Citation Nr: 21070715 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 13-18 631 DATE: November 24, 2021 ORDER For the initial disability rating period on appeal from November 21, 2010 to May 11, 2021, an initial disability rating of 20 percent, but no higher, for the service connected degenerative disc disease (DDD) of the thoracolumbar spine is granted; from May 11, 2021, a staged initial disability rating in excess of 40 percent is denied. For the initial disability rating period on appeal from November 21, 2010 to May 11, 2021, an initial disability rating of 20 percent, but no higher, for the service-connected status post right ulnar decompression and elbow strain is granted under Diagnostic Code 5206; from May 11, 2021, staged initial disability ratings in excess of 30 percent on the basis of limitation of flexion (Diagnostic Code 5206) or limitation of pronation (Diagnostic Code 5213) of the right elbow are denied. FINDINGS OF FACT 1. During the initial rating period on appeal from November 21, 2010 to May 11, 2021, the service connected DDD of the thoracolumbar spine more nearly approximated painful limitation of forward flexion, with flare-ups of pain, to greater than 30 degrees but not greater than 60 degrees, without ankylosis or incapacitating episodes. 2. During the staged initial rating period on appeal from May 11, 2021, the service connected DDD of the thoracolumbar spine did not manifest as ankylosis or incapacitating episodes. 3. During the initial rating period on appeal from November 21, 2010 to May 11, 2021, the service connected status post right ulnar decompression and elbow strain more nearly approximated painful limitation of flexion, with flare-ups of pain, to 90 degrees, limitation of supination to 55 degrees, and limitation of pronation to 60 degrees, without ankylosis, limitation of extension, impairment of the flail joint, nonunion and/or impairment of the radius or ulna, or impairment of supination or pronation other than limitation of motion. 4. During the staged initial rating period on appeal from May 11, 2021, the service connected status post right ulnar decompression and elbow strain more nearly approximated painful limitation of flexion, with flare-ups of pain, to 60 degrees, limitation of supination to 30 degrees, and limitation of pronation to 25 degrees, without ankylosis, limitation of extension, impairment of the flail joint, nonunion and/or impairment of the radius or ulna, or impairment of supination or pronation other than limitation of motion. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, for the initial disability rating period on appeal from November 21, 2010 to May 11, 2021, the criteria for a higher initial disability rating of 20 percent, but no higher, for the service- connected DDD of the thoracolumbar spine have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.14, 4.21, 4.25, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 2. For the staged initial disability rating period on appeal from May 11, 2021, the criteria for a staged initial disability rating in excess of 40 percent for the service connected DDD of the thoracolumbar spine have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.14, 4.21, 4.25, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 3. Resolving reasonable doubt in favor of the Veteran, for the initial disability rating period on appeal from November 21, 2010 to May 11, 2021, the criteria for a higher initial disability rating of 20 percent, but no higher, for the service- connected status post right ulnar decompression and elbow strain, on the basis of limitation of flexion, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.14, 4.21, 4.25, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5205-5213. 4. For the staged initial disability rating period on appeal from May 11, 2021, the criteria for a staged initial disability rating in excess of 30 percent for the service- connected status post right ulnar decompression and elbow strain, on the basis of limitation of flexion, have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.14, 4.21, 4.25, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5206. 5. For the staged initial disability rating period on appeal from May 11, 2021, the criteria for a staged initial disability rating in excess of 30 percent for the service connected status post right ulnar decompression and elbow strain, on the basis of limitation of pronation, have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.14, 4.21, 4.25, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5213. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, had active service from November 2007 to November 2010. This matter came before the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston Salem, North Carolina, which granted service connection for DDD of thoracolumbar spine and status post right ulnar decompression and elbow strain. During the course of this appeal, staged initial disability ratings for the back and right elbow were also granted. The instant matter has been before the Board on multiple occasions. In an August 2019 decision, the Board dismissed the issues of a higher initial disability rating for status post right carpal tunnel release and entitlement to a total disability rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU), and remanded the remaining higher initial disability rating issues on appeal. Specifically, the rating issues were remanded to obtain an addendum opinion that was complaint with Sharp v. Shulkin, 29 Vet. App. 26 (2017). In later May 2020 and March 2021 Remands, the Board found that subsequently obtained Sharp examinations and opinions were inadequate, and the Board remanded for additional development. Adequate Sharp examinations and opinions were obtained in October 2021, and the remaining issues on appeal are now ripe for adjudication. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran testified before the undersigned Veterans Law Judge at a May 2017 Board videoconference hearing in Roanoke, Virginia. The hearing transcript has been associated with the record. The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). Concerning the duty to notify, as the back and right elbow rating issues arise from the Veteran's disagreement with the initial rating assigned following the grant of service connection, no additional notice is required regarding this downstream element of the service connection claim. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3). Regarding the duty to assist, the record reflects that VA obtained all relevant documentation and provided the Veteran with adequate VA back and elbow examinations. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As such, the Board finds that the duties to notify and assist the Veteran in this case have been fulfilled. Initial Disability Rating Law and Regulation Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits compensating a veteran twice for the same symptoms or functional impairment). The Veteran has appealed from the initial ratings assigned for the service connected back and right elbow. In Fenderson v. West, 12 Vet. App. 119, 125 26 (1999), the United States Court of Appeals for Veterans Claims (Court) addressed a similar appeal and directed that such appeal of the initial rating assigned following a grant of service connection was specifically not a claim for an increased disability rating. The Court also directed that separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 9-98. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The 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. 38 C.F.R. § 4.59. A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. 303. The Board has thoroughly reviewed all the evidence in the Veteran's claims file and adequately addresses the relevant evidence in the instant decision. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, every piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The Board notes that the Veteran received a VA general medical examination in August 2010. While range of motion testing was performed at that time, the VA examiner failed to identify the point at which painful motion first set in, and instead merely found that the Veteran had full range of motion in both the back and right elbow. As such, the Board finds the August 2010 VA general medical examination to be inadequate for VA rating purposes, and will not be relying upon the findings of the VA examiner at that time in the instant decision. 1. Initial Disability Rating for DDD of the Thoracolumbar Spine Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes (IVDS Rating Formula). Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The General Rating Formula provides a 10 percent disability rating for forward flexion of the lumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range-of-motion of the lumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is provided for forward flexion of the lumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range-of-motion of the lumbar spine 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 disability rating is provided for forward flexion of the lumbar spine 30 degrees or less, or favorable ankylosis of the entire lumbar spine, while a 50 percent disability rating is assigned for unfavorable ankylosis of the entire lumbar spine. Finally, a 100 percent disability rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2) (See also Plate V) provides that, for VA compensation purposes, normal forward flexion of the lumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. 