Citation Nr: 0000629 Decision Date: 01/10/00 Archive Date: 01/19/00 DOCKET NO. 94-35 708 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to a compensable evaluation for the residuals of a fracture of the fifth metatarsal of the left foot. 2. Entitlement to an increased evaluation for a disability of the cervical segment of the spine, currently rated as 10 percent disabling. 3. Entitlement to compensable evaluation for "right tennis elbow", also described as osteochondritis dissecans of the capitellum of the right elbow with multiple intra-articular loose bodies, prior to October 21, 1996. 4. Entitlement to an increased evaluation for osteochondritis dissecans of the capitellum of the right elbow with multiple intra-articular loose bodies after October 20, 1996. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Patrick J. Costello, Counsel INTRODUCTION The veteran had active military service from January 1974 to January 1977, and from October 1983 to November 1990. This matter came before the Board of Veterans' Appeals (hereinafter the Board) on appeal from a March 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), in Montgomery, Alabama. In that decision service connection was granted for degenerative disease of the cervical spine, right tennis elbow, and the residuals of a fracture of the left fifth metatarsal. All three conditions were assigned a noncompensable evaluation. In February 1996, the Board remanded the claim to the RO for the purpose of obtaining additional medical information. The Board also requested clarification of the issues being appealed by the veteran. Although the medical information has since been obtained and has been included in the claims file for review, it is the opinion of the Board that there is still some uncertainty as to what issues the veteran is appealing. Thus, to ensure that the VA has met its duty to assist the veteran in the development of his claim, the Board will specifically address the clarification enigma in the Remand portion of this decision. The Board would add that as a result of the requested additional information, the VA granted a 10 percent disability rating the veteran's neck condition. It also assigned a 10 percent rating for the right elbow condition. VA Form 21-6796, Rating Decision, September 11, 1998. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the agency of original jurisdiction. 2. Residuals of fracture of the fifth metatarsal are currently asymptomatic. 3. Residuals of the veteran's cervical segment of the spine injury include some limitation of motion, degenerative disease, pain, and minimal narrowing of disk space. 4. Examination of the veteran's right elbow reveals no tenderness upon palpitation and does not have any restriction of motion. 5. Per an August 1996 medical evaluation, the veteran experiences pain on movement of the right elbow along with some functional limitations. CONCLUSIONS OF LAW 1. The criteria for a compensable evaluation for the residuals of a fracture of the fifth metatarsal of the left foot have not been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, Part 4, Diagnostic Code 5284 (1999). 2. The criteria for an evaluation of 30 percent for a disability of the cervical segment of the spine have been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, Part 4, Diagnostic Code 5290 (1999). 3. The criteria for a compensable evaluation for a right elbow condition, prior to October 21, 1996, have not been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, Part 4, Diagnostic Codes 5003, 5024, 5206, 5207, and 5213 (1999). 4. The criteria for an evaluation in excess of 10 percent for a right elbow condition, after October 20, 1996, have not been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, Part 4, Diagnostic Codes 5003, 5024, 5206, 5207, and 5213 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As reported, the veteran was awarded service connection for a neck condition, a right elbow disability, and a left foot condition in March 1991. He appealed the assignment of a noncompensable evaluation for all three conditions, and although a 10 percent rating has since been awarded for the neck and elbow conditions, he has continued his appeal on all three issues. The United States Court of Appeals for Veterans Claims, formerly known at the United States Court of Veterans Appeals, and hereinafter the Court, has previously held that a claim for an increased rating for a disability is generally well-grounded when an appellant indicates that the severity of the disability has increased. See Proscelle v. Derwinski, 2 Vet. App. 629, 631-632 (1992). Although the veteran in the instance case does seek an increased rating, this case differs from Proscelle because the appellant is appealing the original assignment of a disability rating, not pursuing an increased rating after a rating has been initially established by a final VA decision. The initial assignment of a rating following the award of service connection is part of the original claim. See West v. Brown, 7 Vet. App. 329, 332 (1995) (en banc). In light of this, when a claimant is awarded service connection for a disability and subsequently appeals the RO's initial assignment of a rating for that disability, the claim continues to be well-grounded as long as the rating schedule provides for a higher rating and the claim remains open. Shipwash v. Brown, 8 Vet. App. 218 (1995). Thus, in accordance with 38 U.S.C.A. § 5107 (West 1991 & Supp. 1997), and Murphy v. Derwinski, 1 Vet. App. 78 (1990), the appellant has presented a well-grounded claim. The facts relevant to this appeal have been properly developed and the obligation of the VA to assist the veteran in the development of his claim has been satisfied. Id. Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1999); 38 C.F.R. Part 4 (1999). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4 (1999). In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. §§ 4.2, 4.41 (1999). "The regulations do not give past medical reports precedent over current findings." Francisco v. Brown, 7 Vet. App. 55, 58 (1994). While the evaluation of a service-connected disability requires a review of the appellant's medical history with regard to that disorder, the Court has held that, where entitlement to compensation has already been established, and an increased in the disability rating is at issue, the present level of disability is of primary concern. Ibid; Peyton v. Derwinski, 1 Vet. App. 282 (1991); 38 C.F.R. §§ 4.1, 4.2 (1999). An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment, and the effect of pain on the functional abilities. 38 C.F.R. §§ 4.10, 4.40, 4.45, and 4.59 (1999). I. Fracture of the Left Fifth Metatarsal While in service, the veteran fractured the fifth metatarsal of his left foot. This condition has been rated pursuant to 38 C.F.R. Part 4, Diagnostic Code 5084 (1999), which states that moderate foot injuries will be assigned a 10 percent disability rating. If the injury is moderately severe or severe, a disability rating of 20 or 30 percent respectively will be awarded. When there is an actual loss of the use of the foot, a 40 percent evaluation will be assigned. Alternatively, per 38 C.F.R. Part 4, Diagnostic Code 5083 (1999), malunion or nonunion of the tarsal or metatarsal bones, moderate, will warrant a 10 percent evaluation. A moderately severe disability warrants a 20 percent rating, and severe disability merits a 30 percent rating. Additionally, in DeLuca v. Brown, 8 Vet. App. 202 (1995), the Court held that 38 C.F.R. §§ 4.40, 4.45 (1995) were not subsumed into the diagnostic codes under which a veteran's disabilities are rated. Therefore, the Board must consider the "functional loss" of a musculoskeletal disability under 38 C.F.R. § 4.40 (1999), separate from any consideration of the veteran's disability under the diagnostic codes. See DeLuca, 8 Vet. App. 202, 206 (1995). Functional loss may occur as a result of weakness or pain on motion of the affected body part. 38 C.F.R. § 4.40 (1999). The factors involved in evaluating, and rating, disabilities of the joints include: weakness; fatigability; incoordination; restricted or excess movement of the joint; or, pain on movement. 38 C.F.R. § 4.45 (1999). These factors do not specifically relate to muscle or nerve injuries independently of each other, but rather, refer to overall factors which must be considered when rating the veteran's joint injury. See DeLuca, 8 Vet. App. 202, 206-07 (1995). In conjunction with the veteran's appeal, a Joints Examination was conducted in August 1996. During the pre- exam interview, the veteran told the examiner that he sometimes experienced pain and tenderness in the left foot usually after periods of weight-bearing. Examination of the left foot produced the following results: . . . Examination of the left foot reveals that there was no tenderness over the area of the fifth metatarsal. He did have tenderness to palpation across the ball of the foot. The ankle had five degrees of dorsiflexion and 40 degrees of plantar flexion. He had full range of motion of the toes. He had a palpable posterior tibial pulse in the left foot. He was able to toe walk at this time without particular problems, but he demonstrated a slight limp with heel walking on the right secondary to complaints of knee pain. A diagnosis of "healed fracture of the left fifth metatarsal" was given. When asked whether the healed fracture of the foot presented the veteran with any functional difficulties, the doctor merely noted that the veteran should avoid prolonged standing and using steps. The rest of the medical records are silent as to complaints resulting from the healed fracture in the left foot. In determining whether an increased rating is warranted, the VA must determine whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case an increased rating must be denied. