Citation Nr: 22016340 Decision Date: 03/22/22 Archive Date: 03/21/22 DOCKET NO. 16-11 526 DATE: March 22, 2022 ORDER For the appeal period prior to December 2, 2016, entitlement to a rating in excess of 20 percent for residuals of a hyperextension injury of the right elbow with mild degenerative changes (impairment of supination/pronation) is denied. From December 2, 2016, entitlement to a 30 percent rating, but no higher, for residuals of a hyperextension injury of the right elbow with mild degenerative changes (impairment of supination/pronation) is granted. Entitlement to a rating in excess of 10 percent for residuals of a hyperextension injury of the right elbow with mild degenerative changes and limited painful motion is denied. FINDINGS OF FACT 1. For the appeal period prior to December 2, 2016, the Veteran's residuals of hyperextension injury of the right elbow with mild degenerative changes (impairment of supination/pronation) more nearly approximates limitation of pronation with motion lost beyond last quarter of the arc. 2. From December 2, 2016, the Veteran's residuals of a hyperextension injury of the right elbow with mild degenerative changes (impairment of supination/pronation) more nearly approximates limitation of pronation with lost motion beyond the middle of the arc of the major extremity. 3. For the appeal period, the Veteran's residuals of hyperextension injury of the right elbow with mild degenerative changes and limited painful motion manifested in subjective complaints of chronic pain and flares but objective findings did not demonstrate extension limited 45 degrees nor flexion limited to 90 degrees. CONCLUSIONS OF LAW 1. For the appeal period prior to December 2, 2016, the criteria for entitlement to a rating in excess of 20 percent for residuals of a hyperextension injury of the right elbow with mild degenerative changes (impairment of supination/pronation) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5213. 2. From December 2, 2016, the criteria for entitlement to a 30 percent rating, but no higher, for residuals of a hyperextension injury of the right elbow with mild degenerative changes (impairment of supination/pronation) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.71a, DC 5213. 3. The criteria for entitlement to a rating in excess of 10 percent for residuals of hyperextension injury of the right elbow with mild degenerative changes and limited painful motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.71A, DCs 5207-5003. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1990 to August 1991. He then had a period of active duty for training (ACDUTRA) from April 2005 to May 2005. He served on active duty from January 2010 to January 2011, on ACDUTRA from January 2011 to May 2011, on active duty from July 2011 to September 2012, and on active duty from February 2019 to March 2020. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In May 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the claims file. In August 2021, the Board remanded these matters to the RO for further development. As an initial matter, the Board notes that in a December 2021 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for right wrist arthritis with nonunion fracture of scaphoid and ligamentous tear and service connection for right upper extremity ulnar neuropathy. As the grant of service connection for the Veteran's right wrist disability is considered a full grant of the issue sought on appeal, the issue is not before the Board in this decision. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Entitlement to increased ratings for the Veteran's service-connected residuals of a hyperextension injury of the right elbow with mild degenerative changes (impairment of supination/pronation) and residuals of a hyperextension injury of the right elbow with mild degenerative changes and limited painful motion The Veteran seeks increased ratings for his right elbow disability and asserts that his right elbow has worsened over time. He filed a formal increased rating claim in November 2014 and, as such, the Board will consider the evidence of record from the year prior to the date of his increased rating claim (i.e., from November 12, 2013). As an initial matter, the evidence reflects that the Veteran received private acupuncture treatment for his right elbow. As such, the August 2021 Board decision remanded the Veteran's claims, in part, to attempt to obtain and associate with the claims file any outstanding private treatment records. Therefore, in an August 2021 development letter, the AOJ asked the Veteran to complete and return an enclosed VA Form 21-4142 and VA Form 21-4142a so that the AOJ could obtain treatment records on his behalf for any non-VA medical providers he had seen for his claimed disabilities. The Veteran did not respond to this correspondence or provide information regarding his private treatment. The subsequent December 2021 Supplemental Statement of the Case (SSOC) also noted that although VA sent the Veteran a letter requesting that he submit any additional/outstanding private treatment records and/or submit VA Forms 21-4142 so that VA could assist the Veteran in obtaining the outstanding records, to date, the AOJ had not received a response to this request. Thereafter, in January 2022 correspondence, the Veteran provided information for where he received acupuncture treatment and listed dates of treatment for his right wrist and elbow between February and September 2016. He further indicated that this information was never recorded in his case. The Board notes, however, that the Veteran failed to fill out an authorization form (VA Form 21-4142) for the AOJ to attempt to obtain these records despite the specific requests for him to do so and has not otherwise submitted these treatment records to the AOJ. Thus, the AOJ has been unable to obtain these records despite attempts to assist to Veteran. The duty to assist the Veteran in the development of evidence pertinent to his claim is not a "one-way street." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). If the Veteran wishes help, he cannot passively wait for it in circumstances where she may or should have evidence that is essential in obtaining the putative evidence. Id. In light of the forgoing, the Board finds that VA satisfied its duty to assist the Veteran with obtaining these records and substantially complied with the August 2021 Board remand directives such that no further action regarding outstanding private treatment records is required in this case. Stegall v. West, 11 Vet. App. 268 (1998). 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 ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). 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. See 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. In addition, the intent of the Rating Schedule is to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. This regulation also provides that the intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability, and that crepitation should be noted carefully as points of contact which are diseased. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. The Board notes that in Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. Disabilities of the elbow and forearm are rated, generally, under DCs 5205 to 5213. The Veteran's right elbow is his dominant arm. Therefore, the Board will discuss the ratings pertaining to the "major" elbow and forearm. 38 C.F.R. § 4.71a. In the present case, the Veteran is currently in receipt of a 20 percent rating for residuals of a hyperextension injury of the right elbow with mild degenerative changes under DC 5213 and is in receipt of a 10 percent rating for residuals of a hyperextension injury of the right elbow with mild degenerative changes and limited painful motion under DCs 5207 to 5003, which pertains to limitation of extension of the elbow and arthritis, respectively. Hyphenated DCs are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned. During the pendency of the Veteran's appeal, the criteria for rating musculoskeletal disabilities were changed by an amendment to the Rating Schedule that became effective on February 7, 2021. 85 Fed. Reg. 76453, 76464 (November 30, 2020). The criteria that are most favorable to the Veteran's pending claim will apply; however, an award based on the amended regulations may not be made effective before the effective date of the change. See 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). DC 5003 provides that degenerative arthritis established by x-ray findings is to be evaluated on the basis of limitation of motion under the appropriate DC 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 DC, 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 DC 5003. 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, a 10 percent rating is assignable for x-ray evidence of involvement of arthritis of two or more major joints or two or more minor joint groups. A 20 percent evaluation is assignable for x-ray evidence of involvement of arthritis of two or more major joints or two or more minor joint groups, with occasional incapacitating episodes. 38 C.F.R. § 4.71a. Effective February 7, 2021, DC 5003 was revised only insofar as it was renamed to make clear that this DC only applies to degenerative arthritis. Prior to February 7, 2021, DC 5010 provided that the rating for arthritis due to trauma was determined under the criteria pertaining to degenerative arthritis, DC 5003, which rated based on limited motion. 38 C.F.R. § 4.71a. Since February 7, 2021, DC 5010 provides that post-traumatic arthritis shall be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. The Board notes that the amendments to the musculoskeletal rating schedule did not affect DCs 5205 to 5213 for all elbow and forearm disabilities. 38 C.F.R. § 4.71a. DC 5206 applies where there is limitation of flexion of the forearm. A noncompensable rating is warranted for flexion limited to 110 degrees. A 10 percent rating is warranted for flexion limited to 100 degrees. A 20 percent rating is warranted for flexion limited to 90 degrees (minor or major arm). A 30 percent rating is warranted for flexion limited to 70 degrees (major arm). A 40 percent rating is warranted for flexion limited to 55 degrees (major arm). A 50 percent rating is warranted for flexion limited to 45 degrees (major arm). DC 5207 applies where there is limitation of extension of the forearm. A 10 percent rating is warranted for extension limited to 45 degrees (minor or major arm). A 10 percent rating is warranted for extension limited to 60 degrees (minor or major arm). A 20 percent rating is warranted for extension limited to 75 degrees (minor or major