Citation Nr: 21014761 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 14-38 386 DATE: March 15, 2021 ORDER As of August 26, 2011, a rating of 10 percent, but no higher, for rheumatoid arthritis of the right elbow is granted, subject to the laws and regulations governing the payment of monetary benefits. As of August 26, 2011, a rating of 10 percent, but no higher, for rheumatoid arthritis of the left elbow is granted, subject to the laws and regulations governing the payment of monetary benefits. As of August 26, 2011, a rating of 10 percent, but no higher, for rheumatoid arthritis of the right knee is granted, subject to the laws and regulations governing the payment of monetary benefits. As of August 26, 2011, a rating of 10 percent, but no higher, for rheumatoid arthritis of the left knee is granted, subject to the laws and regulations governing the payment of monetary benefits. As of August 26, 2011, a rating of 10 percent, but no higher, for rheumatoid arthritis of the right foot is granted, subject to the laws and regulations governing the payment of monetary benefits. As of August 26, 2011, a rating of 10 percent, but no higher, for rheumatoid arthritis of the left foot is granted, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to a separate rating for rheumatoid arthritis of the neck, bilateral shoulders, and bilateral wrists is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. For the entire appeal period, the Veteran’s rheumatoid arthritis of the right and left elbows is manifested by symptoms of pain, tenderness, stiffness, and swelling without limitation of motion, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. 2. For the entire appeal period, the Veteran’s rheumatoid arthritis of the right and left knees is manifested by symptoms of pain, stiffness, and swelling without limitation of motion, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis, recurrent subluxation or lateral instability, dislocation or removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. 3. For the entire appeal period, the Veteran’s rheumatoid arthritis of the right and left foot resulted in, at most, a moderate foot injury as demonstrated by pain and disturbance of locomotion. CONCLUSIONS OF LAW 1. As of August 26, 2011, the criteria for a rating of 10 percent, but no higher, for rheumatoid arthritis of the right elbow have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5002-5206. 2. As of August 26, 2011, the criteria for a rating of 10 percent, but no higher, for rheumatoid arthritis of the left elbow have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5002-5206. 3. As of August 26, 2011, the criteria for a rating of 10 percent, but no higher, for rheumatoid arthritis of the right knee have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5002-5260. 4. As of August 26, 2011, the criteria for a rating of 10 percent, but no higher, for rheumatoid arthritis of the left knee have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5002-5260. 5. As of August 26, 2011, the criteria for a rating of 10 percent, but no higher, for rheumatoid arthritis of the right foot have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5002-5284. 6. As of August 26, 2011, the criteria for a rating of 10 percent, but no higher, for rheumatoid arthritis of the left foot have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5002-5284. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1988 to November 1993. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in September 2012 and August 215 by a Department of Veterans Affairs (VA) Regional Office. In June 2018, the Board denied a rating in excess of 20 percent for rheumatoid arthritis from August 26, 2011, to September 19, 2014, and ratings in excess of 10 percent for rheumatoid arthritis of the bilateral elbows, knees, and feet, as of September 19, 2014, and remanded the claim of entitlement to a TDIU for additional development. The Veteran subsequently appealed the Board’s denial of his increased rating claims to the United States Court of Appeals for Veterans Claims (Court). In June 2019, the Court granted a Joint Motion for Remand (JMR) that vacated the Board’s June 2018 decision as to such issues. In October 2019, the Board remanded the Veteran’s increased rating claims for additional development. Such claims, as well as the claim for a TDIU, now returns for further appellate consideration. 1. Entitlement to a rating in excess of 20 percent for rheumatoid arthritis from August 26, 2011, to September 19, 2014. 2. Entitlement to a rating of in excess of 10 percent for rheumatoid arthritis of the left elbow as of September 19, 2014. 3. Entitlement to a rating in excess of 10 percent for rheumatoid arthritis of the right knee as of September 19, 2014. 4. Entitlement to a rating in excess of 10 percent for rheumatoid arthritis of the left knee as of September 19, 2014. 5. Entitlement to a rating in excess of 10 percent for rheumatoid arthritis of the right foot as of September 19, 2014. 6. Entitlement to a rating in excess of 10 percent for rheumatoid arthritis of the left foot as of September 19, 2014. The Veteran contends the severity of his rheumatoid arthritis in multiple joints warrants ratings in excess of those currently assigned. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. 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, 44 (2011), the United States Court of Appeals for Veterans Claims (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.” Id., quoting 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; DeLuca v. Brown, 8 Vet. App. 202 (1995). 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, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The appeal period before the Board begins on August 26, 2011, the date VA received the Veteran’s increased rating claim for rheumatoid arthritis, plus the one-year look-back period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). From August 26, 2011, to September 19, 2014, the Veteran’s rheumatoid arthritis is rated as 20 percent disabling as an active process pursuant to Diagnostic Code 5002. As of February 7, 2021, VA amended the rule pertaining to the evaluation of musculoskeletal disabilities. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 25,450 (November 27, 2020). Prior to such date, Diagnostic Code 5002 addressed arthritis rheumatoid (atrophic) and provided a 20 percent rating when there is an active process with one or two exacerbations a year in a well-established diagnosis. A 40 percent evaluation is warranted when there is an active process with symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year. A 60 percent rating is provided where there is an active process of a severity less than the criteria for 100 percent, but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods. A 100 percent rating is warranted for constitutional manifestations associated with active joint involvement, totally incapacitating. 38 C.F.R. § 4.71a. For chronic residuals such as limitation of motion or ankylosis, favorable or unfavorable, such should be rated under the appropriate diagnostic code for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. A Note indicates that the ratings for the active process will not be combined with the residual ratings for limitation of motion or ankylosis. Rather, the higher evaluation should be assigned. Id. As of February 7, 2020, Diagnostic Code 5002 addresses multi-joint arthritis (except post-traumatic and gout), 2 or more joints, as an active process. Notably, the amended rule does not alter the criteria necessary to warrant the 20, 40, 60, and 100 percent ratings. Note (1) to the amended rule, however, provides examples of the conditions to be rated using this diagnostic code, which include rheumatoid arthritis, psoriatic arthritis, and spondyloarthropathies. Note (2) states that chronic residuals should be rated under Diagnostic Code 5003, and Note (3) indicates that the ratings for the active process will not be combined with the residual ratings for limitation of motion, ankylosis, or Diagnostic Code 5003. Instead, the higher evaluation should be assigned. Id. In the August 2015 rating decision, the AOJ awarded separate 10 percent ratings for rheumatoid arthritis of the bilateral elbows and knees, effective March 14, 2015, and separate noncompensable ratings for rheumatoid arthritis of the bilateral feet, effective March 14, 2015. An August 2017 rating decision assigned an earlier effective date of September 19, 2014, for the awarded of the 10 percent ratings and granted increased ratings of 10 percent for rheumatoid arthritis of the bilateral feet, effective July 12, 2017. In the June 2018 decision, the Board awarded 10 percent ratings for rheumatoid arthritis of the bilateral feet for the period from September 19, 2014, to July 12, 2017. In sum, the Veteran’s rheumatoid arthritis of multiple joints is rated as 20 percent disabling from August 26, 2011, to September 19, 2014, and, thereafter, each joint (i.e., right elbow, left elbow, right knee, left knee, right foot, left foot) is separately rated as 10 percent disabling under the diagnostic code relevant to such body parts. In order to afford the Veteran all possible avenues of entitlement to higher ratings, the Board has considered all applicable diagnostic codes, under both the old and new criteria, in light of his reports of his symptoms and the medical evidence. For the period prior to September 19, 2014, as noted above, the Veteran’s rheumatoid arthritis of multiple joints is rated as 20 percent disabling as an active process pursuant to Diagnostic Code 5002. To warrant a higher rating, therefore, the evidence must show an active process with symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year. During this period, the Veteran underwent VA examination in June 2012, at which time it was noted that, although he required continuous medication, he had not lost weight and did not have anemia due to his arthritis condition. In addition, he had experienced only one non-incapacitating exacerbation of his rheumatoid arthritis in the right knee in the past year, which lasted one month, in May 2012, but he had not had any incapacitating exacerbations or constitutional manifestations associated with active joint involvement that were totally incapacitating. In fact, the VA examiner determined the Veteran did not