Citation Nr: 1326532 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 02-12 041 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUE Entitlement to an initial compensable rating for left mid scapular myositis from June 20, 2001, and in excess of 20 percent from April 13, 2004. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Conner, Counsel INTRODUCTION The appellant served on active duty from June 1997 to June 2001. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2001 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. In the December 2001 rating decision, the RO, in pertinent part, granted service connection for left mid scapular myositis and left shoulder bursitis and assigned each disability a separate initial noncompensable rating, effective June 20, 2001. Before the matter was certified to the Board, in a March 2004 rating decision, the RO increased the rating for the appellant's left shoulder bursitis to 30 percent, effective August 1, 2003. The RO also assigned a temporary total rating for that disability under 38 C.F.R. § 4.30 for the period from June 2 to July 31, 2003. In a June 2004 rating decision, the RO increased the rating for the appellant's left mid scapular myositis to 20 percent, effective April 13, 2004. Although higher ratings were granted, the issues remained in appellate status, as the maximum schedular rating were not assigned from the date of the award of service connection nor did the appellant withdraw her appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993) (holding that a decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). In March 2006 and May 2011, the Board remanded both issues to the RO for additional evidentiary development and due process considerations. Following the completion of that development action, in a November 2012 decision, the Board denied an initial compensable rating for left shoulder bursitis from June 20, 2001, and in excess of 30 percent from August 1, 2003. The record on appeal contains no indication that the appellant appealed the Board's November 2012 decision. Also in November 2012, the Board remanded remaining issue on appeal - entitlement to a higher initial rating for left mid scapular myositis -to the RO via the Appeals Management Center (AMC) for additional evidentiary development and due process considerations. After pursuing the additional evidentiary development ordered by the Board in its November 2012 remand, the AMC issued a Supplemental Statement of the Case in June 2013 addressing both the left shoulder bursitis and the left mid scapular myositis issues. As set forth above, however, the Board issued a final decision regarding the left shoulder bursitis issue in November 2012. Thus, it appears that the AMC's inclusion of this issue in the June 2013 Supplemental Statement of the Case was in error. Should the appellant wish to pursue the issue of entitlement to an increased rating for her service-connected left shoulder bursitis, however, she should so advised the RO with the assistance of her representative, if necessary. FINDINGS OF FACT 1. For the period from June 20, 2001, to April 12, 2004, the appellant's service-connected left mid scapular myositis was shown to be manifested by episodic pain in the left scapular region, mild scapular muscle spasm, and mild tenderness to palpation in that area. 2. For the period from April 13, 2004, the appellant's service-connected left mid scapular myositis was manifested by pain in the scapular region; scapular and paravertebral muscle spasm; tenderness to palpation in the trapezius and rhomboids major; and limitation of motion of the thoracolumbar spine, including forward flexion limited by pain to 60 degrees, extension to 15 degrees, lateral flexion to 20 degrees, and lateral rotation to 25 degrees. CONCLUSIONS OF LAW 1. For the period from June 20, 2001, to April 12, 2004, the criteria for an initial 10 percent disability rating, but no higher, for the service-connected left mid scapular myositis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.71a, Diagnostic Codes 5021-5242 (2012), and 4.71a, Diagnostic Code 5291 (2002). 2. From April 13, 2004, the criteria for an initial disability rating in excess of 20 percent for the service-connected left mid scapular myositis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.71a, Diagnostic Codes 5021-5242 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As a preliminary matter, the Board finds that no further notice or development action is necessary in order to satisfy VA's duties to the appellant under the VCAA. The record shows that in June 2001, prior to the initial decision on her claim, VA notified the appellant of the information and evidence needed to substantiate and complete her claim of service connection, and of what part of that evidence she was to provide and what part VA would attempt to obtain for her. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1). Because the matter at issue in this case concerns an appeal from an initial rating following an award of service connection, VA's VCAA notice obligations have been fully satisfied. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490 (2006) (holding that once a decision awarding service connection and assigning a disability rating and an effective date has been made, the section 5103(a) notice has served its purpose, and its application is no longer required because the claim has been substantiated). The record in this case does not show, nor does the appellant contend, that there are any notification deficiencies which have resulted in prejudice to her. See Goodwin v. Peake, 22 Vet. App. 128 (holding that the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements such as the disability rating and effective date). With respect to the duty to assist, the Board finds that VA has undertaken all necessary development action. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The appellant's service treatment records are on file, as are all available post-service clinical records which the appellant has specifically identified and authorized VA to obtain. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(2), (3). The appellant has also been afforded multiple VA medical examinations in connection with her claim. 