arm). A 30 percent rating is warranted for extension limited to 90 degrees (major arm). A 40 percent rating is warranted for extension limited to 100 degrees (major arm). A 50 percent rating is warranted for extension limited to 110 degrees (major arm). Under DC 5213, a disability rating of 10 percent is assigned for limitation of supination of the dominant elbow to 30 degrees or less, and a disability rating of 20 percent is assigned for limitation of pronation of the dominant forearm such that motion is lost beyond the last quarter of arc or the hand does not approach full pronation. A disability rating of 30 percent is assigned for limitation of pronation of the dominant forearm such that motion is lost beyond the middle of the arc. The criterion under this DC also provides for disability ratings based on loss of bone fusion. The medical evidence of record does not establish a loss of bone fusion, and, therefore, this does not provide an adequate basis for an increased disability rating; and the Board shall not consider it any further. 38 C.F.R. § 4.71a, DC 5213. Full elbow flexion and extension is from zero to 145 degrees. Full pronation is to 80 degrees, and full supination is to 85 degrees. 38 C.F.R. § 4.71, Plate I. The note to the rating criteria for DCs 5205 to 5213 provides that, in all the forearm and wrist injuries, DCs 5205 through 5213, multiple impaired finger movements due to tendon tie-up, muscle or nerve injury, are to be separately rated and combined not to exceed rating for loss of use of hand. Under the facts of this case, the Board concludes that DCs 5205 (ankylosis), 5208 (forearm, flexion limited to 100 degrees and extension to 45 degrees), 5209 (other impairment of the flail joint of the elbow), 5210 (nonunion of radius and ulna with flail false joint), 5211 (impairment of the ulna), and 5212 (impairment of the radius) are not applicable, as there is no evidence of any of these enumerated conditions. As such, these DCs will not be discussed further in adjudicating the Veteran's claims. Turning to the evidence of record, in November 2014, the Veteran requested a right elbow magnetic resonance imaging (MRI) because he reportedly could no longer hold up his body in a "front lean and rest" position compared to being able to do ten pushups several months prior. See November 2014 VA primary care secure messaging record. He was also concerned about progressive weakness in his right arm. See id. A December 2014 VA treatment record also reflects the Veteran's report that his right elbow hurt when he did pushups. On examination, he was noted to have right elbow joint line tenderness but no epicondyle tenderness. The Veteran underwent a VA elbow and forearm conditions examination in December 2014. At the time of the examination, he reported that while recently doing yoga, he could not support his body weight on his right arm in a certain yoga position, which he used to be able to do. He also reported experiencing flare-ups of the right elbow. Specifically, when he did not move his elbow, he reported that he experienced a pain level, on a pain scale of one to ten, of one or two out of ten but that when he tried to extend the elbow beyond its then natural stop in extension, the pain would increase to about a six out of ten for a few seconds after returning the elbow to a more natural position. On physical examination, range of motion measurements revealed flexion to 120 degrees, extension to 30 degrees, forearm supination to 80 degrees, and forearm pronation to 80 degrees. There was evidence of pain with extension and on weight-bearing. Pain was noted to cause functional loss and range of motion contributed to functional loss because there was a loss of ability to straighten the right elbow and to have that elbow support his entire weight, which had reduced his ability to exercise and maintain fitness. There was no additional functional loss or range of motion after three repetitions. At the time of the December 2014 VA examination, both condyles of the humerus at the elbow joint had painful osteophytes palpable. The examiner found that pain, weakness, fatigue, and lack of endurance significantly limited functional ability with repeated use over time and during flares but could not provide a range of motion estimate for these situations without resorting to speculation. The Veteran had a reduction in muscle strength testing with four out of five muscle strength in his right elbow extension and flexion. He was also noted to have muscle atrophy with 36 cm circumference of the normal side and 34 cm circumference of the atrophied side. There was no ankylosis, flail joint, joint fracture, ununited fracture, malaligned fracture, nor impairment of supination or pronation. There was objective evidence of crepitus. The examiner found that the Veteran's elbow disability impacted his ability to work and noted that the Veteran was in computer security and reported that if he held his right elbow in a flexed position for any period of time, it was very hard to get it unlocked into extension. Thereafter, a January 2015 VA telehealth telephone note reflects that the Veteran's elbow MRI results showed moderate arthritis. The evidence of record also shows that the Veteran continued to report and seek treatment for right elbow pain. For instance, a February 2015 VA treatment record reflects that the