Citation Nr: 21009370 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 10-19 647 DATE: February 22, 2021 ORDER A rating in excess of 20 percent for limited flexion, epicondylitis of the right elbow is denied. A 10 percent rating for limited extension, epicondylitis of the right elbow is granted. A 10 percent rating for painful forearm supination, right elbow from September 14, 2015, to February 27, 2018 is granted. A compensable rating for painful forearm supination, right elbow prior to September 14, 2015; and a rating in excess of 10 percent disabling from February 27, 2018 is denied. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran’s limited flexion of the right elbow has been manifested with pain, but it has not been manifested by flexion limited to 70 degrees or less. 2. Throughout the appeal period, the Veteran has had functional loss manifested by painful extension of the right elbow, but it has not been limited to 45 degrees or greater. 3. Prior to September 14, 2015, the Veteran’s forearm supination, right elbow has not been manifested with painful limitation of motion or other functional loss. 4. From September 14, 2015, the Veteran’s painful forearm supination, right elbow has been manifested with painful limitation of supination with difficulty lifting more than a gallon of milk which causes functional loss; but not supination limited to 45 degrees or limitation of pronation beyond the last quarter arc. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for limited flexion, epicondylitis of the right elbow have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5206. 2. The criteria for a 10 percent rating, but no higher, for limited extension of the right elbow have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5207. 3. The criteria for a 10 percent rating, but no higher, for painful forearm supination, from September 14, 2015 to February 27, 2018 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5213. 4. The criteria for a compensable rating for painful forearm supination prior to September 14, 2015; and a rating in excess of 10 percent from February 27, 2018 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5213. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1983 to August 2001 to include two years, one month and five days of prior active service. He served honorably in the United States Army, during Peacetime and the Gulf War Era. He was awarded the National Defense Service Medal. The Board thanks the Veteran and his family for his service to our country. This matter is before the Board of Veteran’s Appeals (Board) from an August 2008 rating decision (RD) by the Department of Veteran Affairs (VA) Regional Office (RO). In June 2018, based on the findings of a February 2018 VA examination report, the RO granted service connection for the Veteran’s painful forearm supination, right elbow disability, rated as 10 percent disabling, with an effective date of February 27, 2018. Additionally, in a February 2016 rating decision, the RO granted an increased rating to 20 percent for the Veteran’s limited flexion, epicondylitis of the right elbow, effective April 23, 2008 and service connection for limited extension, epicondylitis of the right elbow with a noncompensable rating, effective April 23, 2008. See RD Narrative received June 2018; RD Narrative received February 2016. In October 2019, November 2017 and November 2016, this matter was previously before the Board. In the most recent Board remand to the Agency of Original Jurisdiction (AOJ) for further development, the issue that was remanded included an increased rating claim for the Veteran’s epicondylitis of the right elbow. Specifically, the remand directives required that the claims file be return to the AOJ to allow for review of the additional VA treatment records and then, required the AOJ to readjudicate the claim. Also, the remand directives required the AOJ to issue a supplemental statement of the case (SSOC) if the decision was unfavorable to the Veteran. See BVA Decision received October 2019. Per the Board’s remand directives, the AOJ readjudicated the claim and issued an SSOC in August 2020. Thus, the Board finds that there has been substantial compliance with the remand directives. Stegall v. West, 11 Vet. App. 289 (1998); Also see SSOC received August 2020. Increased Rating – Legal Criteria Disability ratings are determined by comparing a Veteran’s symptomatology during the pertinent period on appeal with criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher rating will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. An exception to this rule applies when the rating criteria are successive. In such a case, all the requirements of the lower levels must be met before a higher level is awarded, and 38 C.F.R. §§ 4.7 and 4.21 do not apply. Johnson v. Wilkie, 30 Vet. App. 245 (2018). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. With a claim for an increased initial rating, separate staged ratings may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In a claim for increase in a previously established rating, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, stage ratings are to be considered. Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107(a). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Competent medical evidence is evidence provided by a person who is qualified through education, training, and experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises and statements contained in authoritative writings, such as medical and scientific articles and research reports and analyses. 38 C.F.R. § 3.159(a)(1). Medical opinions must contain conclusions with a reasoned medical explanation based on supporting data. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In McGrath v. Gober, 14 Vet. App. 28 (2000), the Court held that when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the examination reports noting pertinent findings. The Board has also considered the history of the Veteran’s disabilities prior to the rating period on appeal to see if the history supports a higher rating during the rating period on appeal. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Musculoskeletal Rating Criteria In rating disabilities of the musculoskeletal system, it is necessary to consider, subject to the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. Deluca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40 and 4.45. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant 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. Pain on movement, swelling, deformity, or atrophy of disuse as well as instability of station, disturbance of location, interference with sitting, standing, and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to a healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 4 (2011) (holding that 38 C.F.R. § 4.50 applies to disabilities other than arthritis). However, painful motion alone is not a functional loss without some restriction of the normal working movements of the body. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that “[t]he joints involved should be tested for pain on both active and passive motion, in weightbearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint.” The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. Correia, 28 Vet. App. at 169-170. In Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), the Court addressed the adequacy of medical opinions that decline to present clear estimations by citing that such estimations would be “mere speculation.” The Court explained that case law and VA guidelines do not require direct observation of functional impairment after repetitive use or during a flare-up as a prerequisite to offering a DeLuca opinion. DeLuca v. Brown, 8 Vet. App. 202 (1995). Indeed, it is not expected that such observation will usually occur; therefore, VA examiners should offer opinions based on estimates derived from information procured from all relevant sources, including the lay statements of Veterans. VA examiners have a duty to elicit information from the Veteran when attempting to describe functional loss associated with pain during unobserved exacerbations. If a non-speculative opinion still cannot be offered, the VA examiner must explain the basis for this conclusion. It must be apparent that the inability to provide an opinion without resorting to speculation reflects the limitation of knowledge in the medical community at large and not a limitation (whether based on lack of expertise, insufficient information, or unprocured testing) of the individual examiner. When evaluating musculoskeletal disabilities, VA must consider whether a higher evaluation is warranted, where the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Painful motion is an important factor of disability, and it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Nevertheless, pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Moreover, functional impairment must be supported by adequate pathology. Id.; Johnson v. Brown, 9 Vet. App. 7, 10 (1996) (both citing to 38 C.F.R. § 4.40). A rating in excess of 20 percent for limited flexion of the right elbow A compensable rating for limited extension of the right elbow A rating of 10 percent disabling for painful forearm supination, right elbow from September 14, 2015, but no higher, and prior to February 27, 2018 A compensable rating for painful forearm supination prior to February 27, 2018, and a rating in excess of 10 percent disabling thereafter The Veteran seeks an increased rating for his service-connected limited flexion, epicondylitis of the right elbow disability. Specifically, he contends that his right elbow disability is more disabling than the current evaluation reflects. Also, he asserts that his right elbow pain now affects his sleep and has started to affect his ability to work. See Appellate Brief received September 2017; VA Form 9 received April 2010; Correspondence received April 2008. The beginning of the rating period on appeal in this matter is one year prior to the received date of the Veteran’s claim for an increased evaluation of his service-connected limited flexion, epicondylitis of the right elbow disability: April 23, 2007. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Veteran’s limited flexion, epicondylitis of the right elbow disability is currently rated at 20 percent disabling from April 23, 2008 for limitation of flexion under Diagnostic Codes (DC) 5015-5206. Hyphenated diagnostic codes are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27. The first four numbers reflect the diagnosed disability, in this case DC 5015 governs benign bone growth. The second four numbers after the hyphen identifies the criteria used to evaluate that disability. Id. In this case, the hyphenated code indicates the disability is rated by analogy to Diagnostic Code 5206 governing limitation of flexion of the elbow. 38 C.F.R. § 4.71a, Diagnostic Code 5206; Also see RD Narrative received February 2016; Additionally, as stated above, the RO in interim rating decisions, granted service connection for limited extension, epicondylitis of the right elbow, currently rated noncompensable from April 23, 2008 for limitation of extension under Diagnostic Code 5207; and painful forearm supination, right elbow currently rated at 10 percent disabling from February 27, 2018 for painful motion of the forearm under Diagnostic Code 5213. 38 C.F.R. § 4.71a, Diagnostic Codes 5207 and 5213. Also see RD Narrative received June 2018; RD Narrative received February 2016. Disability ratings are determined by comparing a Veteran’s present symptomatology with criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Normal ranges of motion of the elbow are zero degrees of extension to 145 degrees of flexion. 38 C.F.R. § 4.71, Plate I. Normal ranges of motion of the forearm are 80 degrees of pronation and 85 degrees of supination. Id. The appropriate diagnostic codes for evaluating limitation of motion of the elbow joint are Diagnostic Codes 5206 and 5207, applicable to limitation of flexion and extension of the elbow, respectively. Pursuant to 38 C.F.R. § 4.71a, Schedule for Rating Musculoskeletal Systems, under Diagnostic Code 5206, a 20 percent rating for a major or minor arm is warranted when flexion is limited to 90 degrees; a 30 percent rating for a major arm and a 20 percent rating for a minor is warranted when flexion is limited to 70 degrees; a 40 percent rating for a major and a 30 percent rating for a minor is warranted when flexion is limited to 55 degrees; and a 50 percent rating for a major arm and a 40 percent rating for a minor arm is warranted when flexion is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5206. Under Diagnostic Code 5207, a 10 percent rating for a major or minor arm is warranted when extension is limited to 45 degrees; a 10 percent rating a major or minor arm is warranted when extension is limited to 60 degrees; a 20 percent rating a major or minor arm is warranted when extension is limited to 75 degrees; a 30 percent rating for a major arm and a 20 percent for a minor arm is warranted when extension is limited to 90 degrees; a 40 percent rating for a major arm and a 30 percent rating for a minor arm is warranted when extension is limited to 100 degrees; a 50 percent rating for a major arm and a 40 percent rating for a minor arm is warranted when extension is limited to 110 degrees. Id., Diagnostic Code 5207. Under Diagnostic Code 5208, a 20 percent rating is warranted when forearm flexion is limited to 100 degrees and extension is limited to 45 degrees. Id., Diagnostic Code 5208. Under Code 5213, pertaining to supination and pronation, loss of (bone fusion), a 20 percent rating is warranted for the hand fixed near the middle of the arc or moderate pronation; a 30 percent rating for a major arm and a 20 percent for a minor arm is warranted for the hand fixed in full pronation; and a 40 percent rating for a major arm and a 30 percent rating for a minor arm is warranted for the hand fixed in supination or hyperpronation. Further, a 10 percent rating is warranted for limitation of supination to 30 degrees or less; a 20 percent rating is warranted for limitation of pronation for motion lost beyond last quarter of arc; and a 30 percent rating for major arm and a 20 percent for a minor arm for motion lost beyond middle of arc. Id., Diagnostic Code 5213. Evidence and Analysis The evidence of record fails to show ankylosis of the elbow, limitation of flexion to 100 degrees and limitation of extension to 45 degrees, or impairment of the flail joint, radius or ulna, accordingly, DCs 5205 (ankylosis of the elbow), 5208 (limitation of flexion to 100 degrees and extension to 45 degrees), 5209 (flail joint), 5210 (nonunion of radius and ulna), 5211 (ulna), and 5212 (radius) are not applicable to evaluating the Veteran’s right elbow disability. As a result, these provisions will not be discussed further in this decision. 38 C.F.R. § 4.71a, DCs 5205, 5208, 5209, 5210, 5211, 5212. Based on the evidence of record, the Board concludes that a rating in excess of 20 percent disabling is not warranted for the Veteran’s service-connected limited flexion of the right elbow for any part of the appeal period; that a 10 percent rating, but no higher, is warranted for the Veteran’s limited extension of the right elbow for the entire appeal period. 