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 lumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range-of-motion. Note (3) provides that, in exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range-of-motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range-of-motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range-of-motion is normal for that individual will be accepted. Note (4) instructs to round each range-of-motion measurement to the nearest five degrees. Note (5) provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire lumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. The diagnostic codes for the spine are as follows: 5235 Vertebral fracture or dislocation; 5236 Sacroiliac injury and weakness; 5237 Lumbosacral or cervical strain; 5238 Spinal stenosis; 5239 Spondylolisthesis or segmental instability; 5240 Ankylosing spondylitis; 5241 Spinal fusion; 5242 Degenerative arthritis of the spine (see also DC 5003); 5243 Intervertebral disc syndrome. The IVDS Rating Formula provides a 10 percent disability rating for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. During the pendency of this appeal, various portions of 38 C.F.R. § 4.71a were amended, effective February 7, 2021. The Board has considered whether these changes could result in an increased disability rating from the effective date of the regulation changes; however, the Board does not find the February 7, 2021 amendments to be relevant to the instant decision. Significantly, the amendments do not alter the General Rating Formula or the IVDS Rating Formula, which are the primary focus of the instant rating decision. 38 C.F.R. § 4.71a (2021). November 21, 2010 to May 11, 2021 Having reviewed the evidence of record, lay and medical, the Board finds that, during the initial rating period on appeal from November 21, 2010 to May 11, 2021, the service connected DDD of the thoracolumbar spine manifested as painful limitation of forward flexion to greater than 30 degrees, but not greater than 60 degrees, without ankylosis or incapacitating episodes. As discussed in the introduction, the Board obtained an adequate Sharp back examination and opinion in May 2021. Relevant to the instant matter, the May 2021 examination report reflects an assessment that, during a flare-up of pain, forward flexion is limited by an additional 15 degrees. The Veteran received a VA back examination in March 2019. As the Board has found the August 2010 VA general medical examination inadequate, as discussed above, this is the earliest adequate VA examination relevant to the initial rating period on appeal. At that time, range of motion testing showed forward flexion limited to 65 degrees. As such, during a flare-up of pain forward flexion would have been limited to approximately 50 degrees. Upon examination there was no ankylosis of the spine and no incapacitating episodes due to IVDS. A new VA back examination was performed in October 2020. Per range of motion testing, forward flexion at that time was limited to 70 degrees; therefore, during a flare-up of pain forward flexion would have been limited to approximately 55 degrees. Again, upon examination there was no ankylosis of the spine and no incapacitating episodes due to IVDS. Review of the available VA and private medical records do not reflect that, during the initial rating period from November 21, 2010 to May 11, 2021, the Veteran's back disability, even when accounting for additional loss of motion due to flare ups of pain, manifested as forward flexion limited to 30 degrees or less, ankylosis of the spine, or incapacitating episodes due to IVDS. After a review of all the evidence, lay and medical, the Board finds that, from November 21, 2010 to May 11, 2021, the service connected DDD of the thoracolumbar spine more nearly approximated painful limitation of flexion, with flare-ups of pain, to greater than 30 degrees but not greater than 60 degrees, without ankylosis or incapacitating episodes. As such, the Board will resolve reasonable doubt in favor of the Veteran to find that, from November 21, 2010 to May 11, 2021, an initial 20 percent disability rating for the service connected DDD of the thoracolumbar spine due to painful limitation of motion is warranted. 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242; DeLuca. As forward flexion was not limited to 30 degrees or less, even during a flare-up, and as there was no ankylosis of the spine or incapacitating episodes due to IVDS, a disability rating in excess of 20 percent for this rating period is not warranted. Id. From May 11, 2021 In an August 2021 rating decision, the RO granted a staged initial disability rating of 40 percent for the service-connected DDD of the thoracolumbar spine from May 11, 2021. Having reviewed the evidence of record, lay and medical, the Board finds that, during the staged initial rating period on appeal from May 11, 2021, the service connected DDD of the thoracolumbar spine did not manifest as ankylosis or incapacitating episodes due to IVDS to warrant a rating in excess of 40 percent. The Veteran received a new VA back examination in May 2021. At that time, examination of the Veteran showed no ankylosis of the thoracolumbar spine and no incapacitating episodes due to IVDS. Further, review of the available VA and private medical records do not reflect that, during the staged initial rating period from May 11, 2021, the Veteran had ankylosis of the spine or incapacitating episodes due to IVDS. After a review of all the evidence, lay and medical, the Board finds that, during the staged initial rating period on appeal from May 11, 2021, the service connected