Citation Nr: 21072181 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 17-06 286 DATE: December 2, 2021 ORDER Entitlement to an initial compensable rating for left distal radius fracture with limitation of flexion is denied. Entitlement to an initial rating of 10 percent, and no higher, for limitation of extension, left forearm, is granted. Entitlement to an initial compensable rating for right ulnar shaft fracture with limitation of flexion is denied. Entitlement to an initial rating of 10 percent, and no higher, for limitation of extension, right forearm, is granted. Entitlement to an initial rating of 20 percent, and no higher, for left distal radius fracture with limited supination is granted. Entitlement to an initial rating of 30 percent, and no higher, for right ulnar shaft fracture with limited supination is granted. Entitlement to an initial rating of 10 percent, and no higher, for left de Quervain's syndrome is granted. REMANDED Entitlement to service connection for a heart disability is remanded. Entitlement to service connection for a respiratory disability is remanded. FINDINGS OF FACT 1. The appellant is right-hand dominant. 2. Throughout the period on appeal, the appellant's left distal radius fracture has been manifested by, at worst, pain, weakness, and limitation of flexion to 105 degrees. 3. Throughout the period on appeal, the appellant's left distal radius fracture has been manifested by, at worst, pain, weakness, and limitation of extension to 30 degrees, with X-ray evidence of arthritis. 4. Throughout the period on appeal, the appellant's right ulnar shaft fracture has been manifested by, at worst, pain, weakness, and limitation of flexion to 105 degrees. 5. Throughout the period on appeal, the appellant's right ulnar shaft fracture has been manifested by, at worst, pain, weakness, and limitation of extension to 30 degrees, with X-ray evidence of arthritis. 6. Throughout the period on appeal, the appellant's left distal radius fracture with limited supination has been manifested by, at worst, limitation of pronation where motion is lost beyond the middle of the arc. 7. Throughout the period on appeal, the appellant's right ulnar shaft fracture with limited supination has been manifested by, at worst, limitation of pronation where motion is lost beyond the middle of the arc. 8. Throughout the period on appeal, the appellant's left de Quervain's syndrome has been manifested by, at worst, painful motion, weakness, and X-ray evidence of arthritis. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial compensable rating for left distal radius fracture with limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.14, 4.40, 4.45, 4.59, 4.71a, DC 5206. 2. The criteria for entitlement to an initial rating of 10 percent, and no higher, for limitation of extension, left forearm, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5207. 3. The criteria for entitlement to an initial compensable rating for right ulnar shaft fracture with limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.14, 4.40, 4.45, 4.59, 4.71a, DC 5206. 4. The criteria for entitlement to an initial of 10 percent, and no higher, for limitation of extension, right forearm, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5207. 5. The criteria for entitlement to an initial rating of 20 percent, and no higher, for left distal radius fracture with limited supination have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5213. 6. The criteria for entitlement to an initial rating of 30 percent, and no higher, for right ulnar shaft fracture with limited supination have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5213. 7. The criteria for entitlement to an initial rating of 10 percent, and no higher, for left de Quervain's syndrome have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5003-5215. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty in the U.S. Navy from October 1982 to December 1985. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). A January 2016 rating decision, in pertinent part, denied service connection for a respiratory disability and a heart disability, and determined that new and material evidence had not been received to reopen a previously denied claim of entitlement to service connection for a right knee disability. A February 2016 rating decision, in pertinent part, awarded service connection for left distal radius fracture, left distal radius fracture with limited supination, de Quervain's syndrome of the left arm, right ulna shaft fracture, and right ulna shaft fracture with limited supination, and assigned initial compensable ratings for each, effective September 28, 2015. Such rating decision also awarded entitlement to service connection for right ulnar shaft scar and assigned an initial noncompensable rating, effective January 30, 2016. The appellant filed a timely Notice of Disagreement (NOD), received in February 2016. A Statement of the Case (SOC) was issued in January 2017. A timely substantive appeal was received in February 2017. The appellant was afforded a hearing by videoconference before the undersigned in November 2019. A transcript is of record. The Board, in pertinent part, reopened the previously denied claim of entitlement to service connection for a right knee disability, granted entitlement to an initial rating of 10 percent for right ulnar shaft scar, and remanded the remaining issues in November 2020. A July 2021 rating decision, in pertinent part, awarded entitlement to service connection for right knee strain and assigned an initial noncompensable rating, effective September 28, 2015, and an initial 40 percent rating, effective February 11, 2021. Such also awarded service connection for a scar of the left distal forearm, and assigned an initial noncompensable rating, effective September 28, 2015. The grant of service connection for a right knee disability constitutes a full award of the benefit sought on appeal with respect to that claim. