Citation Nr: 21005984 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 13-00 583A DATE: February 3, 2021 ORDER Entitlement to a 50 percent initial disability rating for migraines prior to August 29, 2019 is granted. Entitlement to a 50 percent disability rating for migraines from August 29, 2019 is granted. Entitlement to a 30 percent initial disability rating for cervical spine degenerative changes prior to August 29, 2019 is granted. Entitlement to a 30 percent disability rating for cervical spine degenerative changes from August 29, 2019 is granted. Entitlement to a 20 percent initial disability rating for thoracolumbar spine degenerative arthritis is granted. Entitlement to an initial disability rating higher than 20 percent for left shoulder strain is denied. Entitlement to an initial disability rating higher than 10 percent for right elbow epicondylitis is denied. Entitlement to an initial disability rating higher than 10 percent for right knee patellofemoral syndrome is denied. Entitlement to an initial disability rating higher than 10 percent for left knee patellofemoral pain syndrome is denied. Entitlement to an initial disability rating higher than 10 percent for right ankle strain is denied. Entitlement to a 20 percent initial disability rating for left ankle degenerative changes, residual from left fibula fracture, is granted. Special monthly compensation at the housebound rate is granted effective August 3, 2016. FINDINGS OF FACT 1. For all periods relevant to this appeal, the Veteran’s migraines have been marked by very frequent completely prostrating and prolonged attacks that have been productive of severe economic inadaptability. 2. For all periods relevant to this appeal, the Veteran’s cervical spine degenerative changes have been marked by pain, stiffness, spasms, muscle tightness, and decreased cervical spine motion that includes painless flexion to no less than 10 degrees. 3. The Veteran’s thoracolumbar spine degenerative arthritis has been manifested predominantly by chronic pain, stiffness, spasms, guarding, and decreased thoracolumbar spine motion that includes painless forward flexion to no less than 50 degrees and combined thoracolumbar spine motion of no less than 170 degrees. 4. The Veteran’s left shoulder strain has been manifested predominantly by pain, stiffness, grinding, and decreased left arm flexion and abduction that remains well in excess of shoulder level. 5. The Veteran’s right elbow epicondylitis has been manifested predominantly by pain, weakness, stiffness, and decreased right arm motion that includes painless flexion to no less than 110 degrees, painless extension to zero degrees, painless pronation to no less than 80 degrees, and painless supination to no less than 45 degrees. 6. The Veteran’s right knee patellofemoral syndrome has been manifested predominantly by pain, stiffness, weakness, and painless flexion to no less than 90 degrees. 7. The Veteran’s left knee patellofemoral pain syndrome has been manifested predominantly by pain, stiffness, weakness, and painless flexion to no less than 85 degrees. 8. The Veteran’s right ankle strain has been manifested predominantly by pain, swelling, audible clicking in the joint, weakness, painless right foot dorsiflexion to no less than 20 degrees, and painless plantar flexion to no less than 25 degrees, which considered together equate to moderate loss of ankle motion. 9. The Veteran’s left ankle degenerative changes, residual from left fibula fracture has been manifested predominantly by pain, swelling, audible clicking in the joint, weakness, periodic instability, painless dorsiflexion to 10 degrees, and painless plantar flexion to 15 degrees, which considered together equate to marked loss of ankle motion. 10. From August 3, 2016, the Veteran has TDIU based on impairment caused by her orthopedic disabilities and additional service-connected disabilities that are ratable as 60 percent or more. CONCLUSIONS OF LAW 1. The criteria for a 50 percent initial disability rating for migraines prior to August 29, 2019 are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code (DC) 8100 (2019). 2. The criteria for a 50 percent disability rating for migraines from August 29, 2019 are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.124a, DC 8100 (2019). 3. The criteria for a 30 percent initial disability rating for cervical spine degenerative changes prior to August 29, 2019 are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.71a, DC 5242 (2019). 4. The criteria for a 30 percent disability rating for cervical spine degenerative changes from August 29, 2019 are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.71a, DC 5242 (2019). 5. The criteria for a 20 percent initial disability rating for thoracolumbar spine degenerative arthritis are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.71a, DC 5242 (2019). 6. The criteria for an initial disability rating higher than 20 percent for left shoulder strain are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.71a, DC 5201 (2019). 7. The criteria for an initial disability rating higher than 10 percent for right elbow epicondylitis are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.71a, DCs 5206, 5207, and 5213 (2019). 8. The criteria for an initial disability rating higher than 10 percent for right knee patellofemoral syndrome are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.71a, DC 5260 (2019). 9. The criteria for an initial disability rating higher than 10 percent for left knee patellofemoral pain syndrome are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.71a, DC 5260 (2019). 