DDD of the thoracolumbar spine did not manifest as ankylosis or incapacitating episodes due to IVDS. For these reasons, the Board finds the preponderance of the evidence is against a staged initial disability rating in excess of 40 percent for the service connected DDD of the thoracolumbar spine from May 11, 2021, and a higher initial disability rating for that staged rating period must be denied. Id. Separate Compensable Disability Ratings The Board has considered whether the Veteran is entitled to separate compensable disability ratings for any objective neurologic, or other, disabilities related to the service connected DJD of the lumbosacral spine. During the course of this appeal, in a March 2013 rating decision, the RO granted separate compensable disability ratings for right and left lower extremity radiculopathy. The disabilities were rated as 10 percent disabling from April 19, 2011, the date VA medical records first showed lower extremity neurological symptoms. The Board finds that a review of the evidence of record does not support that disability ratings in excess of 10 percent are warranted for the left or right lower extremity radiculopathy. Further, the evidence does not support that an earlier effective date for the grant of these separate compensable disability ratings is warranted. Finally, the Board notes that review of the VA spinal examinations, along with all the other lay and medical evidence of record, conveys no diagnosis of any neurologic or other disabilities related to the service connected DDD of the thoracolumbar spine (other than scarring, which is not before the Board at this time), that would warrant the grant of a separate compensable disability rating. As such, no additional separate compensable disability ratings are warranted for any additional disabilities related to the service connected back disability. 2. Initial Disability Rating for Status Post Right Ulnar Decompression and Elbow Strain At the outset, the Board will address the complex procedural history of this issue. In an April 2011 rating decision, the RO granted service connection for status post right ulnar decompression. At that time, the right elbow disability was rated as noncompensable (0 percent) under Diagnostic Code 8516, which contemplates a disability of the ulnar nerve. 38 C.F.R. § 4.124a. Upon the Veteran appealing the initial rating assigned, in a March 2013 statement of the case (SOC) the RO granted a higher initial 10 percent disability rating based on noncompensable painful limitation of motion. While the Diagnostic Code was listed as 5213, which contemplates impairment of supination and pronation, the Board notes the RO could have also rated the noncompensable painful limitation of motion under Diagnostic Code 5206, limitation of flexion. 38 C.F.R. § 4.71a. At that time, the service connected disability was reframed as status post right ulnar decompression and elbow strain. In the April 2011 rating decision, the RO also granted service connection for post right carpal tunnel release, and assigned an initial noncompensable disability rating. The disability was rated pursuant to Diagnostic Code 8515, which contemplates a disability of the median nerve. 38 C.F.R. § 4.124a. This initial rating was also appealed by the Veteran, and in a July 2019 rating decision, following Board remand for additional development, the RO granted a staged initial 20 percent disability rating for the service-connected status post carpal tunnel release from March 29, 2019, the date of VA examination. The 20 percent disability rating for the status post carpal tunnel release was granted pursuant to Diagnostic Code 8513, which contemplates a disability of all radicular groups, including both the median nerve and the ulnar nerve; therefore, this staged initial disability rating includes the neurological symptoms of the of the status post right ulnar decompression. As discussed in the introduction, following the grant of the 20 percent disability rating for status post carpal tunnel release, the Veteran withdrew that issue on appeal. Such action removed any question of law or fact concerning the propriety of rating the ulnar nerve with the median nerve, and/or the question of whether the 20 percent disability rating was warranted during the entire initial rating period on appeal. For these reasons, the Board finds that any question of a higher initial disability rating under Diagnostic Code 8516 for the service-connected status post right ulnar decompression is no longer before the Board. In a November 2020 rating decision, the RO granted a separate compensable disability rating for limitation of flexion of the right elbow. A 10 percent disability rating was assigned from October 8, 2020, as that was the date the RO found that the medical evidence of record first showed compensable limitation of flexion. Finally, in an August 2021 rating decision, the RO granted a staged higher initial disability rating of 30 percent for the service-connected status post right ulnar decompression under Diagnostic Code 5213. The staged rating was