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1999); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board finds that evidence has not been presented which would indicate that the veteran's left foot disability has become so severe as to be classified as moderately disabling under any of the diagnostic codes which could be analogized to the veteran's toe fracture residual. X-rays have not shown any abnormalities resulting from the fracture. Although he has complained of pain in connection with his claim, the clinical records for the past several years do not show recent or regular treatment for complaints of pain in the left foot. Moreover, when examined in 1996, findings were not chronicled that would corroborate the veteran's subjective complaints of occasional pain in the left foot. While his foot may be undergoing some degenerative changes due to the residuals of the fracture, comparable objective findings do not support a compensable evaluation. Accordingly, the preponderance of the evidence is against the claim for a compensable rating. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.10, Part 4, Diagnostic Code 5284 (1999). Finally, the Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (1997) in the first instance. See Floyd v. Brown, 9 Vet. App. 88 (1996). The Court has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) (1997) only where circumstances are presented which the Director of the VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Having reviewed the record with these mandates in mind, the Board finds no basis for further action on this question. II. Cervical Segment of the Spine The RO has rated the veteran's neck condition as 10 percent disabling pursuant to the rating criteria for degenerative joint disease (limitation of motion of the cervical segment of the spine) found at 38 C.F.R. Part 4, Diagnostic Codes 5003 and 5290 (1999). Arthritis due to trauma, substantiated by x-ray findings, is rated as degenerative arthritis. 38 C.F.R. Part 4, Diagnostic Code 5010 (1999). Degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasms, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation will be assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent evaluation will be assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. Part 4, Diagnostic Code 5003 (1999). The shoulder, elbow, wrist, hip, knee, and ankle are considered to be major joints for the purpose of rating disability for arthritis. 38 C.F.R. § 4.45, Part 4, Diagnostic Code 5002 (1999). Slight limitation of motion of the cervical segment of the spine warrants a 10 percent evaluation. A 20 percent evaluation requires moderate limitation of motion. A 30 percent evaluation requires severe limitation of motion. 38 C.F.R. Part 4, Diagnostic Code 5290 (1996). Although it has since been repealed, the VA Physician's Guide for Disability Evaluation Examinations does provide the Board with a guide as to what may be considered normal or average range of motion measurements. Those measurements are as follows: Flexion Forward 30 degrees Extension Backward 30 degrees Lateral Flexion 40 degrees Rotation 55 degrees Since Diagnostic Code 5290 [38 C.F.R. Part 4 (1999)] provides for three levels of disability based upon limitation of motion in the four planes of movement in the lumbar spine, designated as slight, moderate or severe, the Board suggests that the levels of disability based upon limitation of motion correspond generally to ranges of degrees in each of the planes of movement. Accordingly, a slight disability would be measured as a loss of motion up to approximately 33 percent of the normal range of motion; a moderate disability would be measured as a loss of motion between 33 and 66 percent of normal range of motion; and, a severe disability would be measured as a loss of motion greater than 66 percent of normal range of motion. Per 38 C.F.R. Part 4, Diagnostic Code 5293 (1999), intervertebral disc syndrome will be rated as follows: Pronounced; with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to site of diseased disc, little intermittent relief. 60 Percent Disabling Severe; recurring attacks, with intermittent relief. 40 Percent Disabling Moderate; recurring attacks. 20 Percent Disabling Mild. 10 Percent Disabling Additionally, in DeLuca v. Brown, 8 Vet. App. 202 (1995), the Court held that 38 C.F.R. §§ 4.40, 4.45 (1995) were not subsumed into the diagnostic codes under which a veteran's disabilities are rated. Therefore, the Board must consider the "functional loss" of a musculoskeletal disability under 38 C.F.R. § 4.40 (1999), separate from any consideration of the veteran's disability under the diagnostic codes. See DeLuca, 8 Vet. App. 202, 206 (1995). Functional loss may occur as a result of weakness or pain on motion of the affected body part. 38 C.F.R. § 4.40 (1999). The factors involved in evaluating, and rating, disabilities of the joints include: weakness; fatigability; incoordination; restricted or excess movement of the joint; or, pain on movement. 