10. The criteria for an initial disability rating higher than 10 percent for right ankle strain are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.71a, DC 5271 (2019). 11. The criteria for a 20 percent initial disability for left ankle degenerative changes, residual from left fibula fracture, are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.71a, DC 5271 (2019). 12. The criteria for special monthly compensation at the housebound rate from August 3, 2016 are met. 38 U.S.C. § 1114(s) (2012); 38 C.F.R. § 3.350(i) (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from December 1984 through December 1995. The issues on appeal arise from the Veteran’s September 2009 claim and the Agency of Original Jurisdiction’s (AOJ’s) April 2010 rating decision. This appeal was remanded previously by the Board in October 2017 and again in June 2020. The development directed by the Board has been completed. The matter now returns to the Board for review. Increased Ratings 1. Entitlement to an initial disability rating higher than 10 percent for migraines prior to August 29, 2019. Service connection for migraines was granted to the Veteran in the AOJ’s April 2010 rating decision effective from September 22, 2009. A 10 percent initial disability rating was assigned. That rating continued through August 28, 2019. The Veteran claims entitlement to a higher initial disability rating for that part of the appeal period. The Veteran’s migraines were rated in accordance with the criteria under 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8100. Under DC 8100, migraines that are marked by less frequent attacks are assigned a non-compensable disability rating. Where the evidence shows that the migraines occur on average once every two months over the last several months with characteristic prostrating attacks, a 10 percent disability rating is assigned. Where migraine headaches occur with characteristic prostrating attacks on an average of once a month over the last several months, a 30 percent disability rating is appropriate. Migraine headaches with very frequent, completely prostrating and prolonged attacks that are productive of severe economic inadaptability warrant a maximum schedular 50 percent disability rating. 38 C.F.R. § 4.124a, DC 8100 (2016). The rating criteria do not define the term "prostrating." According to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." Essentially the same definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), which defines "prostration" as "extreme exhaustion or powerlessness." The evidence in this case shows that the frequency and severity of the Veteran’s headaches are such that the criteria for a 50 percent disability rating are met for the part of the appeal period prior to August 29, 2019. The Veteran asserts in her September 2009 claim that her migraine attacks cause her to become totally incapacitated. That assertion is supported by lay statements received in March 2017 from her friend and in April 2017 from her spouse. The statement from the Veteran’s spouse statement describes that the Veteran’s headaches were occurring at least once or twice every two weeks and caused the Veteran to sleep in a dark and quiet room until the headaches subsided. During a March 2010 examination, the Veteran reported that generally all her migraine attacks were prostrating. The VA treatment records show that the Veteran was followed periodically for frequently occurring headaches. In May 2012, she reported that her headaches were occurring daily and that she had frequently experienced the “worst headache of her life,” accompanied by nausea and sensitivity to light and sound. Records for subsequent treatment received by the Veteran document that the Veteran’s headaches were continuing to occur at least weekly and generally lasted an entire day. Overall, the evidence related to the part of the appeal period prior to August 29, 2019 show that the Veteran experienced headaches generally weekly (at times more than once a week) and that each of her attacks were generally prostrating. The described frequency and severity of the Veteran’s migraines are consistent with likely economic inadaptability. The Veteran’s migraines meet the criteria for a 50 percent disability rating under DC 8100 for the part of the appeal period prior to August 29, 2019. The Veteran is entitled to a 50 percent disability rating for migraines prior to August 29, 2019. To that extent, this appeal is granted. 2. Entitlement to a disability rating higher than 30 percent for migraines from August 29, 2019. Effective from August 29, 2019, a September 2019 rating decision granted to the Veteran a 30 percent disability rating for migraines, also pursuant to the rating criteria under DC 8100. Those criteria are discussed fully above and are incorporated herein by reference. The evidence for the part of the appeal period from August 29, 2019 show that the Veteran has continued to experience multiple headaches a week and that each of her attacks have remained prostrating in nature. During an August 2019 examination, she continued to describe headaches that occurred twice a week, were accompanied by nausea, sensitivity to light and sound, and vision changes. She continued to report that her headaches were debilitating and required her to lie in a dark and quiet room. Records for subsequent VA and private treatment received by the Veteran reflect no new or contradictory information related to the Veteran’s headaches. Given the frequency and severity of the Veteran’s headaches, the criteria for a 50 percent disability rating continue to be met for the part of the appeal period from August 29, 2019. The Veteran is entitled to a 50 percent disability rating for migraines from August 29, 2019. To that extent also, this appeal is granted. 