Citation Nr: 22011045 Decision Date: 02/25/22 Archive Date: 02/25/22 DOCKET NO. 09-04 745 DATE: February 25, 2022 ORDER The claim of entitlement to service connection for a cervical spine disorder, to include on a secondary basis, is denied. The claim of entitlement to service connection for a cervical spine disorder, to include on a secondary basis, is denied. A rating in excess of 20 percent for a left shoulder disability prior to November 22, 2013, is denied. A 20 percent rating for a right elbow disability with limitation of flexion prior to January 6, 2020, is assigned, replacing the previously assigned 20 percent rating for a right elbow injury with traumatic arthritis. A rating in excess of 20 percent for limitation of flexion of the right elbow since January 6, 2020, is denied. A separate 10 percent rating for limitation of extension of the right elbow prior to January 6, 2020, is granted. A rating in excess of 10 percent for limitation of extension of the right elbow since January 6, 2020, is denied. A separate 20 percent rating for limitation of pronation of the right elbow prior to January 6, 2020, is granted. A rating in excess of 20 percent for limitation of pronation of the right elbow since January 6, 2020, is denied. A total disability rating based upon individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. The Veteran's lumbar spine disability and cervical spine disability are not related to an in-service injury or disease, and are not proximately due to or the result of, or aggravated by, the service-connected left shoulder disability and/or right elbow disability. 2. Prior to November 22, 2013, the range of motion of the Veteran's left shoulder was limited no more than midway between his side and shoulder level. 3. Prior to January 6, 2020, the Veteran's right elbow disability was primarily manifested by flexion limited to 90 degrees and extension limited to 45 degrees. 4. Since January 6, 2020, the Veteran's right elbow disability has resulted in no more than limitation of flexion to 90 degrees and limitation of extension to 60 degrees. 5. Throughout the appeal period, the Veteran's right elbow disability has resulted in limitation of pronation akin to motion lost beyond the last quarter of arc, the hand does not approach full pronation. 6. The Veteran's service-connected disabilities preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical spine disability, to include on a secondary basis, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for a lumbar spine disability, to include on a secondary basis, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 3. Prior to November 22, 2013, the criteria are not met for entitlement to a rating greater than 20 percent for the Veteran's left shoulder disability. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5201. 4. Prior to January 6, 2020, the criteria are met for a 20 percent rating for the Veteran's right elbow disability for loss of flexion. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5206. 5. Prior to January 6, 2020, the criteria are met for a 10 percent rating for the Veteran's right elbow disability for loss of extension. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5207. 6. Prior to January 6, 2020, the criteria are met for a 20 percent rating for the Veteran's right elbow loss of pronation. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5213. 7. Since January 6, 2020, the criteria are not met for a rating in excess of 20 percent for the Veteran's right elbow loss of pronation. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5213. 8. Since January 6, 2020, the criteria are not met for a rating in excess of 20 percent for the Veteran's right elbow loss of flexion. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5206. 9. Since January 6, 2020, the criteria are not met for a rating in excess of 10 percent for the Veteran's right elbow loss of extension. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5207. 10. Throughout the appeal period, the criteria have been met for entitlement to a TDIU. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1984 to April 1992. These issues come to the Board on appeal from July 2007, March 2008, and January 2009 rating decisions. This appeal was remanded in February 2011, December 2017, September 2018, December 2019, March 2021, and August 2021. As explained in the decision, the Board awards a 20 percent rating for limitation of flexion and a separate 10 percent rating for limitation of extension for the Veteran's right elbow prior to January 6, 2020. Prior to that date, with the exception of period from February 18, 2010, to May 31, 2010 (when the Veteran is in receipt of a temporary total disability rating), the Veteran is in receipt of a 20 percent disability rating that contemplates both limited flexion and extension of the right elbow. The separate ratings granted herein will replace the 20 percent right elbow rating previously assigned under DC 5208, which again contemplates both limited flexion and extension. 1. Service connection for a lumbar spine disability is denied. 2. Service connection for a cervical spine disability is denied. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310l The Veteran contends that his lumbar spine disability and cervical spine disability are caused or aggravated by his service or his service-connected left shoulder disability and/or right elbow disability. In this case, the Board finds that the evidence is not in approximate balance, and therefore the claims for service connection for a lumbar spine disability and cervical spine disability must be denied. Significantly, all VA examination opinions obtained in this case are in agreement that the Veteran's lumbar spine disability and cervical spine disability are not at least as likely as not related to an in-service injury, event, or disease, or caused or aggravated by his service-connected left shoulder disability and/or right elbow disability. The most probative and persuasive opinion, obtained in October 2021, concludes that, on a direct basis, both in-service indications of injury to the low back and pain in the upper back resolved prior to separation from service. The examiner noted that the Veteran received treatment for right upper back pain diagnosed as a muscle spasm in March 1986 which appeared to resolve following treatment. He was then treated in August 1988 for left lower back pain and also was treated with resolution. He was then seen in September 1988 for a stiff neck associated with a viral syndrome, only, and thus not a true cervical spine injury. There was no further evidence in the record that all of the above symptoms did not resolve. Rather, on November 1991 separation examination, the Veteran reported "no" to the question of whether he suffered from recurrent back pain. Furthermore, the first indication in the record of a cervical spine diagnosis post-service was not until 2006, and a lumbar spine diagnosis post-service was not until 2007, at which time he was diagnosed with degenerative disc disease of the lumbar and cervical spine. On a secondary basis, the October 2021 examiner explained that there was no medical evidence in the literature or based upon clinical knowledge that lumbar spine or cervical spine disc disease would be caused or aggravated by a left shoulder disability or right elbow disability. The examiner also noted that the Veteran reported that both disabilities began 10-15 years ago, and did not himself report ongoing symptoms since service. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board finds that the October 2021 VA opinion to be highly probative and persuasive evidence against the claims for service connection. The opinion is entirely consistent with the record and with the other VA opinions that have been obtained in this case. Notably, there is no positive medical evidence or medical opinion that is supportive of the Veteran's claim. To that extent, on January 2020 and May 2021 VA examinations, the examiner also concluded that on a secondary basis, there was no plausible clinical link between the Veteran's left shoulder disability and/or his right shoulder disability as causing or aggravating his cervical spine disability or lumbar spine disability. The Veteran believes his lumbar spine disability and his cervical spine disability are related to an in-service injury, event, or disease. The Veteran in this case is not competent to provide a nexus opinion regarding these issues. The issues are medically complex, as they require knowledge of anatomical relationships, pathology, and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the competent and probative VA medical opinions that been obtained and discussed above. Of note, other than more general contentions provided upon filing his claim, the Veteran has not provided any specific contentions throughout the appeal period as to how his service caused or aggravated his current lumbar spine disability and cervical spine disability, or how his service-connected right elbow disability and/or left shoulder disability caused or aggravated his lumbar spine disability and cervical spine disability. Given the above, the Board finds that the evidence does not weigh in the Veteran's favor, and therefore, as the elements of service connection have not been met, the claims must be denied. 3. A rating in excess of 20 percent for a left shoulder disability prior to November 22, 2013, is denied. Disability evaluations are determined by comparing the Veteran's present symptomatology with the criteria set forth in the VA's Schedule for Ratings Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. § Part 4. Higher ratings are assigned if the disability more nearly approximates the criteria for that rating; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. All reasonable doubt material to the determination is resolved in the Veteran's favor. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. The medical evidence shows the Veteran is right-handed (right hand dominant), so his left shoulder is his "minor" rather than "major" shoulder. According to 38 C.F.R. § 4.71a, DC 5201, limitation of motion of the minor arm at shoulder level (meaning at 90 degrees) or at midway between the side and shoulder level (so at 45 degrees) warrants a 20 percent rating. Limitation of motion to 25 degrees from the side warrants a higher 30 percent rating. Id. See also 38 C.F.R. § 4.71, Plate I, and the revisions to VA's Rating Schedule as concerning musculoskeletal disabilities that recently took effect on February 7, 2021. The standardized description of joint measurements is provided in Plate I of 38 C.F.R. § 4.71. These descriptions indicate that normal forward elevation (flexion) of the shoulder is from 0 to 180 degrees, normal abduction