38 C.F.R. § 4.71a, DCs 5206, 5207. Additionally, the Board concludes that a compensable rating is not warranted for the period prior to September 14, 2015, but that a 10 percent rating, but no higher, is warranted for the Veteran’s service-connected painful forearm supination from September 14, 2015. 38 C.F.R. § 4.71a, DC 5213. In a June 2008 private radiology interpretation report, for the complete right elbow, the provider opined that multiple views ot the right elbow show no evidence for fracture or other significant bone or soft tissue abnormality. The examiner’s impression was negative right elbow. See C&P Exam received July 2008. In an April 2010 private orthopedic visit note, the Veteran presented with right elbow pain. The examination revealed that his right elbow had tenderness to palpation directly over his lateral epicondyle. The provider noted that this pain was aggravated by resisted restriction wrist extension and forceful grip. Also, in a June 2010 private orthopedic visit note, the examination of the right elbow revealed “ROM 5 to full flexion.” The provider also noted tenderness to palpation over his lateral epicondyle and similar aggravation as noted above. See Medical Treatment Record received July 2010; Medical Treatment Record received April 2010. In a September 2015 Disability Benefit Questionnaire (DBQ) for elbow and forearm conditions, the Veteran’s was diagnosed with right epicondylitis. In the examination report, flare-ups was not reported by the Veteran. For functional loss or impairment, the Veteran reported that he is unable to pick up or carry anything weighing as much as gallon of milk. The Veteran’s initial range of motion (ROM) testing revealed flexion of 15 to 90 degrees, extension of 90 to 15 degrees, forearm supination to 85 degrees, and forearm pronation to 80 degrees. The examiner noted pain, which causes functional loss (flexion and extension). There was no response provided for ankylosis on the right side. There was no crepitus or pain with weight bearing. The examiner marked “No” for flail joint, joint fracture, ununited fracture, malaligned fracture or impairment of supination or pronation. For functional impact, the examiner noted a limited ability to lift using right arm. See C&P Exam received September 2015. In a March 2017 DBQ for elbow and forearm conditions, the Veteran’s was diagnosed with lateral epicondylitis, right. In the examination report, the Veteran reported pain and chronic soreness with repeated use and prolonged grip. Flare-ups and functional loss or impairment were not reported. The Veteran’s initial ROM testing revealed flexion of 0 to 130 degrees, extension of 145 to 0 degrees, forearm supination to 85 degrees, and forearm pronation to 80 degrees. The examiner noted pain, but it does not result in or causes functional loss (flexion and forearm supination). There was no ankylosis on the right side. There was no crepitus, but there was pain with weight bearing. The examiner marked “No” for flail joint, joint fracture, ununited fracture, malaligned fracture or impairment of supination or pronation. For functional impact, the examiner marked “No.” See C&P Exam received March 2017. In a February 2018 DBQ for elbow and forearm conditions, the Veteran’s was diagnosed with limited extension and flexion, epicondylitis of the right elbow. In the examination report, the Veteran reported that his current symptoms include intermittent pain, that is worse with activity; sharp pain that will last 10 minutes; limited range and painful ROM; painful grip of steering wheel; and unable to put items in his right back pocket. Flare-ups were reported by the Veteran. For functional loss or impairment, the Veteran restated his current symptoms. The Veteran’s initial ROM testing revealed flexion of 20 to 90 degrees, extension of 90 to 20 degrees, forearm supination to 45 degrees, and forearm pronation to 80 degrees. The examiner noted pain on examination that causes functional loss (flexion, extension and forearm supination). There was no crepitus or pain with weight bearing. There was no ankylosis on the right side. The examiner marked “No” for flail joint, joint fracture, ununited fracture, malaligned fracture or impairment of supination or pronation. For functional impact, the examiner noted the Veteran works as a contractor and repetitive motion caused pain and decreased efficiency. In remarks, for Correia criteria, there was objective evidence of pain when the right elbow is used in non-weight bearing; however, the examiner marked that passive ROM cannot be performed or is not medically appropriate. Correia, 28 Vet. App. at 158; Also see C&P Exam received March 2018. In the February 2018 medical opinion report based on February 2018 DBQ for elbow and forearm conditions, in remarks, for question two, the examiner opined that there would be additional functional