3. Entitlement to an initial disability rating higher than 10 percent for cervical spine degenerative changes prior to August 29, 2019. Service connection for cervical spine degenerative changes was also granted to the Veteran in the AOJ’s April 2010 rating decision, effective from September 22, 2009. A 10 percent initial disability rating was assigned pursuant to the rating criteria under 38 C.F.R. § 4.71a, DC 5242. Cervical spine disabilities are rated generally under DCs 5235 through 5242. Regardless of which of those DCs that VA selects, disabilities rated under those criteria are rated pursuant to the General Rating Formula for Diseases and Injuries of the Spine (Spine Formula). Under the Spine Formula, a 10 percent disability rating is assigned where forward flexion of the cervical spine is greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine is greater than 170 degrees but not greater than 335 degrees; or, muscle spasms, guarding, or localized tenderness not resulting in abnormal gait or abnormal spine contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is warranted for disabilities marked by forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 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 30 percent disability rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent disability rating is in order for unfavorable ankylosis of the entire cervical spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is warranted for unfavorable ankylosis of the entire spine. The "combined range of motion" refers to the sum of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees. Ankylosis is defined as, "immobility and consolidation of a joint due to disease, injury, or surgical procedure." See Lewis v. Derwinski, 3 Vet. App. 259 (1992). The evidence for the part of the appeal period prior to August 29, 2019 shows that the Veteran’s cervical spine disability was manifested predominantly by pain, stiffness, spasms and tightness in the cervical muscles, and decreased cervical spine motion as reported and demonstrated during repeated treatment and examinations. Repeated range of motion studies conducted during a March 2010 spine examination, August 2016 private treatment with Dr. G.I.D., and during a September 2016 VA treatment visit demonstrated that painless range of cervical spine motion retained by the Veteran ranged as low as 10 degrees (shown during September 2016 VA treatment). Subject to the same, the evidence for the part of the appeal period at issue showed no evidence of ankylosis in the Veteran’s spine. As noted in Dr. G.I.D.’s August 2016 report, neurological examinations showed various positive findings in the Veteran’s upper extremities that were diagnosed as radiculopathies associated with the Veteran’s cervical spine disability. The Board observes that service connection and separate disability ratings for the Veteran’s bilateral upper extremity radiculopathies have already been granted, effective from August 2016. The Veteran has requested higher level review of those decisions by the AOJ. Overall, the evidence shows that the Veteran’s cervical spine degenerative changes were manifested primarily by pain, stiffness, spasms, muscle tightness, and decreased painless cervical spine flexion to no less than 10 degrees. Given the same and where the evidence indicates no sign of ankylosis in the Veteran’s spine, the criteria for a 30 percent initial disability rating, and no higher, are met for the Veteran’s cervical spine degenerative changes for the part of the appeal period prior to August 29, 2019. The Veteran is entitled to a 30 percent initial disability rating for cervical spine degenerative changes prior to August 29, 2019. To that extent, this appeal is granted. 4. Entitlement to a disability rating higher than 20 percent for cervical spine degenerative changes from August 29, 2019. In the September 2019 rating decision, the AOJ granted to the Veteran a 20 percent disability rating for cervical spine degenerative changes, effective from August 29, 2019. The newly assigned disability rating was also pursuant to the criteria under DC 5242 and the Spine Formula. Those criteria are discussed above fully and are incorporated herein by reference. The 20 percent disability assigned by the AOJ was granted pursuant to findings from an August 2019 spine examination. During that examination, the Veteran described ongoing neck pain and continuing neurological symptoms in her upper extremities. She stated that she had flare-ups that occurred daily and were marked by increased pain. A repeat spine examination showed that the Veteran was able to produce cervical spine flexion to 20 degrees. Pain was present even during weight bearing. Again, no evidence of ankylosis was observed. Records for subsequent VA treatment received by the Veteran show no ongoing treatment related to her neck or cervical spine. As noted above, previous range of motion tests conducted as part of VA treatment in September 2016 showed that the Veteran was able to produce only 10 degrees of cervical spine flexion. The extent of symptoms and flare-ups reported by the Veteran during the August 2019 examination do not indicate improvement of her cervical spine disabilities. Although the examiner recorded that the Veteran was able to flex her cervical spine to 20 degrees, she acknowledges that the Veteran’s cervical spine was not being examined during a flare-up or after repetitive use over time. The examiner concluded that the Veteran did not likely experience further loss of motion or other functional deficit during flare-ups or after repetitive use over