Veteran was diagnosed with right elbow and wrist pain and that he complained of right elbow and arm pain for one year. He reported pain doing yoga positions and pushups and denied noises or locking of the joints. Examination of the elbow revealed full range of motion and positive tenderness to palpation at the lateral epicondyle. A June 2015 service medical record further shows that the Veteran had increased pain and weakness in both wrists and his right elbow and that his right elbow was limited to certain weight limits (20 to 30 pushups). In his July 2015 Notice of Disagreement, the Veteran reported that he experienced increased pain and weakness in the right elbow that negatively affected his life and was considerably worse than it was two years prior. Likewise, in his March 2016 substantive appeal (VA Form 9), the Veteran reported that he believed he was entitled to an increased rating for his right elbow due to elevated pain and increased weakness. He reported that his condition had severely deteriorated to the point where he could not hold his body weight in a front leaning rest. He explained that the increased weakness prevented him from partaking in sports that he once exceled in, including tennis, racquetball, softball, and golf, and that his disability affected his ability to practice at full capacity when teaching his children to throw a ball. He reported that he currently received acupuncture treatment and would continue the treatment in an effort to reduce increasing pain and weakness in the right wrist, elbow, and shoulder. A subsequent December 2, 2016, VA orthopedic surgery outpatient note reflects that the Veteran was seen for right elbow and wrist pain. On that day, he reported that his pain was a four to five out of ten and was located along the base of his right thumb. He did not take anything for the pain. He also complained of numbness/tingling radiating from his bicep down the dorsum of his forearm to his thumb for a few weeks. He reported that he had tried acupuncture in the past year with minimal relief and admitted that his right upper extremity was weaker compared to the left upper extremity. He stated that he was unable to do pushups or grip a cup of coffee at times. The outpatient note reflects that the Veteran worked for computer security and that the pain did not affect his work. Upon examination of the right elbow, he had abnormal range of motion of 10 to 160 degrees and pronation and supination to 20 degrees. His bicep/tricep strength was a five out of five and there was no tenderness to palpation along the lateral or medial epicondyl. It was assessed that his pain was most likely due to osteoarthritis of the right wrist. Thereafter, a February 2021 VA treatment record reflects that the Veteran experienced right upper extremity pain involving the wrist, elbow, and shoulder with some arm weakness. At the May 2021 Board hearing, the Veteran testified that he experienced worsening elbow pain with pain going from his elbow down to his wrist and that he experienced numbness of the right hand. See May 2021 Board hearing transcript, pp. 4-5. He testified that his elbow hurt when throwing a ball and reported that he wore sleeves for his elbow when it started to act up. See id. at pp. 7-8. He explained that his right elbow did not hurt him from a work perspective and that he could certainly work around it. See id. at p. 8. He reported that his elbow hurt most of the time with extension but that he experienced pain with flexion when he tried to touch his shoulder. See id. at p. 9. As the August 2021 Board decision found that the December 2014 VA examination did not comply with all the requirements in Correia v. McDonald, 28 Vet. App. 158, 168 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017), the Veteran underwent another VA elbow and forearm conditions examination in November 2021. At the time of the November 2021 VA examination, the Veteran reported experiencing daily elbow pain that was worse with lifting, carrying, pulling, and repetitive movements. He also noted numbness and tingling from the right elbow to the fourth and fifth fingers. He further reported experiencing flares of increased pain (seven out of ten on a pain scale to ten) that lasted six to twelve hours and occurred with repetitive activities, lifting, pushing, and pulling. He described functional loss in the form of difficulty with repetitive activities, lifting, pushing, pulling, and push-ups. He also reported painful motion with extension, flexion, and forearm supination. Upon physical examination, range of motion testing on both active and passive motion at the November 2021 VA examination revealed flexion to 110 degrees, extension to 25 degrees, supination to 65 degrees, and pronation to 70 degrees. The examiner noted that the range of motion itself contributed to a functional loss and that active motion, passive motion, and weight-bearing caused functional loss as it affected activities requiring the use of the upper extremity. The examiner noted that flexion, extension, supination, and pronation exhibited pain and indicated by omission that there was no additional degree of limitation of motion specifically attributable to pain, weakness, fatigability, incoordination or other. There was also no additional loss of function or range of motion after three repetitions. There was objective evidence