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). The July 2021 rating decision also increased the initial rating for left distal radius fracture with limited supination to 20 percent, effective February 11, 2021, increased the initial rating for right ulna shaft fracture with limited supination to 20 percent, effective February 11, 2021, increased the initial rating of De Quervain's syndrome to 10 percent, effective February 11, 2021, awarded a separate 10 percent rating for limitation of extension of the left forearm, effective February 11, 2021, and awarded a separate 10 percent rating for limitation of extension of the right forearm, effective February 11, 2021. Although higher ratings were granted, to include separate compensable ratings for already-service-connected disabilities, these issues remain in appellate status, as the maximum schedular ratings were not assigned for the entire period on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). A Supplemental Statement of the Case (SSOC) was issued in August 2021. Initial Ratings Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if that disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the initial rating assigned following an award of service connection, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous. . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. The appellant's service-connected left distal radius fracture and right ulna shaft fracture are each rated under Diagnostic Codes (DC) 5003-5206, 5207, and 5213. These diagnostic codes pertain to limitation of flexion of the forearm, limitation of extension of the forearm, and impairment of supination and pronation of the forearm, respectively. The appellant's service-connected left de Quervain's syndrome is rated under DC 5215, which pertains to limitation of motion of the wrist. DC 5003 pertains to arthritis and is discussed below, also with respect to hyphenated diagnostic codes. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. 38 C.F.R. § 4.69. The evidence of record indicates the appellant is right hand dominant. Therefore, the right upper extremity is rated as the dominant or major joint, while the left upper extremity is rated as the minor joint. Normal range of motion of the elbow is flexion to 145 degrees, extension to 0 degrees, forearm supination from 0 to 85 degrees, and forearm pronation from 0 to 80 degrees. 38 C.F.R. § 4.71, Plate I. Under DC 5206, a noncompensable or 0 percent rating is assigned when flexion of the dominant forearm is limited 110 degrees, a 10 percent rating is assigned for flexion limited to 100 degrees, 20 percent for flexion limited to 90 degrees, 30 percent for flexion limited to 70 degrees, 40 percent for flexion limited to 55 degrees, and 50 percent for flexion limited to 45 Degrees. 38 C.F.R. § 4.71a, DC 5206. Under DC 5207, a 10 percent rating is assigned for extension of the major forearm limited to 45 degrees or to 60 degrees, 20 percent rating is warranted for extension limited to 75 degrees, 30 percent for extension limited to 90 degrees, 40 percent for extension limited to 100 degrees, and 50 percent for extension limited to 110 degrees. Id., DC 5207. Finally, under DC 5213, supination of the forearm limited to 30 degrees or less is rated 10 percent disabling. Limitation of pronation with motion lost beyond the last quarter of arc, so the hand does not approach full pronation, is rated 20 percent disabling; limitation of pronation with motion lost beyond the middle of arc is rated 30 percent for the major joint. 38 C.F.R. § 4.71a, DC 5213. For VA compensation purposes, normal range of motion for the wrist is dorsiflexion to 70 degrees and palmar flexion to 90 degrees with 0 degrees being the anatomical or neutral position. 38 C.F.R. § 4.71, Plate I. Under DC 5215, a 10 percent disability rating is warranted for either the major or minor wrist joint where palmar flexion is limited in line with the forearm, or where dorsiflexion is less than 15 degrees. 38 C.F.R. § 4.71a, DC 5215. This is the maximum schedular rating based on limitation of motion of the wrist. A higher schedular rating is only warranted when there is evidence of ankylosis. 38 C.F.R. § 4.71a, Diagnostic Code 5214. In addition, in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the rating assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. In this case, Diagnostic Code 5003 pertains to degenerative arthritis, and 5206 refers to limitation of flexion of the forearm. 