effective from May 11, 2021, the date of VA examination. Per the rating decision, the staged initial rating was based upon a finding of limitation of pronation with motion lost beyond the middle of the arc. Relevant Evidence The Veteran received a VA general medical examination in August 2010. As discussed above, the Board has found the August 2010 VA general medical examination inadequate for VA rating purposes because the VA examiner did not document where painful limitation of motion first manifested. Multiple VA treatment records reported full range of motion of the right elbow; however, such VA treatment records also reported the Veteran's complaints of pain, but also do not note at what point painful limitation of motion set in during range of motion testing. As such, the Board finds no adequate range of motion readings of the right elbow prior to an April 2019 VA elbow examination, discussed below; therefore, the Board will resolve reasonable doubt in favor of the Veteran to find that the limitation of motion readings taken in April 2019 have been present throughout the initial rating period on appeal, from November 21, 2010. As discussed in the introduction, the Board obtained an adequate Sharp elbow examination and opinion in May 2021. Per the examination report, during a flare up of pain an additional 30 degrees is lost on flexion, an additional 15 degrees is lost on supination, and an additional 10 degrees is lost on pronation. There is no loss on extension, as the Veteran has always shown full range of extension of the right elbow during the initial rating period on appeal. The Veteran received a VA elbow examination in March 2019. At that time, range of motion testing showed full extension, flexion limited to 120 degrees, supination limited to 70 degrees, and pronation limited to 70 degrees. As such, during painful flare-ups flexion would be limited to 90 degrees, supination to 55 degrees, and pronation to 60 degrees. Upon examination there was no ankylosis, flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation (or than limitation of motion). Functioning was not so diminished that the Veteran would have been equally served by amputation with prosthesis. A new VA elbow examination was performed in October 2020. At that time, range of motion testing showed full extension, full pronation, flexion limited to 130 degrees, and supination limited to 80 degrees. As such, during painful flare-ups flexion would be limited to 100 degrees, supination to 65 degrees, and pronation to 70 degrees. Upon examination there was no ankylosis, flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation (or than limitation of motion). Functioning was not so diminished that the Veteran would have been equally served by amputation with prosthesis. Finally, a third VA elbow examination was conducted in May 2021. At that time, range of motion testing showed full extension, flexion limited to 90 degrees, supination limited to 45 degrees, and pronation limited to 40 degrees. During a flare-up of pain, it was opined that flexion would end at 60 degrees, supination would end at 30 degrees, and pronation would end at 25 degrees. Upon examination there was no ankylosis, flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation (or than limitation of motion). Functioning was not so diminished that the Veteran would have been equally served by amputation with prosthesis. Review of the available VA and private medical records do not reflect any right elbow symptoms beyond those discussed above. Rating Criteria Per the evidence discussed above, during the initial rating period on appeal the record reflects that the Veteran did not have ankylosis, limitation of extension, impairment of the flail joint, or nonunion and/or impairment of the radius or ulna. As such, increased or separate compensable disability ratings are not warranted under Diagnostic Codes 5205, 5207, 5208, 5209, 5210, 5211, or 5212. As such, the remainder of the decision will focus on whether higher initial disability ratings are warranted under Diagnostic Code 5206 and/or Diagnostic Code 5213. 38 C.F.R. § 4.71a. Under Diagnostic Code 5206, limitation of flexion of either the major or minor forearm to 100 degrees warrants a 10 percent rating; limitation of flexion of either forearm to 90 degrees warrants a 20 percent rating; limitation of flexion of the major and minor forearm to 70 degrees warrants 30 and 20 percent ratings, respectively; limitation of flexion of the major and minor forearm to 55 degrees warrants 40 and 30 percent ratings, respectively; and limitation of flexion of the major and minor forearm to 45 degrees warrants 50 and 40 percent ratings, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5206. Id. Review of the record reflects that the Veteran's right extremity is the major extremity. Diagnostic Code 5213 applies to impairment of supination and pronation. Under Diagnostic Code 5213, a 40 percent rating is assigned when the hand is fixed in supination or hyperpronation with respect to the major extremity. A 30 percent rating is assigned for the major extremity when the hand is fixed in full pronation or when there is loss of pronation from beyond the middle of the arc for the major extremity. A 20 percent rating is assigned where the hand is fixed near the middle of the arc or moderate pronation, or motion lost beyond the last quarter of the arc, where the hand does not approach full pronation with respect to the major extremity. Limitation of supination to 30 degrees or less is assigned a 10 percent rating for both arms. Id. The standard range of motion for the elbow is flexion from 0 to 145 degrees, forearm pronation from 0 to 80 degrees, and forearm supination from 0 to 85 degrees. 