have pain, limitation of joint movement, or any joint deformities attributable to his rheumatoid arthritis. Further, treatment records dated prior to September 19, 2014, do not reflect anemia or weight loss attributed to the Veteran’s rheumatoid arthritis. With respect to incapacitating episodes, a February 2011 VA treatment record shows he reported that his rheumatoid arthritis had gotten “so bad” that he could no longer walk. However, the record does not reflect prescribed bed rest, and follow-up records indicate that the Veteran could walk albeit, with difficulty. Moreover, although he reported symptoms of pain, swelling, and stiffness, such reports do not show that he was rendered incapacitated by them. Nevertheless, as noted by the parties in the JMR, the Board must address whether separate ratings are warranted for the period from August 26, 2011, to September 19, 2014, based on the Veteran’s chronic residuals of rheumatoid arthritis per Diagnostic Code 5002. 38 C.F.R. § 4.71a. In this regard, the JMR cited the Court’s holding in Petitti v. McDonald that Diagnostic Code 5002 authorizes the minimum disability rating per joint where there is painful, albeit nonlimited, motion so long as there is sufficient objective evidence to verify painful motion. 27 Vet. App. 415, 426 (2015). Such evidence includes “a doctor’s observations of a veteran’s painful motion – including that observed during range-of-motion tests” as well as “lay descriptions of a veteran’s painful motion”. Id. at 427. In this regard, a February 2011 VA treatment record indicates the Veteran had difficulty walking on his right foot and requested to start some type of regimen for his rheumatoid arthritis, and a March 2011 VA treatment record shows that he had chronic right foot/ankle arthralgia, for which the VA physician referred him to rheumatology for treatment. An April 2011 VA treatment record indicates that recent lab work showed a positive ANA, but RF less than 10, with an assessment of chronic right foot arthropathy. Subsequent April 2011 VA treatment records reflect the Veteran’s report of ongoing right foot pain, right knee pain, and constant joint pain, the latter of which he attributed to his rheumatoid arthritis, and a May 2011 VA treatment record shows that he had pain in the joints involving the lower leg, ankle, and foot, and rheumatoid arthritis. In June 2011, the Veteran reported chronic pain in the bilateral knees and lower extremities, and VA treatment records dated in June 2011 also indicate that he underwent treatment for left knee pain and foot pain “possibly related to” rheumatoid arthritis. An additional June 2011 VA treatment record reflects the Veteran’s complaints of severe pain in multiple joints, including the feet, although his primary care physician’s work-up was negative for rheumatoid arthritis in August 2011. Additionally, the June 2012 VA examination report reflects the Veteran’s reports of constant pain and stiffness in multiple joints, to include the bilateral knees and feet. An October 2013 VA treatment record shows the Veteran experienced pain in his left knee and foot, while a January 2014 VA treatment record reflects the Veteran’s reports of right elbow pain absent other additional joint symptoms. In April 2014, the Veteran had left foot pain, and magnetic resonance imaging in May 2014 corroborated inflammatory changes. VA treatment records dated in August 2014 show the Veteran had bilateral foot pain. Given the Court’s holding in Petitti, as described above, the Board finds that the foregoing constitutes sufficient objective evidence of painful motion to warrant a minimum 10 percent rating as of August 26, 2011, under Diagnostic Code 5002 for each of the joints awarded such separate ratings as of September 19, 2014, namely, the Veteran’s bilateral elbows, knees, and feet. 27 Vet. App. at 427. When combined pursuant to the combined ratings table under 38 C.F.R. § 4.25, such results in an overall rating of 50 percent. As such is the higher evaluation assignable under Diagnostic Code 5002, when compared to the 20 percent assigned for an active process of multiple joints, the Board finds the award of such separate ratings is proper. Notably, the issue of entitlement to separate ratings for the Veteran’s rheumatoid arthritis affecting the neck, bilateral shoulders, and bilateral wrists, the joints previously acknowledged to have been affected by such disease process, are discussed in the Remand section below. Upon review, however, the Board finds ratings in excess of the 10 percent ratings now assigned for the separate joints throughout the appeal period stemming from August 26, 2011, are not warranted. Initially, the Board has considered whether the assignment of a rating for rheumatoid arthritis as an active process under Diagnostic Code 5002, in lieu of the separate ratings for the affected joints, would produce a higher overall evaluation at any time during the appeal period. In this regard, a July 2017 VA examination indicates the Veteran required continuous use of medication for his rheumatoid arthritis; however, he had not lost weight due to such condition nor did he have anemia as a result. Although the Veteran reported