time. Although that conclusion appears to be somewhat at odds with the Veteran’s description of increased pain during her daily flare-ups, the examiner gives no explanation or rationale for her conclusion. Certainly, given that the demonstrated cervical spine motion during the previous range of motion study conducted in September 2016 was to only 10 degrees, and given that the extent of cervical spine flexion shown during the August 2019 spine examination was only slightly improved to 20 degrees, it appears likely that the Veteran’s cervical spine flexion would be decreased to 15 degrees or less during periods of flare-ups and after repetitive use over time. Subject to the same, the August 2019 spine examination revealed no evidence of ankylosis in the Veteran’s spine. Under the circumstances, the Board does not find it necessary to request that the August 2019 spine examiner provide an addendum opinion regarding the Veteran’s function during flare-ups or after repetitive use over time. The Board does find, however, that there is sufficient evidence to conclude that the criteria for a 30 percent disability rating, and no higher, are met for the Veteran’s cervical spine degenerative changes under the Spine Formula. The Veteran is entitled to a 30 percent disability rating for cervical spine degenerative changes prior to August 29, 2019. To that extent, this appeal is granted. 5. Entitlement to an initial disability rating higher than 10 percent for thoracolumbar spine degenerative arthritis. The AOJ’s April 2010 rating decision also granted service connection for thoracolumbar spine degenerative arthritis, effective September 22, 2009. A 10 percent initial disability rating was assigned pursuant to the criteria under DC 5242 and the Spine Formula. In relation to disabilities involving the thoracolumbar spine, the Spine Formula provides for a 10 percent disability rating for disabilities that are marked by forward flexion of the thoracolumbar spine that is greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine that is greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or abnormal spine contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is assigned where the evidence shows forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a combined range of motion of the thoracolumbar 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 appropriate where there is evidence of forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is warranted where the disability has resulted in unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating contemplates unfavorable ankylosis of the entire spine. The "combined range of motion" for the thoracolumbar spine refers to the sum of forward flexion, extension, left and right lateral flexion, and left and right rotation. 38 C.F.R. § 4.71a (Plate V) indicates that normal range of motion of the thoracolumbar spine consists of flexion to 90 degrees and extension, bilateral lateral flexion, and bilateral rotation to 30 degrees. The normal combined range of thoracolumbar spine motion is 240 degrees. Ankylosis is defined as, "immobility and consolidation of a joint due to disease, injury, or surgical procedure." See Lewis v. Derwinski, 3 Vet. App. 259 (1992). The evidence shows that the Veteran’s thoracolumbar spine disability has been marked over the entire course of the appeal period predominantly by low back pain, stiffness, spasms, guarding of movement, and decreased spine motion. Range of motion tests conducted during a March 2010 spine examination, August 2016 private treatment with Dr. G.I.D., and a September 2019 spine examination show that the Veteran demonstrated painless thoracolumbar spine flexion to no less than 50 degrees (as recorded during in August 2016 by Dr. G.I.D.) and painless combined thoracolumbar spine motion to no less than 190 degrees. Notably, the Veteran has not reported having any flare-ups in relation to her back. The September 2019 examiner stated that the findings from the examination were medically consistent with the Veteran’s statements describing the extent of her functional loss with repetitive use over time. He opined that the Veteran did not likely experience further loss of motion or other loss of function after repetitive use over time. Indeed, the Veteran has not described additional loss of motion after activity. Similarly, such findings are not noted elsewhere in the record. Notably, Dr. G.I.D. estimates in an August 2016 lumbar spine impairment questionnaire that the Veteran’s thoracolumbar spine flexion might range anywhere from 31 to 60 degrees. It is unclear, however, as to what factual basis serves as the foundation for Dr. G.I.D.’s broad estimate. For that reason, the Board does not assign significant weight to Dr. G.I.D.’s estimated range, however, does assign weight to the objectively observed and measured flexion reported in his August 2016 report. The Board notes further that the thoracolumbar spine measurements reported by Dr. G.I.D. in his August 2016 report omits measurements for extension and right lateral rotation. In the absence of such measurements, the findings reported in Dr. G.I.D.’s August 2016 report do not permit the Board to evaluate the extent of total combined thoracolumbar spine motion shown by the Veteran during her examination by Dr. G.I.D. As discussed above, the Board does accept and assign weight to the extent of thoracolumbar spine flexion expressed in Dr. G.I.D.’s report. Given the extent of thoracolumbar spine motion shown by the Veteran during the appeal period, the criteria for a 20 percent disability rating, and no higher, are met. In the absence of evidence showing ankylosis in the Veteran’s spine, there is no basis currently for granting a disability rating higher than 20 percent under the Spine Formula. The Veteran is entitled to a 20 percent initial disability rating for thoracolumbar spine degenerative arthritis. To that extent, this appeal is granted. 