Citation Nr: 21040640 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 10-04 235A DATE: July 6, 2021 ORDER Entitlement to an initial disability evaluation of 70 percent, but no higher, prior to May 29, 2012 for post-traumatic stress disorder (PTSD) is granted. Entitlement to an initial disability evaluation of 40 percent prior to September 18, 2012 for cervical-spine disorder is granted. Entitlement to an increased disability evaluation in excess of 20 percent from September 18, 2012 for cervical-spine disorder is denied. Entitlement to an initial disability evaluation in excess of 10 percent for left-elbow disorder, to include epicondylitis, is denied. Entitlement to an initial disability evaluation in excess of 10 percent for a left-elbow scar is denied. FINDINGS OF FACT 1. The objective medical evidence shows in the period prior to May 29, 2012 the Veteran's PTSD more nearly approximated occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to associated symptoms. 2. The objective medical evidence shows in the period prior to September 18, 2012 cervical-spine disorder more closely approximated intervertebral disc syndrome (IVDS), with incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months. 3. The objective medical evidence shows in the period from September 18, 2012 cervical-spine disorder did not more closely approximate 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; or forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine, unfavorable ankylosis of the entire cervical spine or unfavorable ankylosis of the entire spine; nor did it more closely approximate IVDS with any incapacitating episodes over the past 12 months. 4. The objective medical evidence shows during the appeal period left-elbow, to include epicondylitis, did not more closely approximate limitation of left-forearm flexion to 90 degrees or less; limitation of left-forearm extension to 75 degrees or more; or a combination of left-forearm flexion limited to 100 degrees and extension to 45 degrees. 5. The objective medical evidence shows during the appeal left-elbow scar did not more closely approximate a scar which is unstable and painful; deep and nonlinear, covering an area of at least 6 square inches (39 square (sq.) cm., 12 square inches (77 sq. cm.), 72 square inches (465 sq. cm), or scars involving an area or areas of 144 square inches (929 sq. cm.); or scars causing functional impairment. CONCLUSIONS OF LAW 1. With resolution of reasonable doubt in the Veteran's favor, in the period prior to May 29, 2012, the criteria for an increased disability evaluation to 70 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.6, 4.130, Diagnostic Code 9411 (2020). 2. With resolution of reasonable doubt in the Veteran's favor, in the period prior to September 18, 2012, the criteria for an initial disability evaluation of 40 percent, but no higher, for cervical-spine disorder have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.25 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5243 (2020). 3. The criteria for an increased disability evaluation in excess of 20 percent from September 18, 2012 for cervical-spine disorder have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.25 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5243 (2020). 4. The criteria for an initial disability evaluation in excess of 10 percent for left-elbow disorder, to include epicondylitis, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5024, 5206, 5207, 5208 (2020, 2021). 5. The criteria for an initial disability evaluation in excess of 10 percent for left-elbow scar are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.118, Diagnostic Codes 7800, 7801, 7802, 7804, 7805 (2008, 2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January to April 1992 and from March 1996 to April 2009. In February 2017, the Veteran testified at a videoconference Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. These matters were remanded for further development in December 2017, and have now been returned to the Board. Schedular Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Additionally, it is possible for a veteran to be awarded separate percentage evaluations for separate periods (staged ratings), based on the facts. See Fenderson v. West, 12 Vet. App. 119, 12627 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the relevant overall temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating musculoskeletal disabilities, VA, in addition to applying the schedular criteria, may assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Nonetheless, a disability rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,'" as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that while "pain may cause a functional loss, pain itself does not constitute a functional loss," and, is therefore, not grounds for entitlement to a higher disability rating). Additionally, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, actually painful, unstable or malaligned joints, due to a healed injury, are recognized as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see also Burton v. Shinseki at 5 (holding that the provisions of 38 C.F.R. § 4.59 are not limited to disabilities involving arthritis). 