, demonstrates that the Veteran's left knee range of motion would be reduced to 95 degrees and right knee range of motion would be 100, well in excess of the requirement for a 20 percent or 30 percent disability rating. As to the lay statements describing pain, the evidence does not demonstrate additional functional limitation more closely approximating the criteria for a higher rating. Such would not warrant a higher evaluation. The reported flare-ups are not of such length or duration that a staged rating would not violate the rule regarding stabilization of ratings. The Board acknowledges the June 2021 VA examiner did not provide range of motion measurements for the Veteran's flare-ups. Additionally, the contemporaneous treatment records contain little, if any, findings pertaining to flare-ups much less information regarding the Veteran's functional ability during a flare-up or after repeated use over time. In sum, 38 C.F.R. § 4.1 provides that the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illness proportionate to the severity of the several grades of disability. The report of flare-ups in 2020 are not of sufficient duration or severity to warrant a change in evaluation without violating the spirit of Mitchell, the spirit of 38 C.F.R. § 4.1 and the rule regarding stabilization of ratings. The current disability ratings were assigned by the RO under 38 C.F.R. § 4.59 in recognition of the Veteran's left knee and right knee painful motion and limited motion. To that end, the Board has considered the application of a separate compensable rating under DC 5003 as the Veteran suffers from osteoarthritis. However, as discussed, the pain and limited ROM associated with osteoarthritis are already accorded for in relation to his current ratings. Additionally, higher 20 percent rating is not warranted for the left knee or right knee disability at any point during the appeal because there was no evidence of arthritic changes involving two or more major joints or two or more minor joint groups. Therefore, to provide for additional 10 percent ratings for left knee and/or right knee arthritis would equate to impermissible pyramiding. 38 C.F.R. § 4.14. The Board has also considered the lay statements that the Veteran's bilateral knee disabilities warrant a higher rating and acknowledges that the Veteran is competent to report symptoms of pain. Layno v. Brown, 6 Vet. App. 465 (1994). Lay witnesses are not, however, competent to identify a specific level of disability according to the applicable diagnostic code. Such competent evidence concerning the nature and extent of the Veteran's service-connected left knee and right knee disabilities have been provided by the VA medical professionals who examined him. The medical findings adequately address the criteria under which these disabilities are evaluated. The Board accords the objective medical findings greater weight than subjective complaints of increased symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Accordingly, the Board finds that the claim of entitlement to a disability rating greater than 10 percent prior to May 10, 2021 for posttraumatic osteoarthritis of the left knee; a disability rating greater than 20 percent from May 10, 2021 for posttraumatic osteoarthritis of the left knee; and a disability rating greater than 10 percent for posttraumatic osteoarthritis of the right knee must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. The Board has considered the applicability of other rating criteria for evaluating the musculoskeletal disabilities of the left knee and right knee under 38 C.F.R. § 4.71a; however, there is no basis for assigning a higher or separate compensable rating under an alternate diagnostic code such as DCs 5256, 5258, 5259, 5262 or 5263. 2. Entitlement to a disability rating greater than 10 percent prior to May 10, 2021 for posttraumatic osteoarthritis of the left elbow; a disability rating greater than 20 percent from May 10, 2021 for posttraumatic osteoarthritis of the left elbow. The Veteran's posttraumatic left elbow osteoarthritis and left elbow, limitation of extension are evaluated under Diagnostic Codes 5010-5206 (limitation of flexion of the forearm) and 5010-5207 (limitation of extension of the forearm), respectively. Generally, hyphenated diagnostic codes are used when an unlisted disability is at issue. 38 C.F.R. § 4.27. Use of the second diagnostic code helps provide further detail regarding the origins of the unlisted disability, the bodily functions affected, the symptomatology, and anatomical location. Id. Additionally, the diagnostic code following the hyphen is the diagnostic code by which the disability is evaluated. Id. These diagnostic codes contain different ratings depending on whether the affected extremity is major or minor. The Veteran is right-handed and the criteria applicable to the minor extremity are therefore for application. Under DC 5206, limitation of flexion of the minor forearm to 90 degrees warrants a 20 percent rating; limitation of flexion to 70 degrees warrants a 20 percent rating; limitation of flexion to 55 degrees warrants a 30 percent rating. Under DC 5207, limitation of extension to 45 degrees warrants a 10 percent rating; limitation of extension to 60 degrees warrants a 10 percent rating. A November 2014 VA examination report shows the Veteran denied flare-ups and range of motion testing indicated normal flexion and extension range of motion measurements. The examiner indicated no functional loss or impairment of the elbow and forearm. The Veteran reported severe daily flare-ups that last all day and are not alleviated by anything he does during a