6. Entitlement to an initial disability rating higher than 20 percent for left shoulder strain. Service connection for left shoulder strain was also granted to the Veteran in the AOJ’s April 2010 rating decision, effective from September 22, 2009. A 20 percent initial disability rating was assigned pursuant to the criteria under 38 C.F.R. § 4.71a, DC 5201. DC 5201 provides the rating criteria for disabilities marked by limitation of motion of the arm. Under those criteria, a 20 percent disability rating is assigned for limitation of motion of the minor (non-dominant) arm to shoulder level or to midway between the side and shoulder level. A 30 percent disability rating is assigned where the evidence shows that motion of the minor arm is limited to 25 degrees from the side. As the Veteran reported during her August 2019 joints examinations, she is right hand dominant. Hence, the Veteran’s left shoulder disability will be rated in accordance with the ratings schedule for the minor arm. The evidence shows that the Veteran’s left shoulder strain has been manifested primarily by pain, stiffness, grinding in her shoulder, and decreased left arm motion. Range of motion tests conducted during shoulder examinations conducted in March 2010 and August 2019 showed that the Veteran was able flex painlessly to no less than 110 degrees and abduct her left arm painlessly to no less than 120 degrees. Muscle strength in the Veteran’s left upper extremity was decreased to 4/5 during the August 2019 examination, however, there was no evidence of atrophy. Similarly, neither examination revealed any evidence of instability, dislocation, ankylosis, or involvement of the humerus, clavicle, or scapula. The examiner from the August 2019 examination remarked that the Veteran’s left shoulder was not being examined after repetitive use over time and that no flare-ups were observed during the examination. She opined, however, that there is no basis in the examination, the Veteran’s reported history, and other evidence in the record to offer additional loss of function or motion after repetitive use over time or during flare-ups. Indeed, the Veteran did not describe any flare-ups in relation to her shoulder and she did not describe further loss of motion or immobility after activity as being among her symptoms. The examiner’s conclusion that the evidence does not support the finding that the Veteran experiences additional loss of motion during flare-ups or after repetitive use over time appears to be supported by the record. Private and VA treatment records reflect no additional findings or complaints related to the Veteran’s left shoulder. Overall, the evidence shows that the Veteran has been able to produce left arm motion that well exceeds shoulder level throughout the course of the appeal period. Given the same, the criteria for a disability rating higher than 20 percent under DC 5201 are not met for the Veteran’s left shoulder disability. As noted, the Veteran’s left shoulder disability has been manifested also by symptoms of pain, stiffness, and audible grinding in her shoulder. Those symptoms are contemplated and adequately compensated by the 20 percent disability rating that is currently in effect. The Veteran is not entitled to a disability rating higher than 20 percent for left shoulder strain. To that extent, this appeal is denied. 7. Entitlement to an initial disability rating higher than 10 percent for right elbow epicondylitis. The AOJ’s April 2010 rating decision also granted to the Veteran service connection for right elbow epicondylitis, effective September 22, 2009. A 10 percent initial disability rating was assigned pursuant to the rating criteria under 38 C.F.R. § 4.71a, DC 5206. Notably, the Board’s previous June 2020 remand identifies erroneously that the Veteran’s right elbow disability has been rated as being 20 percent disabling. Perhaps because of that typographical error, an October 2020 Supplemental Statement of the Case likewise lists the erroneous 20 percent disability rating for the Veteran’s right elbow disability. There is no indication in the record that the Veteran has ever been awarded a disability rating higher than 10 percent for her right elbow disability. The Board apologizes for its error and emphasizes that the question on appeal concerning the Veteran’s right elbow disability is whether she is entitled to an initial disability rating higher than 10 percent. DC 5206 provides the criteria for disabilities that are marked by limitation of flexion of the forearm. As mentioned above, the Veteran reported during August 2019 examinations of her joints that she is right hand dominant. As such, her right elbow disability will be rated in accordance with the schedule for the major arm. Under DC 5206, a non-compensable disability rating is assigned where flexion of the major arm is limited to 110 degrees. A 10 percent disability rating is assigned where flexion of the major arm is limited to 100 degrees. A 20 percent disability rating is contemplated where flexion of the major arm is limited to 90 degrees. A 30 percent disability rating is warranted where flexion of the major arm is limited to 70 degrees. A 40 percent disability rating is assigned where flexion of the major arm is limited to 55 degrees. Finally, a maximum schedular 50 percent disability rating is warranted were flexion of the major arm is limited to 45 degrees. As described