1. Entitlement to an initial disability evaluation in excess of 30 percent prior to May 29, 2012 for PTSD. The Veteran's PTSD is currently evaluated under Diagnostic Code 9411, which defers to the General Rating Formula for Mental Disorders (General Rating Formula), which provides a 30 percent evaluation for occupational and social impairment, with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: Depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and/or mild memory loss (such as forgetting names, directions, or recent events). 38 C.F.R. § 4.130. A 50 percent evaluation requires demonstrated evidence of occupational and social impairment, with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability rating will be assigned for total occupational and social impairment, due to symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, one's own occupation or own name. Id. The symptoms listed in the General Rating Formula are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of symptoms, or their effects, which would justify a rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that the claimant's psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating, then that rating will be assigned. Mauerhan, 16 Vet. App. at 443. Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th Edition (DSM IV) at 32). The Board is aware that the DSM IV, which used GAF scores, was superseded in May 2013 by DSM 5 (5th edition), which does not. Nonetheless, the GAF scores were assigned in the period prior to the advent of DSM 5 and, if necessary, are for relevant consideration in the period at issue. As relevant to the record, a GAF score between 41 and 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job, cannot work). 51 to 60 is defined as "moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers)," while a score between 61 and 70 is defined as "some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships." While the Rating Schedule does indicate that the rating agency must be familiar with the Diagnostic and Statistical Manual of Mental Disorders, it does not assign disability percentages based solely on GAFs cores. See 38 C.F.R. § 4.130. Rather, GAF score of scores are but one factor to be considered in conjunction with all other pertinent evidence of record. Turning to the record from April 11, 2009, the day following the Veteran's discharge from active service, from late July through the first week of August 2009, the Veteran was hospitalized at a private psychiatric hospital in New Mexico, in which his treatment provider diagnosed, opioid dependency, PTSD, personality disorder, as well as TBI and lumbar-spine degenerative arthritis. Late in August 2009, the Veteran presented at another private facility in El Paso, Texas. The treatment provider's psychiatric evaluation addendum noted the Veteran's reports of difficulty controlling his anger, irritability, "on edge," not sleeping well, overwhelmed with chronic pain, and contemplating suicide. Ultimately, he was stabilized well enough to be considered for outpatient treatment. Dr. A.M.R. noted mental status examination results showing a degree of anxiety dysphoria, not homicidal, not suicidal, not considered a danger to himself or others, oriented to time, place, person, and situation, no overt signs of thought disorder, not psychotic or delusional, poor insight, questionable judgment, and an average fund of knowledge and intelligence. His diagnosed PTSD, mood disorder, depressed type, secondary to medical condition (chronic pain), marital problems, and mixed cognitive disorder. He assigned a GAF score of 42, indicating serious symptoms. Dr. A.M.R. in his subsequent progress notes later in August 2009 noted the Veteran appearing "somewhat dysphoric and anxious," his anger and his "significant mood swings." However, Dr. A,M,R. also suspected he was overmedicating and discussed with the Veteran opioid detoxification and moving off benzodiazepine use. His last assessment was opioid dependence, benzodiazepine abuse and dependence, PTSD, and cognitive disorder. Dr. A.M.R. further arranged for the Veteran's readmission to the New Mexico psychiatric facility for detoxification and further stabilization. An undated medical statement of a VA clinical psychiatrist, Dr. L.E., associated with the file in January 2010, states the Veteran "has been diagnosed with significant PTSD and was hospitalized for Suicidal Ideations between these visits. His mental health condition is extremely unstable and he has required high doses of anti-psychotic medication[,] anti manic medication and tranquilizers. This only at present gives him a modicum of control over his emotions." He added, "In my medical opinion at this point in time and for the foreseeable future there is no way that he can emotionally function in any work situation." A January 2010 letter to the Veteran from VA acknowledged his participation in VA's Persian Gulf Registry