of the shoulder is from 0 to 180 degrees, normal external rotation is from 0 to 90 degrees, and normal internal rotation is from 0 to 90 degrees. When considering these prescribed ranges, also the Veteran's pain and its effect on his range of motion, the Board finds that a rating higher than 20 percent prior to November 22, 2013, for his left shoulder disability under DC 5201 is not warranted. On April 2007 VA examination, range of motion of the left shoulder showed forward flexion on active range of motion to 170 degrees, with pain at 110 degrees. Abduction was to 120 degrees, with pain at 110 degrees. Both internal and external rotation were to 70 degrees. He denied flare-ups of the left shoulder and reported constant symptoms of pain that was 5/10. His shoulder felt stiff and his left arm felt weak. On February 2008 private disability examination, the Veteran's showed forward flexion to 100 degrees, abduction to 90 degrees, 40 degrees of internal and 60 degrees of external rotation. There was moderate crepitus and tenderness at the joint. On April 2012 VA examination, forward flexion of the left shoulder was to 105 degrees, with pain beginning at 105 degrees. Abduction was to 70 degrees with pain. There was no evidence of additional functional loss due to pain on repetitive testing. There was evidence of less movement than normal and pain on movement in terms of functional impairment. In October 2021, the Board obtained a retrospective opinion to determine the functional limitation of the Veteran's left shoulder disability prior to November 2013. The examiner reviewed the treatment records for this period of time and noted that that Veteran did have evidence of increased pain on motion that would limit his left shoulder range of motion. The examiner did not find evidence of more severe decreased range of motion when considering passive verses active range of motion testing, or when considering weight-bearing verses nonweight-bearing activity. Based upon the evidence as delineated above, a rating higher than 20 percent is not warranted for the period prior to November 22, 2013. The Veteran's primary symptoms related to his left shoulder disability are pain on movement and loss of strength on repetitive movement. But mere pain, alone, does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss. Pain may cause a functional loss but does not, itself, constitute functional loss; rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). The Court explained in Mitchell that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Consequently, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. See also Burton v. Shinseki, 25 Vet. App. 1 (2011) (indicating to apply 38 C.F.R. § 4.59, concerning painful motion, even in cases that do not involve arthritis). But the Court also has held that 38 C.F.R. § 4.40 does not require a separate rating for pain but rather provides guidance for determining ratings under other DCs assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). Moreover, in Mitchell, the Court held that the evaluation of painful motion as limited motion only applies when limitation of motion is noncompensable (meaning 0-percent disabling) under the applicable DC. The Court further explained that, although painful motion is entitled to a minimum 10 percent rating under Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991), when read together with DC 5003 regarding arthritis, it does not follow that the maximum rating is warranted under the applicable DC pertaining to range of motion simply because pain is present throughout the range of motion. See id. Accordingly, the totality of the evidence of record does not show range of motion of the Veteran's left shoulder limited to 25 degrees from his side such that a rating higher than 20 percent would be warranted, even when considering his pain and consequent need to rest his shoulder after repetitive movement of it. Based on the VA examination findings and treatment records in the file, as well as a weighing of the competent and credible evidence of record, the Board finds that a higher rating under DC 5201 is not warranted. A separate rating also is not warranted under any other shoulder rating code, as such would amount to pyramiding (i.e., compensating him for the same symptoms and impairment) or he does not have the type of impairment contemplated by any other DC providing greater compensation. 4. A 20 percent rating for a right elbow disability with limitation of flexion prior to January 6, 2020, is assigned. 5. A separate 10 percent rating for a right elbow disability with limitation of extension prior to January 6, 2020, is granted. 6. A rating in excess of 20 percent for limitation of flexion of the right elbow since January 6, 2020, is denied. 7. A rating in excess of 10 percent for limitation of extension of the right elbow since January 6, 2020, is denied. 8. A 20 percent rating for limitation of pronation of the right elbow prior to January 6, 2020, is granted. 9. A rating in excess of 20 percent for limitation of pronation of the right elbow since January 6, 2020, is denied. Throughout the majority of the appeal period, which begins in 2006, the Veteran was in receipt of one 20 percent rating pursuant to DC 5208 as described below for his right elbow disability. Beginning January 6, 2020, the RO discontinued that rating and instead rated the Veteran pursuant to DC 5206 and DC 5207, as described below, entitling him to a higher overall rating for his right elbow disability. The RO additionally assigned a separate rating under DC 5213, as described below, since January 6, 2020, for limitation of pronation. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic 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 5003. 38 C.F.R. § 4.71a. Normal range of motion of the elbow is from 0 degrees of extension to 145 degrees of flexion. 38 C.F.R. § 4.71a. Plate I. Normal forearm pronation is from zero to 80 degrees. Id. Normal forearm supination is from zero to 85 degrees. Id. Under DC 5206, a 0 percent rating is warranted when forearm flexion of the major arm is limited to 110 degrees; a 10 percent rating is warranted when forearm flexion of the major arm is limited to 100 degrees; a 20 percent rating is warranted when forearm flexion is limited to 90 degrees; a 30 percent rating is warranted when forearm flexion is limited to 70 degrees; a 40 percent rating is warranted when forearm flexion is limited to 55 degrees; and a 50 percent rating is warranted when forearm flexion is limited to 45 degrees. 38 C.F.R. § 4.71a. 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 or to 60 degrees warrants a 10 percent rating for a major arm. Limitation of forearm extension to 75 degrees or to 90 degrees warrants a 20 percent rating or 30 percent rating, respectively. Limitation of forearm extension to 100 degrees warrants a 40 percent rating. Limitation of forearm extension to 110 degrees warrants a 50 percent rating. Under DC 5208, a 20 percent rating contemplates a combination of flexion limited to 100 degrees and extension to 45 degrees in either forearm. Under DC 5213, a 30 percent rating is assigned for the major extremity when the hand is fixed in full pronation or with motion is lost beyond the middle of the arc, and a 20 percent rating is warranted when the hand is near the middle of the arc or moderate pronation, or when there is loss of pronation beyond the last quarter of the arc (i.e., 20 degrees), where the hand does not approach full pronation. Limitation of supination to 30 degrees or less is assigned a 10 percent rating for both arms. Normal forearm supination is from 0 to 85 degrees, and normal forearm pronation is from 0 to 80 degrees. See 38 C.F.R. § 4.71. Factual History Turning to the evidence of record, VA treatment records reflect that in January 2005, the Veteran reported increasing right elbow pain. Range of motion testing showed flexion to 110 degrees. He lacked 50 degrees in elbow extension. He could pronate and supinate his elbow to 140 degrees. A May 2005 private treatment record demonstrated ongoing right elbow pain. Flexion of the elbow was to 90 degrees, extension was full, pronation was to 90 degrees, and supination was to 65 degrees. On April 2007 VA examination, the Veteran reported that his right arm was stiff and weak with swelling at times. He wore a right elbow brace. Range of motion testing showed flexion to 110 degrees, with pain beginning at 90 degrees, passive flexion to 115 degrees, full extension, supination was to 60 degrees with pain at 60 degrees, and pronation was to 50 degrees with pain at 50 degrees. Repetitive motion was stated to cause pain but no other signs of additional functional loss. Strength of the arm was normal. A February 2008 medical evaluation showed range of motion of the right elbow of 90 degrees to 120 degrees of flexion. This examination did not mention extension. He had full pronation and supination. June 2008 private records document motion from 50 degrees extension to 90 degrees flexion with significant crepitus, popping, and locking. A November 2009 VA treatment record showed the Veteran's report of painful crepitation and popping. He reported very limited range of motion and was hesitant to go beyond a comfortable range. Range of motion testing showed 45 degrees extension to 90 degrees flexion. There was audible and palpable crepitus and popping noted. The evidence reflects that the Veteran underwent right elbow surgery in February 2010. In June 2010, he was shown to have very reduced range of motion, measuring 60 to 110 degrees. On September 2011 VA examination, range of motion of the right elbow showed flexion to 120 degrees with no evidence of painful motion, and extension to 20 degrees with no evidence of painful motion. There was no additional functional loss noted. Muscle strength testing was 5/5. On October 2013 VA examination, range of motion of the right elbow showed flexion to 90 degrees without pain, extension ending at 40 degrees without pain, and no evidence of additional functional loss on repetitive movement but for lessened movement. There was pain on palpation of the right elbow. Muscle strength testing was normal. On March 2018 VA examination, the Veteran reported experiencing weekly flare-ups that felt like sharp pain followed by aching pain, lasting up to one day. Examination of the right elbow showed functional loss by way of weakness and limited range of motion. He had difficulty lifting due to pain and weakness of the elbow. Range of motion testing showed flexion 120 degrees, extension to 55 degrees, supination to 50 degrees, and pronation to 50 degrees. The examiner did not find evidence of additional functional loss on repetitive testing. Muscle strength testing was 4/5. On range of motion testing, the examiner