January 2021 VA examination. The medical report noted the Veteran had difficulty with repetitive upper extremities and handling anything exceeding 10 lbs. Initial range of motion testing measure flexion at 115 degrees and extension at 0 degrees. Pain was noted on flexion, extension, supination, and pronation but did not result in or cause functional loss. Observed repetitive use testing showed flexion ending at 105 degrees and extension ending at 0 degrees. There was no evidence of pain with weight-bearing, pain on palpation or tenderness of the joint, or crepitus. The Veteran was not examined immediately after repetitive use over time or during a flare-up. The examiner indicated the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss. The report indicated pain caused functional impairment and estimated left range of motion during repetitive use over time and flare-ups measured flexion ending at 105 degrees and extension ending at zero degrees. The examiner noted the procured evidence did not suggest pain, fatigability, weakness, lack of endurance, and incoordination limited functional ability with flare-ups, bilaterally. The Veteran denied flare-ups to a June 2021 VA examiner. However, the report noted the Veteran had difficulty buttoning shirts, holding objects, and needs help dressing. The examiner found painful motion on flexion and extension. Initial range of motion testing measured flexion ending at 70 degrees and extension ending at 10 degrees. The examiner stated passive range of motion and repetitive use testing measurements were the same as active range of motion testing. There was evidence of pain with weight-bearing, active motion, and moderate localized pain of the lateral epicondyle, which caused functional. Pain was noted on flexion, extension, supination, and pronation but did not result in or cause functional loss. Observed repetitive use testing showed flexion ending at 105 degrees and extension ending at 0 degrees. There was no evidence of pain with weight-bearing, pain on palpation or tenderness of the joint, or crepitus. The Veteran was not examined immediately after repetitive use over time. The examiner indicated the Veteran's statements suggested pain, fatigability, and weakness significantly limited functional ability. The examiner estimated left elbow flexion during repetitive use over time ending at 60 degrees and extension ending at 10 degrees. The examiner noted weakened movement and less movement than normal related to hyperextension injury with osteoarthritis contributed to the Veteran's disability. The examiner indicated x-ray imaging showed left elbow posttraumatic osteoarthritis. Based on the evidence of record, the Veteran's claims for a disability rating greater than 10 percent prior to May 10, 2021 for posttraumatic osteoarthritis of the left elbow; a disability rating greater than 20 percent from May 10, 2021 for posttraumatic osteoarthritis of the left elbow; and initial compensable disability rating for posttraumatic osteoarthritis of the left elbow, limitation of extension is not warranted. In order to warrant higher ratings, prior to May 10, 2021, there must be the functional equivalent of flexion to 90 degrees; from May 10, 2021 there must be flexion to 55 degrees; and for a compensable disability rating for extension, the evidence must show extension was limited to 60 degrees. The evidence of record shows prior to May 10, 2021, elbow flexion measured well in excess of 90 degrees; from May 10, 2021, flexion measured well in excess of 55 degrees; and extension measured well in excess of 60 degrees. See 38 C.F.R. § 4.71a; DC 5206, 5207. The Board has also considered whether higher ratings for the Veteran's left elbow disability is appropriate under 38 C.F.R. §§ 4.40, 4.45, and 4.59, and concluded that such is not warranted. Pain on flexion and extension was noted on examination. However, left elbow range of motion prior to May 10, 2021 still measured well in excess of 90 degrees; from May 10, 2021, left elbow flexion measured well in excess of 55 degrees; and left elbow measured well in excess of 45 degrees during the entire period on appeal. See 38 C.F.R. § 4.71a; DC 5206, 5207. The Court has also established that flare-ups must be considered. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Guidance on how to evaluate flare-ups has not been particularly clear. However, the Board finds overall wisdom in Mitchell. Flare-ups must be quantifiable and must result in limitation of motion or function beyond that contemplated by the already provided evaluation. In addition, because there is a regulation addressing stabilization of ratings, the flare-up must be of such length as to establish that the overall impairment is more severe than currently evaluated, rather than a brief snapshot in time. With that in mind, consideration has been given the reports of flare-ups during the January 2021 VA examination. The January 2021 VA examiner found that pain reduced left elbow flexion by 10 degrees. This evidence, however, demonstrates that the Veteran's left elbow flexion range of motion would be reduced to 105 degrees, well in excess of the requirements for a 20 or 30 percent disability rating. As to the lay statements describing pain, the evidence does not demonstrate additional functional limitation more closely approximating the criteria for a higher rating. Such would not warrant a higher evaluation. The contemporaneous treatment records contain little, if any, findings pertaining to flare-ups much less information regarding the Veteran's functional ability during a flare-up or after repeated use over time. In sum, 38 C.F.R. § 4.1 provides that