Program, which, after examination, indicated among the Veteran's several diagnoses PTSD and depression/anxiety. A VA suicide risk assessment note in August 2011 noted the Veteran's history of multiple suicide attempts/hospitalizations and a diagnoses of PTSD and recurrent major depressive disorder. The treatment provider concluded, "It has been determined that Veteran continues to remain at high risk for suicide." She further noted that her records review indicated that the Veteran was last seen in VA's mental health clinic in September2010, but has not followed up as recommended since that time. "Since he is not actively engaged in treatment, it is not possible to assess his risk and protective factors at this time." Her note contained a notice to "all medical providers," stating, "Please be alert to veteran making any threats of harm to self, seeking access to means to harm self[,] such as extra medications or firearms, or talking or writing about death, dying or suicide. Contact veteran's principal mental health provider, the facility suicide prevention coordinator, or the psychiatrist on duty if you notice any of these signs." To "all staff" she added, "If veteran is exhibiting any of the warning signs for suicide, or if you have concerns for any reason, please contact a provider." For the comparatively short period of prior to May 29, 2012 and going back to the April 11, 2009, the record contains no VA examinations, but the Veteran's record of treatment first indicates suicidal thoughts in August 2009, followed by ever-more consistent reports and findings pertaining to suicidal ideation, culminating in the VA suicide risk assessment in August 2011, announcing outright warnings to treatment providers and staff of the Veteran's high risk status. Moreover, during the period, the Veteran continued to have serious marital problems for which he and his wife, at least at one point, attended counseling sessions. Additionally, a January 2010 VA progress note of Dr. L.E. noted the Veteran's reports of no longer being able to maintain "control" under his current psychiatric medications. The Board notes that the next higher evaluation under the General Rating Formula of 50 percent requires demonstrated evidence of occupational and social impairment, with reduced reliability and productivity, due to associated symptoms. The Board finds the record demonstrates considerably more than that. As already set forth above, a 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. These criteria more closely reflect the Veteran symptoms in this period. For example, the Veteran was hospitalized twice in 2 private psychiatric hospitals between July and August 2009, with the treatment provider in second facility stating he would arrange for the Veteran's return to the first facility for a third hospitalization for further "stabilization." That treatment provider assigned a GAF score of 42, indicating serious symptoms associated with that score by way of example, such as suicidal ideation, severe obsessional rituals, frequent shoplifting, or any serious impairment in social, occupational or school functioning, such as no friends, unable to keep a job and cannot work. In his January 2010 medical statement, Dr. L.E. noted the Veteran being "extremely unstable," medications allow him only a "modicum of control over his emotions" and, most pertinently for determining the Veteran's occupational and social impairment in this period, "there is no way that he can emotionally function in any work situation," thereby indicating more appropriately "occupational and social impairment, with deficiencies in most areas." For these reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence supports an initial disability evaluation of 70 percent, but no higher, in the period prior to May 29, 2012. 2. Entitlement to an initial disability evaluation in excess of 10 percent prior to September 18, 2012 for cervical-spine disorder. 3. Entitlement to an increased disability evaluation in excess of 20 percent from September 18, 2012 for cervical-spine disorder. Cervical-spine disorder is evaluated under Diagnostic Code 5243 (for IVDS), which in turn defers either to the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula), whichever rating method results in a higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Under the General Rating Formula, a 10 percent disability rating is assigned for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a. A 20 percent disability rating is warranted for 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 assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent disability rating is assigned for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is assigned if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Note (2) of the General Rating Formula provides that, for VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. The combined range of motion refers to the sum of the range of motion 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. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. Although Note (4) of the General Rating Formula offers the choice of alternatively rating lumbar spine disorder under the IVDS Formula for whichever criteria of the two rating formulae provides a higher evaluation, the latter rating formula must be based on incapacitating episodes in the last 12 months, defined as a period of acute signs and symptoms due to intervertebral disc syndrome which requires bed rest prescribed by a physician and treatment by a physician. A 20 percent rating is warranted when there are incapacitating episodes having a total duration of at least two weeks, but less than four weeks during the past 12 months. A 40 percent rating is warranted when there are incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months. A 60 percent rating is warranted when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. The Board will briefly note here that the rating criteria for Diagnostic Code 5243 for IVDS have been revised, effective February 7, 2021. The revision simply directs the rater or adjudicator to assign Diagnostic Code 5243 only when there is disc herniation with compression and/or irritation of the adjacent nerve root, or another diagnostic code for degenerative arthritis should be assigned. Turning to the record, a May 2010 General Medical VA examination shows the Veteran's report that, due to cervical-spine disorder, he is limited to lifting less than 10 pounds, he avoids sudden movement when performing daily activities or when driving and he cannot run. The examination recorded the Veteran's cervical-spine range of motion measurements for forward flexion at "0-400" and backward extension also at "0-400." (The Board takes this to mean 0-40 degrees with the second 0 representing the degree sign, otherwise such a finding makes no sense..) Moreover, the Board's further review of the record has revealed another "version" of this examination, in which the range of motion measurements cervical spine, made with a goniometer, appear to have been substituted for the above measurements. Cervical spine forward flexion now shows 0-40 degrees (45 degrees, normal) and extension also at 0-40 degrees (45 degrees, normal). On repetitive use testing, forward flexion was reduced to 35 degrees. Some other maneuvers were noted, others were not and there is therefore no combined range of motion. A VA orthopedic surgery consult note in May 2010 notes, on physical examination, the Veteran's cervical spine exhibited "good ROM [range of motion]," but the treatment provider did not provide range of motion measurements in degrees using a goniometer. He diagnosed cervicalgia, with no focal neurological deficit. In August 2010, the Veteran underwent an anterior cervical discectomy, fusion instrumentation C4-5, 5-6, and 6-7 for his diagnosed cervical disc herniation, with radiculopathy instability. In an August 2012 VA examination for cervical-spine conditions, the VA examiner stated an updated diagnosis of "degenerative disc disease and spondylotic changes of the cervical spine with intervertebral disc syndrome, cervical radiculopathy with cervical fusion surgery." She noted the Veteran's reports of neck pain, with numbness and tingling in the upper extremities periodically since the injury, he underwent cervical-spine fusion surgery in August 2010, producing only very mild improvement after the surgery, but he still experiences pain with head movement and almost all activities with his arms. Range of motion measurements show cervical forward flexion at 30 degrees (45 degrees, normal), with painful motion beginning at 20 degrees. Extension was at 30 degrees (45 degrees, normal), with painful motion beginning at the same point. Combined range of motion for forward flexion, extension, and other maneuvers (right-lateral flexion, left-lateral flexion, right-lateral rotation, and left-lateral rotation) was at 260 degrees. On repetitive use testing, forward flexion and extension remained the same, but the combined rating overall was lessened to 250 degrees. Functional loss was demonstrated by less movement than normal, weakened movement and pain on movement. The Veteran reported flare-ups cause severe neck pain, numbness and tingling in both arms and difficulty in head movement, with flare-ups occurring 6-8 times a year and each lasting 2 weeks. The examiner found the Veteran did not have cervical-spine guarding or muscle spasm. She made no finding of ankylosis. However, she found the Veteran has IVDS, with incapacitating episodes over the past 12 months, requiring prescribed bed rest and treatment by a physician, which had lasted at least 4 weeks, but less than 6 weeks. Based on the record for the period prior to September 18, 2012, the August 2012 VA examiner's finding for IVDS entitles the Veteran to a disability evaluation of 40 percent under the IVDS Formula with resolution of reasonable doubt in his favor. In the period from September 18, 2012, the record shows the Veteran also underwent a September 2012 VA examination for cervical spine, in which the examiner stated a 2010 diagnosis of cervical disc disease. She noted the same reports