impairment on repeated use or during flare-ups, but the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional ROM loss is not feasible to determine. Also, for question 3, the examiner opined that the Veteran “reports after repeated use and flare-ups,” the loss of ROM is variable, depending on how strenuously the joint was used. At its worst, the Veteran cannot move it at all due to the factors indicated above, but there are other times where the ROM loss is minimal. See C&P Exam received March 2018. In a February 2019 DBQ for elbow and forearm conditions, the Veteran’s was diagnosed with right lateral epicondylitis. In the examination report, the Veteran reported pain of the right elbow when he tries to straighten it, when he lifts objects, and sometimes at rest. Flare-ups was reported by the Veteran, in which he indicated that if he uses his right arm repeatedly, he will have increase right elbow pain for a few hours. For functional loss or impairment, the Veteran reported that he is unable to use his right hand/arm to lift heavy objects of to do repetitive tasks. The Veteran’s initial ROM testing revealed flexion of 4 to 120 degrees, extension of 120 to 4 degrees, forearm supination to 85 degrees, and forearm pronation to 82 degrees. Pain was noted on the examination on rest/non-movement (flexion, extension), but there was no pain with weight bearing or crepitus. There was no ankylosis on the right side. The examiner marked “No” for flail joint, joint fracture, ununited fracture, malaligned fracture or impairment of supination or pronation. For functional impact, the examiner noted that the Veteran could not do physical work, which required repetitive use of right arm. In remarks, for Correia criteria, the examiner noted that there was no change in ROM or pain with ROM with weightbearing; right elbow has pain at limits of ROM with both flexion and extension at 4 degrees of extension and 120 degrees of flexion where pain limits motion with both passive and active motion; and active ROM and pain, which limited it was the same as passive ROM. Correia, 28 Vet. App. at 158; Also see C&P Exam received February 2019. The Board acknowledges the Veteran’s report of experiencing symptoms such as pain and limited motion with respect to his service-connected right elbow disabilities and he is competent to attest to such symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). Furthermore, these reports are credible and thus, of probative weight; however, these statements must be viewed in conjunction with the medical evidence as required by the rating criteria. Limited flexion and extension of the right elbow Based on the record, the Board finds that the most probative evidence does not reach the level of equipoise as to whether a higher rating is warranted based on flexion for the Veteran’s service-connected limited flexion, epicondylitis of the right elbow disability throughout the appeal period. Specifically, in the February 2019 DBQ for elbow and forearm conditions, the report findings revealed flexion of 4 to 120 degrees; the February 2018 DBQ report revealed flexion of 20 to 90 degrees; the March 2017 DBQ report revealed flexion of 0 to 130 degrees; and the September 2015 DBQ revealed flexion of 15 to 90 degrees. Also, a 2010 private orthopedic treatment record revealed flexion of 5 to full flexion (145 degrees). Importantly, the February 2019 DBQ revealed that the Veteran’s service-connected limited flexion, epicondylitis of the right elbow disability showed improvement as of the date of the examination. Accordingly, flexion of the major or minor elbow does not more nearly approximate limitation to 70 degrees; or flexion limited to 55 degrees; or flexion limited to 45 degrees to warrant an increase in rating. In fact, his limitation of flexion has varied from a limitation of 90 degrees to full flexion over the appeal period, and thus he has not warranted even a 10 percent under DC 5206 for flexion limited to100 degrees throughout the appeal period. Therefore, a higher rating for the Veteran’s service-connected limited flexion, epicondylitis of the right elbow disability for any period on appeal, is not warranted in this case. 38 C.F.R. § 4.71a, Diagnostic Code 5206. As with the right elbow flexion, the Board finds that the most probative evidence does not reach the level of equipoise as to whether a compensable rating is warranted based on limitation of extension for the Veteran’s service-connected limited extension, epicondylitis of the right elbow disability throughout the appeal period. Specifically, in the February 2019 DBQ for elbow and forearm conditions, the report findings revealed extension of 120 to 4 degrees; the February 2018 DBQ report revealed extension of 90 to 20 degrees; the March 2017 DBQ report revealed extension of 145 to 0 degrees; and the September 2015 DBQ revealed extension of 90 to 15 degrees. At worst, the Veteran’s limitation of flexion was 15 degrees. Accordingly, extension of the major or minor elbow does not more nearly approximate limitation to 45 degrees or greater to warrant a compensable rating on a schedular basis. Therefore, a compensable rating for the Veteran’s service-connected limited extension, epicondylitis of the right elbow disability for any period on appeal, is not warranted under DC 5207. 