Citation Nr: A21020137 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 200908-107543 DATE: December 16, 2021 ORDER Prior to February 22, 2016, entitlement to a 20 percent rating for chronic epicondylitis with neuropathy of the right upper extremity is granted. From February 22, 2016 to February 29, 2020, entitlement to a 30 percent rating for chronic epicondylitis with neuropathy of the right upper extremity is granted. From February 29, 2020, entitlement to an evaluation in excess of 30 percent for chronic epicondylitis with neuropathy of the right upper extremity is denied. Entitlement to an evaluation greater than 10 percent tendinitis, right wrist with painful motion is denied. Entitlement to an evaluation greater than 10 percent for supination and pronation impairment, right elbow is denied. Entitlement to an evaluation greater than 10 percent for limitation of flexion of the forearm, right is denied. Entitlement to an evaluation greater than 0 percent for limitation of extension of the forearm, right is denied. FINDINGS OF FACT 1. The Veteran is right-handed. 2. Prior to February 22, 2016, the Veteran's neuropathy of the right upper extremity was productive of mild incomplete paralysis of all radicular groups. 3. From February 22, 2016 to February 29, 2020 the Veteran's neuropathy of the right upper extremity was productive of moderate incomplete paralysis of the radial and median groups. 4. From February 29, 2020, the Veteran's right upper extremity disability was productive of moderate incomplete paralysis of the radial group. 5. The Veteran has limitation of motion but no ankylosis of the right wrist. 6. The Veteran has limitation of flexion of the right forearm to, at worst, 115 degrees. 7. The Veteran had full extension of the right forearm with pain. 8. The Veteran had impairment of supination of the right elbow to 30 degrees or less. CONCLUSIONS OF LAW 1. Prior to February 22, 2016, the criteria for a rating of 20 percent for right epicondylitis with right upper extremity neuropathy have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.124a, Diagnostic Code 8713. 2. From February 22, 2016 to February 29, 2020, the criteria for a rating of 30 percent for right epicondylitis with right upper extremity neuropathy have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.124a, Diagnostic Code 8714. 3. From February 29, 2020, the criteria for a rating in excess of 30 percent for right epicondylitis with right upper extremity neuropathy have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.124a, Diagnostic Code 8714. 4. The criteria for a rating in excess of 10 percent for right wrist disorder have not been met. 38 U.S.C. §§ 1155, 5107 (b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.59, 4.71a, Diagnostic Code 5215. 5. The criteria for a rating in excess of 10 percent for limitation of motion of the right forearm have not been met. 38 U.S.C. §§ 1155, 5107 (b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.59, 4.71a, Diagnostic Code 5206. 6. The criteria for a compensable rating limitation of extension of the right forearm have not been met. 38 U.S.C. §§ 1155, 5107 (b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.59, 4.71a, Diagnostic Code 5207. 7. The criteria for a rating in excess of 10 percent for right elbow impairment of supination and/or pronation have not been met. 38 U.S.C. §§ 1155, 5107 (b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.59, 4.71a, Diagnostic Code 5213. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Coast Guard from August 1959 to August 1979. Procedural history In May 2009, the Veteran filed a claim for an increased rating for his service-connected chronic epicondylitis with neuropathy of the right upper extremity. A July 2009 rating decision continued the Veteran's 10 percent rating. The Veteran disagreed with this decision in September 2009. A statement of the case was issued in December 2009. The Veteran filed a substantive appeal, VA Form 9, in January 2010. In March 2010, the Veteran filed a claim for "damaged nerves on both wrists and shoulders." A Board hearing was held in this matter in April 2010. In June 2011, the Board remanded the claims for a VA examination. In a July 2017 rating decision, the RO increased the Veteran's rating for chronic epicondylitis with neuropathy of the right upper extremity to 20 percent, effective February 22, 2016 and increased the Veteran's rating for tendinitis of the right wrist to 10 percent, effective May 28, 2009. The rating decision also granted service connection for a right elbow disorder and assigned a 10 percent rating, effective May 28, 2009 and for limitation of extension of the right forearm, and a noncompensable rating, effective February 22, 2016. The RO also found clear and unmistakable error in the evaluation of chronic epicondylitis with neuropathy of the right upper extremity and established a separate 10 percent evaluation from November 7, 2003. In July 2017, the Veteran submitted a notice of disagreement with the July 2017 rating decision. A July 2017 supplemental statement of the case was issued for the issues of service connection for left elbow and wrist disorders and an increased rating for