by the Veteran as those in the August 2012 cervical spine examination. Range of motion measurements show cervical forward flexion at 20 degrees, with painful motion beginning at 5 degrees. Extension was at 25 degrees, with painful motion beginning at 5 degrees. Combined range of motion for all maneuvers was at 170 degrees. Repetitive use testing in fact showed forward flexion increased to 22 degrees, extension the same, with the combined rating now at 172 degrees. Functional loss was demonstrated by less movement than normal, pain on movement and disturbance of locomotion. The Veteran's reports of flare-ups were the same as in the previous VA examination. The examiner found the Veteran had guarding or muscle spasm severe enough to result in an abnormal gait. She made no finding of ankylosis. However, this examiner found the Veteran did not have IVDS, as well as no incapacitating episodes. In a January 2018 VA examination for cervical-spine conditions, the VA examiner stated 2010 diagnoses of arthritis of the cervical spine and status post cervical fusion. He noted the Veteran's reports of difficulty in sitting at a computer. Range of motion measurements were all normal, showing cervical forward flexion at 45 degrees and extension at 45 degrees. Combined range of motion for all maneuvers was at 340 degrees. The examiner observed pain with weight-bearing. He found repeated use over time did not include significant limitation of functional ability by pain, weakness, fatigability, or incoordination and the Veteran did not report cervical-spine flare-ups. The examiner further found there is no ankylosis of the cervical spine and the Veteran does not have IVDS. The record from September 18, 2012 shows findings in the September 2012 VA examination for range of motion, as well as guarding or muscle spasm severe enough to affect the Veteran's gait, being sufficient to give the Veteran a rating of 20 percent under the General Rating Formula. However, there were no findings of ankylosis of any sort or IVDS with any incapacitating episodes beyond 4 weeks duration throughout this period. Without such findings, the Board has no basis on which to assign a higher rating. Functional loss due to pain on movement were noted in all VA examinations in the appeal period, based on the Veteran's reports. Those findings were sufficiently reviewed and considered and are consistent with the assigned disability evaluations. Additional consideration for changes affecting normal working movements have also been considered, but the Board finds they do not present a basis for any higher evaluation. See 38 C.F.R. §§ 4.40, 4.45, 4.59; See DeLuca v. Brown, 8 Vet. App. at 204-07; Mitchell v. Shinseki, 25 Vet. App. at 37; Burton v. Shinseki, 25 Vet. App. at 5. The Board has carefully considered the Veteran's February 2017 Board hearing testimony and his lay statements in the record, as well as his reports to and examiners and treatment providers, as they appear throughout the record. The Board is well aware that lay persons are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses and there is no reason to doubt his credibility. Nonetheless, his lay evidence in turn must be weighed against other evidence, as all relevant evidence of varying kinds must be considered. The Veteran's essential and consistent contention in his testimony, statements and reports is his neck pain and limitation of motion has been worsening. Although the record supports this in the period prior to September 18, 2012, particularly in regard to IVDS and at least one incapacitating episode over the past 12 months prior to the examination, in the period after that date, neither VA examiner found signs of IVDS or ankylosis, which would provide possibly higher ratings under the IVDS Formula or the General Rating Formula. The Board therefore assigns more probative weight to the findings of the several VA examiners, as they are medical professionals, they conducted in-person examinations of the Veteran, all examiners thoroughly reviewed the Veteran's medical history, and their findings indicate adequate and sound conclusions for VA rating purposes. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). Based on the objective medical evidence, the Board finds the preponderance of the evidence supports an initial disability evaluation of 40 percent in the period prior to September 18, 2012, but no higher. Thereafter, a rating in excess of 20 percent is denied. 