noted pain on examination of all motion that resulted in functional loss, though no loss was described other than the limited motion documented above. On January 2020 VA examination, the Veteran reported similar symptoms of pain and reduced range of motion. His symptoms were worse with repetitive and heavy use. Range of motion testing showed flexion to 100 degrees, extension to 50 degrees, supination to 85 degrees and pronation to 80 degrees. There was pain on all range of motion. On repetitive testing, there was lessened motion, flexion was from 60 to 80 degrees, extension was from 80 to 60 degrees, and supination and pronation were to 60 degrees. There was no additional functional loss. There was no current flare, and the examiner did not find additional loss of motion during a potential flare. Muscle strength testing was 4/5. On November 2020 VA examination, range of motion testing showed flexion to 95 degrees, extension to 30 degrees, supination to 55 degrees, pronation to 80 degrees. There was evidence of crepitus. There was pain noted on examination that resulted in functional loss. On January 2021 VA examination, the Veteran reported increasing pain in his right elbow and limited range of motion. He described current sharp pain in the elbow that was 7-8 out of 10. He reported elbow flares every day. Range of motion testing showed flexion from 50 to 100 degrees, extension from 100 to 50 degrees, supination to 85 degrees, and pronation to 80 degrees. There was pain noted on examination that caused functional loss. Because the examination was conducted during a flare, the examiner was able to provide range of motion testing during flare ups as flexion from 50 to 100 degrees, extension from 100 to 50 degrees, supination to 85 degrees, and pronation to 80 degrees. Muscle strength testing was 4/5. In October 2021, a retrospective opinion was obtained to determine whether the Veteran's right elbow would have shown objective evidence of pain in passive motion and in nonweightbearing prior to February 2010, and to address any functional limitations in terms of range of motion on repetitive use and during flares for this time period. The examiner opined that there was no objective evidence to show pain on passive motion or nonweightbearing motion during this time frame based upon a thorough review of the treatment records and VA examinations. The examiner could not provide further opinion as to functional loss without resort to speculation. Analysis For the period prior to January 6, 2020, the Veteran has been in receipt of a 20 percent rating for his right elbow disability under DC 5208, which contemplates flexion limited to 100 degrees and extension limited to 45 degrees. This diagnostic code acknowledges the compounding impact of having limitation in both forms of elbow motion by providing a higher rating than otherwise would have been available for those motions rated individually. A higher overall disability rating is available, however, if the Veteran were to qualify for a 20 percent rating for right elbow limited flexion and 10 percent rating for right elbow limited extension, under DCs 5206 and 5207. Awarding separate ratings under DCs 5206 and 5207, while keeping the DC 5208 rating prior to January 6, 2020, would essentially rate limited flexion and extension twice, which would constitute prohibited pyramiding. 38 C.F.R. § 4.14. Thus, regarding the question of flexion and extension, the Board will consider whether the Veteran's right elbow disability may be rated to supplant the current 20 percent rating under DC 5208 prior to January 6, 2020. Resolving all doubt in the Veteran's favor, the Board finds that his right elbow disability more closely approximates limitation up to 90 degrees flexion prior to January 6, 2020, and that a rating of 20 percent under DC 5206 for limitation of flexion should be assigned instead of the previously assigned rating under DC 5208. The evidence suggests right elbow flexion limited to 90 degrees several times during the early portion of this period on appeal. See April 2007 VA Examination, February 2008 evaluation, June 2008 private treatment records, November 2009 VA treatment records, and October 2013 VA examination. The Board acknowledges the March 2018 VA examination shows flexion that does not approximate 90 degrees limitation. However, the evidence prior to and after this examination shows symptoms of greater severity. Thus, a 20 percent evaluation for limited flexion of the right elbow is assigned for the appeal period prior to January 6, 2020. Next, the Board awards a separate rating of 10 percent for limited extension prior to January 6, 2020. Again, while some evidence suggests extension not limited to 45 degrees or greater, there are several records that do so, and the Board resolves all doubt in the Veteran's favor. The February 2008 evaluation shows extension to 50 degrees. The November 2009 VA treatment record document extension to 45 degrees. In June 2010, extension was limited to 60 degrees. The 2011 and 2013 VA examinations document extension with limitation less than 45 degrees. However, again, the evidence prior to and after these instances shows more severe symptoms. As such, the Board finds that a separate 10 percent evaluation for limited extension of the right elbow is warranted. To summarize, the Veteran is now in receipt of a 20 percent evaluation for limitation of