38 C.F.R. § 4.71a, DCs 5003, 5206. Effective February 7, 2021, VA amended its Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, including the diagnostic codes for arthritis. In cases where rating criteria are amended during the course of the appeal, the Board must consider both the former and current schedular criteria. Should an increased rating be warranted under new, revised criteria, the award may not be made effective before the effective date of change. See Kuzma v. Principi, 341 F.3d 1327, 1328 (Fed. Cir. 2003). No changes were made to diagnostic codes 5206, 5207, 5213, and 5215. Under the version of the diagnostic code in effect prior to February 7, 2021, DC Code 5010 (traumatic arthritis) provides that traumatic arthritis should be rated as arthritis, degenerative. DC 5003 (arthritis, degenerative) indicated that arthritis 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 there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, DC 5003 provides a 20 percent rating for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on x-ray findings, above, will not be utilized in rating conditions listed under DCs 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, DC 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Effective February 7, 2021, DC 5003 was renamed from "arthritis, degenerative (hypertrophic or osteoarthritis)" to "degenerative arthritis, other than post-traumatic." DC 5010 had been "arthritis, due to trauma, substantiated by X-ray findings," and such was to be rated as arthritis, degenerative. Following the changes, DC 5010 now pertains to post-traumatic arthritis and is to be rated as 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 § 4.25. Regarding the version of DC 5003 effective February 7, 2021, the Board finds that it is no more or less favorable than the prior version because the new version simply rephrased "arthritis, degenerative (hypertrophic or osteoarthritis)" to "degenerative arthritis, other than post-traumatic." Background The appellant was afforded a VA elbow and forearm examination in January 2016. The claims file was reviewed. The appellant reported that he had undergone open reduction internal fixation for both forearms. He stated that he currently experiences weakness and reported that his motion has not been full since surgery. Flare-ups were denied. Functional loss or impairment was reported in the form of decreased motion and weakness of both hands. Range of motion testing revealed right elbow flexion to 145 degrees, right elbow extension to 0 degrees, right forearm supination to 60 degrees, and right forearm pronation to 80 degrees. No pain was noted on examination. Range of motion itself did not contribute to functional loss and there was no evidence of pain with weight-bearing, localized tenderness or pain on palpation, or crepitus. Left elbow flexion was measured to 145 degrees, left elbow extension to 0 degrees, left forearm supination to 60 degrees, and left forearm pronation to 80 degrees. No pain was noted on examination. Range of motion itself did not contribute to functional loss and there was no evidence of pain with weight-bearing, localized tenderness or pain on palpation, or crepitus. There was no additional limitation of motion following repetitive-use testing of either extremity. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time for either extremity. There were no additional factors contributing to disability, muscle strength was full bilaterally, there was no atrophy, and there was no ankylosis. There was no flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation. The appellant was noted to have undergone surgery bilaterally prior to the appeal period, with weakness as the residual. No assistive devices were used. Amputation with prosthesis would not equally serve the appellant. Imaging studies revealed arthritis bilaterally and hardware in place in both arms, without signs of lucency. There was no functional impact. The appellant was afforded a VA wrist examination in January 2016. The claims file was reviewed. The appellant reported weakness and limitation of motion since his forearm surgery. Flare-ups were denied. Functional loss or impairment was reported in the form of weakness and inability to pick up coffee cup. Range of motion testing revealed left palmar flexion to 80 degrees, left dorsiflexion to 70 degrees, left ulnar deviation to 45 degrees, and left radial deviation to 20 degrees. No pain was noted on examination, there was no pain with weight-bearing, no localized tenderness or pain on palpation, and there was no crepitus. There was no additional limitation of motion following repetitive-use testing. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. There were no additional contributing factors of disability. Left muscle strength was 5/5, while right muscle strength was 4/5. There was no atrophy and there was no ankylosis. No assistive devices were used and amputation with prosthesis would not equally serve the appellant. Imaging studies revealed arthritis bilaterally. There was no functional impact. An August 2016 VA Urgent Care Triage and Medical Flow Sheet states that the appellant fell the previous Friday and had right wrist and right hip pain. He was diagnosed with right wrist sprain and was issued a sling and splint. A contemporaneous August 2016 VA clinical note notes that examination was negative for joint swelling or bony deformities. There was reduced right wrist range of motion due to pain. During his November 2019 hearing before the undersigned Veterans Law Judge, the appellant testified that he had painful and limited motion of his right arm. The appellant demonstrated that he could turn his right arm about 90 degrees, maybe just slightly more than 90, but he could not perform full rotation. The appellant was observed to be sitting with his arms bent and resting on the table, palms facing each other. The palms were observed to be parallel to each other, approximately 90 degrees. The appellant stated that he could not place the back of his right hand on the table due to pain and the plate in his arm from surgery. He also reported that his entire left arm goes numb on him, up to the fingertips, and that he cannot fully extend his left arm. Sharp pains shooting down into the hand were also endorsed. He reported that, since his last examination in January 2016, both upper extremities had worsened in the form of reduced range of motion and increased pain. Due to his upper extremity disabilities, the appellant was no longer able to perform the occupational tasks required by his job as a dump truck driver, which ended in 2012. The appellant was afforded a contracted elbow and forearm examination in February 2021. The claims file was reviewed. The appellant reported that his symptoms had worsened and that he currently experienced sharp, achy pain of both elbows. Flare-ups were reported, which were described as occurring almost daily, lasted five hours at a time, were precipitated by movement or picking up something, and were manifested by sharp pain. Such were moderate in severity. During these flare-ups, the appellant was unable to pick up objects or move at all. Functional loss or impairment was reported in the form of his disabilities being very painful, such that he did not want his elbow to touch an armrest. The appellant complained of painful motion on flexion, extension, supination, and pronation, all bilaterally. Range of motion testing revealed right flexion to 110 degrees, right extension to 35 degrees, right forearm supination to 50 degrees, and right forearm pronation to 50 degrees. Such was the same on both active and passive range of motion. There was pain on weight-bearing, active motion, and passive motion, but such did not result in functional loss. There was no crepitus. Localized tenderness or pain on palpation was present on the posterior elbow, described as 6/10. Range of motion testing also revealed left flexion to 110 degrees, left extension to 35 degrees, left forearm supination to 45 degrees, and left forearm pronation to 45 degrees. Such was the same on both active and passive range of motion. There was pain on weight-bearing, active motion, and passive motion, but such did not result in functional loss. There was no crepitus. Localized tenderness or pain on palpation was present on the posterior elbow, described as 7/10. There was no additional limitation of motion following repetitive-use testing. Following repeated use over time and during flare-ups, pain would limit right upper extremity range of motion further, with flexion to 105 degrees, extension to 30 degrees, supination to 45 degrees, and pronation to 45 degrees. Following repeated use over time and during flare-ups, pain would limit left upper extremity range of motion further, with flexion to 105 degrees, extension to 30 degrees, supination to 40 degrees, and pronation to 40 degrees. Additional factors contributing to disability included less movement than normal and an inability to lift or carry objects/loads. There was no muscle atrophy or ankylosis. There was no flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation. No assistive devices were used and amputation with prosthesis would not equally serve the appellant. Regarding functional impact, the appellant was unable to lift or carry objects/loads. The appellant was afforded a contracted wrist examination in February 2021. The claims file was reviewed. The appellant reported that his left wrist disability had worsened and that he experienced sharp pain. Flare-ups were reported as occurring almost every day, lasting four hours at a time, and manifested by sharp pain. Such were precipitated by movement and picking up things. Such were described as moderate in severity. During flare-ups, the appellant could not pick up objects or move his wrist. Functional loss or impairment was endorsed in the form of very severe pain and an inability to do a lot of things, including difficulty using a cane. Range of motion testing revealed left wrist dorsiflexion to 45 degrees, palmar flexion to 45 degrees, ulnar deviation to 30 degrees, and radial deviation to 10 degrees. There was no difference between passive and active range of motion. Pain was present on weight-bearing, active motion, and passive motion, but did not result in functional loss. There was no crepitus, but there was localized tenderness or pain to palpation, at the anterior wrist, described as 8/10. There was no additional limitation of motion following repetitive-use testing. Pain significantly limited functional ability with repeated use over time and during