4. Entitlement to an initial disability evaluation in excess of 10 percent for left-elbow disorder, to include epicondylitis. The Veteran contends that he is entitled to a rating in excess of 10 percent for his left-elbow tendinitis. The Veteran's left-elbow disability is rated as 10 percent disabling pursuant to Diagnostic Code 5024 for tenosynovitis. Diagnostic Code 5024 addressing tenosynovitis indicates that diseases under that code will be rated on limitation of motion of the affected parts. Accordingly, the Board will address whether a higher rating is warranted based on limitation of motion. The revised VA regulations, effective February 7, 2021, clarify that Diagnostic Code 5024 includes tenosynovitis, tendinitis, tendinosis, or tendinopathy. As revised, the diseases listed under Diagnostic Codes 5013 through 5024 continue to be rated on limitation of motion of affected parts. The language, "arthritis, degenerative, except gout which will be rated under diagnostic code 5002," was removed in the note following Diagnostic Code 5024. Additionally, in an effort to provide the Veteran with the broadest possible opportunity for benefits, all potentially applicable diagnostic codes will be considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The Veteran's left elbow tendinitis, pursuant to the revised VA regulations, therefore will continue to be evaluated under the closely related or analogous Diagnostic Codes 5206, 5207 and 5208 for limitation of motion. There are no February 2021 revisions for those diagnostic codes. Diagnostic Code 5206 provides compensation for limitation of flexion of the forearm. 38 C.F.R. § 4.71a. Limitation of forearm flexion of 110 degrees or more warrants a noncompensable rating for a major arm and a minor arm. Limitation of forearm flexion to 100 degrees warrants a 10 percent rating for a major arm or a minor arm. Limitation of forearm flexion to 90 degrees warrants a 20 percent rating for a major arm or a minor arm. Limitation of forearm flexion to 70 degrees warrants a 30 percent rating for a major arm and a 20 percent rating for a minor arm. Limitation of forearm flexion to 55 degrees warrants a 40 percent rating for a major arm and a 30 percent rating for a minor arm. Limitation of forearm flexion to 45 degrees warrants a 50 percent rating for a major arm and a 40 percent rating for a minor arm. Diagnostic Code 5207 provides compensation for limitation of extension of the forearm. 38 C.F.R. § 4.71. Limitation of forearm extension to 45 degrees warrants a 10 percent rating for a major arm or a minor arm. Limitation of forearm extension to 60 degrees warrants a 10 percent rating for a major arm or a minor arm. Limitation of forearm extension to 75 degrees warrants a 20 percent rating for a major arm or a minor arm. Limitation of forearm extension to 90 degrees warrants a 30 percent rating for a major arm and a 20 percent rating for a minor arm. Limitation of forearm extension to 100 degrees warrants a 40 percent rating for a major arm and a 30 percent rating for a minor arm. Limitation of forearm extension to 110 degrees warrants a 50 percent rating for a major arm and a 40 percent rating for a minor arm. Under Diagnostic Code 5208, a 20 percent rating contemplates a combination of flexion limited to 100 degrees and extension to 45 degrees in either forearm. Full elbow extension and flexion is from 0 to 145 degrees, full pronation is to 80 degrees, and full supination is to 85 degrees. 38 C.F.R. § 4.71, Plate I. Turning to the record, the Board will first note that the January 2018 VA examination for elbow and forearm states the Veteran is "ambidextrous." However, the record further reveals that both the May 2010 General Medical VA examination and the October 2010 Gulf War VA examination state, based on the Veteran's reports, he is right-hand dominant. Additionally, the June 2011 and March 2013 VA examinations for peripheral nerves conditions state the Veteran is right-hand dominant, the former adding, "DETERMNED BY: Veteran's statement." As 4 reports by the Veteran to his examiners indicate right-hand dominance and only one report asserts ambidexterity, the Board finds the preponderance of the evidence, provided by the Veteran himself, shows he is right-hand dominant. Review of a pertinent version of this examination, in which the range of motion measurements for left elbow, made with a goniometer, reveal left-elbow forward flexion now shows 0-140 degrees and extension also at "-10 degrees," with pain observed at those measurements and no further limitation following repetitive movements. In a June 2011 VA examination for peripheral nerves conditions, the VA examiner noted that the Veteran's injuries to both elbows affected the ulnar nerves and required surgery. She noted the Veteran's reports of episodes of tingling, numbness and pain, as well as constant sharp pain at 6-10 intensity, stiffness, without locking, but with weakness. (Separate neurological ratings have been assigned for the upper extremities, and are not herein at issue.) Left-elbow/forearm range of motion measurements show left flexion at 0 to 120 degrees and extension at "0" (indicating 120 to 0 degrees), with no objective evidence of pain with active motion. Repetitive motion showed forward flexion decreased to 110 degrees, but extension remained the same, with objective evidence of pain observed and causing the additional flexion limitation. The June 2011 VA examiner made no findings of inflammatory arthritis and her diagnoses included left-ulnar entrapment and left-elbow epicondylitis. A January 2018 VA examination for elbow and forearm conditions includes 2009 and 2012 diagnoses of lateral epicondylitis and olecranon bone spur. Left-elbow range of motion measurements were all normal, showing left flexion at 0 to 145 degrees and extension at 145 to 0 degrees. Although pain was noted on examination, it did not cause functional loss. Repetitive use showed no additional left-elbow functional loss. The examiner further found pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time, nor did the Veteran report flare-ups. Available imaging studies did not document any form of arthritis. The findings of the VA examinations are consistent and do not come close to the criteria necessary for higher ratings rating due to limited range of motion under any of the related diagnostic codes set forth above. From this evidence, the Board has no basis on which to assign a higher disability evaluation. 