of tenderness over both the medial and lateral condyles. The examiner found that pain, fatigability, weakness, and lack of endurance significantly limited functional ability with repeated use over time and during flare-ups and estimated that the Veteran's range of motion measurements under these conditions would result in flexion to 100 degrees, extension to 15 degrees, supination to 55 degrees, and pronation to 60 degrees. The examiner noted that she based these estimates on the Veteran's subjective statements that range of motion decreased slightly during repetitive use over time and during flares as there were no medical records indicating range of motion during repetitive use or flares. The examiner noted that the Veteran had muscle atrophy in his right upper extremity as the circumference of his normal side was 36 cm and the circumference of his atrophied side was 34.2 cm. The Veteran did not have ankylosis, flail joint, joint fracture, ununited fracture, malaligned fracture, nor impairment of supination or pronation. His disability impacted his ability to work in activities involving elbow range of motion and weight bearing (reaching, lifting/carrying, pushing/pulling) caused right elbow pain and decreased range of motion affected the upper extremity. In November 2021, the Veteran also underwent a VA peripheral nerves examination where he reported burning pain, numbness, and tingling extending from the elbow to the fingers and was diagnosed with ulnar neuropathy of the right upper extremity. Thereafter, in a December 2021 rating decision, the AOJ granted service connection for right upper extremity ulnar neuropathy from November 12, 2014, to include based upon the Veteran's reported symptoms at the November 2021 VA peripheral nerves examination. Applying the facts in this case to the criteria set forth above, the Board first finds that the Veteran's right elbow disability more nearly approximates forearm limitation of pronation with motion lost beyond the last quarter of the arc prior to December 2, 2016, and forearm limitation of pronation with motion lost beyond the middle of the arc thereafter. Specifically, for the appeal period prior to December 2, 2016, the evidence does not demonstrate that the Veteran had pronation causing motion to be lost beyond the middle of the arc, which is contemplated under the next-higher 30 percent rating. In this regard, the evidence shows that the Veteran was able to do pushups, albeit with pain, while a February 2015 treatment record noted that the Veteran had full range of motion of the elbow. Additionally, there is no indication from either the objective medical evidence or the Veteran's own statements that his right hand was fixed near the middle of the arc during this period. Moreover, there is no medical evidence to show that there is any additional loss of motion of the right forearm pronation due to pain or flare-ups of pain, supported by objective findings, or due to excess fatigability, weakness or incoordination, to a degree that supports a rating in excess of 20 percent. To the extent that any of the VA examinations do not document range of motion during flares or after repetitive use or with pain, the Board notes that the examination reports of record detail the Veteran's reported pain during flares and his reported functional loss. The Board finds such information pertinent and useful when evaluating his disability picture. As such, the Board finds that a rating in excess of 20 percent under DC 5213 for the appeal period prior to December 2, 2016, is not warranted. However, the Board finds that the next-higher 30 percent rating, under DC 5213, is warranted from December 2, 2016, which is the date a VA orthopedic treatment record indicates the Veteran had limitation of pronation with motion lost beyond the middle of the arc and, thus, is the date the Board finds there is a factually ascertainable increase in the Veteran's disability. In this regard, a December 2, 2016, VA orthopedic surgery treatment record reflects that pronation was limited to 20 degrees. This is less than the middle of the arc, which is normally considered to end at 85 degrees and supports an increased rating. The Board notes that while the November 2021 VA examiner estimated that the Veteran's forearm pronation would be limited to 60 degrees during flare-ups or after repeated use over time, which is more than the middle of the arc, as the December 2016 treatment record and November 2021 examination indicate the Veteran experienced similar symptoms of pain and functional loss, the Board will resolve the benefit of doubt in the Veteran's favor and find that his disability picture more nearly approximated pronation with motion lost beyond the middle of the arc from December 2, 2016. Accordingly, the Board finds that a 30 percent rating is warranted from December 2, 2016, under DC 5213, for the Veteran's right elbow disability. The Board notes that this 30 percent rating is the maximum evaluation assignable under DC 5213 without bone fusion and fixation of the hand. At no time during the appeal period, to include prior to December 2, 2016, does the evidence, including the Veteran's lay statements, indicate that such fusion and fixation of the hand position exists. Rather, the November 2021 VA examiner indicated that range of motion remained for the forearm, including during