and demonstrated by the Veteran during elbow examinations conducted in March 2010 and August 2019, the Veteran’s right elbow disability has been manifested primarily by progressive pain, weakness, stiffness, and decreased right forearm motion that has included painless flexion to no less than 110 degrees. Right arm extension has remained full to zero degrees throughout the course of the appeal period. Pronation has remained to no less than 80 degrees and supination to no less than 45 degrees. Although muscle strength in the Veteran’s right elbow was decreased to 4/5 during the August 2019 examination, there was no evidence of atrophy. Neither examination revealed any evidence of ankylosis. X-rays of the Veteran’s elbow taken during both examinations were normal. The examiner from the August 2019 examination noted that the Veteran’s elbow was not being examined after repetitive use over time and that no flare-ups were observed during the examination. She opined, however, that there is no basis in the examination, the Veteran’s reported history, and other evidence in the record to offer additional loss of function or motion after repetitive use over time or during flare-ups. Indeed, the Veteran did not describe any flare-ups in relation to her right elbow and she did not describe further loss of motion or immobility after activity as being among her symptoms. The examiner’s conclusion that the evidence does not support the finding that the Veteran experiences additional loss of motion during flare-ups or after repetitive use over time appears to be supported by the record. Records for VA and private treatment received by the Veteran reflect no additional information concerning the symptoms and the extent of motion and other function in the Veteran’s right elbow. The extent of right elbow and forearm motion demonstrated by the Veteran over the course of the appeal period is not consistent with the criteria contemplated under DC 5206 for a disability rating higher than 10 percent. Although the Board is aware that separate disability ratings may be assigned for limitation of extension (DC 5207) and limitation of pronation and/or supination (DC 5213) in the Veteran’s right arm, the extent of motion shown also does not meet the criteria for a compensable disability rating under either of those criteria. Again, the Board recognizes that the Veteran’s right elbow disability has been productive of symptoms including pain, weakness, and stiffness, such symptoms are contemplated and compensated adequately by the 10 percent disability rating that is currently in effect. The Veteran is not entitled to an initial disability rating higher than 10 percent for right elbow epicondylitis. To that extent also, this appeal is denied. 8. Entitlement to an initial disability rating higher than 10 percent for right knee patellofemoral syndrome. The AOJ’s April 2010 rating decision granted to the Veteran service connection for right knee patellofemoral syndrome, effective from September 22, 2009, and assigned a non-compensable initial disability rating. A September 2019 rating decision that was issued during the development of the Veteran’s appeal granted a higher 10 percent initial disability rating on the basis of demonstrated painful motion of the knee, pursuant to the criteria under 38 C.F.R. § 4.71a, DC 5260. DC 5260 provides the criteria for rating disabilities due to loss of flexion of the leg. Under those criteria, a 10 percent disability rating is assigned where flexion of the leg is limited to 45 degrees. A 20 percent disability rating is in order where leg flexion is limited to 30 degrees. A maximum schedular 30 percent disability rating is assigned where leg flexion is limited to 15 degrees. For reference, normal range of motion for the knee is defined under the regulations as consisting of extension to zero degrees and flexion to 140 degrees. See 38 C.F.R. § 4.71, Plate II (2019). The records show that the Veteran has reported primarily symptoms of pain, stiffness, weakness, and decreased knee motion. Range of motion tests conducted during a March 2010 examination, August 2019 examination, and during VA treatment in November 2020 and October 2020 have shown that the Veteran has retained no less than 90 degrees of painless flexion (as shown during the August 2019 examination following three repetitions of motion). The range of motion tests show also that the Veteran has consistently maintained full extension in her knee. Muscle strength in the Veteran’s right leg was noted for being diminished to 4/5. Tests for joint stability were also consistently normal. No evidence of meniscal injury or involvement is noted in any of the examinations. The examiner from the August 2019 examination observed that the Veteran’s knee was not being examined after repetitive use over time and that no flare-ups were observed during the examination. She opined, however, that there is no basis in the examination, the Veteran’s reported history, and other evidence in the record to offer additional loss of function or motion after repetitive use over time or during flare-ups. Indeed, the Veteran did describe that flare-ups were marked by increased pain but did not describe further loss of motion as being among the manifestations of her flare-ups. The examiner’s conclusion that the evidence does not support the finding that the Veteran experiences additional loss of motion during flare-ups or after repetitive use over time appears to be supported by the record. Overall, the evidence shows that the Veteran’s right knee patellofemoral pain syndrome has been manifested predominantly by pain, stiffness, weakness and decreased right leg flexion to no less than 90 degrees. Given the extent of the motion shown by the Veteran in her right knee, the criteria for a disability rating higher than 10 percent under DC 5260 are not met. The Board concludes also that other predominant symptoms of pain, stiffness, and weakness are compensated adequately by the 10 percent disability rating already assigned. Given the findings in the record, the Board finds also that there is no basis at this time to award separate disability ratings based on loss of extension or instability in the Veteran’s right knee. The Veteran is not entitled to an initial disability rating higher than 10 percent for right knee patellofemoral pain syndrome. To that extent also, this appeal is denied. 