38 C.F.R. § 4.71, Plate I. During the pendency of this appeal, various portions of 38 C.F.R. § 4.71a were amended, effective February 7, 2021. The amendments are not relevant to the right elbow rating issue on appeal. November 21, 2010 to May 11, 2021 Again, as discussed above, the service-connected status post right ulnar decompression and elbow strain was originally rated as 10 percent disabling due to noncompensable limitation of motion. As such, a higher initial disability rating could be warranted if the Veteran had compensable limitation flexion, extension, supination, and/or pronation. Having reviewed the evidence of record, lay and medical, the Board finds that, for the initial rating period on appeal from November 21, 2010 to May 11, 2021, the service connected status post right ulnar decompression and elbow strain more nearly approximated painful limitation of flexion, with flare-ups of pain, to 90 degrees, limitation of supination to 55 degrees, and limitation of pronation to 60 degrees, without ankylosis, limitation of extension, impairment of the flail joint, nonunion and/or impairment of the radius or ulna, or impairment of supination or pronation, other than limitation of motion. Such a finding warrants a higher initial disability rating of 20 percent based on limitation of flexion in the right elbow. As discussed above, per the report from a May 2019 VA elbow examination, which the Board has found to be the earliest adequate VA examination relevant to the initial rating period on appeal, upon range of motion testing the Veteran had limitation of flexion to 120 degrees; therefore, during a flare-up of pain flexion would have been limited to approximately 90 degrees. Pursuant to Diagnostic Code 5206, elbow flexion limited to 90 degrees warrants a 20 percent disability rating. 38 C.F.R. § 4.71a. The Board notes that at a subsequent October 2020 VA elbow examination, flexion was limited to 130 degrees, or 100 degrees during a flare-up. While such limitation would only constitute a 10 percent disability rating under Diagnostic Code 5206, the Board notes that in a subsequent May 2021 VA elbow examination, approximately seven months later, pain limited flexion of the elbow to 90 degrees before a flare-up of pain. As such, when considering all the evidence of record, lay and medical, the Board finds the March 2019 flexion reading of 120 degrees (90 degrees during a flare-up) to be more in line with the Veteran's overall limitation of flexion in the right elbow during the rating period from November 21, 2010 to May 11, 2021, with the October 2020 reading being an outlier. The Board has considered whether a higher or separate compensable disability rating may be warranted based on limitation of pronation or supination. As to supination, during the rating period from November 21, 2010 to May 11, 2021, even during a flare-up of pain, supination was not limited to 30 degrees or less. Further, as to pronation, even during a flare-up, the Board does not find that motion was lost beyond the last quarter of the arc. Review of the available VA and private medical records do not reflect that, during the initial rating period from November 21, 2010 to May 11, 2021, the Veteran's right elbow had loss of flexion, supination, and/or pronation beyond the measurements discussed above. After a review of all the evidence, lay and medical, the Board finds that, from November 21, 2010 to May 11, 2021, the service connected status post right ulnar decompression and elbow strain more nearly approximated painful limitation of flexion, with flare-ups of pain, to 90 degrees, limitation of supination to 55 degrees, and limitation of pronation to 60 degrees, without ankylosis, limitation of extension, impairment of the flail joint, nonunion and/or impairment of the radius or ulna, or impairment of supination or pronation, other than limitation of motion. As such, the Board will resolve reasonable doubt in favor of the Veteran to find that, from November 21, 2010 to May 11, 2021, an initial 20 percent disability rating for the service connected status post right ulnar decompression and elbow strain due to compensable painful limitation of flexion is warranted. 