Citation Nr: 22013399 Decision Date: 03/09/22 Archive Date: 03/09/22 DOCKET NO. 14-18 746A DATE: March 9, 2022 ORDER Entitlement to a rating in excess of 10 percent disabling for service-connected rheumatoid arthritis of the left shoulder prior to May 21, 2009, and in excess of 20 percent disabling thereafter, is denied. Entitlement to a rating in excess of 10 percent disabling for service-connected rheumatoid arthritis of the right shoulder prior to May 21, 2009, and in excess of 20 percent disabling thereafter, is denied. Entitlement to a compensable rating for service-connected rheumatoid arthritis of the left hand prior to May 21, 2009, and in excess of 10 percent disabling thereafter, is denied. Entitlement to a compensable rating for service-connected rheumatoid arthritis of the right hand prior to May 21, 2009, and in excess of 10 percent disabling thereafter, is denied. Entitlement to a rating in excess of 10 percent disabling for service-connected rheumatoid arthritis of the right knee is denied. Entitlement to a separate 10 percent rating, but no higher, for limitation of extension of the Veteran's right knee is granted. Entitlement to a rating in excess of 10 percent disabling for service-connected rheumatoid arthritis of the left ankle is denied. Entitlement to a rating in excess of 10 percent disabling for service-connected rheumatoid arthritis of the right ankle is denied. Entitlement to a compensable rating for service-connected osteoporosis of both feet prior to May 21, 2009, and in excess of 10 percent disabling thereafter, is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities, prior to April 26, 2010, to include extraschedular consideration, is remanded. FINDINGS OF FACT 1. For the period prior to May 21, 2009, the Veteran's rheumatoid arthritis of the left shoulder was active and manifested by limitation of motion of a major joint or group of minor joints, without one or two exacerbations a year, and without more severe manifestations to include symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year, weight loss and anemia productive of severe impairment of health or involving severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods or constitutional manifestations associated with active joint involvement that are totally incapacitating, and without compensable 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, and without malunion or nonunion with or without loose movement or dislocation, ankylosis scapulohumeral articulation, or impairment of the humerus. 2. For the period beginning May 21, 2009, the Veteran's rheumatoid arthritis of the left shoulder is manifested by loss of range of motion of the arm, but not to flexion and/or abduction limited to 25 degrees from side, 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 of the scapulohumeral articulation, impairment of the humerus, or impairment of the clavicle or scapula and without more severe manifestations to include symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year, weight loss and anemia productive of severe impairment of health or involving severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods or constitutional manifestations associated with active joint involvement that are totally incapacitating. 3. For the period prior to May 21, 2009, the Veteran's rheumatoid arthritis of the right shoulder was active and manifested by limitation of motion of a major joint or group of minor joints, without one or two exacerbations a year, and without more severe manifestations to include symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year, weight loss and anemia productive of severe impairment of health or involving severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods or constitutional manifestations associated with active joint involvement that are totally incapacitating, and without compensable 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, and without malunion or nonunion with or without loose movement or dislocation, ankylosis scapulohumeral articulation, or impairment of the humerus. 4. For the period beginning May 21, 2009, the Veteran's rheumatoid arthritis of the right shoulder is manifested by loss of range of motion of the arm, but not to flexion and/or abduction limited to 25 degrees from side, 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 of the scapulohumeral articulation, impairment of the humerus, or impairment of the clavicle or scapula and without more severe manifestations to include symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year, weight loss and anemia productive of severe impairment of health or involving severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods or constitutional manifestations associated with active joint involvement that are totally incapacitating. 5. For the period prior to May 21, 2009, the Veteran's rheumatoid arthritis of the left hand was not an active process and did not manifest by pain or limitation of motion of the wrist or ankylosis. 6. For the period beginning May 21, 2009, the Veteran's rheumatoid arthritis of the left hand is active and manifested by limitation of motion of a major joint or group of minor joints, without one or two exacerbations a year, and without more severe manifestations to include symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year, weight loss and anemia productive of severe impairment of health or involving severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods or constitutional manifestations associated with active joint involvement that are totally incapacitating, or ankylosis. 7. For the period prior to May 21, 2009, the Veteran's rheumatoid arthritis of the right hand was not an active process and did not manifest by pain or limitation of motion of the wrist or ankylosis. 8. For the period beginning May 21, 2009, the Veteran's rheumatoid arthritis of the right hand is active and manifested by limitation of motion of a major joint or group of minor joints, without one or two exacerbations a year, and without more severe manifestations to include symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year, weight loss and anemia productive of severe impairment of health or involving severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods or constitutional manifestations associated with active joint involvement that are totally incapacitating, or ankylosis. 9. The Veteran's rheumatoid arthritis of the right knee is active and manifested by limitation of motion of a major joint or group of minor joints, without one or two exacerbations a year, and without more severe manifestations to include symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year, weight loss and anemia productive of severe impairment of health or involving severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods or constitutional manifestations associated with active joint involvement that are totally incapacitating, or other symptoms so as to limit flexion to 30 degrees or less, or recurrent subluxation or lateral instability, ankylosis, dislocation or removal of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. 10. The Veteran's rheumatoid arthritis of the right knee caused limitation of extension to 10 degrees, without more severe manifestations. 11. The Veteran's rheumatoid arthritis of the left ankle is active and manifested by moderate limitation of motion, without more severe manifestations to include marked limitation of motion, or ankylosis, ankylosis of the subastragalar or tarsal joint, malunion of os calcis or astragalus or limitation of motion of a major joint or group of minor joints, without one or two exacerbations a year, and without more severe manifestations to include symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year, weight loss and anemia productive of severe impairment of health or involving severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods or constitutional manifestations associated with active joint involvement that are totally incapacitating. 12. The Veteran's rheumatoid arthritis of the right ankle is active and manifested by moderate limitation of motion, without more severe manifestations to include marked limitation of motion, or ankylosis, ankylosis of the subastragalar or tarsal joint, malunion of os calcis or astragalus or limitation of motion of a major joint or group of minor joints, without one or two exacerbations a year, and without more severe manifestations to include symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year, weight loss and anemia productive of severe impairment of health or involving severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods or constitutional manifestations associated with active joint involvement that are totally incapacitating. 13. For the period prior to May 21, 2009, the Veteran's osteoporosis of the feet was not manifested by painful or limited motion, or incapacitating exacerbations, plantar fasciitis, acquired flatfoot, bilateral week foot, claw foot (pes cavus), anterior unilateral or bilateral metatarsalgia, unilateral hallux valgus, hammer toe, malunion or nonunion of tarsal or metatarsal bones, or other foot injuries. 14. For the period beginning May 21, 2009, the Veteran's osteoporosis of the feet was manifested by pain and limitation of motion, with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, without more severe manifestations to include incapacitating exacerbations or plantar fasciitis, acquired flatfoot, bilateral week foot, claw foot (pes cavus), anterior unilateral or bilateral metatarsalgia, unilateral hallux valgus, hammer toe, malunion or nonunion of tarsal or metatarsal bones, or other foot injuries. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent disabling prior to May 21, 2009, for service-connected rheumatoid arthritis of the left shoulder have not been met. 38 U.S.C. §§ 1155, 5107; 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 Codes 5002-5203. 2. The criteria for a rating in excess of 20 percent disabling beginning May 21, 2009, for service-connected rheumatoid arthritis of the left shoulder have not been met. 38 U.S.C. §§ 1155, 5107; 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 Codes 5002-5201. 3. The criteria for a rating in excess of 10 percent disabling prior to May 21, 2009, for service-connected rheumatoid arthritis of the right shoulder have not been met. 38 U.S.C. §§ 1155, 5107; 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 Codes 5002-5203. 4. The criteria for a rating in excess of 20 percent disabling beginning May 21, 2009, for service-connected rheumatoid arthritis of the right shoulder have not been met. 38 U.S.C. §§ 1155, 5107; 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 Codes 5002-5201. 5. The criteria for a compensable rating prior to May 21, 2009, and in excess of 10 percent disabling thereafter, for service-connected rheumatoid arthritis of the left hand have not been met. 38 U.S.C. §§ 1155, 5107; 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 Codes 5002-5215. 