5. Entitlement to an initial disability evaluation in excess of 10 percent for a left-elbow scar. Left-elbow scar is evaluated under Diagnostic Code 7804. However, since the initial filing of the Veteran's claim, changes to the rating criteria for skin disabilities (38 C.F.R. § 4.118 ) became effective on August 13, 2018. The amendment added a General Rating Formula for the Skin (General Rating Formula) for certain diagnostic codes, and it amended still other diagnostic codes. See 83 Fed. Reg. 32,592 (July 13, 2018). When a law or regulation changes during the pendency of a Veteran's appeal, the version most favorable to the Veteran applies. Therefore, generally, VA is required to consider an increased rating claim in light of both the former and revised schedular rating criteria, absent congressional intent to the contrary. However, the amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change. However, the old regulations will be considered for the periods both before and after the change was made. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). As stated, the Veteran seeks an initial increased disability evaluation for left-elbow scar. The applicable rating period is from April 11, 2009, the effective date for the award of service connection for that disability through the present. See 38 C.F.R. § 3.400. Therefore, the criteria for rating skin disabilities have changed once during the award of service connection, with those changes made effective on August 13, 2018. Prior to the August 2018 version, Diagnostic Code 7804 applied to scars which are unstable or painful. A 10 percent rating was warranted for one or two scars that are unstable or painful. A 20 percent rating was warranted for three or four such scars. A 30 percent rating was warranted for five or more scars that are unstable or painful. Note (1): An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2): If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3): Scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). However, as separate ratings could be assigned for left-elbow scar under various related diagnostic codes, once again, in the effort to afford the Veteran every possible consideration the Board will also look to those related or analogous diagnostic codes pertaining to scars in the range of 7800 through 7805 to determine if a higher evaluation might be available under those codes. Diagnostic Code 7800 required involvement of the head, face or neck and as such is not applicable to the Veteran's left-elbow-scar claim. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2004). Diagnostic Code 7801 provided ratings for scars, other than the head, face, or neck, that are associated with underlying soft tissue damage. Scars that are associated with underlying soft tissue damage in an area or areas exceeding 6 square inches (39 sq. cm.) are rated as 10 percent disabling. Scars in an area or areas exceeding 12 square inches (77 sq. cm.) are rated as 20 percent disabling. Scars in an area or areas exceeding 72 square inches (465 sq. cm.) are rated as 30 percent disabling. Scars in an area or areas exceeding 144 square inches (929 sq.cm.) are rated as 40 percent disabling. Note (1): Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with § 4.25 of this part. Note (2): A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2004). Diagnostic Code 7802 provided ratings for scars, other than the head, face, or neck, that were superficial or that did not cause limited motion. Superficial scars that did not cause limited motion, in an area or areas of 144 square inches (929 sq. cm.) or greater, were rated as 10 percent disabling. Note (1) to Diagnostic Code 7802 provided that a superficial scar was one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118 (2004). However, Diagnostic Codes 7801 and 7802 in fact are not applicable, as findings on examination do not show the extensive areas in square inches or their equivalent square centimeters required for a compensable rating. At this time, the Rating Schedule no longer included a "Diagnostic Code 7803." 