38 C.F.R. § 4.71a, Diagnostic Code 5207. However, the Board notes that the Veteran has reported painful motion on extension of the elbow, and thus, a 10 percent rating is warranted pursuant to 38 C.F.R. § 4.59 for functional loss due to pain on motion for the entire appeal period. Burton v. Shinseki, supra. With regard to additional functional loss based on right elbow extension and flexion, the evidence does not show that additional compensation is warranted on this basis. As noted above, even with pain and on repetitive use the Veteran’s limitation of extension and flexion do not approach the flexion limited to 70 degrees or extension to 60 degrees. While the Veteran has reported flare-ups, these are based on the amount of use of the elbow, and the subsequent impairment varies on this basis as well, with reports of minimal loss of function to the inability to move the elbow for a period of time. Given that these flares are not consistent in their functional impact, the Board does not find that warranting additional compensation for an occasional increased loss of motion is supported given the overall disability picture that shows that the Veteran has not got limitation of motion approaching compensable levels on repetitive use at examination. Accordingly, the Board finds that the Veteran’s painful motion and functional loss are adequately compensated in the assigned ratings. Painful forearm supination Based on the evidence of record, the Board finds that a 10 percent rating is warranted for the Veteran service-connected painful forearm supination, right elbow from September 14, 2015, based on painful motion that causes functional loss, but not prior to that date; and that a rating greater than 10 percent is not warranted for any period after September 14, 2015. Initially, the Board notes that a compensable rating for limitation of motion is not warranted under the DC governing supination, as a 10 percent rating requires 30 degrees or less limited motion, and the evidence of record shows that the Veteran’s supination was limited to 45 degrees and does not show pronation limited to the last quarter of the arc. DC 5213. 38 C.F.R. § 4.71a, Diagnostic Code 5213. Specifically, in the 2019, 2018, 2017 and 2015 DBQs, the examiners collectively marked “No” for impairment of supination or pronation. Therefore, a rating in excess of 10 percent from February 27, 2018, and prior to that date, is not warranted in this case under DC 5213. The Veteran’s assigned 10 percent rating is based on painful motion pursuant to 38 C.F.R. § 4.59. See Burton v. Shinseki, 25 Vet.App. 1 (2011) (painful motion of a joint can be entitled to at least the minimum compensable rating for the joint). Under this provision, the earliest date for a finding of functional loss due to pain is in the 2015 DBQ, in which the Veteran described his functional loss or impairment as being unable to pick up or carry anything weighing as much as a gallon of milk. Subsequent records, to include the 2017 DBQ continue to show complaints of pain. However, the examinations and evidence prior to September 14, 2015, fail to show painful motion on supination or pronation or other functional loss related to supination or pronation of the forearm. Further, the Board does not find additional evidence of functional loss that is not compensated in the assigned 10 percent rating for supination from September 14, 2015. As noted, no impairment of the supination or pronation were noted and the Veteran’s report of painful motion during flare-ups is compensated in the 10 percent assigned for painful supination of the forearm on use as the evidence does not indicate that his functional loss causes limitation of supination close to 30 degrees or pronation limited to any part of the arc. Further, the Board finds that his painful motion on flare-ups is adequately compensated by the assigned to percent for painful extension of the elbow and the 10 percent assigned for painful supination on use, as well as the recognition of his limited flexion due to pain. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for his service-connected limited flexion of the right elbow. Further, the Board finds that a 10 percent rating, but no higher, for painful extension of the right elbow is warranted for the entire appeal period. Lastly, the Board finds that a compensable rating for limited supination of the forearm prior to September 14, 2015, is not warranted, but a 10 percent, but no higher is appropriate thereafter. The Veteran and his representative have not raised any other issues in connection with the issue on appeal, nor have any other issues been reasonably raised by the record in connections with this matter on appeal. Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. D. Hayes, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.