38 C.F.R. § 4.45 (1999). These factors do not specifically relate to muscle or nerve injuries independently of each other, but rather, refer to overall factors which must be considered when rating the veteran's joint injury. See DeLuca, 202 Vet. App. 202, 206-07 (1995). During this appeal, the veteran underwent a physical that produced the following range of motion test results: Normal ROM (In Degrees ) Exam - 8/21/96 (In Degrees ) Forward Flexion 30 40 Backwar d Flexion 40 25 Right Lateral Flexion 40 -- Left Lateral Flexion 40 -- Rotatio n to the Right 55 55 Rotatio n to the Left 55 55 On the exam, the examiner noted that the veteran complained of pain and had appropriate facial wincing. Grating was not reported and there was no sensory or motor loss present in the upper extremities. The diagnosis given was: Chronic cervical disk syndrome - prior MRI [magnetic resonance imaging] scan report indicates spondylotic pathology from C4-5 to C6-7. At both C4-5 and C5- 6, there are disk lesions suggesting combined herniation and end-plate ridge formation, left-sided. No definite mass lesion identified at C6-7. The examiner further wrote: . . . It is this examiner's opinion that he has very significant functional impairment related to his degenerative joint disease of the cervical spine and of the right elbow. . . In general, I think that he would have rather significant difficulty with lifting and carrying. He would have difficulty with any attempts at overhead work. He should not work around unprotected heights or moving machinery. . . In determining whether an increased evaluation is warranted, the VA must determine whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case an increased rating must be denied. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1999); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). If the Board relies solely on the medical findings, it would not be able to grant an increased evaluation for this condition. That is, the symptoms exhibited by the veteran would not entitle him to a rating greater than 10 percent disabling. He only has a minimal amount of decreased mobility of the neck. He has not exhibited radiculopathy and the range of motion studies do not show severely restricted, or even moderately restricted, movement of the veteran's neck. Although he does complain of pain, he has nearly full motor strength and all reflexes are present. However, the Court has said that the VA must also consider functional loss when evaluating a disability. A VA physician has classified the veteran's functional loss as a result of his neck injury as significant. To the Board, this is a rather nebulous term - it gives the Board some leeway in assigning a disability evaluation. Yet, the VA is obliged to give the veteran the benefit of the doubt and to apply the rating criteria that more closely approximates the limitations experienced by the veteran as a result of the disability. Keeping this in mind, it is the conclusion of the Board that the rating criteria used for cervical disc disease is not for application. Although the veteran has been diagnosed with a disc condition, he does not display any of the manifestations and symptoms indicative of a disc condition. Thus, the Board believes that it should use the rating criteria found at 38 C.F.R. Part 4, Diagnostic Code 5290 (1999). Does significant restriction of function equate to moderate limitation of motion or severe limitation of motion? It is a toss-up and since the veteran is entitled to the benefit of the doubt, the Board will assign the higher rating of 30 percent. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.10, Part 4, Diagnostic Codes 5290 (1999). Finally, the Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (1997) in the first instance. See Floyd v. Brown, 9 Vet. App. 88 (1996). The Court has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) (1997) only where circumstances are presented which the Director of the VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Having reviewed the record with these mandates in mind, the Board finds no basis for further action on this question. III. Right Elbow - Prior to August 21, 1996 The third disability for which the veteran is seeking an increased evaluation is that of the right elbow - osteochondritis dissecans of the capitellum of the right elbow with multiple intra-articular loose bodies. This condition has been rated, by analogy, pursuant to the criteria found at 38 C.F.R. Part 4, Diagnostic Code 5003 (1999). When a veteran has been diagnosed as having a specific condition and the diagnosed condition is not listed in the Schedule for Rating Disabilities, the diagnosed condition will be evaluated by analogy to a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (1999). Degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasms, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation will be assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent evaluation will be assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. Part 4, Diagnostic Code 5003 (1999). The shoulder, elbow, wrist, hip, knee, and ankle are considered to be major joints for the purpose of rating disability for arthritis. 