pain in both elbows, knees, and feet, the VA examiner found he did not have any limitation of joint motion or joint deformities attributable to his arthritis condition. Additionally, while the Veteran reported four or more episodes of non-incapacitating exacerbations involving severe joint pain in the last year, he had not experienced any incapacitating exacerbations as a result of his rheumatoid arthritis. Notably, the VA examiner determined the Veteran’s arthritis was not manifested by constitutional manifestations associated with active joint involvement that were totally incapacitating, weight loss and/or anemia productive of severe impairment of health, severely incapacitating exacerbations occurring four or more times a year or a lesser number over prolonged periods, or symptom combinations productive of definite impairment of health objectively supported by examination findings. On VA examination in December 2019, the VA examiner determined the Veteran’s rheumatoid arthritis was migratory in its early stages with joint deformity in later stages. At that time, the Veteran did not have any deformity and he had full range of motion and strength in all joints affected by his rheumatoid arthritis. The VA examiner clarified that both active and passive range of motion was full without restrictions or limitations. According to the VA examination report, the Veteran did not require continuous medication for his arthritis condition, and he did not have any weight loss or anemia due to it. The VA examiner attributed pain in the Veteran’s bilateral elbows, knees, and feet to his rheumatoid arthritis and reported that, during flare-ups, such joints were painful to flex and extend. Moreover, flare-ups made walking, running, and repetitive motions such as lifting, picking, and bending more difficult. The Veteran did not have any joint deformities, and did not experience any incapacitating or non-incapacitating exacerbations. Again, the VA examiner specifically found the Veteran’s arthritis was not manifested by constitutional manifestations associated with active joint involvement that were totally incapacitating, weight loss and/or anemia productive of severe impairment of health, severely incapacitating exacerbations occurring four or more times a year or a lesser number over prolonged periods, or symptom combinations productive of definite impairment of health objectively supported by examination findings. In sum, the medical evidence does not reflect an active process with symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year to warrant a rating in excess of 20 percent for rheumatoid arthritis as an active process under Diagnostic Code 5002. With respect to the separate 10 percent ratings assigned for the Veteran’s rheumatoid arthritis of the bilateral elbows, such are currently rated pursuant to Diagnostic Code 5206. Such provides that limitation of flexion of the forearm to 100 degrees warrants a 10 percent rating for both the major and minor extremities, limitation to 90 degrees warrants a 20 percent rating for both the major and minor extremities, and limitation to 70 degrees warrants a 30 percent rating for the major extremity and a 20 percent rating for the minor extremity. Limitation to 55 degrees warrants a 40 percent rating for the major extremity and a 30 percent rating for the minor extremity. Limitation to 45 degrees warrants a maximum 50 percent rating for the major extremity and a maximum 40 percent rating for the minor extremity. Diagnostic Code 5207 provides that limitation of extension of the forearm to 60 degrees or less warrants a 10 percent rating for both the major extremity and minor extremity. Limitation to 75 degrees warrants a 20 percent rating for both the major and minor extremities, whereas limitation to 90 degrees warrants a 30 percent rating for the major extremity and a 20 percent rating for the minor extremity. Limitation to 100 degrees warrants a 40 percent rating for the major extremity and a 30 percent rating for the minor extremity, and limitation to 110 degrees warrants a maximum 50 percent rating for the major extremity and a 40 percent rating for the minor extremity. Pursuant to Diagnostic Code 5208, when forearm flexion of either extremity is limited to 100 degrees and extension is limited to 45 degrees, a 20 percent rating is warranted. A June 2011 private treatment record shows the Veteran had full range of motion in the right elbows and only “some discomfort” with full extension. He had normal strength in his right elbow and no joint instability. He also had full range of motion of the left elbow, without pain, tenderness, swelling, instability, subluxations, weakness, or atrophy. As noted above, the June 2012 VA examiner determined the Veteran did not have any limitation of joint movement attributable to rheumatoid arthritis. A January 2014 private treatment record also shows the Veteran had full range of motion in both elbows, without pain except for some discomfort with full extension of the right elbow. According to a July 2015 VA examination report, the Veteran had full flexion and extension of both elbows, and he had no additional loss of function or range of motion after three