6. The criteria for a compensable rating prior to May 21, 2009, and in excess of 10 percent disabling thereafter for service-connected rheumatoid arthritis of the right hand have not been met. 38 U.S.C. §§ 1155, 5107; 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 Codes 5002-5215. 7. The criteria for a rating in excess of 10 percent disabling for service-connected rheumatoid arthritis of the right knee have not been met. 38 U.S.C. §§ 1155, 5107; 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. 8. The criteria for a separate 10 percent rating, but no higher, for limitation of extension of the Veteran's right knee have been met. 38 U.S.C. §§ 1155, 5107; 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 5261. 9. The criteria for a rating in excess of 10 percent disabling for service-connected rheumatoid arthritis of the left ankle have not been met. 38 U.S.C. §§ 1155, 5107; 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 Codes 5002-5271. 10. The criteria for a rating in excess of 10 percent disabling for service-connected rheumatoid arthritis of the right ankle have not been met. 38 U.S.C. §§ 1155, 5107; 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 Codes 5002-5271. 11. The criteria for a compensable rating prior to May 21, 2009, and in excess of 10 percent disabling thereafter for service-connected osteoporosis of both feet have not been met. 38 U.S.C. §§ 1155, 5107; 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 Codes 5002-5013. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 1966 to August 1968, to include service in the Republic of Vietnam. These matters come before the Board of Veterans' Appeals (Board) from an October 2009 Rating Decision of a Department of Veterans Affairs (VA) Regional Office (RO). These issues were previously before the Board in October 2019. The Board acknowledges that its October 2019 decision also remanded the issue of entitlement to service connection for an acquired psychiatric disorder for additional development. However, in a February 2021 Rating Decision, the RO granted entitlement to service connection for posttraumatic stress disorder (PTSD). As this constitutes a full grant of the benefit sought on appeal with respect to this issue, it is no longer before the Board. The Board's October 2019 decision also denied the Veteran's claims of entitlement to a rating in excess of 20 percent for rheumatoid arthritis of the right shoulder, a rating in excess of 20 percent for rheumatoid arthritis of the left shoulder, a rating in excess of 10 percent for rheumatoid arthritis of the right hand, a rating in excess of 10 percent for rheumatoid arthritis of the left hand, a rating in excess of 10percentfor rheumatoid arthritis of the right knee, a rating in excess of 10 percent for rheumatoid arthritis of the right ankle, a rating in excess of 10 percent for rheumatoid arthritis of the left ankle, and a rating in excess of 10 percent for osteoporosis of both feet. Thereafter, the Veteran appealed the Board's October 2019 decision to the United States Court of Appeals for Veterans Claims (Court). In a November 2020 Joint Motion for Partial Remand (JMPR) and accompanying Court Order, the Court vacated the October 2019 Board decision to the extent that it denied higher disability ratings for the Veteran's service-connected rheumatoid arthritis of the right shoulder, rheumatoid arthritis of the left shoulder, rheumatoid arthritis of the right hand, rheumatoid arthritis of the left hand, rheumatoid arthritis of the right knee, rheumatoid arthritis of the right ankle, rheumatoid arthritis of the left ankle, and osteoporosis of both feet, and then remanded these issues to the Board with directions to further develop the file in support of the Veteran's claims. In June 2021, the Board remanded the claims for further development and adjudication. The Board finds that there was substantial compliance with its June 2021 remand directives. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). Nonetheless, it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to an internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). Finally, the Board notes that in an August 2021 Rating Decision, the RO granted an earlier effective date for the Veteran's TDIU. The RO found that the Veteran's TDIU should be effective April 26, 2010, the date upon which the Veteran met the schedular criteria for a TDIU. However, the Board notes that the Veteran has contended that his disabilities rendered him unemployable prior to such date, and therefore extraschedular consideration should be considered. Increased Rating The Veteran contends that his service-connected rheumatoid arthritis and osteoporosis in his bilateral shoulders, hands, ankles, feet, and right knee are worse than his current ratings reflect. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. 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. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). While the Veteran's entire history is reviewed when making a disability determination, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that, in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the Veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, are expected in all instances. 38 C.F.R. § 4.21. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). 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. 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The instant appeal stems from the Veteran's claims for increased ratings for his service-connected joints affected by rheumatoid arthritis and osteoporosis, which he filed in May 2009. Therefore, the appeal period begins May 2008. Entitlement to ratings in excess of 10 percent disabling for service-connected rheumatoid arthritis of the left and right shoulders prior to May 21, 2009, and in excess of 20 percent disabling thereafter, are denied. The Veteran's rheumatoid arthritis of the left and right shoulders is rated under Diagnostic Codes 5002-5201. Hyphenated codes are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27. The hyphenated diagnostic codes in this case indicate that multi-joint arthritis under Diagnostic Code 5002 is the service-connected disorder and that limitation of motion of the arm under Diagnostic Code 5201 is the residual condition. In this regard, such disabilities were rated as 10 percent disabling effective February 2, 2001, to May 21, 2009, under Diagnostic Codes 5002-5203, and 20 percent disabling thereafter, pursuant to Diagnostic Codes 5010-5201. Under Diagnostic Code 5002, constitutional manifestations associated with active joint involvement that are totally incapacitating warrants a 100 percent evaluation. A 60 percent evaluation is warranted when the condition is less than the criteria for 100 percent, but with weight loss and anemia productive of severe impairment of health or involving severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods. Symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year warrants a 40 percent evaluation. One or two exacerbations a year in a well-established diagnosis warrants a 20 percent evaluation. Otherwise, chronic residuals are evaluated as follows: for residuals such as limitation of motion or ankylosis, favorable or unfavorable, rate under the appropriate diagnostic codes 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. The ratings for the active process will not be combined with the residual ratings for limitation of motion or ankylosis, and the higher evaluation is to be assigned. See 38 C.F.R. § 4.71a, Diagnostic Code 5002. Under Diagnostic Code 5201, limitation of arm motion that is limited to shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent rating in both the minor and major extremities. Such limitation that is limited midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees) also warrants a 20 percent rating in the minor extremity and a 30 percent rating in the major extremity. Such limitation to 25 degrees from the side (flexion and/or abduction) warrants a 30 percent rating in the minor extremity and a 40 percent rating in the major extremity. 38 C.F.R. § 4.71a. Normal range of motion in the shoulder is from zero to 180 degrees of forward elevation (flexion) and zero to 180 degrees of shoulder abduction. 38 C.F.R. § 4.71a, Plate I. Under Diagnostic Code 5203, impairment of the clavicle or scapula with malunion warrants a 10 percent rating for both the minor and major joints. Such impairment with nonunion without loose movement also warrants a 10 percent rating for both the minor and major joints. Such impairment with nonunion and loose movement warrants a 20 percent rating for both the minor and major joints. Such impairment with dislocation warrants a 20 percent rating for both the minor and major joints. Under 38 C.F.R. § 4.71a, additional diagnostic codes evaluate impairment resulting from arm disorders, including Diagnostic Code 5200 (ankylosis), and Diagnostic Code 5202 (other impairment of the humerus). The normal ranges of motion in the arm and shoulder include shoulder forward flexion zero to 180 degrees, shoulder abduction zero to 90 degrees, shoulder external rotation zero to 90 degrees, shoulder internal rotation zero to 90 degrees. See 38 C.F.R. § 4.71, Plate I. The Board notes that the record, including all the VA examinations, indicates that the Veteran is right hand dominant. Turning to the evidence of record, the Board notes that the Veteran underwent several VA examinations throughout the appeal period, to include in June 2009, April 2015, and August 2021. In June 2009 the Veteran underwent a VA Joints (Shoulder, Elbow, Wrist, Hip, Knee, Ankle) examination. The examiner initially noted that the Veteran was right hand dominant. The Veteran reported that he had been diagnosed with rheumatoid arthritis in his shoulders and that over the years his symptoms had progressed. He noted intermittent pain, weakness, and stiffness, but denied swelling, heat, or redness. He also denied instability or giving way. He did note some locking and fatiguability and lack of endurance with increased activity and lifting. He noted daily morning flare-ups of pain that were not incapacitating, which are alleviated with rest and over the counter (OTC) pain medication. He also denied episodes of dislocation and subluxation and no constitutional symptoms of inflammatory arthritis. Upon examination, the examiner noted no evidence of ankylosis and no constitutional symptoms of inflammatory arthritis. The examiner did note palpable crepitus with passive motion and some guarding. The examiner noted no muscle spasms or atrophy. Range of motion testing revealed bilateral forward flexion of zero to 150 degrees, and abduction was zero to 130 degrees bilaterally. Right shoulder external rotation was zero to 80 degrees with no loss of motion after repetitive testing. Left shoulder external rotation was zero to 70 degrees with no loss of motion after repetitive testing. Right shoulder internal rotation was zero to 70 degrees and left shoulder internal rotation was zero to 70 degrees, both without loss of motion after repetitive testing. X-ray evidence confirmed that the Veteran suffered from rheumatoid arthritis of the bilateral shoulders with osteopenia. In April 2015 the Veteran underwent a VA Shoulder and Arm examination with an