38 C.F.R. § 4.45, Part 4, Diagnostic Code 5002 (1999). The rating schedule provides a noncompensable evaluation for limitation of flexion of the forearm to 110 degrees. A 10 percent evaluation is assigned for limitation of flexion of the forearm to 100 degrees. A 20 percent evaluation is provided for limitation of flexion of the forearm to 90 degrees. 38 C.F.R. Part 4, Diagnostic Code 5206 (1999). The rating schedule provides a 10 percent evaluation for limitation of extension of the forearm to 60 degrees. A 20 percent evaluation is provided for limitation of extension of the forearm to 75 degrees. 38 C.F.R. Part 4, Diagnostic Code 5207 (1999). Additionally, per 38 C.F.R. Part 4, Diagnostic Code 5213 (1999), a 10 percent rating will be assigned for limitation of supination of the forearm to 30 degrees or less. A 20 percent rating will be provided for limitation of pronation with loss of motion beyond the last quarter of the arc with the hand not approaching full pronation. Additionally, in DeLuca v. Brown, 8 Vet. App. 202 (1995), the Court held that 38 C.F.R. §§ 4.40, 4.45 (1995) were not subsumed into the diagnostic codes under which a veteran's disabilities are rated. Therefore, the Board must consider the "functional loss" of a musculoskeletal disability under 38 C.F.R. § 4.40 (1999), separate from any consideration of the veteran's disability under the diagnostic codes. See DeLuca, 8 Vet. App. 202, 206 (1995). Functional loss may occur as a result of weakness or pain on motion of the affected body part. 38 C.F.R. § 4.40 (1999). The factors involved in evaluating, and rating, disabilities of the joints include: weakness; fatigability; incoordination; restricted or excess movement of the joint; or, pain on movement. 38 C.F.R. § 4.45 (1999). These factors do not specifically relate to muscle or nerve injuries independently of each other, but rather, refer to overall factors which must be considered when rating the veteran's joint injury. See DeLuca, 202 Vet. App. 202, 206-07 (1995). Prior to the veteran retiring from the US Army, he underwent a general medical examination in May 1990. Optional Form 275, Medical Record Report, May 5, 1990. The right elbow was noted as being nontender with full supination, pronation, flexion, and extension. Pain was not reported nor was it complained of by the veteran. Reports of pain in the elbow do not appear in the claims folder until August 1992 when the veteran mentions it as a part of his appeal to the Board. The private medical records the veteran proffered in support of his claim for an increased evaluation do not chronicle any treatment for the right elbow disability. These same records also do not report any complaints by the veteran concerning his right elbow. In determining whether an increased evaluation is warranted, the VA must determine whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case an increased rating must be denied. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1999); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Although the veteran contends that he should receive a compensable evaluation for his right elbow condition, evidence has not been presented which would support his assertions. Prior to October 1996, there is no evidence showing that the elbow is restricted in motion. Moreover, arthritis was not diagnosed and pain was not noted in the medical treatment records. Therefore, it is the conclusion of the Board that the evidence is against the veteran's claim for a compensable evaluation for a right elbow condition. Finally, the Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (1997) in the first instance. See Floyd v. Brown, 9 Vet. App. 88 (1996). The Court has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) (1997) only where circumstances are presented which the Director of the VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Having reviewed the record with these mandates in mind, the Board finds no basis for further action on this question. IV. Right Elbow - After August 20, 1996 On the 21st of August, 1996, the veteran underwent an orthopaedic examination of the right elbow. Upon completion of the exam, the examiner reported the following: . . . The right elbow had 0-135 degrees range of motion actively and passively. He had rather marked pain on full extension of the elbow. No swelling or tenderness is noted. He had a full pronation and supination noted. . . . Strength of the upper extremities was felt to be normal. . . .... . . . It is this examiner's opinion that he has very significant functional impairment related to his degenerative joint disease of the cervical spine and of the right elbow. . . . In general, I think he would have rather significant difficulty with lifting and carrying. He would have difficulty with any attempts at overhead work. He should not work around unprotected heights or moving machinery. He should avoid repetitive use or pushing-and-pulling type movements with the right arm secondary to his elbow problem. . . Arthritis was not shown by x-ray films. Based on this examination, the RO increased the veteran's right arm disability rating from zero to 10 percent. VA Form 21-6796, Rating Decision, September 11, 1998. The diagnosis criteria used was 38 C.F.R. Part 4, Diagnostic Code 5024 (1999). Per this code: The diseases under diagnostic code 5013 through 5024 will be rated on limitation of motion of affected parts, as arthritis, degenerative, except gout which will be rated under diagnostic code 5002. Degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasms, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation will be assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent evaluation will be assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. Part 4, Diagnostic Code 5003 (1993). The shoulder, elbow, wrist, hip, knee, and ankle are considered to be major joints for the purpose of rating disability for arthritis. 