the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illness proportionate to the severity of the several grades of disability. The report of flare-ups in 2021 are not of sufficient duration or severity to warrant a change in evaluation without violating the spirit of Mitchell, the spirit of 38 C.F.R. § 4.1 and the rule regarding stabilization of ratings. The current disability ratings were assigned by the RO under 38 C.F.R. § 4.59 in recognition of the Veteran's left elbow painful motion and limited motion. To that end, the Board has considered the application of a separate compensable rating under DC 5003 as the Veteran suffers from osteoarthritis. However, as discussed, the pain and limited ROM associated with osteoarthritis are already accorded for in relation to his current ratings. Additionally, higher 20 percent rating is not warranted for the left elbow disability at any point during the appeal because there was no evidence of X-ray evidence of arthritic changes involving two or more major joints or two or more minor joint groups. Therefore, to provide for additional 10 percent ratings for left elbow arthritis would equate to impermissible pyramiding. 38 C.F.R. § 4.14. The Board has also considered the lay statements that the Veteran's left elbow disabilities warrant higher ratings and acknowledge that the Veteran is competent to report symptoms of pain. Layno v. Brown, 6 Vet. App. 465 (1994). Lay witnesses are not, however, competent to identify a specific level of disability according to the applicable diagnostic code. Such competent evidence concerning the nature and extent of the Veteran's service-connected left elbow disability has been provided by the VA medical professionals who examined him. The medical findings adequately address the criteria under which this disability is evaluated. The Board accords the objective medical findings greater weight than subjective complaints of increased symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Accordingly, the Board finds that the claim of entitlement to a disability rating greater than 10 percent prior to May 10, 2021 for posttraumatic osteoarthritis of the left elbow; a disability rating greater than 20 percent from May 10, 2021 for posttraumatic osteoarthritis of the left elbow; and an initial compensable disability rating for posttraumatic osteoarthritis of the left elbow must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. 3. Entitlement to a disability rating greater than 10 percent for posttraumatic osteoarthritis of the left wrist is denied. The Veteran a disability evaluation greater than 10 percent is warranted for left wrist osteoarthritis. The Veteran's posttraumatic osteoarthritis of the left wrist is evaluated under Diagnostic Codes 5010-5215. Generally, hyphenated diagnostic codes are used when an unlisted disability is at issue. 38 C.F.R. § 4.27. Use of the second diagnostic code helps provide further detail regarding the origins of the unlisted disability, the bodily functions affected, the symptomatology, and anatomical location. Id. Additionally, the diagnostic code following the hyphen is the diagnostic code by which the disability is evaluated. Id. Diagnostic Code 5215 provides ratings based on limitation of motion of the wrist. Limitation of palmar flexion in line with the forearm is rated 10 percent disabling for the major wrist and 10 percent for the minor wrist. Limitation of dorsiflexion to less than 15 degrees is also rated 10 percent disabling for the major wrist or minor wrist. 38 C.F.R. § 4.71a. A 10 percent rating is the maximum rating under Diagnostic Code 5215. Diagnostic Code 5214 provides ratings for ankylosis of the wrist. Favorable ankylosis of the wrist in 20 degrees to 30 degrees dorsiflexion is rated 30 percent disabling for the major wrist and 20 percent for the minor wrist; ankylosis of the wrist in any other position except favorable is rated 40 percent disabling for the major wrist and 30 percent for the minor wrist; and unfavorable ankylosis of the wrist in any degree of palmar flexion, or with ulnar or radial deviation, is rated 50 percent disabling for the major wrist and 40 percent for the minor wrist. 38 C.F.R. § 4.71a. A Note provides that extremely unfavorable ankylosis will be rated as loss of use of hands under Diagnostic Code 5125. 38 C.F.R. § 4.71a. Service connection for left wrist for posttraumatic osteoarthritis, left wrist was initially granted in a January 2007 rating decision. A 10 percent disability rating was assigned. He is thereby in receipt of the maximum schedular rating under Diagnostic Code 5215. A higher rating could be assigned if ankylosis were shown. Recently the Court issued a decision in Chavis v. McDonough, No. 18-2928 (April 16, 2021), and found that when evaluating a disability under VA's General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), the criteria for a rating based on ankylosis may be met by evidence demonstrating the functional equivalent of ankylosis; i.e., functional loss consistent with that contemplated by ankylosis. See also 38 C.F.R. §§ 4.40, 4.45; Mitchell v. Shinseki, 25 Vet. App. 32 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995). In Chavis, the Court additionally noted the definition of ankylosis as "complete limitation of motion." See Dorland's Illustrated Medical Dictionary at 94 (33d ed. 2019). Accordingly, a rating in excess of 10 percent rating is not warranted for ankylosis or the functional equivalent of ankylosis throughout the appeal period. The Court in Chavis has determined that ankylosis is an objective finding and not a diagnosis and the evidence of record does not support such a