chronic epicondylitis with neuropathy of the right upper extremity. In March 2018, the Board denied service connection for disorders of the left wrist and left elbow and an increased rating for neuropathy of the right upper extremity. The Veteran appealed the March 2018 denial to the United States Court of Appeals for Veterans Claims (Court). In March 2019, the Court issued a memorandum decision vacating the March 2018 decision. In an August 2020 rating decision, the Veteran's rating for chronic epicondylitis with neuropathy of the right upper extremity was increased to 30 percent, effective February 29, 2020. An accompanying August 2020 statement of the case denied increased ratings in excess of 10 percent for tendinitis of the right wrist, impairment of the right elbow, and limitation of flexion for chronic epicondylitis, right elbow. A compensable evaluation for limitation of extension of the right forearm was also denied. In September 2020, the Veteran submitted a Decision Review Request form, opting into the Appeals Modernization Act (AMA) review system on the issues denied in the August 2020 statement of the case. A supplemental statement of the case was issued in September 2020 regarding the issues of entitlement to increased ratings for chronic epicondylitis with neuropathy of the right upper extremity and service connection for left elbow, wrist, and upper extremity disorders. In September 2020, the Veteran submitted a Decision Review Request form, opting into the AMA regarding his claim of entitlement to increased ratings for chronic epicondylitis with neuropathy of the right upper extremity. In July 2021, the Board issued a decision denying the Veteran's claims of service connection for a left wrist, elbow, and neurological disorder of the upper extremity. Therefore, those claims are not presently before the Board. INCREASED RATING CLAIMS Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, where the question for consideration is entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In making its determination, the Board is obligated to weigh the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Kahana v. Shinseki, 24 Vet. App. 428, 433-34 (2011). The credibility of lay evidence may not be refuted solely by the absence of corroborating contemporaneous medical evidence, but it is a factor. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Other credibility factors are the lapse of time in recollecting events attested to, prior conflicting statements as opposed to consistency with other statements and evidence, internal consistency, facial plausibility, bias, interest, the length of time between alleged incurrence of disability and the earliest or first corroborating medical or lay evidence of the disability, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset of the disability). Caluza v. Brown, 7 Vet. App. 498, 511 (1995). Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). 1. Prior to February 22, 2016, entitlement to a rating in excess of 10 percent rating for chronic epicondylitis with neuropathy of the right upper extremity 2. From February 22, 2016 to February 29, 2020, entitlement to a rating in excess of 20 percent rating for chronic epicondylitis with neuropathy of the right upper extremity 3. From February 29, 2020, entitlement to an evaluation in excess of 30 percent for of chronic epicondylitis with neuropathy of the right upper extremity The Veteran's right arm is his major extremity. The Veteran's right upper extremity neuropathy was rated first under Diagnostic Code 8515 prior to February 22, 2016, then under Diagnostic Code 8713 from February 22, 2016 to February 29, 2020 and then under Diagnostic Code 8714 thereafter. The evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the nerves of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. 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. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Diagnostic Code 8513, 8613, and 8713 provide ratings for paralysis, neuritis, and neuralgia of all radicular groups. A 20 percent rating is warranted for mild incomplete paralysis, a 40 percent rating is warranted moderate incomplete paralysis; a 70 percent rating is warranted for severe incomplete paralysis; and a 90 percent rating is warranted for complete paralysis of the major radicular groups. Diagnostic Codes 8514, 8614, and 8714 provide ratings for paralysis, neuritis, and neuralgia of the radial nerve. Under these criteria, mild incomplete paralysis of the radial nerve is rated as 20 percent; moderate incomplete paralysis is rated as 30 percent for the major extremity; severe incomplete paralysis is rated as 50 percent for the major extremity; and complete paralysis is rated as 70 percent. Diagnostic Codes 8515, 8615, and 8715 provide ratings for paralysis, neuritis, and neuralgia of the median nerve. Under these criteria, mild incomplete paralysis of is rated as 10 percent; moderate incomplete paralysis is rated as 30 percent for the major extremity; severe incomplete paralysis is rated as 50 percent for the major extremity; and complete paralysis is rated as 70 percent. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. In rating diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. In a June 2009 VA examination, the examiner noted that the Veteran was right hand dominant. He described right elbow pain, which was intermittent with remissions emanating from the wrist, and spreading toward his arm until it persisted on his shoulder. He denied any weakness or paresthesias. He reported good response to self-administered treatment for pain killers. The only symptom observed or reported was pain in the wrist, arm, and shoulders. There was no history of trauma to the nerve or hospitalization. The affected muscles were noted to be the brachioradialis, thenar, and hypothenar. Muscle strength testing was 5/5, with no observed motor function impairment. A sensory function examination revealed the right upper extremity was normal, along with vibration, pain, light touch, and position sense, which were all also noted to be normal. There was no muscle atrophy, or abnormal muscle tone or bulk, no tremors, tics, or abnormal movement, and the examiner noted that no joint function was affected by the joint disorder. Gait and balance were also normal. An electromyography (EMG) was conducted which revealed radiculopathy of the left paracervical. Paralysis and neuritis were absent, neuralgia was present. In a February 2016 VA examination, the examiner continued a diagnosis of right radial nerve neuropathy secondary to right lateral epicondylitis. The Veteran asserted that his symptoms had worsened over the years, with numbness on both hands and arms, involving his shoulders to his fingers. He also reported constant pain from his wrists down to his fingers. He rated his pain at a 9 out of 10. He also reported a pins and needles sensation on his right hand, and difficulty holding and lifting things. The examiner stated that the Veteran suffered from moderate constant pain, moderate intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness of the upper right extremity. Muscle strength testing of the elbow flexion and extension was rated as 5 out of 5, with wrist extension, grip, and pinch as 4 out of 5. A sensory examination revealed normal sensation testing for the right shoulder area, but decreased sensation touching for the right inner/outer forearm, and hand and fingers. Mild incomplete paralysis of the right radial nerve and median nerve were noted. The ulnar nerve, musculocutaneous nerve, and circumflex nerve were noted as normal without paralysis. The right upper and middle radicular groups were also normal and without any paralysis. An EMG showed bilateral carpal tunnel syndrome, severe on the right. The examiner opined that the Veteran's condition mildly affected his functional impact as he had mild difficulty with activities using his right hand like grip and holding things. In a February 2020 VA examination, the examiner noted a diagnosis of right radial neuropathy associated with chronic right elbow lateral epicondylitis. The Veteran reported symptoms of pain, paresthesia, numbness, decreased sensitivity, and weakness of the bilateral upper extremities. The examiner noted moderate intermittent pain, paresthesias, and numbness. Muscle strength testing was 4 out of 5 and reflexes were hypoactive. A sensory examination showed decreased sensation to touch in all areas. There were trophic changes, including smooth, shiny skin on both arms and legs. The examiner opined that the Veteran had moderate incomplete paralysis of the right radial nerve, medial nerve, ulnar nerve, musculocutaneous nerve, circumflex nerve, long thoracic nerve, and the upper, middle, and lower radicular groups. The examiner noted that the Veteran's neurological symptoms were related to his diabetes. Regarding his upper extremities, the examiner opined that "it is impossible to differentiate symptoms between the upper extremity conditions due to symptom overlap. However, the only nerve involved with carpal tunnel syndrome is the median nerve. The only nerve involved with neuropathy associated with his chronic right lateral epicondylitis of the elbow is the radial nerve. All other nerve involvement is related to diabetic peripheral neuropathy." An August 2020 rating decision increased the Veteran evaluation for chronic epicondylitis with neuropathy of the right upper extremity to 30 percent, effective February 29, 2020. Upon review of the record, the Board finds that prior to February 22, 2016, a rating of 20 percent is warranted pursuant to Diagnostic Code 8713. The June 2009 VA examination showed that the Veteran reported radiating pain from his wrist to his shoulder that responded to self-administered treatment. Peripheral nerve examination indicated motor and sensory examinations to be normal. There was no atrophy, abnormal muscle tone, or abnormal movements, and the Veteran denied weakness or paresthesias. Although the Veteran was provided with a peripheral nerves examination, the specific nerve(s) involved was not identified. The Veteran reported pain primarily in his elbow, but traveling to both his shoulder and wrist. With resolution of the doubt in favor of the Veteran, the Board finds that Diagnostic Code 8713 for all radicular groups of the upper extremity is appropriate. Given