repetitions. In addition, pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over time, although the VA examiner found pain during flare-ups would significantly limit functional ability. The VA examiner stated such could not be described in terms of degrees of range of motion, but the examination report shows the Veteran reported pain and intermittent limitation of motion, lifting, and weight-bearing during flare-ups. The VA examiner also reported that the Veteran did not have flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation. According to a January 2016 VA treatment record, pain was elicited with full extension of the right elbow and the Veteran reported soreness with flexion, and a February 2016 VA treatment record shows he had full range of motion in his right elbow. Likewise, an August 2016 VA treatment record indicates examination of the elbows was normal. The Veteran also underwent VA examination in July 2017, at which time, he had full range of motion in both elbows, with no additional loss of function or range of motion after three repetitions. The VA examiner did not provide an opinion as to whether pain, weakness, fatigability, or incoordination would significantly limit functional ability with repeated use over a period of time because the examination was not being conducted immediately after repeated use over time. Likewise, he could not provide such an opinion with respect to flare-ups as the examination was not being conducted during a flare-up. The VA examiner did find the Veteran had weakened movement in both elbows, but muscle strength was normal on physical examination and there was no muscle atrophy or ankylosis. He further determined the Veteran did not have flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation. On VA examination in December 2019, the Veteran reported random flare-ups in both elbows that were of moderate severity, precipitated by repetitive movement, lasted from hours to days, and alleviated by massage and NSAIDS. The Veteran had full range of motion in both elbows with pain on initial examination and following repetitive use. There was no evidence of pain with weight-bearing, on passive range of motion, or on non-weight bearing testing, and he had full range of motion in consideration of such factors. With respect to repeated use over time and flare-ups, the VA examiner found the Veteran would not have any additional loss of range of motion; however, pain would limit functional ability. Examination revealed full muscle strength and no muscle atrophy or ankylosis. The Veteran did not have flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation. Here, the evidence does not demonstrate limitation of flexion to 90 degrees or less, limitation of extension to 75 degrees or less, flexion of either extremity limited to 100 degrees and extension limited to 45 degrees, limitation of pronation with motion lost beyond the last quarter of the arc, with the hand not approaching full pronation, bone fusion with the hand fixed near the middle of the arc, or moderate pronation. Additionally, the evidence fails to demonstrate impairment of the flail joint, nonunion of the radius and ulna with flail false joint, impairment of the ulna or radius, or impairment of supination and pronation. Therefore, the Board a rating in excess of 10 percent and/or separate ratings for the Veteran’s rheumatoid arthritis of the right elbow and left elbow under Diagnostic Codes 5206 through 5213 are not warranted at any time during the appeal period. 38 C.F.R. § 4.71a. With respect to the Veteran’s rheumatoid arthritis of the bilateral knees, such is evaluated pursuant to Diagnostic Code 5260 based on painful limitation of motion. 38 C.F.R. §§ 4.59, 4.71a. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5260 provides for a zero percent rating where flexion of the leg is only limited to 60 degrees. For a 10 percent rating, flexion must be limited to 45 degrees. For a 20 percent rating is warranted where flexion is limited to 30 degrees. A 30 percent rating may be assigned where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a zero percent rating where extension of the leg is limited to five degrees. A 10 percent rating requires extension limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent rating, extension must be limited to 30 degrees. Finally, where extension is limited to 45 degrees, a 50 percent rating may be assigned. A June 2011 VA treatment record indicates the Veteran had full range of motion without crepitation in the right knee, and as noted above, he did not have any limitation of motion attributable to his rheumatoid arthritis on VA examination in June 2012. Similarly, at the July 2015 VA examination, he had full range of motion in both knees upon initial testing and repetitive use, and the VA examiner found that he would not have additional loss of range of motion with repeated use over time. Specifically, pain, weakness, fatigability, and incoordination would not significantly limit functional ability with repeated use over a period of time. He also noted the Veteran’s reports of flare-ups involving pain and intermittent limitation with standing, ambulating, stairs, squatting, kneeling, and