38 C.F.R. § 4.45, Part 4, Diagnostic Code 5002 (1993). The rating schedule provides a noncompensable evaluation for limitation of flexion of the forearm to 110 degrees. A 10 percent evaluation is assigned for limitation of flexion of the forearm to 100 degrees. A 20 percent evaluation is provided for limitation of flexion of the forearm to 90 degrees. 38 C.F.R. Part 4, Diagnostic Code 5206 (1999). The rating schedule provides a 10 percent evaluation for limitation of extension of the forearm to 60 degrees. A 20 percent evaluation is provided for limitation of extension of the forearm to 75 degrees. 38 C.F.R. Part 4, Diagnostic Code 5207 (1999). Additionally, per 38 C.F.R. Part 4, Diagnostic Code 5213 (1999), a 10 percent rating will be assigned for limitation of supination of the forearm to 30 degrees or less. A 20 percent rating will be provided for limitation of pronation with loss of motion beyond the last quarter of the arc with the hand not approaching full pronation. Additionally, in DeLuca v. Brown, 8 Vet. App. 202 (1995), the Court held that 38 C.F.R. §§ 4.40, 4.45 (1995) were not subsumed into the diagnostic codes under which a veteran's disabilities are rated. Therefore, the Board must consider the "functional loss" of a musculoskeletal disability under 38 C.F.R. § 4.40 (1999), separate from any consideration of the veteran's disability under the diagnostic codes. See DeLuca, 8 Vet. App. 202, 206 (1995). Functional loss may occur as a result of weakness or pain on motion of the affected body part. 38 C.F.R. § 4.40 (1999). The factors involved in evaluating, and rating, disabilities of the joints include: weakness; fatigability; incoordination; restricted or excess movement of the joint; or, pain on movement. 38 C.F.R. § 4.45 (1999). These factors do not specifically relate to muscle or nerve injuries independently of each other, but rather, refer to overall factors which must be considered when rating the veteran's joint injury. See DeLuca, 202 Vet. App. 202, 206-07 (1995). In determining whether an increased evaluation is warranted, the VA must determine whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case an increased rating must be denied. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1999); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). No other evidence has been presented in support of the veteran's claim. As evidenced above, symptomatology indicative of a more serious or severe elbow condition has not been presented. While the veteran has complained of pain on motion, the elbow shows no signs of angulatory deformity, false motion, restriction of motion, or shortening. Additionally, there is no ankylosis of the elbow and no flail joint. Therefore, it is the opinion of the 10 percent evaluation currently assigned to the condition adequately compensates the veteran for the pain and functional limitations he now suffers. Thus, since indicators of a more severe condition have not been presented, an increased rating for a right elbow disability is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.10, Part 4, Diagnostic Codes 5206, 5207, and 5213 (1999). Finally, the Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (1997) in the first instance. See Floyd v. Brown, 9 Vet. App. 88 (1996). The Court has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) (1997) only where circumstances are presented which the Director of the VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Having reviewed the record with these mandates in mind, the Board finds no basis for further action on this question. ORDER 1. Entitlement to a compensable evaluation for the residuals of a fracture of the fifth metatarsal of the left foot is denied. 2. An evaluation of 30 percent for a disability of the cervical segment of the spine is granted, subject to the regulations governing the disbursement of monetary benefits. 3. Entitlement to compensable evaluation for "right tennis elbow", also described as osteochondritis dissecans of the capitellum of the right elbow with multiple intra-articular loose bodies, prior to October 21, 1996, is denied. 4. Entitlement to an increased evaluation for osteochondritis dissecans of the capitellum of the right elbow with multiple intra-articular loose bodies, after October 20, 1996, is denied. JACK W. BLASINGAME Member, Board of Veterans' Appeals