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). Diagnostic Code 7805 addressed other scars (including linear scars) and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, and 7804, directing the rater or adjudicator to evaluate any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800 - 7804 under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2008). Under the August 2018 amended rating criteria, Diagnostic Code 7804 remains the same, as do Diagnostic Codes 7800, 7801 and 7802. No criteria as yet have been assigned for a "Diagnostic Code 7803." Diagnostic Code 7805 also remains the same. The record shows in the June 2011 VA examination for peripheral nerves conditions, the examiner diagnosed "[r]residuals of elbows injury with scars of nerve transposition." She made no further findings. A March 2013 VA examination for scars made findings only regarding knee scars. The examiner made a specific findings of "not affected" concerning the left left-upper extremity. The December 2017 Board Remand directed the Veteran be afforded VA examinations "to address the current severity of his cervical spine, left elbow, and left elbow scar disabilities." The January 2018 VA examiner for elbow and forearm made pertinent findings regarding the Veteran's left elbow scar. He found the Veteran has right and left-elbow scars, but also found there is no objective evidence indicating the either scar is painful, unstable, has a total area equal to or greater than 39 square cm (6 square inches), or are located on the head, face or neck. He stated the measurements of the left-elbow scar as 8 centimeters (cm.) in length and 0.5 cm. in width, adding that this scar, as well as the right-elbow scar, indicate "no dehiscence [separated or open wound], no pain on palpation." On these findings, the Board finds no higher initial disability evaluation is available under the pre-August 2018 version of Diagnostic Code 7804, as the January 2018 VA examiner specifically found the scar is not painful and there is no skin breakdown, as well as the examiner making no finding of underlying tissue damage, thereby indicating it is not unstable. However, the current version of Diagnostic Code 7804, as amended in August 2018, has not been considered, as amended rating criteria, if favorable to the claim, can be applied only for the period from the effective date of the regulatory change, approximately 7 months after this VA examination. Looking to the related or analogous diagnostic codes, as stated, 7800 contemplates scars of the head, face or neck only. Diagnostic Codes 7801 and 7802 are inapplicable under each version of those codes, as the January 2018 VA examiner's findings show measurements of the scar area of 8 cm. by 0.1 cm, far below the square-inch and equivalent square-centimeter requirements for a compensable rating. Diagnostic Code 7805 under any version is not applicable, as the January 2018 VA examiner specifically made normal findings of left-elbow range of motion, thereby indicating the scar does not limit function, as further shown by the examination making no finding whatsoever for left-elbow ankylosis (immobility of the joint due to fusion of the bones). Therefore, the pre-August 2018 and the current amended versions of Diagnostic Codes 7800 7805 offer no higher compensable evaluations for left-elbow scar. The Board has reviewed the Veteran's February 2017 Board hearing testimony and his reports to examiners and treatment providers. The Veteran essentially contends that scar tissue periodically builds up. It presses on the ulnar nerve causing pain and then has to be surgically reduced. However, as shown by the rating criteria above, no examination findings satisfy those criteria for a higher rating. Moreover, when service-connected was granted in May 2009, the scar was noted as having been painful on examination, thereby warranting the minimal compensable evaluation (10 percent) allowed under the rating criteria. The January 2018 VA examiner made no finding of pain on examination. As already stated, the Veteran is wholly credible in his assertions of sensations and observations, but he already has been compensated for pain, whenever it may manifest. Once again, there is no basis for a higher evaluation without relevant findings on examination. The Board therefore assigns more probative weight to the findings of the January 2018 VA examiner, as he is a medical professional, he conducted an in-person examination of the Veteran, he thoroughly reviewed the Veteran's medical history, and his findings are adequate and sound for VA rating purposes. See generally Nieves-Rodriguez at 302-04. For the foregoing reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence does not support an initial disability evaluation in excess of 10 percent rating based on relevant rating criteria. The Board has considered the benefit-of-the-doubt doctrine. However, regarding those claims on which the Board has not ruled favorably, the Board does not perceive an approximate balance of positive and negative evidence. As the preponderance of the evidence is against the claims, the doctrine is not applicable and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. MICHAEL D. LYON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Franke, 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.