accompanying disability benefits questionnaire (DBQ). The examiner noted that the Veteran suffered from bilateral degenerative arthritis. The Veteran reported a history of bilateral rheumatoid arthritis with painful range of motion and sharp and achy pains. He also stated that he was right hand dominant and that flare ups caused pain with motion resulting in difficulty lifting, pushing, or pulling, however the Veteran did not report any functional loss or impairment. Upon examination, the examiner found the Veteran's range of motion was normal bilaterally (flexion zero to 180 degrees, abduction zero to 180 degrees, external rotation zero to 90 degrees, and internal rotation zero to 90 degrees). The examiner noted pain on the examination, specifically in flexion, abduction, and internal rotation, but found that it did not result in or cause functional loss. The examiner also noted no pain with weight bearing or objective evidence of crepitus, or localized pain on palpation. The examiner noted that the Veteran was able to perform repetitive use testing and that there was no additional loss of function or range of motion. The examiner noted that the examination was not being conducted immediately after repetitive use over time or during a flare-up. The examiner noted that the examination neither supports nor contradicts the Veteran's statements describing functional loss with repetitive use over time or during a flare-up. Furthermore, the examiner noted that he could not say without resorting to speculation whether pain, weakness, fatigability, or incoordination significantly limit functional ability. The examiner noted that there was no conceptual or empirical basis for making such a determination without directly observing function under such conditions. Muscle strength testing was all normal and without evidence of muscle atrophy. The examiner also noted no rotator cuff conditions, instability, dislocation or labral pathology, clavicle, scapula, acromioclavicular joint and sternoclavicular joint conditions, or conditions or impairments of the humerus. Finally, the examiner found no evidence of ankylosis. Following the Board's remand in June 2021, an additional examination was requested. In August 2021 the Veteran underwent an additional VA Shoulder and Arm examination with an accompanying DBQ. The Veteran reported that he was right hand dominant and the examiner noted that the Veteran suffered from bilateral rheumatoid arthritis. The Veteran reported sharp and achy pains and that he took OTS pain medication. He further noted that there was always something that cased a flare of his pain, i.e. push, pull, lift, and carry, reach above his head. Upon examination, the examiner found the Veteran's range of motion was normal bilaterally (flexion zero to 180 degrees, abduction zero to 180 degrees, external rotation zero to 90 degrees, and internal rotation zero to 90 degrees). The examiner noted pain on all directions during examination. Furthermore, the examiner noted that range of motion was the same during passive motion to include pain. In addition, the examiner noted pain during both weight bearing and non-weight bearing. In addition, the examiner noted that such pain caused functional loss as the Veteran stated that shoulder pain reduced his ability to push, pull, lift, and carry, or reach above his head. The examiner found no objective evidence of crepitus but did note evidence of localized tenderness or pain on palpation. Range of motion testing after observed repetitive use showed additional loss of function after testing due to pain. Right shoulder flexion zero to 170 degrees, abduction zero to 170 degrees, internal rotation zero to 90 degrees, and external rotation zero to 90 degrees. Left shoulder flexion zero to 175 degrees, abduction zero to 175 degrees, internal rotation zero to 90 degrees, external rotation zero to 90 degrees. Furthermore, range of motion testing after repeated use over time showed additional functional loss due to pain. Range of motion testing revealed right shoulder flexion zero to 170 degrees, abduction zero to 170 degrees, internal rotation zero to 90 degrees, external rotation zero to 90 degrees. Left shoulder flexion zero to 175 degrees, abduction zero to 175 degrees, internal rotation zero to 90 degrees, external rotation zero to 90 degrees. In addition the examiner noted that while the examination was not being conducted during a flare-up, the examiner noted that additional functional loss due to pain would result. Furthermore, he noted that right shoulder flexion was zero to 170 degrees, abduction zero to 170 degrees, internal rotation zero to 85 degrees, external rotation zero to 85 degrees. Left shoulder flexion was zero to 170 degrees, abduction zero to 170 degrees, internal rotation zero to 85 degrees, and external rotation zero to 85 degrees. The examiner found no evidence of muscle atrophy, ankylosis, rotator cuff conditions, shoulder instability, dislocation or labral pathology, clavicle, scapula, acromioclavicular joint and sternoclavicular joint conditions, conditions, or impairments of the humerus. Furthermore, while the Veteran consistently sought treatment through VA for his rheumatoid arthritis, to include pain, during the appeal period, such do not reflect any additional findings pertinent to the rating criteria that were not documented at the aforementioned VA examinations. Period prior to May 21, 2009 Based on the foregoing, the Board finds that for the period prior to May 21, 2009, a rating in excess of 10 percent is not warranted for the Veteran's rheumatoid arthritis of the left and right shoulders under Diagnostic Codes 5002-5203. In this regard, while such disability resulted in limitation of motion, such was not limited to shoulder level or midway between his side and shoulder level, 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. Rather, the Veteran's bilateral shoulder abduction and flexion was limited to, at most, a range above his shoulder. Furthermore, while the Veteran reported additional pain after use or during flare-ups, there is no indication that such additional symptoms resulted in functional loss that more nearly approximates limitation of the arms to shoulder level or to midway between his side and shoulder level. Furthermore, there was no evidence of malunion, nonunion or dislocation of the scapula. Finally there is no evidence of any constitutional manifestations of inflammatory arthritis. Therefore, the Veteran is not entitled to a rating in excess of 10 percent disabling for the period prior to May 21, 2009, under Diagnostic Codes 5002-5203. The Board further finds that a separate or higher rating is not warranted under any other potentially applicable Diagnostic Codes related to the shoulder for the period prior to May 21, 2009. In this regard, the evidence, to include treatment records, does not show, nor does the Veteran contend, that his bilateral shoulder disabilities resulted in ankylosis of the scapulohumeral articulation, limitation of motion of the arm, or impairment of the humerus. Consequently, higher, or separate ratings are not warranted under Diagnostic Codes 5200, 5201, and 5202, respectively. Finally, while the 20, 40, 60, or 100 percent evaluations under Diagnostic Code 5002 are higher than the current 10 percent evaluations, as previously noted the evidence does not show constitutional manifestations of inflammatory arthritis or that his arthritis is productive of one or two exacerbations per year, incapacitation, severe impairment of health, or severely incapacitating exacerbations. As such, a higher rating under Diagnostic Code 5002 is not warranted. Therefore, the evidence shows that the Veteran is not entitled to a rating in excess of 10 percent disabling or an additional separate rating for his service-connected bilateral shoulder disabilities prior to May 21, 2009. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Period beginning May 21, 2009 Based on the foregoing, the Board finds that for the period beginning May 21, 2009, a rating in excess of 20 percent is not warranted for the Veteran's rheumatoid arthritis of the left and right shoulders under Diagnostic Codes 5002-5201. In this regard, while such disability results in the loss of range of motion of the arm, such is not limited to flexion and/or abduction limited to midway between his side and shoulder level (flexion and/or abduction limited to 45 degrees) or 25 degrees from his side, 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. In this regard, the VA examinations of record reflect that the Veteran's flexion and abduction were normal during range of motion testing. See June 2009, April 2015, and August 2021 VA examinations. Furthermore, the June 2009 examiner noted no additional loss of motion after repetitive testing. While the April 2015 examiner found that he could not provide an opinion or range of motion testing results without resulting to speculation in regard to repetitive use, use over time, and flare-ups, the August 2021 examiner noted some reduction in function under such conditions, but the most restrictive measurements were flexion and abduction to 170 degrees. Therefore, there is no objective reliable evidence that the Veteran's bilateral shoulder disability resulted in limitation of motion midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) or flexion and/or abduction limited to 25 degrees from his side. In addition, there is no evidence of any constitutional manifestations of inflammatory arthritis. Therefore, the Veteran is not entitled to a rating in excess of 20 percent disabling for the period beginning May 21, 2009, under Diagnostic Code 5201 for limitation of motion or under Diagnostic Code 5002 for multi-joint arthritis. The Board further finds that a separate or higher rating is not warranted under any other potentially applicable Diagnostic Codes related to the shoulder for the period beginning May 21, 2009. In this regard, the evidence, to include VA examination reports and treatment records, does not show, nor did the Veteran contend, that his bilateral shoulder disability resulted in ankylosis of the scapulohumeral articulation, impairment of the humerus, or impairment of the clavicle or scapula. Consequently, higher, or separate ratings are not warranted under Diagnostic Codes 5200, 5202, and 5203, respectively. Finally, while the 40, 60, or 100 percent evaluations under Diagnostic Code 5002 are higher than the current 20 percent evaluations, as previously noted, the evidence does not show that the Veteran's rheumatoid arthritis of the bilateral shoulders, is productive of incapacitation, severe impairment of health, or severely incapacitating exacerbations. As such, a higher rating under Diagnostic Code 5002 is not warranted. Therefore, the evidence shows that the Veteran is not entitled to a rating in excess of 20 percent disabling or an additional separate rating for his service-connected bilateral shoulder disabilities beginning May 21, 2009. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Entitlement to compensable ratings for service-connected rheumatoid arthritis of the left and right hands prior to May 21, 2009, and in excess of 10 percent disabling thereafter, are denied. The Veteran's rheumatoid arthritis of the left and right hands is rated under Diagnostic Codes 5002-5215. Again hyphenated codes are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27. The hyphenated diagnostic codes in this case indicate that multi-joint arthritis under Diagnostic Code 5002 is the service-connected disorder and that limitation of motion of the wrist under Diagnostic Code 5215 is the residual condition. In this regard, such disabilities are rated as noncompensable prior to May 21, 2009, and 10 percent disabling thereafter, pursuant to Diagnostic Codes 5002-5215. Under Diagnostic Code 5215, limitation of the wrist that results in palmar flexion limited in line with the forearm warrants a 10 percent rating for both the minor and major extremities. Such limitation that results in dorsiflexion less than 15 degrees warrants a 10 percent rating for both the minor and major extremities. Under 38 C.F.R. § 4.71a, an additional diagnostic code used to evaluate impairment resulting from wrist disorders, is Diagnostic Code 5214 (ankylosis). The normal ranges of motion in the wrist include dorsiflexion extension zero to 70 degrees, wrist palmar flexion zero to 80 degrees, wrist ulnar deviation zero to 45 degrees, and radial deviation zero to 20 degrees. See 38 C.F.R. § 4.71, Plate I. Under 38 C.F.R. § 4.71a, additional diagnostic codes used to evaluate impairment resulting from finger disorders, are Diagnostic Code 5216 (unfavorable ankylosis of five digits of one hand), Diagnostic Code 5217 (unfavorable ankylosis of four digits of one hand), Diagnostic Code 5218 (unfavorable ankylosis of three digits of one hand), Diagnostic Code 5219 (unfavorable ankylosis two digits of one hand), Diagnostic Code 5220 (favorable ankylosis of five digits of one hand), Diagnostic Code 5221 (favorable ankylosis of four digits of one hand), Diagnostic Code 5222 (favorable ankylosis of three digits of one hand), Diagnostic Code 5223 (favorable ankylosis of two digits of one hand), Diagnostic Code 5224 (ankylosis of thumb), Diagnostic Code 5225 (ankylosis of index finger), Diagnostic Code 5226 (ankylosis of long finger), Diagnostic Code 5227 (ankylosis of ring or little finger), Diagnostic Code 5228 (limitation of motion of the thumb), Diagnostic Code 5229 (limitation of motion of the index or long finger), and Diagnostic Code 5230 (limitation of motion of ring or little finger). Turning to the evidence of record, the Board notes that the Veteran underwent several VA examinations throughout the appeal period, to include in June 2009, April 2015, and August 2021. In June 2009 the Veteran underwent a VA Joints (Shoulder, Elbow, Wrist, Hip, Knee, Ankle) examination. The Veteran reported a history of rheumatoid arthritis in both hands/wrists and that he was right hand dominant. The Veteran stated that he suffered pain, weakness, and stiffness along with swelling. The Veteran denied redness, instability, giving way, locking, or fatigability or lack of endurance. The Veteran also reported that he took OTC pain medication. The Veteran reported daily flare-ups of pain, but denied any periods of incapacitation. The examiner noted that the Veteran suffered from bilateral hand rheumatoid arthritis. Upon examination, the examiner noted no evidence of ankylosis, edema, effusion, redness, or heat, and no pain with palpation. Strength testing was 4/5 due to weakness and pain. The examiner noted that the Veteran could push and pull as well as twist, but did exhibit decreased strength. Range of motion testing revealed that the Veteran's right wrist dorsiflexion was zero to 50 degrees, with no loss of motion after three repetitions. Left wrist dorsiflexion was zero to 60 degrees with no loss of motion after three repetitions. Right wrist extension was zero to 50 degrees with no loss of motion after three repetitions. Left wrist extension was zero to 60 degrees with no loss of motion after three repetitions. Right wrist palmar flexion was zero to 80 degrees with no loss of motion after three repetitions. Left wrist palmar flexion was zero to 80 degrees with no loss of motion after three repetitions. The Veteran was additionally limited first by pain, second by weakness after repetitious activity. However, he was not additionally limited by fatigability, lack of endurance, and in-coordination with repetitious activity of range of motion. Range of motion of the Veteran's fingers (index, long, ring and little fingers, bilaterally) was normal. Metacarpophalangeal (MCP) joint flexion was zero to 80 degrees. Proximal Interphalangeal (PIP) joint flexion was zero to 100 degrees, and Distal Interphalangeal (DIP) joint flexion was zero to 70 degrees. There was no loss of motion after three repetitions of metacarpophalangeal joint flexion, proximal interphalangeal joint flexion, and distal interphalangeal joint flexion after three repetitions of active range of motion. The Veteran was not additionally limited by pain, weakness, fatigability, and lack of endurance and in-coordination with repetitious activity of the bilateral hands and fingers. In April 2015 the Veteran underwent a VA Hand and Fingers examination with an accompanying DBQ. The examiner noted that the Veteran had bilateral hand rheumatoid arthritis. The Veteran reported that he was right hand dominant and that he experienced aches, pains, and stiffness as well as reduced grip strength. He reported taking OTC pain medication. The Veteran further reported flare-ups of pain and stiffness which limited grasping, pushing, pulling, and lifting. Upon examination, the examiner noted that there was no limitation of motion or evidence of painful motion for any fingers or thumb. The examiner noted that the Veteran was able to perform repetitive-use testing and that there was no additional limitation of motion for any fingers, no gap between the thumb pad and the fingers, no gap between any fingertips and the proximal transverse crease of the palm in attempting to touch the palm with the fingertips, and no limitation of extension. The examiner further found no functional loss or functional impairment of any of the fingers or thumbs, and no additional limitation in range of motion after repetitive use testing. The examiner noted that muscle strength testing was 4/5 and that there was no pain on palpation or ankylosis. Following the Board's remand in June 2021, an additional examination was requested. In August 2021 the Veteran underwent another VA Hand and Fingers examination with an accompanying DBQ. The Veteran reported that he was right hand dominant and that he suffered sharp and achy pains with increased activity of his hands. He reported taking OTC pain medication. The Veteran further reported daily flare-ups of pain and functional loss and impairment in a reduced ability to perform grasping, gripping, and dropping. Upon examination, the examiner noted that the Veteran's range of motion testing was all normal. Bilateral index finger flexion was MCP 90 degrees, PIP 100 degrees, DIP 70 degrees; extension was MCP, PIP, and DIP were 0 degrees. Bilateral long finger flexion was MCP 90 degrees, PIP 100 degrees, DIP 70 degrees; extension was MCP, PIP, and DIP were 0 degrees. Bilateral ring finger flexion MCP 90 degrees, PIP 100 degrees, DIP 70 degrees; extension MCP, PIP, and DIP 0 degrees. Bilateral little finger flexion MCP 90 degrees, PIP 100 degrees, DIP 70 degrees; extension MCP, PIP, DIP were 0 degrees. Bilateral thumb flexion MCP 100 degrees, IP 90 degrees, extension MCP and IP were 0 degrees. The examiner noted that there was no gap between the thumb and fingers, no gap between the finger and proximal transverse crease of the hand on maximal finger flexion, and no objective evidence of localized tenderness or pain on palpation. The examiner noted that passive range of motion testing had the same results as active range of motion. The examiner noted no pain in the right hand on examination, but pain with weight bearing non-weight bearing in the left hand. The examiner noted that the Veteran was able to perform observed repetitive use testing and that such did not result in additional loss of function or range of motion. They also noted that the examination was conducted immediately after repeated use over time and that the Veteran suffered pain as a result. Range of motion testing revealed bilateral index finger flexion was MCP 90 degrees, PIP 100 degrees, DIP 70 degrees; extension was MCP, PIP, and DIP were 0 degrees. Bilateral long finger flexion was MCP 90 degrees, PIP 100 degrees, DIP 70 degrees; extension was MCP, PIP, and DIP were 0 degrees. Bilateral ring finger flexion MCP 90 degrees, PIP 100 degrees, DIP 70 degrees; extension MCP, PIP, and DIP 0 degrees. Bilateral little finger flexion MCP 90 degrees, PIP 100 degrees, DIP 70 degrees; extension MCP, PIP, DIP were 0 degrees. Bilateral thumb flexion MCP 100 degrees, IP 90 degrees, extension MCP and IP were 0 degrees. The examiner further noted that the Veteran was not being examined during a flare-up, however procured evidence suggested pain in the right hand during a flare-up but not in the left. Range of motion testing indicated right hand index finger flexion would be MCP 85 degrees, PIP 95 degrees, DIP 65 degrees; extension would be MCP, PIP, and DIP at 0 degrees. Right hand long finger flexion would be MCP 85 degrees, PIP 95 degrees, DIP 65 degrees; extension would be MCP, PIP, and DIP at 0 degrees. Right hand ring finger flexion MCP 85 degrees, PIP 95 degrees, DIP 65 degrees; extension MCP, PIP, and DIP at 0 degrees. Right hand little finger flexion MCP 85 degrees, PIP 95 degrees, DIP 65 degrees; extension MCP, PIP, DIP at 0 degrees. Right hand thumb flexion MCP 95 degrees, IP 85 degrees, extension MCP and IP would be 0 degrees. Muscle strength testing was normal and no evidence of muscle atrophy. The examiner found no evidence of ankylosis. Furthermore, while the Veteran consistently sought treatment through VA for his rheumatoid arthritis during the appeal period, such do not reflect any additional findings pertinent to the rating criteria that were not documented at the aforementioned VA examinations. Period prior to May 21, 2009 Based on the foregoing, the Board finds that for the period prior to May 21, 2009, a compensable rating is not warranted for the Veteran's rheumatoid arthritis of the left and right hands under Diagnostic Codes 5002-5215. In this regard, such disabilities resulted in no pain or 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. Rather, the Veteran's bilateral hand condition symptoms appeared to be resolved and not active, as the evidence does not show constitutional manifestations of inflammatory arthritis. Furthermore, there is no evidence that the Veteran's bilateral hand conditions resulted in dorsiflexion less than 15 degrees or palmar flexion limited in line with the forearm. Furthermore, while the Veteran reported additional pain after use or during flare-ups, there is no indication that such symptoms resulted in functional loss that more nearly approximates dorsiflexion less than 15 degrees or palmar flexion limited in line with the forearm. Therefore, the Veteran is not