that the record showed no more than mild incomplete paralysis of these nerve groups, an increased rating of 20 percent is granted pursuant to Diagnostic Code 8713. From February 22, 2016 to February 29, 2020, the Board finds that the Veteran has moderate incomplete paralysis of the upper right extremity. Although the VA examiner concluded that the Veteran's condition mildly impacted his functional impact, she also noted objectively moderate symptoms. The Board has also considered that multiple nerve groups are affected. Therefore, with resolution of the doubt in favor of the Veteran, a 30 percent rating under Diagnostic Code 8714. As stated, the VA examiner noted that both the radial and median nerves are affected. However, to assign additional ratings under other neurological Diagnostic Codes for the upper extremities would constitute impermissible pyramiding, as Diagnostic Code 8714 contemplates symptoms affecting the right upper extremity from the elbow to the fingers and thus would overlap with symptomatology considered by Diagnostic Code 8515, 8615, 8715. From February 29, 2020, the Board finds that a rating in excess of 30 percent currently assigned is denied. The February 2020 VA examiner noted moderate symptoms in all area in moderate incomplete paralysis of all nerve groups. However, the examiner opined that only the radial nerve is involved with the Veteran's chronic right lateral epicondylitis of the elbow and the other nerve disorders are a result of his non-service connected diabetes and diabetic neuropathy and carpal tunnel syndrome. Therefore, a 30 percent rating for moderate incomplete paralysis of the radial nerve is appropriate under Diagnostic Code 8714. As severe symptoms were not shown, a higher 50 percent rating is denied. The Veteran is considered to be competent to report what comes to him through his senses, such as experiencing pain and limited function. Layno v. Brown, 6 Vet. App. 465 (1994). The Board has considered the Veteran's statements regarding the severity of his disability and finds that his complaints regarding pain, weakness, and functional loss are contemplated by the assigned ratings. In summary, the Board finds that with resolution of the doubt in favor of the Veteran, increased, staged ratings of 20 and 30 percent for the rating periods prior to February 29, 2020 are warranted and a rating in excess of 30 percent thereafter is denied. To the extent that higher ratings are denied, the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 4. Entitlement to an evaluation greater than 10 percent tendinitis, right wrist with painful motion 5. Entitlement to an evaluation greater than 10 percent for supination and pronation impairment, right elbow 6. Entitlement to an evaluation greater than 10 percent for limitation of flexion of the forearm, right 7. Entitlement to an evaluation greater than 0 percent for limitation of extension of the forearm, right For purposes of the Rating Schedule, major joints are considered to be the shoulder, elbow, wrist, hip, knee, and ankle. Multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities; the interphalangeal, metatarsal and tarsal joints of the lower extremities; the cervical vertebrae; the dorsal vertebrae; and the lumbar vertebrae, are considered groups of minor joints, ratable on a parity with major joints. See 38 C.F.R. § 4.45. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. The Veteran's disabilities are currently rated under Diagnostic Codes 5206, 5207, 5213, and 5215. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, these diagnostic codes were not changed. Under Diagnostic Code 5206, a 10 percent disability rating is warranted for limitation of flexion of either the major forearm to 100 degrees; a 20 percent disability rating is warranted for limitation of flexion of either the major forearm to 90 degrees; limitation of flexion of the major forearm to 70 degrees warrants a 30 percent rating; limitation of flexion of the major forearm to 55 degrees warrants a 40 percent rating; and limitation of flexion of the major forearm to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a. Under Diagnostic Code 5207, a 10 percent disability rating is warranted when extension is limited to either 45 or 60 degrees for the major elbow; a 20 percent disability rating is warranted when extension is limited to 75 degrees for the major elbow; a 30 percent disability rating is warranted when extension is limited to 90 degrees for the major elbow; a 40 percent disability rating is warranted when extension is limited to 100 degrees for the major elbow; and a 50 percent disability rating is warranted when extension is limited to 110 degrees for the major elbow. Under Diagnostic Code 5213, a 10 percent disability rating is warranted for limitation of supination to 30 degrees or less for the major arm. A 20 percent rating is warranted both the major arm for limitation of pronation with motion lost beyond last quarter of arc, where the hand does not approach full pronation. For limitation of pronation with motion lost beyond middle of arc, a 30 percent rating is warranted for the major arm. Under Diagnostic Code 5215, a 10 percent is warranted when dorsiflexion