9. Entitlement to an initial disability rating higher than 10 percent for left knee patellofemoral pain syndrome. The April 2010 rating decision also granted to the Veteran service connection for left knee patellofemoral syndrome, effective from September 22, 2009. A non-compensable initial disability rating was assigned. The September 2019 rating decision granted a higher 10 percent initial disability rating based on painful motion of the knee, also pursuant to DC 5260. Those criteria are discussed fully above and are incorporated herein by reference. Like the Veteran’s right knee, the records show that the Veteran has reported primarily pain, stiffness, weakness, and decreased knee motion in her left knee. Range of motion tests conducted during a March 2010 examination, August 2019 examination, and during VA treatment in November 2020 show that the Veteran has been able to flex her left knee painlessly to no less than 85 degrees (as shown during the August 2019 examination following three repetitions of motion). Again, tests conducted over the course of the appeal period have shown that the Veteran has been able to fully extend her knee. Muscle strength in the Veteran’s left leg was also decreased to 4/5. Again, tests for joint stability and meniscal involvement in the Veteran’s left knee were negative. Again, the August 2019 stated that the Veteran’s knee was not being examined after repetitive use over time and that no flare-ups were observed during the examination. She opined that there is no basis in the examination, the Veteran’s reported history, and other evidence in the record to offer additional loss of function or motion after repetitive use over time or during flare-ups. Under the same analysis given above in relation to the Veteran’s right knee, the examiner’s conclusion that the evidence does not support the finding that the Veteran experiences additional loss of motion during flare-ups or after repetitive use over time is supported by the evidence in the record. Overall, the Veteran’s left knee patellofemoral pain syndrome has been manifested predominantly by pain, stiffness, weakness and decreased right leg flexion to no less than 85 degrees. Given the extent of the motion shown by the Veteran, the criteria for a disability rating higher than 10 percent for her left knee also are not met under DC 5260. The Board concludes also that other predominant symptoms of pain, stiffness, and weakness are compensated adequately by the 10 percent disability rating already assigned. The Board finds also that there is no basis at this time to award separate disability ratings based on loss of extension or instability in the Veteran’s right knee. The Veteran is not entitled to an initial disability rating higher than 10 percent for left knee patellofemoral pain syndrome. To that extent also, this appeal is denied. 10. Entitlement to an initial disability rating higher than 10 percent for right ankle strain. Service connection for right ankle strain was also granted to the Veteran, effective September 22, 2009. A 10 percent initial disability rating was assigned pursuant to the criteria under 38 C.F.R. § 4.71a, DC 5271. DC 5271 provides criteria for rating disabilities based on limited ankle motion. Under those criteria, a 10 percent disability rating is warranted for moderate limitation of motion and a 20 percent rating is warranted for marked limitation of motion. The words moderate and marked are not defined in the regulations. For reference, normal range of motion for the ankles is 20 degrees of dorsiflexion and 45 degrees of plantar flexion. See 38 C.F.R. § 4.71, Plate II (2019). The evidence shows that the Veteran’s right ankle disability has been manifested predominantly by pain, swelling, audible clicking in the joint, and decreased motion. Range of motion tests conducted during a March 2010 examination, August 2016 private examination by Dr. G.I.D., and August 2019 examination show that the Veteran has demonstrated painless right foot dorsiflexion to no less than 20 degrees and plantar flexion to no less than 25 degrees. The repeated tests and examinations showed no evidence of instability. Although Dr. G.I.D. stated in his August 2016 report that the Veteran was reporting pain in her right Achilles tendon, no evidence of tendon abnormality was seen during the March 2010 and August 2019 examinations. The Veteran has not reported experiencing any flare-ups in relation to her ankles. The August 2019 examiner commented that the Veteran’s ankle was not being examined after repetitive use over time and that no flare-ups were observed during the examination. Still, she opined that there is no basis in the examination, the Veteran’s reported history, and other evidence in the record to offer additional loss of function or motion after repetitive use over time or during flare-ups. Indeed, the Veteran reported during the August 2019 examination that the pain in her ankle was aggravated prolonged