flare-ups and after repeated use over time. Consequently, the medical evidence does not support a rating in excess of 30 percent for the right (major) elbow disability due to limitation of supination and pronation for the period from December 2, 2016. The Board acknowledges that the evidence shows the Veteran also experiences limitation of supination. However, separate ratings for both limited supination and pronation are not available. See Cullen v. Shinseki, 24 Vet. App. 74, 84 (2010) (holding that within a particular DC, a claimant is not entitled to more than one disability rating for a single disability unless the regulation expressly provides otherwise); see also 38 C.F.R. § 4.71a, DC 5213. Next, the Board finds that a rating in excess of 10 percent for residuals of a hyperextension injury of the right elbow with mild degenerative changes and limited painful motion under DCs 5207 to 5003 is not warranted. The evidence shows that the Veteran's right elbow was manifested by pain and limited motion with flexion and extension. However, even when considering pain and functional loss after repeated use over time and during flare-ups, the Veteran's extension was not shown to reach the level of impairment contemplated by a compensable rating, which is extension limited to 45 degrees. Instead, the objective evidence of record reflects that his extension was limited to less than 45 degrees for the entire appeal period. Likewise, the evidence shows that when considering pain and functional loss after repeated use over time and during flare-ups, the Veteran's flexion was limited to, at most, 100 degrees, which is already contemplated by his current 10 percent rating under his hyphenated DC 5207-5003. None of the evidence of record, including the Veteran's lay statements, treatment records, and examinations demonstrate right elbow flexion that more nearly approximates limitation to 90 degrees (or less), which is contemplated by the next-higher rating. Accordingly, the Board finds there is no medical evidence to show that there is any additional loss of motion of the right elbow flexion or extension due to pain or flare-ups of pain, supported by objective findings, or due to excess fatigability, weakness or incoordination, to a degree that supports a rating in excess of 10 percent. To the extent that any of the VA examinations do not document range of motion during flares or after repetitive use or with pain, the Board notes that the examination reports of record detail the Veteran's reported pain during flares and his reported functional loss. The Board finds such information pertinent and useful when evaluating his disability picture. Moreover, the Board finds the November 2021 VA examiner's findings concerning range of motion during flares and after repeated use over time especially probative as the examiner provided an estimate of the Veteran's range of motion during flares based on the procured evidence of record. Specifically, the November 2021 VA examiner noted that she estimated range of motion measurements after repeated use and during flare-ups based on the Veteran's subjective statements that range of motion decreased slightly during repetitive use over time and during flares. As such the Veteran's reports of functional loss were considered in determining any additional disability impairment with repeated use over time and during flare-ups. Additionally, although the VA examinations reflect that the Veteran experiences some muscle atrophy in his right upper extremity, as the December 2014 VA examination reflects muscle strength as a four out of five in his right elbow extension and flexion and the December 2016 orthopedic surgery record reflects that his bicep/tricep strength was a five out of five, such atrophy does not appear to result in a substantial impact on his right upper extremity muscle strength. Moreover, the Board finds that the Veteran's right elbow weakness is contemplated in his currently assigned ratings. The Board acknowledges that the Veteran is competent to report observable symptoms, as set out in the VA treatment records and examinations, such as pain and weakness. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Board finds that these lay statements are consistent with the assigned ratings. To the extent that the Veteran believes that higher ratings are warranted, this belief is outweighed by the remaining evidence of record, as summarized above. Moreover, although the Veteran is competent to report his symptoms, any opinion regarding whether the Veteran's symptoms have worsened to certain severity requires medical expertise that the Veteran has not demonstrated. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (2007). The Board also notes that in a January 2022 brief, the Veteran's representative stated that the Veteran continued to experience intractable pain or refractory pain, which has led to functional loss, and that he presented with significant deficits with activities of daily living. His representative further indicated that he continued to exude incapacitating attacks of pain, limited range of motion, additional loss of range of motion with repetitive movements, functional loss due to weakness, fatigability, incoordination or pain on movement of a joint, and limitation of motion due to pain on use, include use during flares. Aside from these statements, there is no other evidence of record reflecting that the Veteran's right elbow disability resulted in incapacitating attacks of pain. To this point, the Veteran did not report such symptoms during his recent VA examination, just a few months prior, nor does the other evidence of record reflect reports of incapacitating pain during the course of the appeal period. Similarly, the Veteran has not reported that his right elbow disability impacts his activities of daily living or provided examples of such an impact besides reporting limitations with partaking in sports, such as yoga, pushups, and throwing a ball. While the evidence shows that the Veteran reported difficulties with his grip and holding objects at times, he is separately service connected for a right wrist disability and is receiving separate compensation for symptoms related to that disability. As a final point, the Board acknowledges that during the May 2021 Board hearing, the Veteran's representative requested that the Veteran's disabilities be considered on an extraschedular basis. See May 2021 Board hearing transcript, p. 6. Neither the Veteran nor his representative have presented any specific argument as to why increased ratings are warranted on extraschedular bases in this case; rather, they argue that the current ratings do not adequately capture the Veteran's pain and impairment, to which the Board disagrees. As such, the Board finds that the evidence is also against referring the case for extraschedular consideration under 38 C.F.R. § 3.321(b) because the Veteran's right elbow disability is not so unusual or exceptional in nature as to make the schedular rating inadequate in this case. In this regard, extraschedular ratings are assigned in cases where an exceptional or unusual disability picture is presented that renders application of regular rating schedular standards impractical, due to factors such as marked interference with employment or frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Thun v. Peake, 22 Vet. App. 111, 115 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular criteria for that disability picture are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Here, when comparing the Veteran's disability picture with the symptoms contemplated by the schedular criteria, the Board finds that the Veteran's symptoms are contemplated by the rating assigned for these periods. Specifically, the Board finds that the rating criteria contemplate the pain, weakness, reductions in muscle strength, limited motion, and functional impairments, to include during flare-ups and after repeated use over time. Although the Board acknowledges the Veteran's reports of physical limitations and pain with certain activities as due to his disability, the schedular criteria and assigned evaluations are adequate to evaluate his disability. Moreover, although the Veteran expressed symptoms related to his right wrist and radiating nerve pain manifesting in numbness and tingling, the Veteran is assigned separate disability ratings for his right wrist and right upper extremity ulnar neuropathy, which contemplate such symptoms. Likewise, the Veteran's reports of increased severity and associated functional limitations are now reflected by the 30 percent increased rating from December 2, 2016, for his right elbow pronation impairment. Additionally, the probative evidence does not show that his disability resulted in marked interference with employment or frequent periods of hospitalization. First, there is no evidence showing frequent hospitalization due to the Veteran's service-connected disability. Next, there is also no evidence of marked interference with employment as the Veteran testified at the May 2021 Board hearing that his right elbow did not hurt him from a work perspective and that he could certainly work around it. See May 2021 Board hearing transcript, p. 8. The December 2016 VA treatment record also reflects that the Veteran worked in computer security and the pain did not affect his work. The Board finds this probative evidence against a finding that his right elbow disability resulted in marked interference with employment. Thus, the evidence does not reflect that the Veteran's elbow disabilities are so exceptional in nature as to render application of the regular rating schedular standards impractical. Thus, even with the favorable resolution of doubt, his disabilities are of such a nature that referral for extraschedular evaluation is not warranted. 38 C.F.R. § 3.321(b)(1); Thun, 22Vet. App.at 111. In sum, the Board finds that from December 2, 2016, the Veteran is entitled to a 30 percent rating, but no higher, for residuals of a hyperextension injury of the right elbow with mild degenerative changes based on impairment in pronation under DC 5213. However, for the appeal period prior to December 2, 2016, a rating in excess of 20 percent for residuals of a hyperextension injury of the right elbow with mild degenerative changes based on impairment in pronation under DC 5213 is denied. Likewise, as addressed above, a rating in excess of 10 percent for residuals of a hyperextension injury of the right elbow with mild degenerative changes and limited painful motion under DCs 5207 to 5003 is denied. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Amanda Purcell, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.