flare-ups, resulting in left dorsiflexion to 40 degrees, palmar flexion to 40 degrees, ulnar deviation to 25 degrees, and radial deviation to 5 degrees. There were no additional contributing factors to disability, there was no muscle atrophy, and there was no ankylosis. The appellant made occasional use of a brace to support his left wrist and for the pain. Amputation with prosthesis would not equally serve the appellant. Regarding functional impact, the appellant was unable to lift or carry objects/loads. The appellant was afforded a contracted hand and fingers examination in February 2021. The claims file was reviewed. The appellant reported constant hand pain. Flare-ups and functional impairment were denied. Range of motion testing was normal for the hands bilaterally, during both active and passive testing. There was no additional limitation of function with repeated use over time. Muscle strength testing revealed 4/5 left hand grip, although there was no atrophy. There was no ankylosis. No assistive devices were used and amputation with prosthesis would not equally serve the appellant. Regarding functional impact, the appellant was unable to grip firmly on the left hand and unable to carry objects. 1. Entitlement to an initial compensable rating for left distal radius fracture with limitation of flexion. 2. Entitlement to a separate compensable rating for limitation of extension, left forearm, prior to February 11, 2021, and in excess of 10 percent thereafter. 3. Entitlement to an initial compensable rating for right ulnar shaft fracture with limitation of flexion. 4. Entitlement to a separate compensable rating for limitation of extension, right forearm, prior to February 11, 2021, and a rating in excess of 10 percent thereafter. For the reasons that follow, the Board finds the evidence is in relative equipoise as to whether entitlement to initial ratings of 10 percent, and no higher, for left and right forearm limitation of extension are warranted for the entire period on appeal, and that that the most probative evidence establishes that entitlement to initial compensable ratings for left and right forearm limitation of flexion are not warranted for any portion of the period on appeal. As delineated above, the appellant has arthritis of the left distal radius fracture and right ulnar shaft fracture, with painful motion. As such, the appellant is entitled to initial ratings of 10 percent for the left and right forearms of at least 10 percent for the initial period on appeal. See 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). A rating in excess of 10 percent for arthritis requires x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Here, however, only one joint is involved for each upper extremity. As such, an initial rating in excess of 10 percent would not be warranted under any version of an arthritis diagnostic code for any portion of the period on appeal for either the left or right forearm. A compensable evaluation under DC 5206 requires limitation of flexion of the forearm to 100 degrees or less, for the major or minor extremity. A compensable evaluation under DC 5207 requires limitation of extension of the forearm to 45 degrees or less, for the major or minor extremity. As delineated above, at worst, the appellant's left forearm flexion was limited to 105 degrees and right forearm flexion was limited to 105 degrees, including during flare-ups and following repeated use over time. At worst, the appellant's left forearm extension was limited to 30 degrees and right forearm extension was limited to 30 degrees, including during flare-ups and following repeated use over time. The Board notes that the appellant is already being compensated for painful motion under the diagnostic code for limitation of extension. The minimal compensable rating under both the diagnostic codes for limitation of extension and flexion is 10 percent. 38 C.F.R. § 4.71a, DCs 5206 and 5207. Separate disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). As such, the appellant cannot be assigned separate compensable ratings under the diagnostic code for limitation of flexion due to the symptom of painful motion of the joint, as this would constitute impermissible pyramiding with the ratings assigned to compensate for painful motion under the diagnostic code for limitation of extension. 38 C.F.R. § 4.14. Finally, the Board has considered whether the appellant may be entitled to additional benefits under any other applicable diagnostic code. The record does not reflect that the appellant suffers from ankylosis of the left or right elbow, limitation of left or right forearm flexion to 100 degrees and limitation of right forearm extension to 45 degrees, impairment of flail joint, or nonunion of the radius and ulna. As such, separate ratings are not warranted under Diagnostic Codes 5205, 5208, 5209, or 5210-12. See 38 C.F.R. § 4.71a. It is not contended otherwise. As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award entitlement to initial ratings of 10 percent for left and right forearm limitation of extension for the entire period on appeal. The preponderance of the evidence is against the awards of entitlement to initial ratings in excess of 10 percent for left and right forearm limitation of extension for any portion of the period on appeal and against the awards of entitlement to initial compensable ratings for left and right forearm limitation of flexion for any portion of the period on appeal. As the evidence preponderates against the award of such, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 5. Entitlement to an initial compensable rating for left distal radius fracture with limited supination prior to February 11, 2021, and in excess of 20 percent thereafter. 