entitled to a compensable rating for the period prior to May 21, 2009, under Diagnostic Codes 5002-5215. The Board further finds that a separate or higher rating is not warranted under any other potentially applicable Diagnostic Codes related to the hand, to include Diagnostic Codes for the wrist and fingers, for the period prior to May 21, 2009. In this regard, the evidence, to include treatment records, does not show, nor did the Veteran contend, that his bilateral hand disabilities resulted in ankylosis of the wrist, unfavorable ankylosis of five digits of one hand, unfavorable ankylosis of four digits of one hand, unfavorable ankylosis of three digits of one hand, unfavorable ankylosis two digits of one hand, favorable ankylosis of five digits of one hand, favorable ankylosis of four digits of one hand, favorable ankylosis of three digits of one hand, favorable ankylosis of two digits of one hand, ankylosis of thumb, ankylosis of index finger, ankylosis of long finger, ankylosis of ring or little finger, limitation of motion of the thumb, limitation of motion of the index or long finger, and limitation of motion of ring or little finger. Consequently, higher, or separate ratings are not warranted under Diagnostic Codes 5214, 5217, 5218, 5219, 5220, 5221, 5222, 5223, 5224, 5225, 5226, 5227, 5228, 5229, and 5230, respectively Finally while the 10, 20, 40, 60, or 100 percent evaluations under Diagnostic Code 5002 are higher than the current noncompensable evaluations, the evidence does not show that the Veteran's rheumatoid arthritis of the bilateral hands, was an active process and productive of one or two exacerbations per year, incapacitation, severe impairment of health, or severely incapacitating exacerbations. As such, a higher rating under Diagnostic Code 5002 is not warranted. Therefore, the evidence shows that the Veteran is not entitled to a compensable rating or an additional separate rating for his service-connected bilateral hand disabilities prior to May 21, 2009. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Period beginning May 21, 2009 Based on the foregoing, the Board finds that for the period beginning May 21, 2009, a rating in excess of 10 percent disabling is not warranted for the Veteran's rheumatoid arthritis of the left and right hands under Diagnostic Codes 5002-5215. In this regard, while such disability resulted in limitation of motion, such was not limited to dorsiflexion less than 15 degrees, or palmar flexion limited in line with the forearm, 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. Rather, the Veteran's bilateral hand condition resulted in minor painful motion. Furthermore, while the Veteran reported additional pain after use or during flare-ups, there is no indication that such additional symptoms resulted in functional loss that more nearly approximates dorsiflexion less than 15 degrees, or palmar flexion limited in line with the forearm. Furthermore, there is no evidence that the Veteran's bilateral hand disabilities result in occasional incapacitating exacerbations. Therefore, the Veteran is not entitled to a rating in excess of 10 percent disabling beginning May 21, 2009, under Diagnostic Codes 5002-5215. The Board further finds that a separate or higher rating is not warranted under any other potentially applicable Diagnostic Codes related to the hand, to include Diagnostic Codes for the wrist and fingers, for the period beginning May 21, 2009. In this regard, the evidence, to include treatment records, does not show, nor did the Veteran contend, that his bilateral hand disabilities resulted in ankylosis of the wrist, unfavorable ankylosis of five digits of one hand, unfavorable ankylosis of four digits of one hand, unfavorable ankylosis of three digits of one hand, unfavorable ankylosis two digits of one hand, favorable ankylosis of five digits of one hand, favorable ankylosis of four digits of one hand, favorable ankylosis of three digits of one hand, favorable ankylosis of two digits of one hand, ankylosis of thumb, ankylosis of index finger, ankylosis of long finger, ankylosis of ring or little finger, limitation of motion of the thumb, limitation of motion of the index or long finger, and limitation of motion of ring or little finger. Consequently, higher, or separate ratings are not warranted under Diagnostic Codes 5214, 5217, 5218, 5219, 5220, 5221, 5222, 5223, 5224, 5225, 5226, 5227, 5228, 5229, and 5230, respectively Finally, while the 20, 40, 60, or 100 percent evaluations under Diagnostic Code 5002 are higher than the current 10 percent evaluations, the evidence does not show that the Veteran's rheumatoid arthritis of the bilateral hands, is productive of one or two exacerbations per year, incapacitation, severe impairment of health, or severely incapacitating exacerbations. As such, a higher rating under Diagnostic Code 5002 is not warranted. Therefore, the evidence shows that the Veteran is not entitled to a rating in excess of 10 percent disabling or an additional separate rating for his service-connected bilateral hand disabilities beginning May 21, 2009. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Entitlement to a rating in excess of 10 percent disabling for service-connected rheumatoid arthritis of the right knee is denied; entitlement to a separate 10 percent rating, but no higher, for limitation of extension of the Veteran's right knee is granted. The Veteran's rheumatoid arthritis of the right knee is rated under Diagnostic Code 5002 for multi-joint arthritis. It is rated as 10 percent disabling, pursuant to Diagnostic Code 5002. Under 38 C.F.R. § 4.71a, additional potentially applicable diagnostic codes must be considered to include Diagnostic Codes 5257, 5260, and 5261. Limitation of motion of the knee is contemplated in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. 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 evaluation where flexion of the leg is only limited to 60 degrees. For a 10 percent evaluation, flexion must be limited to 45 degrees. A 20 percent evaluation is warranted where flexion is limited to 30 degrees. A 30 percent evaluation may be assigned where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a zero percent evaluation where extension of the leg is limited to five degrees. A 10 percent evaluation requires extension limited to 10 degrees. A 20 percent evaluation is warranted where extension is limited to 15 degrees. A 30 percent evaluation may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent evaluation, extension must be limited to 30 degrees. And finally, where extension is limited to 45 degrees a 50 percent evaluation may be assigned. VA's General Counsel has also stated that separate ratings under Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 (2004). Under 38 C.F.R. § 4.71a, additional diagnostic codes evaluate impairment resulting from knee disorders, including Diagnostic Code 5055 (knee replacement), Diagnostic Code 5256 (ankylosis), Diagnostic Code 5257 (recurrent subluxation or lateral instability), Diagnostic Code 5258 and 5259 (semilunar cartilage dislocated or removal of, symptomatic), Diagnostic Code 5262 (impairment of tibia and fibula-nonunion or malunion), and Diagnostic Code 5263 (genu recurvatum). The normal ranges of motion in the knee include 1400 degrees of flexion and zero degrees of extension. See 38 C.F.R. § 4.71, Plate II. Under Diagnostic 5257, a 10 percent rating is warranted for slight impairment. A 20 percent rating is warranted for moderate impairment. A 30 percent rating is warranted for severe impairment. According to MERRIAM WEBSTER, "moderate" means "tending toward the mean or average amount or dimension". See www.merriam-webster.com/dictionary/moderate. "Severe" means "of a great degree." See www.merriam-webster.com/dictionary/severe. Turning to the evidence of record, the Board notes that the Veteran underwent several VA examinations throughout the appeal period, to include in June 2009, April 2015, and August 2021. In June 2009 the Veteran underwent a VA Joints (Shoulder, Elbow, Wrist, Hip, Knee, Ankle) examination. The Veteran reported a history of rheumatoid arthritis and noted pain and discomfort in his right knee. He also noted daily flare-ups of pain but that such was not constant and was worse in the morning along with stiffness. He also noted swelling, but denied heat and redness. He complained of instability but denied locking, fatigability, and lack of endurance. He reported that he took OTC pain medication. The Veteran reported that during flare-ups, his pain increases for about an hour until his medication takes effect, but he denied being incapacitated during a flare-up. The Veteran further noted that he used a cane to help with ambulating. He denied dislocation or recurrent subluxation and any constitutional symptoms of inflammatory arthritis. Upon examination, the examiner noted that the Veteran's gait was erect with a slight limp favoring his left extremity. His knees were without evidence of edema, effusion, tenderness, heat, redness, or abnormal movements or guarding. Deep tendon reflexes of the knee and ankle were 2+ bilaterally. The examiner further noted that there was evidence of painful motion with passive range of motion but that there were no functional limitations noted with standing or walking. Bilateral peripheral pulses were 2+ and there was no muscle atrophy. Range of motion testing revealed flexion was zero to 130 degrees and there was no loss of motion after three repetitions. Extension was zero to zero degrees with no loss of motion after three repetitions. The Veteran was additionally limited by pain only, and not by weakness, fatigability, lack of endurance, or incoordination after repetitious movement. The examiner found the right knee to be stable. The examiner found the medial and lateral collateral ligaments were intact, anterior, and posterior cruciate ligaments were intact and there was a negative McMurray test. Palpable crepitus was noted with palpation along with audible popping and clicking with ambulation and active range of motion. The examiner confirmed the Veteran's diagnosis of rheumatoid arthritis of the right knee. In April 2015 the Veteran underwent a VA Knee and Lower Leg examination with an accompanying DBQ. The examiner found that the Veteran suffered from bilateral degenerative arthritis. The Veteran reported sharp and achy pain and stiffness as well as flare-ups of pain which limited his ability to walk. The Veteran reported no functional loss or functional impairment. Upon examination, the examiner found that the Veterans range of motion was all normal, his forward flexion was zero to 140 and extension was 140 to zero. The examiner noted pain on the examination (flexion and extension) but that such did not result in or caused functional loss. The examiner noted no pain on palpation and no evidence of pain with weight bearing. However, the examiner did note evidence of crepitus. The examiner also noted that the Veteran was able to perform observed repetitive use testing and that such did not result in any additional loss of function or range of motion. The examiner noted that the examination was not being conducted