finding at any point of the appeal period. Specifically, VA examiners in November 2014, January 2021, and June 2021 found no evidence ankylosis of the left wrist. The Board has also considered whether the Veteran's functional loss is consistent with that contemplated by ankylosis, but the evidence does not demonstrate the functional equivalent of ankylosis; i.e., wrist is fixed in flexion or extension. Despite the Veteran's June 2021 statement that he's unable to move his wrist "at all," palmar flexion measured 65 degrees and dorsiflexion measured 50 degrees in November 2014; palmar flexion measured 75 degrees and dorsiflexion measured 65 degrees with evidence of pain during palmar flexion and dorsiflexion in January 2021; and palmar flexion measured 60 degrees and dorsiflexion measured 30 degrees. Such evidence belies the notion of complete left wrist limitation of motion. In view of the findings of the November 2014, January 2021, and June 2021 VA examination and treatment records that are negative for findings of ankylosis, the Board finds an assignment of a higher rating under Diagnostic Code 5214 is not warranted. The current disability rating was assigned by the RO under 38 C.F.R. § 4.59 in recognition of the Veteran's left wrist painful motion and limited motion. To that end, the Board has considered the application of a separate compensable rating under DC 5003 as the Veteran suffers from osteoarthritis. However, as discussed, the pain and limited ROM associated with osteoarthritis are already accorded for in relation to his current ratings. Additionally, higher 20 percent rating is not warranted for the left wrist disability at any point during the appeal because there was no evidence of X-ray evidence of arthritic changes involving two or more major joints or two or more minor joint groups. Therefore, to provide for additional 10 percent ratings for left wrist arthritis would equate to impermissible pyramiding. 38 C.F.R. § 4.14. The Board has also considered the Veteran's statements that his wrist disability warrants a higher rating and acknowledges that the Veteran is competent to report symptoms of wrist pain. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability according to the applicable diagnostic code. Such competent evidence concerning the nature and extent of the Veteran's service-connected wrist disability has been provided by the VA medical professionals who examined him. The medical findings adequately address the criteria under which this disability is evaluated. The Board accords the objective medical findings greater weight than subjective complaints of increased symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board finds that an evaluation in excess of 10 percent is not warranted. In reaching this determination, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, because the preponderance of the evidence is against the claim, this doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 4. Entitlement to TDIU prior to January 8, 2021 is denied. A total rating for compensation may be assigned where the schedular rating is less than total when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Rating boards are to refer to the Director of the Compensation Service for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage requirements. 38 C.F.R. § 4.16(b). In determining whether a veteran can secure, follow, and maintain a substantially gainful occupation, the Court in Ray v. Wilkie directed the Board to consider the following factors: (1) the Veteran's occupational history, education, skill, and training; (2) whether the Veteran has the physical ability (both exertional and non-exertional) to perform the type of activities required by the occupation at issue; and (3) whether the Veteran has the mental ability to perform the activities required by the occupation at issue. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a). A Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. Age may not be considered as a factor in evaluating service-connected disability; and unemployability, in service-connected claims, associated with advancing age or intercurrent disability, may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). TDIU is to be awarded based on the judgment of the rating agency. Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). The Veteran was assigned a 60 percent disability rating from January 8, 2021. From September 22, 2014 to January 8, 2021, the Veteran's combined rating was 50 percent and he was service-connected for lumbosacral strain with degenerative joint disease (10 percent from September 22, 2014 to January 8, 2021), left shoulder impingement syndrome (20 percent), left knee posttraumatic osteoarthritis (10 percent prior to May 10, 2021), left elbow posttraumatic osteoarthritis ( 10 percent prior to May 10, 2021), left wrist posttraumatic osteoarthritis (10 percent), right knee posttraumatic osteoarthritis (10 percent), an non-compensable ratings for left wrist and left knee scars. The Board notes that none of the exceptions in 38 C.F.R. § 4.16(a)(1)-(5) (disabilities of extremities, common etiology, single body system, incurred in action, or prisoner of war) are for application. Thus, prior to January 8, 2021 the Veteran did not meet the schedular criteria in 38 C.F.R. § 4.16(a). The initial extraschedular referral decision under § 4.16(b) should address whether there is sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable by reason of his or her service-connected disabilities. Ray v. Wilkie, 31 Vet. App. 58, 66 (2019). For the following reasons, a preponderance of the evidence weighs against a remand for