flexion under DC 5206 for the entire duration of the appeal, both before and after January 6, 2020, excluding that period from February 18, 2010, to May 31, 2010, when the Veteran is in receipt of a temporary total disability rating based on surgical or other treatment necessitating convalescence. Similarly, the Board grants a separate 10 percent evaluation for limitation of extension under DC 5207 for period of the appeal prior to January 6, 2020, again excluding that period from February 18, 2010, to May 31, 2010, when the Veteran is in receipt of a temporary total disability rating based on surgical or other treatment necessitating convalescence. Before and after January 6, 2020, the Veteran has not been shown to suffer from limitation of flexion to less than 90 degrees or limitation of extension to greater than 60 degrees. Therefore, higher ratings are not warranted for this period of the appeal. Lastly, the Board finds that the 20 percent rating that was assigned for limitation of pronation beginning January 6, 2020, should extend throughout the appeal period. When resolving the benefit of the doubt in favor of the Veteran, he was shown to suffer from obvious limitation of motion on rotation of the elbow throughout the entire appeal, making it so that his right elbow disability was more in line with the 20 percent rating for limited pronation rather than a noncompensable rating. While the Veteran's pronation was shown to be better than his supination, the Board finds that the limitation of pronation affords the higher 20 percent rating in line with what was assigned by the RO beginning in January 6, 2020. At multiple times during the appeal period to include in April 2007 and March 2018, the Veteran's pronation was limited to about 50 degrees, which is more similar to the 20 percent rating. Certainly, the hand did not approach full range of motion on pronation at any time. However, a rating higher than 20 percent is not warranted at any time during the appeal period, as there is no evidence of motion lost beyond the middle of arc. Rather, the Veteran's limitation of motion on pronation has been closer to full. 10. A TDIU is granted. It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 38 C.F.R. § 4.16. A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." See 38 C.F.R. §§ 3.340 (a)(1), 4.15. TDIU may be assigned where the schedular rating is less than total and it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the purposes of the above combination, disabilities affecting a single body system, e.g. orthopedic in this case, can be counted together as one disability. Here, the Veteran is in receipt of the minimum 60 percent disability rating throughout the appeal period. Specifically, for the entire appeal period, the Veteran is now in receipt of a 20 percent rating for limitation of flexion of the right elbow, a 20 percent rating for limitation of pronation of the right elbow, a 20 percent rating for a left shoulder disability, and a 10 percent rating for right elbow limitation of extension. These ratings when combined equal one 60 percent rating. They all affect the orthopedic system and thus can be counted as one disability for TDIU purposes. The Veteran was additionally in receipt of a 10 percent rating for psoriasis, a 10 percent rating for tinnitus, and noncompensable ratings for hemorrhoids, bilateral hearing loss, and right elbow and left shoulder scars. The Board finds that the elements of TDIU are met in this case. Specifically, there are multiple physician statements in the record stating that the Veteran's service-connected disabilities preclude activities generally required for employment. In August 2006, the Veteran's private physician stated that the Veteran needed to file for retirement due to his inability to use both of his upper extremities without causing worsening pain and problems. In July 2007, the VA chief of orthopedic surgery stated that the Veteran clearly had sufficient medical issues to cause him to be unable to carry out gainful employment both as far as restriction in the use of his dominant arm due to his right elbow disability and as related to other nonservice-connected orthopedic disabilities. Additionally, multiple VA examinations that have been obtained throughout the history of this case finding that the Veteran's right elbow disability and left shoulder disability cause functional impairment in that the Veteran could not adequately utilize his upper arms to lift or carry. The record reflects that the Veteran worked as a postal carrier prior to accepting a medical retirement due to his inability to carry out his job responsibilities. These records demonstrate that another work accommodation could not be made based upon the severity of the Veteran's disabilities. The record also reflects that the Veteran attempted to work as a substitute bus driver, but due to his right elbow and left shoulder disability, he was unable to maintain that employment. Given the above, the Board finds that the Veteran's service-connected disabilities cause significant impairment to his ability to obtain or maintain gainful employment in line with his educational history and work experience. Accordingly, a TDIU is warranted. Steve Ginski Acting Veterans Law Judge Board of Veterans' Appeals R. Erdheim, Attorney for the Board Department of Veterans Affairs 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.