6. Entitlement to an initial compensable rating for right ulnar shaft fracture with limited supination prior to February 11, 2021, and in excess of 20 percent thereafter. The Board finds that the evidence is in relative equipoise as to whether entitlement to an initial rating of 20 percent, and no higher for left distal radius fracture with limited supination for the entire period on appeal. The Board also finds that the evidence is in relative equipoise as to whether entitlement to an initial rating of 30 percent, and no higher, is warranted for right ulnar shaft fracture with limited supination for the entire period on appeal. As delineated above, for limitation of pronation where motion is lost beyond the middle of arc, a 30 percent rating is warranted for the major extremity and a 20 percent rating is warranted for the minor extremity under DC 5213. The appellant reported during the November 2019 Board hearing, that he could turn his arm just about 90 degrees. He also was observed to be sitting with his arms bent and resting on the table, palms facing each other parallel, at approximately 90 degrees. The February 2021 contracted examination revealed that, during flare-ups and following repeated use over time, pronation was limited to 40 degrees for the left forearm and 45 for the right forearm. 38 C.F.R. § 4.71a, Plate I reveals that forearm pronation goes from 0 to 80 degrees, and forearm supination goes from 0 to 85 degrees. 40 degrees is the middle of an 80-degree arc, and the Board finds that the 45 degrees for the right forearm pronation more nearly approximates motion limited at the middle of the arc. At the time of the January 2016 VA examination, the appellant was found to have full pronation to 80 degrees bilaterally and that supination was limited to 60 degrees bilaterally. However, based upon the appellant's competent and credible lay statements regarding symptom frequency and severity throughout the period on appeal, the Board finds affords the January 2016 VA examination report minimal probative weight as to the appellant's ability to pronate and supinate his left and right forearms for the majority of the period on appeal. Further, to assign lower, or noncompensable, ratings based upon the discrete period during and around the January 2016 VA examination when the range of motion results would be an accurate measure of the appellant's functional ability regarding supination and pronation would violate the rule regarding stabilization of ratings. 38 C.F.R. § 3.344. At no point during the period on appeal was there loss of (bone fusion) supination or pronation, with the hand fixed in supination or hyperpronation. It is not contended otherwise. Thus, higher ratings under DC 5213 for either forearm are not warranted. As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award entitlement to an initial rating of 20 percent, and no higher, for left distal radius fracture with limited supination, and an initial rating of 30 percent, and no higher, for right ulnar shaft fracture with limited supination, both for the entire period on appeal. 7. Entitlement to an initial compensable rating for left de Quervain's syndrome. The Board finds that the evidence is in relative equipoise as to whether an initial 10 percent rating, and no higher, is warranted for left de Quervain's syndrome for the entire period on appeal. Although the appellant's range of motion of the left wrist is noncompensable, even during flare-ups and following repeated use over time, he has competently and credibly reported pain and weakness of the left wrist. Notably, there is X-ray evidence of arthritis of the left wrist. See January 2016 VA and February 2021 contracted examination reports. As such, the Board finds that entitlement to an initial rating of 10 percent, and no higher, is warranted for the entire period on appeal. The maximum schedular rating under DC 5215 for limitation of motion of the wrist is 10 percent. At no point during the period on appeal has the appellant had, or have his symptoms more nearly approximated, ankylosis of the left wrist. As such, a rating under DC 5214 for ankylosis of the wrist is not for application. It is not contended otherwise. A rating in excess of 10 percent for arthritis requires x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Here, however, the only joint involved is the left wrist. As such, an initial rating in excess of 10 percent would not be warranted under any version of an arthritis diagnostic code for any portion of the period on appeal. As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award entitlement to an initial rating of 10 percent, and no higher, for left de Quervain's syndrome for the entire period on appeal. REASONS FOR REMAND 1. Entitlement to service connection for a heart disability. 