standing and found that pain would significantly limit the functional ability of the Veteran’s right knee during such flare-ups. However, pain, weakness, fatigability, and incoordination would not significantly limit functional ability of the left knee during a flare-up. The Veteran’s knees had normal muscle strength and no muscle atrophy or ankylosis. He had no history of recurrent subluxation, lateral instability, or recurrent effusion, and there was no joint instability on physical examination. A February 2016 VA treatment record indicates the Veteran had full range of motion in the lower extremities, and an additional record dated that same month indicated the Veteran’s right knee, in combination with his right ankle, limited him from prolonged standing and bending. The Veteran also reported that his knee stiffened after rest and locked up; however, he had not fallen due to such symptoms. On VA examination in July 2017, the Veteran had pain on flexion, extension, and with weight-bearing, but he had full range of motion of both knees on initial testing and after repetitive-use testing. The VA examiner, however, was unable to provide opinions with respect to functional loss after repetitive use over time or during flare-ups. The Veteran had full muscle strength in both knees, and there was no evidence of muscle atrophy or ankylosis. He did not have a history of recurrent subluxation or lateral instability, and joint stability testing of both knees was normal at that time. There was no objective evidence of pain on non-weight bearing, and the VA examiner indicated that passive range of motion testing either could not be performed or was medically inappropriate. According to a December 2019 VA examination report, the Veteran described flare-ups of both knees that occurred randomly, were moderate in severity, lasted hours, and were precipitated by repetitive movement and alleviated by NSAIDS. Notably, however, he did not report having any functional loss or functional impairment of the joints, to include with repeated use over time. Initial range of motion testing revealed pain on flexion, pain with weight bearing, and crepitus on both knees; however, the Veteran had normal flexion and extension on range of motion testing. The Veteran did not have additional loss of function or range of motion after three repetitions, and the VA examiner found that he would not experience any additional loss of range of motion following repeated use over time or during flare-ups. However, the VA examiner opined pain would significantly limit functional ability with repeated use over time and during flare-ups, explaining that walking and running would become more difficult. There was no evidence of pain on passive range of motion testing or non-weight bearing, and range of motion was full without restrictions or limitations on both active and passive range of motion testing and on weight bearing and non-weight bearing. Here, the medical evidence shows the Veteran had full range of motion in both knees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups for the entire appeal period. Thus, the Board finds higher and/or separate ratings are not warranted under Diagnostic Code 5260 or Diagnostic Code 5261. 38 C.F.R. § 4.71a. Furthermore, as the evidence of record does not demonstrate ankylosis, recurrent subluxation or lateral instability, dislocated or removal of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum at any time during the appeal period, Diagnostic Codes 5256, 5257, 5258, 5259, 5262, and 5263 are not for application. The Board acknowledges the assertions made by the Veteran’s representative in December 2020 with respect to the most recent examinations of his bilateral elbows and knees. Specifically, he contends the examination reports contain information gaps involving the Veteran’s use of NSAIDS. In this respect, the Board finds the VA examiner paid particular attention to the Veteran’s reports of his symptomatology, with and without medication, when completing the examination report, to include descriptions of additional functional loss during flare-ups and with repeated use. Along those lines, the representative also asserts the VA examiner failed to understand the questions posed regarding such functional loss. In this regard, the Board notes the VA examiner repeated the initial range of motion measurements for such estimations; however, such is not contradictory to the finding of functional loss. Rather, the VA examiner clarified that functional loss, although not resulting in limitation of motion in terms of degrees, would be comprised of limited functional ability with respect to the elbows and greater difficulty with walking and running in connection with the knees. As for the representative’s contentions regarding the limited explanation of occupational impairment resulting from the Veteran’s rheumatoid arthritis, the issue of entitlement to a TDIU is remanded herein and the Board has requested additional clarification in connection therewith. Further, the question of employability is a legal one, not a medical one, and the VA examiner is not obligated to obtain a complete employment history in connection