immediately after repeated use over time or during a flare-up and therefore found that the examination neither supported nor contradicted the Veteran's statements describing functional loss, and that he could not state without resorting to speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability. The examiner stated that there was no conceptual or empirical basis for making such a determination without directly observing such conditions. Muscle strength testing was normal, and the examiner noted no muscle atrophy. Furthermore the examiner found no evidence of ankylosis. Stability testing was normal with no history of recurrent subluxation or lateral instability. The examiner noted no evidence of recurrent patellar dislocation, stress fractures, chronic exertional compartment syndrome or any other tibial or fibular impairment, or meniscal conditions. Following the Board's remand in June 2021, an additional examination was requested. In August 2021 the Veteran underwent an additional VA Knee and Lower Leg examination with an accompanying DBQ. The examiner noted that the Veteran suffered from right knee rheumatoid arthritis. The Veteran reported sharp and achy pain and stiffness as well as flare-ups of pain which limited his ability to walk. The Veteran reported some functional loss or impairment in that he had reduced ability to perform prolonged standing, walking, sitting, squatting, kneeling, stooping, and climbing stairs. However, he denied any history of instability or recurrent subluxation. Upon examination, the examiner noted that the Veteran's range of motion was all normal (flexion to 140 degrees and extension to 0 degrees) but that pain was present. The examiner noted that passive range of motion was the same as active. The examiner found evidence of pain with weight bearing, non-weight bearing, active and passive motion. He noted that such caused functional loss in that it reduced the Veteran's ability to perform prolonged standing, walking, sitting, squatting, kneeling, stooping, and climbing stairs. The examiner found no evidence of crepitus but did note localized tenderness on palpation. Observed repetitive use testing revealed additional loss of range of motion, flexion to 130 degrees and extension to 0 degrees. The examiner noted that pain caused functional loss during observed repetitive use testing. Repeated use testing revealed pain again caused a functional loss and that flexion was to 130 degrees and extension to 0 degrees. Finally, while the examination was not conducted during a flare-up, the examiner concluded that such would cause functional loss due to pain. The examiner found that flexion would be to 120 degrees and extension do 10 degrees. The examiner found no muscle atrophy, ankylosis, recurrent subluxation or persistent instability, ligament tear, tibial or fibular impairment, or meniscal conditions. The examiner further noted that joint stability testing was completed, and anterior, posterior, medial instability and lateral instability were all normal. The examiner further stated that there was no history of any recurrent subluxation, recurrent patellar dislocation, or lateral instability. Furthermore, while the Veteran consistently sought treatment through VA for his rheumatoid arthritis, to include pain, during the appeal period, such do not reflect any additional findings pertinent to the rating criteria that were not documented at the aforementioned VA examinations. Based on the foregoing, the Board finds that a rating in excess of 10 percent for the Veteran's rheumatoid arthritis of the right knee is not warranted. The evidence of record indicates that the Veteran's rheumatoid arthritis is active and causes him pain. However, the evidence does not show that the Veteran's rheumatoid arthritis of the right knee, is productive of one or two exacerbations per year, incapacitation, severe impairment of health, or severely incapacitating exacerbations. As such, a higher rating under Diagnostic Code 5002 is not warranted. Furthermore, the Board finds that a higher or separate rating is not warranted for limitation of motion, specifically limitation of flexion. Even considering additional functional loss due to pain, there is no evidence that flexion is limited to 60 degrees so as to warrant a separate rating under Diagnostic Code 5260. Furthermore, there is no indication that flexion is limited to 30 degrees so as to warrant assignment of a higher rating under Diagnostic Code 5260. While the June 2009 examiner noted that the Veteran's flexion was not normal as the later April 2015 and August 2021 examiners found, the June examiner noted that the Veteran's flexion was only limited to 130 degrees. Furthermore, even the most restricted flexion during a flare up was to 120 degrees, such a measurement is not indicative of a higher rating. Therefore, a higher or separate rating under Diagnostic Code 5260 is not warranted. The Board finds that the Veteran should be awarded a separate 10 percent rating for limitation of extension. While the June 2009 and April 2015 examiners found no limitation in the Veteran's extension, the August 2021 examiner noted that during a flare-up the Veteran's extension would be limited to 10 degrees. However, there is no evidence that the Veteran's extension has ever been limited to 15 degrees or more. Therefore, a separate 10 percent rating, but no higher, under Diagnostic Code 5261 is warranted. The Veteran has reported chronic knee pain and thus, the Board recognizes the application of 38 C.F.R. §§ 4.40 and 4.45, and DeLuca, supra, and Mitchell, supra. However, a higher compensation is not warranted under these provisions because there is no persuasive evidence of additional functional loss due to pain, weakness, fatigue, or incoordination which would limit motion to such a degree so as to warrant a rating in excess of the current 10 percent ratings. Importantly, while the VA examiners noted that the Veteran experienced functional loss due to pain, such did not result in limitation of motion. Moreover, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, does not itself constitute functional loss. Mitchell, 25 Vet. App. at 32. 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. Id. at 11; see 38 C.F.R. § 4.40. In this case, it does not. Therefore, ratings in excess of 10 percent are not warranted based on limitation of motion. Additionally, the Board notes that the Veteran reported instability during the June 2009 examination. However, the examiner found the knee to be stable. Furthermore, the April 2015 examiner noted that stability testing was normal with no history of recurrent subluxation or lateral instability. In addition, the August 2021 examiner performed thorough stability testing and noted that anterior, posterior medial stability and lateral stability were all normal. The examiner further stated that there was no history of any recurrent subluxation, recurrent patellar dislocation, or lateral instability. Finally, the Board notes that the Veteran denied any history of instability or recurrent subluxation during the August 2021 examination. Therefore, a higher or separate rating under Diagnostic Code 5257 is not warranted. Finally, as the evidence of record fails to demonstrate ankylosis, dislocation or removal of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum, the Veteran is not entitled to higher or separate ratings under Diagnostic Codes 5256, 5258, 5259, 5262, or 5263, respectively. Therefore, the evidence shows that while the Veteran is entitled to a separate 10 percent rating for limitation of extension, he is not entitled to ratings in excess of 10 percent disabling or any other additional separate ratings for his service-connected rheumatoid arthritis of the right knee. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Entitlement to ratings in excess of 10 percent disabling for service-connected rheumatoid arthritis of the left and right ankles are denied. The Veteran's rheumatoid arthritis of the left and right ankles is rated under Diagnostic Codes 5002-5271. Again, hyphenated codes are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27. The hyphenated diagnostic codes in this case indicate that multi-joint arthritis under Diagnostic Code 5002 is the service-connected disorder and that limitation of motion of the ankle under Diagnostic Code 5271 is the residual condition. In this regard, such disabilities are rated as 10 percent disabling, pursuant to Diagnostic Codes 5002-5271. Under Diagnostic Code 5271, limitation of motion of the ankle with moderate impairment (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion) warrants a 10 percent rating. Such limitation with marked impairment (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion) warrants a 10 percent rating. Under 38 C.F.R. § 4.71a, additional diagnostic codes evaluate impairment resulting from ankle disorders, including Diagnostic Code 5270 (ankylosis), Diagnostic Code 5272 (ankylosis of subastragalar or tarsal joint), Diagnostic Code 5273 (malunion of os calcis or astragalus), and Diagnostic Code 5274 (astragalectomy). The normal ranges of motion in the ankle include dorsiflexion zero to 20 degrees, and plantar flexion zero to 45 degrees. See 38 C.F.R. § 4.71, Plate II. Turning to the evidence of record, the Board notes that the Veteran underwent several VA examinations throughout the appeal period, to include in June 2009, April 2015, and August 2021. In June 2009 the Veteran underwent a VA Joints (Shoulder, Elbow, Wrist, Hip, Knee, Ankle) examination. The examiner confirmed the Veteran's diagnosis of bilateral ankle rheumatoid arthritis. The Veteran reported that he was diagnosed with bilateral ankle rheumatoid arthritis and that he suffered pain and stiffness, which progressed since his original diagnosis. The Veteran also noted swelling, which was worse in the right ankle than the left, but denied heat and redness. He did note instability or giving out of the ankles, but denied locking. He did complain of fatigability and lack of endurance. The Veteran further noted that he took OTC pain medication which helped to alleviate his symptoms. The Veteran did note daily flare-ups of pain but that such were not incapacitating. He denied dislocation, recurrent subluxation, and any symptoms of inflammatory arthritis. Upon examination the examiner noted edema on the right which was nonpitting at 2+/ Peripheral pulses were 2+, vibratory sensory testing was diminished in the right foot and ankle, however it was adequate in the left. Pinpoint sensory testing was intact and motor strength was 4/5 due to pain and weakness. The examiner noted full active and passive range of motion, but that there is some limitation in his active motion. The Veteran's gait was erect and upright, however it was antalgic. The examiner noted bilateral ankle effusion and objective evidence of tenderness with palpation. There was no evidence of heat, redness, muscle spasms, or muscle atrophy; however the examiner did note guarding. The examiner further found no functional loss with standing or walking. Range of motion testing revealed right ankle dorsiflexion zero to 10 degrees with no loss of motion after