2. Entitlement to service connection for a respiratory disability. The Board remanded the issues of entitlement to service connection for heart and respiratory disabilities in November 2020 in order to obtain etiological opinions for such. As previously noted, the October 2019 negative VA medical opinion, incorrectly referenced in the November 2020 remand as having been issued in December 2019, regarding the appellant's claimed respiratory disability did not address aggravation. Thus, following the Board's remand, the claims file was provided to a contracted physician, J.C., M.D. for review and in order to render new opinions in July 2021. The July 2021 contracted physician offered a positive etiological opinion linking the appellant's current respiratory to his active service, specifically the February 1983 pneumonia and September 1985 sinobronchial syndrome. However, this opinion was conclusory in nature. Dr. J.C. also offered negative opinions as to the appellant's respiratory and heart disabilities being due to or the result of service-connected disabilities, or aggravated by such, on the basis that there was no pathophysiologic objective evidence or published literature supporting a nexus between left knee and bilateral upper forearm disabilities, left de Quervain's syndrome, and associated scars, and the current respiratory and heart disabilities. However, Dr. J.C. also opined that the appellant's respiratory and heart disabilities were at least as likely as not aggravated by the multiple procedures and surgeries performed for service-connected left knee, bilateral forearm, and left de Quervain's syndrome disabilities. It was explained that anesthesia and surgery can have a wide range of effects on the cardiovascular system, even in healthy patients having minor operations. Dr. J.C cited articles from the National Institute of Health (NIH) titled "Cardiovascular effects of anesthesia and operation," and "Respiratory complications in the postanesthesia care unit: A review of pathophysiological mechanisms." Dr. J.C agreed with the opinions of other physicians that the appellant's pulmonary embolism was the result of left knee surgery, citing another NIH article, titled "Risk factors for pulmonary embolism after hip and knee arthroplasty: a population-based study." However, because the record is negative for any other competent opinion regarding the nature and etiology of the appellant's pulmonary embolism, the opinion of Dr. J.C. appears to be based solely upon the appellant's lay statements during the November 2019 Board hearing that his cardiologist had told him that his heart has been overworked due to the multiple surgeries, joint replacements, and other implants in his left knee and upper extremities, and that such resulted in heart attacks and strokes. A claimant's lay statements relating what a medical professional told him, filtered as they are through a layperson's sensibilities, are too attenuated and inherently unreliable to constitute competent evidence to support a claim. See e.g. Warren v. Brown, 6 Vet. App. 4 (1993). Dr. J.C. noted that "[m]ultiple procedures/surgeries related to service connected conditions listed above can surely take a toll on [the appellant's] heart," and that "[m]ultiple procedures/surgeries related to service connected conditions listed above can surely take a toll on [the appellant's] respiratory system." An addendum opinion was obtained in August 2021 from Dr. J.C. Dr. J.C. explained that his first report was in error, as there was no aggravation of a heart disability. Indeed, there was no aggravation because there was no pathophysiologic objective evidence or published literature to support a connection between heart disease and any of the appellant's service-connected disabilities. Upon further review of the literature and the appellant's medical history, Dr. J.C. opined that there was no nexus between the appellant's current respiratory issues to active service because there was no explanation that could connect his current respiratory complaints to hospital records of pneumonia in February 1983 and sinobronchial syndrome in September 1985. Despite this addendum opinion, the etiology of the appellant's current heart and respiratory disabilities remains unclear. The July 2021 positive direct service connection opinion regarding the appellant's respiratory disability was essentially rescinded by the August 2021 addendum. However, the positive July 2021 etiological opinions regarding service connection on an aggravation basis for both the heart and respiratory disabilities were not discussed in the addendum, save for a conclusory statement that there had been no aggravation of a heart disability. No baseline level of severity prior to aggravation, for either a heart or respiratory disability, was determined at the time of the July 2021 opinion. With respect to the statement in the August 2021 addendum that there was no aggravation of a heart disability, such appears to be only with respect to whether service-connected disabilities themselves caused any aggravation, as opposed to the theory of entitlement that it was surgical procedures and treatments for the service-connected disabilities that caused or aggravated a heart disability. Dr. J.C.'s July 2021 opinion made this distinction, while the August 2021 addendum opinion did not. To the extent that, despite the August 2021 addendum opinion canceling out portions of the July 2021 medical opinion, the positive opinions as to the appellant having heart and respiratory disabilities which were aggravated by surgical procedures and treatments for service-connected disabilities may warrant the eventual award of service connection, under applicable regulation, VA cannot concede aggravation unless a baseline for the claimed disability can be established with evidence created prior to any aggravation. 