standing and walking. She did not, however, indicate that she experienced further loss of motion or other function in the joint. The examiner’s conclusion that the evidence does not support the finding that the Veteran experiences additional loss of motion during flare-ups or after repetitive use over time is supported by the evidence. The extent of painless right ankle motion shown by the Veteran throughout the appeal period is consistent overall with moderate loss of motion. The Veteran’s other symptoms of pain and swelling are contemplated fully by the 10 percent disability rating that is already assigned. The criteria for an initial disability rating higher than 10 percent for right ankle strain under DC5271 are not met. The Veteran is not entitled to an initial disability rating higher than 10 percent for right ankle strain. To that extent also, this appeal is denied. 11. Entitlement to an initial disability rating higher than 10 percent for left ankle degenerative changes, residual from left fibula fracture. Service connection for left ankle degenerative changes, residual from left fibula fracture, was granted to the Veteran effective September 22, 2009. A 10 percent initial disability rating was assigned pursuant to the criteria under DC 5271. Those criteria are discussed fully above and are incorporated by reference herein. The evidence shows that the Veteran’s left ankle disability has been manifested primarily by pain, swelling, instability, and decreased motion. The range of motion tests conducted during the March 2010 examination, August 2016 private evaluation by Dr. G.I.D., and August 2019 examination show that the Veteran has retained painless left ankle dorsiflexion to 10 degrees and plantar flexion to 15 degrees. Muscle strength in the Veteran’s ankle was decreased to 4/5 during the August 2019 examination. In conjunction with the foregoing range of motion findings, December 2016 VA treatment records reflect that the Veteran was issued a brace to correct instability in her left ankle. Although tests for joint stability conducted during the August 2019 examination were apparently normal, the December 2016 treatment record does support the conclusion that the Veteran does experience some degree of instability in her left ankle. Given the extent of motion shown combined with apparent instability in the Veteran’s left ankle, the objective findings shown in the record appear to be consistent with marked limitation of motion. The criteria for a 20 percent disability rating for the Veteran’s left ankle disability are met under DC 5271. The Veteran’s remaining symptoms of pain and swelling are contemplated fully by those criteria. The Veteran is entitled to a 20 percent initial disability rating for left ankle degenerative changes, residual from left fibula fracture. To that extent, this appeal is granted. 12. Entitlement to special monthly compensation at the housebound rate prior to August 29, 2019. The Veteran was granted special monthly compensation at the housebound rate, effective from August 29, 2019, in a June 2020 Board decision. As basis for the award, the Board noted that the Veteran was being awarded TDIU based on impairment caused by her orthopedic disabilities, effective from September 22, 2009. The Board also observed that service-connected bilateral upper extremity radiculopathies and the Veteran’s migraines (which both involve the neurological system) were rated as being 60 percent disabling combined after being adjusted upward pursuant to 38 C.F.R. § 4.25. Based on the same, the Board concluded that special monthly compensation at the housebound rate was warranted by operation of law under 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350 (i). The Veteran contends on appeal that she is entitled to special monthly compensation at the housebound rate from an earlier date. She raises no specific allegations or theories to support that assertion. By virtue of the Board’s analysis above, the Veteran’s migraines are rated as being 50 percent disabling over the entire appeal period (i.e., effective from September 22, 2009). In conjunction with the same, service connection and a 20 percent disability rating for the Veteran’s right upper extremity radiculopathy has been in effect since August 3, 2016. Pursuant to 38 C.F.R. § 4.25, the combined rating resulting from the Veteran’s migraines and right upper extremity radiculopathy is 60 percent beginning from August 3, 2016. Further, TDIU has remained in effect for the Veteran since September 22, 2009, to include the period from August 3, 2016. Under the circumstances, the schedular criteria for special monthly compensation at the housebound rate are met, effective from August 3, 2016. The Board finds no basis either in law or fact to award special monthly compensation at the housebound rate prior to August 3, 2016. First, the schedular criteria under 38 C.F.R. § 3.350 (i)(1) are not met prior to that date, notwithstanding the award of a higher 50 percent disability rating for migraines. Second, the evidence simply does not show that the Veteran was substantially confined as a direct result of service-connected disabilities to her dwelling, nor is there evidence that the Veteran has required institutionalization or even prolonged hospitalization for any of her service-connected disabilities prior to August 3, 2016. The Veteran is entitled to special monthly compensation at the housebound rate, effective August 3, 2016. To that extent, this appeal is granted. 38 U.S.C. § 1114(s) (2012); 38 C.F.R. § 3.350 (i) (2019). DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D.S. Lee 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.