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5206; DeLuca. For the reasons discussed above, a separate compensable disability rating and/or a disability rating in excess of 20 percent for this rating period is not warranted. Id. From May 11, 2021 As discussed above, during the rating period from May 11, 2021, the Veteran was in receipt of a 30 percent disability rating for the right elbow under Diagnostic Code 5213 due to painful limitation of pronation, and a separate 30 percent disability rating under Diagnostic Code 5206 for painful limitation of flexion. Having reviewed the evidence of record, lay and medical, the Board finds that, during the staged initial rating period on appeal from May 11, 2021, the service connected status post right ulnar decompression and elbow strain more nearly approximated painful limitation of flexion, with flare-ups of pain, to 60 degrees, limitation of supination to 30 degrees, and limitation of pronation to 25 degrees, without ankylosis, limitation of extension, impairment of the flail joint, nonunion and/or impairment of the radius or ulna, or impairment of supination or pronation, other than limitation of motion. Under Diagnostic Code 5213, a higher disability rating from May 11, 2021 would only be warranted if the Veteran's hand was fixed in supination or hyperpronation. As discussed above, per the May 2021 VA elbow examination, the Veteran was only found to have loss of motion on supination and/or pronation. There is no indication that the Veteran's hand is fixed in supination or hyperpronation. As such, a staged initial disability rating in excess of 30 percent for limitation of pronation is not warranted and must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5213. As to Diagnostic Code 5206, a disability rating in excess of 30 percent requires flexion to be limited to 55 degrees or less. Per the above, a VA examiner in May 2021 specifically opined that during a flare-up of pain flexion would be limited to 60 degrees. Such a finding is supported by the other evidence of record; therefore, a staged initial disability rating in excess of 30 percent for limitation of flexion is not warranted and must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5206. Codesheet Due to the long procedural history of the instant matter, along with the various actions taken by the Agency of Original Jurisdiction (AOJ), the Board finds it necessary to clarify how the benefits Codesheet should appear going forward. Currently the Codesheet shows service connection for status post right ulnar decompression and elbow strain, rated under Diagnostic Code 5213. Per the Codesheet, the status post right ulnar decompression and elbow strain has been rated as 10 percent disabling from November 21, 2010 through May 10, 2021, and 30 percent disabling from May 11, 2021. Further, the Codesheet shows a separate disability rating for limitation of flexion of the right elbow, with a 10 percent disability rating from October 8, 2020 through May 10, 2021, and a 30 percent disability rating from May 11, 2021. Based upon the Boards actions in the instant decision, going forward the Codesheet should appear as follows: 5206 Status Post Right Ulnar Decompression and Elbow Strain, Limitation of Flexion 20% from November 21, 2010 30% from May 11, 2021 5206 Status Post Right Ulnar Decompression and Elbow Strain, Limitation of Pronation 30% from May 11, 2021 The Board notes that the above structuring, along with the actions taken in the instant decision, do not reduce the Veteran's benefits for the right elbow at any point during the initial rating period on appeal; however, the Board's actions only constitute an increase in benefits from November 21, 2010 through October 8, 2020. This is because during the period from October 8, 2020 through May 10, 2021, the Veteran had both a 10 percent disability rating under Diagnostic Code 5206 and a 10 percent rating under Diagnostic Code 5213. The Board's actions in the instant decision merely reflect that during the rating period from October 8, 2020 through May 10, 2021, the Veteran was more appropriately rated as 20 percent disabling under Diagnostic Code 5206. Such a finding and restructuring of the Codesheet is actually more beneficial to the Veteran, despite possible appearances to the contrary. (Continued on the next page) Extraschedular Claim Not Raised The Board finds that neither the Veteran nor the record has raised a claim for extraschedular rating under 38 C.F.R. § 3.321(b) for any period for the higher initial rating issues on appeal. See Thun v. Peake, 22 Vet. App. 111 (2008); Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record); Yancy v. McDonald, 27 Vet. App. 484, 494 (2016), citing Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff'd, 226 Fed. Appx. 1004 (Fed. Cir. 2007) (holding that when 38 C.F.R. § 3.321(b)(1) is not "specifically sought by the claimant nor reasonably raised by the facts found by the Board, the Board is not required to discuss whether referral is warranted"). Further, as discussed in the introduction, the Veteran previously withdrew the issue of entitlement to a TDIU, and the issue was dismissed in an August 2019 Board decision. J. PARKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Blowers, 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.