three repetitions and plantar flexion zero to 20 degrees with no loss of motion after three repetitions. Left ankle dorsiflexion was zero to 20 degrees with no loss of motion after three repetitions, and plantar flexion was zero to 30 degrees with no loss of motion after three repetitions. The examiner found that the Veteran was additionally limited by pain, weakness, and fatigability with repetitious activity, but not limited by incoordination or lack of endurance. The examiner found no varus or valgus angulations of the os calcis in relationship to the long axis of the tibia and fibula bilaterally. Furthermore there were no constitutional symptoms of inflammatory arthritis during the examination. The examiner found no evidence of unusual shoe wear indicating abnormal weightbearing, no skin breakdown, and no ankylosis. In April 2015 the Veteran underwent a VA Ankle Conditions examination with an accompanying DBQ. The examiner found that the Veteran suffered from bilateral ankle degenerative arthritis. The Veteran reported a history of rheumatoid arthritis and noted sharp achy pains as well as swelling and stiffness. He also reported flare-ups and functional loss or impairment in that he had limited range of motion with weight bearing during flare-ups. The Veteran also noted that he took OTC pain medication to alleviate his symptoms. Upon examination, the examiner found that range of motion testing was normal bilaterally (dorsiflexion zero to 20 degrees and plantar flexion zero to 45 degrees). The examiner noted pain on the examination in both dorsiflexion and plantar flexion but that such did not result in or cause functional loss. The examiner found no objective evidence of localized tenderness or pain on palpation or crepitus, but did note pain with weight bearing. The examiner noted that the Veteran was able to perform repetitive-use testing and that there was no additional loss of function or range of motion. The examiner further noted that the examination was not being conducted immediately after repetitive use over time or during a flare-up, and that the examination neither supported nor contradicted the Veteran's statements describing functional loss with repetitive use over time or during flare-ups. The examiner further stated that he was unable to say without resorting to mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time or during a flare-up as there was no conception or empirical basis for making such a determination without directly observing function under such conditions. The examiner found no additional factors contributing to the Veteran's disabilities. Muscle strength testing was normal and there was no evidence of atrophy. The examiner noted no history of ankle instability, but it appears he did not conduct joint stability testing. The examiner found no evidence of "shin splints," stress fractures, achilles tendonitis, achilles tendon rupture, mal union of calcaneus, astragalectomy, or ankylosis. Following the Board's remand in June 2021, an additional examination was requested. In August 2021 the Veteran underwent an additional VA Ankle Conditions examination with an accompanying DBQ. The examiner noted that the Veteran suffered from bilateral ankle rheumatoid arthritis. The Veteran reported a history of rheumatoid arthritis and noted sharp achy pains as well as swelling and stiffness. He also reported flare-ups and functional loss or impairment in that he had limited range of motion with weight bearing during flare-ups. The Veteran also noted that he took OTC pain medication to alleviate his symptoms. Upon examination, the examiner found that range of motion testing was normal bilaterally (dorsiflexion zero to 20 degrees and plantar flexion zero to 45 degrees). The examiner noted pain on the examination in both dorsiflexion and plantar flexion but that such did not result in a limitation of motion. The examiner noted that passive range of motion was the same as active and that there was evidence of pain in weight bearing, non-weight bearing, active and passive motion as well as during rest and non-movement (right ankle). The examiner noted that such pain caused functional loss in that the Veteran had a reduced ability to stand and walk. The examiner found objective evidence of localized tenderness or pain on palpation, but no crepitus. The examiner noted that the Veteran was able to perform repetitive-use testing and that there was additional loss of function or range of motion as a result. Bilateral dorsiflexion was zero to 15 degrees and plantar flexion was zero to 40 degrees. Repeated use over time testing revealed that pain would result in additional loss of function or range of motion; bilateral dorsiflexion was zero to 15 degrees and plantar flexion was zero to 40 degrees. The examiner noted that while the examination was not being conducted during a flare-up, he did believe that pain would limit function during a flare-up. Estimated range of motion was bilateral dorsiflexion zero to 15 degrees and plantar flexion zero to 35 degrees. The examiner found no additional factors contributing to the Veteran's disability. The examiner found no evidence of muscle atrophy or ankylosis, and joint stability testing was normal. The examiner also found no evidence of shin splints (medial tibial stress syndrome), stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus) or astragalectomy. Furthermore, while the Veteran consistently sought treatment through VA for his rheumatoid arthritis, to include pain during the appeal period, such do not reflect any additional findings pertinent to the rating criteria that were not documented at the aforementioned VA examinations. Based on the foregoing, the Board finds that ratings in excess of 10 percent are not warranted for the Veteran's rheumatoid arthritis of the left and right ankles under Diagnostic Codes 5002-5271. In this regard, while such disability was active and resulted in limitation of motion, such did not result in marked (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion) limitation, 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. Rather, the Veteran's bilateral ankle dorsiflexion and plantar flexion were, at most, moderately limited. See August 2021 VA examination. Furthermore, while the Veteran reported additional pain after use or during flare-ups, there is no indication that such additional symptoms resulted in functional loss that more nearly approximates marked limitation. In addition, the Board notes that the Veteran complained of joint instability or giving out during the June 2009 examination and that it does not appear that the June 2009 examiner addressed such concerns. Furthermore, while the April 2015 examiner found no history of joint instability, it is unclear if the examiner conducted joint stability testing. However, the August 2021 examiner clearly performed such testing and found the Veteran's joint stability to be normal. Therefore, such complained of symptomatology also did not result in functional loss that more nearly approximates marked limitation. Finally there is no evidence of any constitutional manifestations of inflammatory arthritis to include one or two exacerbations per year. Therefore, the Veteran is not entitled to ratings in excess of 10 percent disabling, under Diagnostic Codes 5002-5271. The Board further finds that the evidence of record fails to demonstrate ankylosis, subastragalar or tarsal joint ankylosis, malunion of os calcis or astragalus, or astragalectomy, the Veteran is not entitled to a higher or separate rating under Diagnostic Codes 5270, 5272, 5273, or 5274, respectively. Finally, while the 20, 40, 60, or 100 percent evaluations under Diagnostic Code 5002 are higher than the current 10 percent evaluations, as previously noted, the evidence does not show that the Veteran's rheumatoid arthritis of his bilateral ankles, is productive of one or two exacerbations per year, incapacitation, severe impairment of health, or severely incapacitating exacerbations. As such, higher ratings under Diagnostic Code 5002 are not warranted. Therefore, the evidence shows that the Veteran is not entitled to ratings in excess of 10 percent disabling or additional separate ratings for his service-connected bilateral ankle disabilities. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Entitlement to a compensable rating for service-connected osteoporosis of both feet prior to May 21, 2009, and in excess of 10 percent disabling thereafter, is denied. The Veteran's osteoporosis of both feet is rated under Diagnostic Codes 5002-5013. Again, hyphenated codes are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27. The hyphenated diagnostic codes in this case indicate that multi-joint arthritis under Diagnostic Code 5002 is the service-connected disorder and that residuals of osteoporosis under Diagnostic Code 5013 is the residual condition. In this regard, such disability was rated as noncompensable prior to May 21, 2009, and 10 percent disabling thereafter, pursuant to Diagnostic Codes 5002-5013. Conditions rated under Diagnostic Code 5013 are to be rated as degenerative arthritis, based on limitation of motion of affected parts. 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 code(s) 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. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations warrants a 20 percent evaluation. X-ray evidence of involvement of two or more major joints or two or more minor joints warrants a 10 percent evaluation. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under 38 C.F.R. § 4.71a, additional diagnostic codes evaluate impairment resulting from foot disorders, including Diagnostic Code 5269 (plantar fasciitis), Diagnostic Code 5276 (acquired flatfoot), Diagnostic Code 5277 (bilateral weak foot), Diagnostic Code 5278 (acquired claw foot (pes cavus)), Diagnostic Code 5279 (unilateral or bilateral metatarsalgia anterior (Morton's disease)), Diagnostic Code 5280 (unilateral Hallux valgus), Diagnostic Code 5281 (severe unilateral Hallux rigidus), Diagnostic Code 5282 (Hammer toe), Diagnostic Code 5283 (Malunion of or nonunion of tarsal or metatarsal bones), and Diagnostic Code 5284 (other foot injuries). Turning to the evidence of record, the Board notes that the Veteran underwent several VA examinations throughout the appeal period, to include in June 2009, April 2015, and August 2021. In June 2009 the Veteran underwent a VA Joints (Shoulder, Elbow, Wrist, Hip, Knee, Ankle) examination. The examiner noted that the Veteran reported that he was diagnosed with both rheumatoid arthritis and osteoporosis of the bilateral feet. He noted bilateral foot pain and stiffness. He denied swelling, heat, redness, or instability and giving way. He also denied locking, fatigability, and lack of endurance. He stated that he took OTC pain medication but that his pain was intermittent with periods of flare-ups. He noted that he was not incapacitated during flare-ups or limited motion. He denied dislocation, recurrent subluxation, or any constitutional symptoms of inflammatory arthritis. He also noted no incapacitating episodes. Upon examination the examiner noted no pain. He did note calluses