is less than 15 degrees or palmar flexion is limited in line with forearm. Diagnostic Code 5214, which evaluates ankylosis of the wrist, provides ratings higher than 10 percent for favorable and unfavorable ankylosis. The Veteran was afforded a VA examination in June 2009. He reported intermittent right elbow pain. Upon examination, the findings included crepitus and guarding of the right elbow and crepitus, tenderness, weakness, and guarding of the right wrist. Range of motion testing of the right elbow and forearm showed flexion to 130 degrees, extension to 0 degrees, pronation to 65 degrees, and supination to 65 degrees. The Veteran was limited an additional 5 degrees of flexion, pronation and supination after repetitive use testing. Range of motion of the right wrist was to 60 degrees of dorsiflexion, 70 degrees of palmar flexion, 20 degrees of radial deviation, and 30 degrees of ulnar deviation. The Veteran was limited by an additional 10 degrees or dorsiflexion and palmar flexion and 5 degrees radial and ulnar deviation after repetitive use testing. There was mild to moderate impairment in his daily activities. In his August 2009 notice of disagreement, the Veteran reported pain in his upper extremities. In a January 2010 statement, the Veteran stated that his doctor verbally told him that he had damaged nerves and that he was having sleepless nights due to the pain. The Veteran appeared at a Board hearing in April 2010. He testified that his right wrist disorder limits his ability to engage in recreational activities and chores. He reported pain and loss of range of motion of the right wrist. The Veteran underwent a VA examination in February 2016. Regarding his right wrist, the examiner noted a diagnosis of osteoarthritis of the right wrist. The Veteran reported flare ups and difficulty carrying, lifting, pushing, and pulling heavy loads. Range of motion testing showed palmar flexion limited to 70 degrees ulnar deviation to 40 degrees and full dorsiflexion and radial deviation. The range of motion itself did not contribute to functional loss but pain was noted on examination in all ranges. There was no evidence of pain with weight bearing, localized tenderness, or crepitus. The Veteran was able to perform repetitive use testing with no additional limitations. The Veteran's function was not significantly limited with repeated use over a period of time due to pain, weakness, fatigability or incoordination. However, during a flare up, the examiner estimated an additional loss of 10 to 15 degrees of range of motion in all directions. There was no reduction in muscle strength or atrophy. Regarding his right elbow, the VA examiner diagnosed lateral epicondylitis and osteoarthritis. The Veteran described symptoms of sharp, stabbing pain of the right elbow. Flare ups were triggered by carrying or lifting. Range of motion testing showed flexion limited to 140 degrees with full extension; forearm supination and pronation were normal. Pain was noted on examination but did not contribute to functional loss. There was evidence of pain with weight bearing but not localized tenderness or crepitus. The Veteran was able to perform repetitive use testing with no additional limitations. The examiner estimated an additional loss of 10 to 15 degrees of range of motion in all directions during a flare up and an additional loss of 5-10 degrees with repeated use over a period of time. There was no reduction in muscle strength or atrophy. In a July 2017 rating decision, the Veteran's evaluation for chronic epicondylitis with neuropathy of the right upper extremity was increased to 20 percent disabling, effective February 22, 2016. The Veteran was afforded a VA examination in February 2020. The examiner noted diagnoses of degenerative arthritis of the right elbow and chronic lateral and medial epicondylitis with radial neuropathy of the upper extremity. The Veteran reported symptoms of pain, weakness, limitation of motion, and guarded motion, bilaterally. The Veteran reported flare ups with sharp pain and that he has difficulty carrying, lifting, pushing and pulling, reaching, turning doorknobs, feeling, and dressing and undressing during flare ups. Range of motion testing of the right elbow showed flexion limited to 125 degrees with full extension, forearm supination limited to 70 degrees, and forearm pronation limited to 80 degrees. The same ranges were noted for passive range of motion. Pain was noted on examination but did not result in functional loss. There was no objective evidence of localized tenderness or crepitus. The Veteran did have pain with weight bearing and non-weight bearing. The Veteran was able to perform repetitive use testing with no additional limitations. The examiner estimated an additional loss of 5 degrees of range of motion in all directions during a flare up and an additional loss of 5-10 degrees with repeated use over a period of time. An additional factor of disability was "moderate to mildly severe diabetic neuropathy causing weakness, paresthesia, numbness/decreased sensitivity." Muscle strength testing was 4 out of 5 due to the neuropathy. The Veteran had no atrophy. The Veteran did not have flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation. Regarding functional impact, the examiner opined "There is a moderate to mildly severe impact on his ability to perform occupational tasks such as carrying, lifting, [and] pushing/pulling heavy loads." The Veteran underwent a VA examination of his wrists in February 2020. The examination primarily focused on his left wrist symptoms; however, the examination report provided the objective findings for the right wrist as well. Active and passive range of motion testing showed palmar flexion limited to 45 degrees, ulnar deviation to 35 degree, dorsiflexion to 30 degrees, and radial deviation to 10 degrees. Pain was noted on examination in all ranges and contributed to functional loss. There was evidence of pain with weight bearing and non-weight bearing and crepitus, but no localized tenderness or pain with palpation. The Veteran was able to perform repetitive use testing with no additional limitations. The Veteran's function was limited an additional 5 degrees in all ranges with repeated use over a period of time due to pain, weakness, fatigability or incoordination and an additional 10 to 20 degrees during a flare up. An additional factor of disability was "moderate weakness and numbness due primarily to diabetic neuropathy." Muscle strength testing was 4 out of 5 due to the neuropathy. The Veteran had no atrophy. Upon review of the record, the Board finds that higher ratings in excess of those currently assigned are not warranted. Regarding the Veteran's right wrist, the Veteran is in receipt of the maximum 10 percent rating based on limitation of motion under Diagnostic Code 5215. To warrant a higher rating under Diagnostic Code 5214, the evidence would have to show favorable ankylosis in 20 to 30 degrees of dorsiflexion. There is no evidence of ankylosis; rather, the VA examinations show flexion limited, at worst, to 25 degrees with a flare up. While the Veteran reported pain and limited motion and function, he has not provided lay evidence of ankylosis. Therefore, a higher rating in excess of 10 percent for a right wrist disorder is denied. Regarding the right elbow limitation of flexion, the evidence shows that at worst, the Veteran's right elbow flexion was to 115 degrees during a flare up. To warrant a higher 20 percent rating for the right elbow under Diagnostic Code 5206, the evidence would need to show flexion limited to 90 degrees. There is no indication that the Veteran's right elbow disorder was limited to 90 degrees, even with consideration of additional loss due to repeated use over time and flare ups. Therefore, a higher rating for limitation of flexion is not warranted. Regarding right elbow limitation of extension, the evidence shows limitation of extension to, at worse, 0 degrees. There is no indication that extension was limited to 45 degrees to warrant a compensable 10 percent rating under Diagnostic Code 5207. In fact, there is no limitation of extension; however, there is pain that is contemplated in the other ratings pertaining to his elbow. Therefore, a compensable rating for limitation of extension is not warranted. Finally, regarding right elbow impairment of supination, the Veteran's right elbow supination was to, at worst, 60 degrees. The evidence did not show any motion lost beyond last quarter of arc, the hand did not approach full pronation for the right elbow, and there was no bone fusion to warrant a higher 20 percent rating under Diagnostic Code 5213. The Board has also considered whether the Veteran may be entitled to separate or higher ratings based on a different Diagnostic Code for rating the elbow and forearm. See 38 C.F.R. § 4.71a. There are already separate evaluations based on limitation of motion of the elbow and forearm under Diagnostic Codes 5206, 5207, and 5213 respectively. The Board finds that the other pertinent Diagnostic Codes 5205, 5208-5212 are not for application. As a lay person, the Veteran is considered to be competent to report what comes to him through his senses, such as experiencing limited motion of his elbows. Layno, supra. The Board has considered the Veteran's statements regarding his symptoms and finds that his pain and functional loss are contemplated by the assigned ratings. To the extent that he was asserting decreased range of motion, the Board places more probative value on the objective findings of the VA examiners, which are measured in degrees, rather than on his subjective complaints which are less precise. The amputation rule provides that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. See 38 C.F.R. § 4.68. In reviewing the above, the Board finds the current ratings have not run afoul of the amputation rule as it pertains to the major upper extremity. 38 C.F.R. § 4.71a, DCs 5120-5151. (Continued on the next page) In summary, the Board finds that the evidence does not support higher evaluations for limitation of flexion, extension, or supination of the elbow and forearm and impairment of the wrist. As such, the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. Emily Tamlyn Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Shana Z. Siesser, 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.