with a medical examination. Moreover, despite VA’s repeated requests, the Veteran himself has yet to provide such information for review. As for the Veteran’s rheumatoid arthritis of the bilateral feet, such is evaluated pursuant to Diagnostic Code 5284, which addresses other foot injuries. Under Diagnostic Code 5284, a 10 percent rating is provided for a “moderate” foot injury. A 20 percent rating is provided for a “moderately severe” foot injury, and a 30 percent evaluation is provided for a “severe” foot injury. The Note to Diagnostic Code 5284 indicates that a maximum 40 percent rating will be assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a. The words “slight,” “moderate,” and “severe” as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. VA treatment records dated in 2011 reflect the Veteran’s reports of chronic foot pain, and a June 2011 VA treatment record indicates that he had a minimally antalgic gait in connection with his reports of severe pain in the feet and hips. However, despite the Veteran’s reports of constant pain, stiffness, and swelling in June 2012, the VA examiner found he had no limitation of motion or joint pain attributable to his rheumatoid arthritis. Still, a January 2014 VA treatment record indicates subtalar motion of the right foot was decreased with tenderness. On VA examination in July 2015, the Veteran reported chronic pain and flare-ups resulting in intermittent limitation with standing and ambulation duration. He had pain on physical examination, and the VA examiner reported that the Veteran had pain on weight bearing, pain on non-weight bearing, disturbance of locomotion, and interference with standing. In September 2015, the Veteran reported right foot pain and, although a February 2016 VA treatment record indicates the Veteran’s right ankle limited him from prolonged standing and bending, he had full range of motion in his lower extremities. Examination of the Veteran’s joints was normal in August 2016, while a March 2017 VA treatment record shows his complaints of sharp, constant pain in his left foot that could last for hours. However, on VA examination, the Veteran did not report pain, functional loss, or functional impairment of the feet at such time. He did report pain on all joints in his feet from his ankles down to his toes and increased pain with flare-ups that impacted the functioning of the feet. The VA examiner found the severity of such symptomatology was moderate. The Veteran’s foot condition did not chronically compromise weight bearing nor did it require arch supports, custom orthotic inserts, or shoe modifications. He did not have pain during the examination, and the VA examiner reported the Veteran did not have any functional loss attributable to his rheumatoid arthritis. Nevertheless, the Veteran reported being unable to walk during severe flare-ups. However, a December 2019 VA examination report indicates the Veteran denied pain of the feet, flare-ups that impacted the functioning of the feet, functional loss, and functional impairment of the feet at such time. He did not have any pain on examination, but the VA examiner determined he did experience disturbance of locomotion due to his rheumatoid arthritis of the feet. Nevertheless, the VA examiner found neither pain, weakness, fatigability, nor incoordination would significantly limit functional ability during flare-ups or when the feet were repeatedly used over a period of time. The VA examiner also reported that the Veteran had full range of motion, both passive and active and on weight bearing and non-weight bearing, and normal strength, without restrictions or limitations. Upon review, the Board finds the medical evidence and the Veteran’s lay statements show his rheumatoid arthritis resulted in, at most, moderate disability of the right foot and left foot. The Board acknowledges the Veteran’s reports of chronic pain and functional impairment related to walking and standing. Nevertheless, the July 2017 VA examiner specifically found the severity of such symptomatology was moderate, even in light of the Veteran’s reports of severe pain during flare-ups that completed limited his ability to walk at those times. Moreover, the medical evidence does not reflect additional symptomatology beyond pain and disturbance of locomotion, such as limited range of motion, more movement than normal, weakened movement, excess fatigability, incoordination, deformity, atrophy of disuse, instability, or lack of endurance. Notably, despite the Veteran’s reports of chronic pain, physical examination of his feet did not consistently produce such symptomatology during the appeal period. Consequently, the Board finds the criteria for ratings in excess of the 10 percent assigned for each foot have not been met at any time during the appeal period. 