and bunions to the great toes as well as calluses to the palmar surfaces of the feet. The Veteran's gait was antalgic and there was no evidence of breakdown or unusual shoe wear pattern that would indicate abnormal weightbearing to the bilateral feet. There was no skin or vascular changes and no evidence of hammertoes, high arches, pes planus, clawfoot, or other deformities. The Veteran's Achilles tendons were in good alignment and there were no valgus or varus deformities bilaterally. There was no pain with manipulation of the longitudinal arches of the bilateral feet. The examiner found that the Veteran's forefoot and midfoot were in good alignment. There was no hallux valgus deformity and the examination of the metatarsal joints showed that the Veteran had active and passive motion of the metatarsal phalangeal joint of the great toe without pain or tenderness. The Veteran's motor strength is the was normal and there was no muscle atrophy. Peripheral pulses in the dorsalis pedis and posterior tibial are 2+ bilaterally, and there was no evidence of bone disease. The examiner noted degenerative arthritis and hallux valgus on x-ray, but did not note pes planus radiographically. The examiner confirmed a diagnosis of osteoporosis of the bilateral feet with evidence of osteopenia. In April 2015 the Veteran underwent a VA Foot Conditions examination with an accompanying DBQ. The examiner noted that the Veteran suffered from degenerative arthritis, specifically osteoporosis. The Veteran reported a history of rheumatoid arthritis and noted sharp achy pains in his feet. He also reported flare-ups but no functional loss or functional impairment. Upon examination the examiner found no evidence of pes planus, plantar, fasciitis, Morton's neuroma and metatarsalgia, hammer toes, hallux valgus, hallux rigidus, acquired pes cavus (claw foot), malunion or nonunion of tarsal or metatarsal bones, or other foot conditions. The examiner noted that the Veteran reported pain, but such was only subjective. The examiner further found no evidence of functional loss due to his conditions. However, he did note that the Veteran had limited weight bearing during flare-ups with no other functional loss during flare-ups. The examiner found no other pertinent findings, complications, conditions, signs, or symptoms related to the Veteran's disabilities. Following the Board's remand in June 2021, an additional examination was requested. In August 2021 the Veteran underwent an additional VA Foot Conditions examination with an accompanying DBQ. The examiner noted that the Veteran suffered from bilateral foot osteoporosis and rheumatoid arthritis. The Veteran reported a history of degenerative arthritis and osteoporosis, and noted sharp, achy pains in his feet and painful range of motion. He also reported flare-ups that caused functional loss or impairment in that they reduced his ability to stand and walk for prolonged periods of time. He also noted that he took OTC pain medication to alleviate his symptoms. Upon examination the examiner found no evidence of pes planus, plantar fasciitis, Morton's neuroma and metatarsalgia, hammer toes, hallux valgus, hallux rigidus, acquired pes cavus (claw foot), malunion or nonunion of tarsal or metatarsal bones. The examiner noted that such were mild and did not compromise weight bearing, or require the use of orthotics. The examiner noted pain on the physical examination. The Veteran reported that such pain, during flare-ups and/or after repeated use over time, caused reduced function and range of motion with increased pain and overuse. Furthermore, the examiner noted that there was functional loss during flare-ups and/or after repeated use over time which reduced the Veteran's ability to walk and stand. However, the examiner also did not note any pain on passive, active, weight-bearing, non-weight bearing or on rest/non-movement. The examiner found no other pertinent physical findings, complications, conditions, signs, or symptoms related to any of his conditions. The examiner noted a change in the Veteran's condition and diagnosed the Veteran with bilateral foot rheumatoid arthritis, osteoporosis, and plantar keratosis. Furthermore, while the Veteran consistently sought treatment through VA for his rheumatoid arthritis during the appeal period, such do not reflect any additional findings pertinent to the rating criteria that were not documented at the aforementioned VA examinations. Period prior to May 21, 2009 Based on the foregoing, the Board finds that for the period prior to May 21, 2009, compensable ratings are not warranted for the Veteran's bilateral foot osteoporosis under Diagnostic Codes 5002-5013. In this regard, while the Veteran reported pain, there was no objective evidence of painful or limited motion of a major joint or group of minor joints, 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. Rather, as previously noted, the Veteran's record is devoid of objective evidence of painful or limited motion. Finally there is no evidence of any constitutional manifestations of inflammatory arthritis. Therefore, the Veteran is not entitled to compensable ratings for his bilateral foot osteoporosis prior to May 21, 2009, under Diagnostic Codes 5002-5013. The Board further finds that the evidence of record fails to demonstrate plantar fasciitis, acquired flatfoot, bilateral weak foot, acquired claw foot (pes cavus), unilateral or bilateral metatarsalgia anterior (Morton's disease), unilateral Hallux valgus, severe unilateral Hallux rigidus, Hammer toe, malunion of or nonunion of tarsal or metatarsal bones, and other foot injuries. Therefore, the Veteran is not entitled to a higher or separate rating under Diagnostic Codes 5269, 5276, 5277, 5278, 5279, 5280, 5281, 5282, 5283, 5284, respectively. Finally, while the 10, 20, 40, 60, or 100 percent evaluations under Diagnostic Code 5002 are higher than the noncompensable evaluations, the evidence does not show that the Veteran's rheumatoid arthritis and osteoporosis of his bilateral feet, is an active process productive of one or two exacerbations per year, incapacitation, severe impairment of health, or severely incapacitating exacerbations. As such, higher ratings under Diagnostic Code 5002 are not warranted. Therefore, the evidence shows that the Veteran is not entitled to compensable ratings for his service-connected bilateral foot disabilities prior to May 21, 2009. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Period beginning May 21, 2009 Based on the foregoing, the Board finds that for the period beginning May 21, 2009, ratings in excess of 10 percent disabling are not warranted for the Veteran's bilateral foot osteoporosis under Diagnostic Codes 5002-5013. In this regard, while the evidence of record shows objective evidence of painful motion and x-ray evidence of the involvement of 2 or more major joints or 2 or more minor joints groups, there is no evidence of incapacitating exacerbations, 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. Rather, as previously noted, while the Veteran's record reflects painful motion, even reduced functioning and range of motion with flare-ups, there is no evidence of any incapacitating exacerbations and the Veteran denied such. Finally there is no evidence of any constitutional manifestations of inflammatory arthritis. Therefore, the Veteran is not entitled to ratings in excess of 10 percent disabling beginning May 21, 2009, under Diagnostic Codes 5002-5013. The Board further finds that the evidence of record fails to demonstrate plantar fasciitis, acquired flatfoot, bilateral weak foot, acquired claw foot (pes cavus), unilateral or bilateral metatarsalgia anterior (Morton's disease), unilateral Hallux valgus, severe unilateral Hallux rigidus, Hammer toe, malunion of or nonunion of tarsal or metatarsal bones, and other foot injuries. Therefore the Veteran is not entitled to a higher or separate rating under Diagnostic Codes 5269, 5276, 5277, 5278, 5279, 5280, 5281, 5282, 5283, 5284, respectively. Finally, while the 20, 40, 60, or 100 percent evaluations under Diagnostic Code 5002 are higher than the current 10 percent disability ratings, the evidence does not show that the Veteran's rheumatoid arthritis and osteoporosis of his bilateral feet, is not productive of one or two exacerbations per year, incapacitation, severe impairment of health, or severely incapacitating exacerbations. As such, higher ratings under Diagnostic Code 5002 are not warranted. Therefore, the evidence shows that the Veteran is not entitled to ratings in excess of 10 percent disabling for his service-connected bilateral foot disabilities beginning May 21, 2009. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Other Considerations In reaching its conclusions in the instant case, the Board acknowledges the Veteran's beliefs that his symptoms associated with his service-connected disabilities are more severe than is reflected by the 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. While the Board recognizes that the Veteran is competent to describe his symptomatology, he is not competent to provide opinions regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Ultimately, 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 the Veteran's reports regarding the severity of his disabilities. The Board has considered whether further staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected disabilities. However, the Board finds that his symptomatology has been stable throughout each stage of the appeal period. Therefore, assigning further staged ratings for such disabilities is not warranted. Furthermore, neither the Veteran nor his representative 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). Consequently, the Board finds that higher ratings for the Veteran's service-connected rheumatoid arthritis and osteoporosis are not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the evidence is against the claims. Therefore, the benefit of the doubt doctrine is not applicable in the instant appeal and the increased rating claims must be denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities, prior to April 26, 2010, to include extraschedular consideration, is remanded. The Board notes that while the Veteran does not meet the schedular requirements for a TDIU prior to April 26, 2010, he asserts that his conditions prevented him from securing substantially gainful employment beginning in 2000; that his disabilities present an unusual disability picture that would entitle him to a TDIU on an extraschedular basis. See 38 C.F.R. § 4.16 (a). The Board notes that it cannot make a determination about entitlement to a TDIU on an extraschedular basis in the first instance, and as the Veteran does not meet the schedular criteria prior to April 26, 2010, the agency of original jurisdiction (AOJ) should consider entitlement to an extraschedular TDIU. The matters are REMANDED for the following action: Refer the Veteran's claim for a TDIU prior to April 26, 2010, to VA's Director of Compensation Service for extraschedular consideration. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Unger, 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.