referral for extraschedular consideration of TDIU. Turning to the evidence of record, the Veteran completed one year of college and worked as a painter in a fabrication shop which involved painting, welding, transportation, and sandblasting. He was required to lift over 100 pounds on that job and stopped working due to back pain, pinched nerve in his elbow, numbness in his hands, and arthritis. September 2010 VA treatment notes indicate the Veteran was unable to perform job duties because of pain, including bilateral foot pain, bilateral knee pain, low back pain, left elbow pain, poor circulation in the left pinky and left foot, and shoulder pain. A January 2010 Social Security Administration (SSA) Adult Function Report indicates the Veteran reported arthritis, right leg tumor, low back pain, elbow and knee pain, diabetes, high blood pressure, and depression limited his ability to work. In June 2010, an SSA disability examiner determined the Veteran's primary and secondary diagnoses were diabetes mellitus with hypertension and affective mood disorder with anxiety. SSA examiners also indicated that the Veteran is able stand or walk about six hours in a an eight-hour workday, can push and/or pull without limitations, occasionally lift 20 lbs. and frequently lift or carry 10 lbs. The examiner found no postural limits, manipulative limitations, visual limitations, communicative limitations, or environmental changes. An Administrative Law Judge found the Veteran's disabilities rendered him unemployable in April 2011. November 2014 and December 2014 VA examination reports show the Veteran's bilateral knee, left elbow, left wrist, left shoulder, and lumbosacral disabilities did not cause functional impairment. The preponderance of the evidence is against finding the Veteran's service-connected disabilities, when considered in combination, though physically limiting, at any time during the period on appeal, contributed to such severe impairment that it would preclude him from being able to secure or maintain gainful employment. Even though the evidence indicates the Veteran's service-connected disabilities precluded physically demanding work, the record shows that prior to January 8, 2021, the Veteran did not suffer from postural, manipulative, visual, communicative, or environmental limitations and was capable of standing or walking six hours in a an eight-hour workday, pushing and/or pulling without limitations of the upper/lower extremities, occasionally lift 20 lbs., and frequently lift or carry 10 lbs. Moreover, the preponderance of the evidence shows the Veteran has severe nonservice-connected physical disabilities that impaired his ability to obtain and maintain gainful employment including right leg tumor, psychiatric disability, hypertension, and diabetes mellitus. In evaluating the Veteran's claim for a TDIU, the Board also recognizes that the Social Security Administration (SSA) has determined that the Veteran is disabled pursuant to SSA rules and regulations. Specifically, the record indicates that the Veteran was found disabled by an Administrative Law Judge beginning in 2011. Although disability determinations made by SSA may be pertinent to claims for VA benefits, they are not controlling for VA determinations. Murincsak v. Derwinski, 2 Vet. App. 363, 370 (1992). Despite some similarities between the two disability regimes, there are "significant differences in the definition of disability under the Social Security and VA systems." Id. In its determination, SSA considered the Veteran's right toe, right leg, osteoarthritis of the hands, diabetes mellitus, hypertension, and side effect related to nonservice-connected disability medications in determining that he was disabled. Furthermore, the Board finds that prior to January 8, 2021, the Veteran was able to perform a wide variety of administrative and clerical jobs, or other forms of employment that would not require him to spend a significant amount of time on his feet, standing or walking, and which would be performed in a seated position a large majority of the time. Thus, the Board determines that, with consideration of his service-connected disabilities only, along with his education, training, and employment history at the time, that he would have been able to obtain or maintain various substantially gainful occupations which would have provided him with a living wage. Moreover, the Board notes that a schedular rating itself is recognition that a claimant's industrial capacity is impaired to some degree. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the injury. 38 C.F.R. § 4.1; Van Hoose, supra. Although the Veteran's service-connected disabilities may have hindered some aspects of employment, a compensable schedular rating of less than 100 percent implies a degree of interference with employment that would not preclude a particular claimant from securing and following all substantially gainful employment. For the foregoing reasons, the preponderance of the evidence reflects that the functional impairment from the Veteran's service-connected disabilities has not been shown to be so severe as to preclude substantially gainful employment. Therefore, the record does not contain sufficient evidence to substantiate a reasonable possibility that he is unemployable by reason of his service-connected disabilities. Accordingly, the procedures for referring this matter for extraschedular consideration are not met, and referral for extraschedular TDIU consideration is not warranted at this time. Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mohammad Mahmoudi, Associate 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.