38 C.F.R. § 4.71a, Diagnostic Code 5284. Additionally, as the medical evidence does not show, and the Veteran does not assert, actual loss of use of either foot, a 40 percent rating is not warranted under Diagnostic Code 5284. The Board has considered whether higher and/or separate ratings are warranted under other relevant diagnostic codes. However, as the medical evidence does not reflect flat foot, weak foot, claw foot, anterior metatarsalgia, hallux valgus, hammer toe, or malunion of tarsal or metatarsal bones associated with his service-connected rheumatoid arthritis, such are not applicable in this case. 38 C.F.R. § 4.71a, Diagnostic Codes 5276-5283. Other Considerations In reaching its conclusions in the instant case, the Board acknowledges the Veteran’s belief that his rheumatoid arthritis of his bilateral elbows, knees, and feet is more severe than as reflected by the currently assigned disability ratings. In this regard, the Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. In awarding the higher overall evaluation via the assignment of separate ratings for the joints affected by his rheumatoid arthritis, the Board has recognized that the Veteran is competent to describe his symptomatology. As for the denial of any available higher and/or additional separate ratings, the Board finds the medical evidence in which professionals with specialized expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disabilities in light of the rating criteria to be more persuasive than his own reports regarding the severity of his disabilities. The Board has also considered whether staged ratings under Hart, supra, are appropriate for the Veteran’s rheumatoid arthritis; however, the Board finds that his symptomatology has been stable throughout the appeal period. Thus, assigning staged ratings for such is not warranted. Furthermore, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the increased rating claims adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). In reaching such determinations, the Board has considered the applicability of the benefit of the doubt doctrine, which has resulted in a partial award of separate ratings for his bilateral elbows, knees, and feet affected by rheumatoid arthritis and an overall increased rating for the period from August 26, 2011, to September 19, 2014. However, insofar as the Board has denied higher or separate ratings for the disabilities on appeal, the preponderance of the evidence is against such aspects of the Veteran’s claims. Thus, the benefit of the doubt doctrine is not applicable in such regard and his claims must otherwise be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 7. Entitlement to a separate rating for rheumatoid arthritis of the neck, bilateral shoulders, and bilateral wrists. In pertinent part, the initial award of service connection for rheumatoid arthritis in the January 1995 rating decision included consideration of multiple joints other than those already separately rated, to include the neck, bilateral shoulders, and bilateral wrists. Based on the Veteran’s March 2015 claim, which specifically identified rheumatoid arthritis of the feet, knees, and right elbow, the AOJ awarded separate ratings for such disabilities. As described above, the Board herein sets the effective dates for such separate ratings as the date of receipt of the Veteran’s increased rating claim for his rheumatoid arthritis. Notably, when combined, the implementation of such ultimately results in a higher evaluation then the rating assignable under Diagnostic Code 5002. However, such do not compensate the Veteran for rheumatoid arthritis affecting the joints in the neck, bilateral shoulders, and bilateral wrists, which VA previously included in the initial award of service connection. In this regard, the medical evidence of record is unclear as to the extent, if any, that the Veteran’s service-connected rheumatoid arthritis affects such joints during the appeal period. Therefore, in order to ensure he is adequately compensated for all joints affected by his rheumatoid arthritis, as dictated by Diagnostic Code 5002, the Board finds a remand is warranted to address such matter. 8. Entitlement to a TDIU. The Veteran contends that his service-connected rheumatoid arthritis prevents him from securing and following a substantial gainful occupation. As the outcome of the claims remanded herein could impact his eligibility for a TDIU, such are inextricably intertwined and adjudication of the latter claim must be deferred pending the outcome of the former. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: Afford the Veteran appropriate VA examination(s) to determine the nature and severity of his rheumatoid arthritis as it affects his neck, bilateral shoulders, and bilateral wrists. The record, to include a copy of this Remand, must be made available to the examiner(s), and all indicated tests and studies should be accomplished. The examiner(s) should review the record and describe, to the extent possible, the nature and severity of the symptoms specifically attributable to the Veteran’s rheumatoid arthritis affecting his neck, bilateral shoulders, and bilateral wrists throughout the entire appeal period stemming from his August 26, 2011, claim. In addition, the examiner is asked to describe the functional impact that the Veteran’s rheumatoid arthritis has had on his occupational functioning for entire appeal period stemming from his August 26, 2011, claim. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. M. Celli, 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.