38 C.F.R. § 3.310 (b); see also Allen v. Brown, 7 Vet. App. 439 (1995). The reason for the examiner's inability to provide such a baseline is not discernable from the reports. As such, the Board finds that remand is warranted to obtain new medical opinions as to the nature and etiology of the appellant's heart and respiratory disabilities. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Finally, the Board makes no credibility findings at this juncture regarding these two issues. The matters are REMANDED for the following action: 1. Obtain a medical opinion from an appropriate clinician as to the nature and etiology of the appellant's claimed heart disability. Access to the claims file should be made available to the examiner for review. After reviewing the claims file, for each heart disability identified, the examiner should opine as to the following: Is it at least as likely as not that the current heart disability is proximately due to or the result of service-connected left knee disability, left distal radius fracture, left de Quervain's syndrome, and/or right ulnar shaft fracture, to include surgical treatment, implants, and replacements for such? If not, is it at least as likely as not that a heart disability was aggravated (made worse) by the service-connected left knee disability, left distal radius fracture, left de Quervain's syndrome, and/or right ulnar shaft fracture, to include surgical treatment, implants, and replacements for such? If aggravation is found, the examiner must attempt to establish a baseline level of severity prior to aggravation. In providing the requested opinions, the clinician should review the relevant evidence of record, to include the appellant's reports that cardiologist told him that his heart has been overworked due to the multiple surgeries, joint replacements, and other implants in his left knee and upper extremities, and that such resulted in heart attacks and strokes. If the clinician determines that an examination of the appellant is necessary, one should be scheduled. 2. Obtain a medical opinion from an appropriate clinician as to the nature and etiology of the appellant's claimed respiratory disability. Access to the claims file should be made available to the examiner for review. After reviewing the claims file, for each respiratory disability identified, the examiner should opine as to the following: Is it at least as likely as not that a respiratory disability had its onset in service or is otherwise related to the appellant's active service, to include February 1983 pneumonia of the right upper lobe in February 1983 and/or September 1985 sinobronchial syndrome with wheezing in the right middle lobe in September 1985? If not, is it at least as likely as that a respiratory disability was proximately due to or the result of repeated surgeries for service-connected disabilities, including on the left knee, including any progressive toll caused by the number of surgeries performed? If neither, is it at least as likely as not that a respiratory disability was aggravated (made worse) by repeated surgeries for service-connected disabilities, including on the left knee, including any progressive toll caused by the number of surgeries performed? If aggravation is found, the examiner must attempt to establish a baseline level of severity prior to aggravation. In providing the requested opinions, the clinician should review the relevant evidence of record, to include the appellant's reports that he has experienced pneumonia at least once a year since separation and that doctors have told him that his pulmonary embolisms are the result of his left knee replacement surgery. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. In providing the requested opinions, the clinician should consider the appellant's reported symptoms in service and thereafter, including the nature, onset, progression and severity of the appellant's reported symptoms. If there is any medical reason to accept or reject the proposition that the appellant's reported in-service and post-service symptoms represented the onset of a disability of recurring pneumonia, this should be noted. Stated another way, do the appellant's reports about his symptoms align with how the current respiratory disability is known to develop or are the appellant's reports generally inconsistent with medical knowledge or implausible? The Board makes no credibility finding at this juncture. (Continued on the next page) If the clinician determines that an examination of the appellant is necessary, one should be scheduled. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Behlen, 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.