38 C.F.R. § 3.159(c) (4). The Board finds that the examination reports contain the necessary findings upon which to decide the issue on appeal. See Massey v. Brown, 7 Vet. App. 204 (1994) (holding that VA medical examination reports must provide sufficient reference to the pertinent schedular criteria). For the reasons set forth above, and given the facts of this case, the Board finds that no further notification or development action is necessary. Background The appellant's service treatment records show that in October 1998, she was seen in connection with her complaints of mid upper back pain. Examination showed tenderness to palpation of the left scapular area. The diagnosis was left trapezium spasm. In June 2001, in connection with her separation from service, the appellant submitted an original application for VA compensation benefits, seeking service connection for an upper back disability, which she indicated had been present since October 1998. In connection with her claim, the appellant was afforded a VA medical examination in August 2001. In pertinent part, she reported that in 1998, during her period of active duty, she had developed pain in the left mid scapular area after doing sit ups. She was treated with NSAID's and physical therapy. She described her symptoms as an "on and off left scapular pain" and indicated that it was not present currently, nor was she experiencing any other symptomatology related to that disability. She indicated that her left mid scapular pain recurred when she performed abdominal exercises. Her pain was alleviated by medication. Examination showed forward flexion of the lumbar spine to 95 degrees, backwards extension and rotation to 30 degrees, and lateral flexion to 40 degrees. There was no painful motion. There was mild scapular muscle spasm and mild tenderness to palpation, but no weakness of the arms. There were no postural abnormalities of the back and no fixed deformities. There were no neurologic abnormalities. The diagnosis was left mid scapular myositis. Based on this evidence, in a December 2001 rating decision, the RO granted service connection for left mid scapular myositis, claimed as a back condition, and granted an initial zero percent rating, effective June 20, 2001. At a January 2004 VA medical examination, the appellant reported that she had been employed full time as a physical education teacher. She indicated that her multiple service-connected disabilities, particularly her service-connected left shoulder and bilateral knee disabilities, produced certain limitations in her job, including limiting her ability to demonstrate certain physical skills to her students. In an April 2004 letter, the appellant's private physician indicated that he had examined the appellant and noted that she exhibited severe muscle spasm, especially in the trunk of the neck and both trapezii, as well as painful motion in the neck. The appellant also demonstrated forward flexion of the trunk to 90 degrees and extension to 50 degrees. Left and right lateralization was not painful. The diagnoses included strained dorsal region. The physician indicated that the appellant was unable to work in a sitting position for long periods of time as a result of upper back pain caused by cervicodorsal syndrome. An April 2004 letter from another private physician indicated that the appellant's symptoms included spasms of the trapezii musculature upon palpation. She also exhibited 60 degrees of forward lumbar flexion, extension to 20 degrees, and lateral flexion to 30 degrees. The diagnoses included trapezii muscles strain. At a May 2004 VA medical examination, the appellant complaints included constant pain in the cervical and upper back regions, as well as neck stiffness. She indicated that she felt less effective in her job as a physical education teacher as a result of her symptoms. On examination, the appellant exhibited a normal gait and posture. The examiner observed spasms in the paravertebral muscles and the dorsal scapular muscles. Sensation in the upper extremities was normal. The diagnoses included cervical myositis and dorsal myositis. In a June 2004 rating decision, the RO increased the rating for the appellant's service-connected left mid scapular myositis to 20 percent, effective April 13, 2004. At a November 2004 VA medical examination, the appellant reported constant pain in the dorsal region in the paravertebral muscles, occasionally radiating towards her head. She experienced occasional flare-ups of pain for which she took Advil. She denied any additional limitation of motion or functional impairment during flare-ups. The appellant reported that she continued to work as a physical education teacher and was independent in her activities of daily living. Examination revealed pain and loss of motion of the cervical spine. The appellant also exhibited exquisite tenderness in the cervical, trapezius, and interscapular areas. There was also tenderness to palpation at the lumbosacral paravertebral muscles. There was normal sensation and strength in the upper extremities. The diagnoses included chronic active cervical strain - myositis; trapezius strain; and dorsal (interscapular) myositis. The examiner explained that the appellant's cervical strain or myositis was separate and unrelated to her service-connected left mid scapular myositis. X-ray studies of the lumbar spine performed in September 2006 showed narrowing of the L-5-S1 disc space. Otherwise, lordosis, vertebral bodies, and alignment were preserved and the soft tissues were normal. In an October 2006 letter, the appellant's private physician indicated that the appellant was under treatment for cervical pain associated with cervical disc disease. In a February 2007 letter, the appellant's private physician indicated that he had evaluated the appellant for multiple complaints, including pain in the high dorsal area with muscle spasm of the high dorsal and right scapular muscles. The diagnoses included cervical disc disease and sprain of the cervical musculature, trapezii and scapular. In a June 2007 note, a private chiropractor indicated that the appellant exhibited unbalanced shoulders and a slight limitation of motion in the low back. The appellant underwent VA medical examination in August 2011 at which she exhibited mild tenderness over the mid trapezius and rhomboids major. Strength was normal. The appellant reported that she was employed full time and had lost less than one week of work in the past year due to the flu. The diagnoses included mild left shoulder mid scapular myositis. The examiner indicated that the symptoms which were part and parcel of the service-connected mid scapular myositis disability were mild tenderness to palpation at the left mid trapezius and left rhomboids major muscle bellies. He indicated that the appellant's service-connected mid scapular myositis disability was not closely analogous in anatomic location or function to the cervical spine. He explained that the trapezius and the rhomboids major were not part of the intrinsic neck muscles which controlled movements of the head. He further indicated that the appellant's service-connected mid scapular myositis was not manifested by pain on motion, evidence of weakness, excess fatigability, or incoordination. At a January 2013 VA medical examination, the examiner noted that the appellant had been diagnosed as having left trapezius myositis, secondary to a strain of Muscle Group I, the extrinsic muscles of the shoulder girdle: the trapezius, levator scapulae, and serratus magnus. He noted that there was no evidence of a penetrating muscle injury, hernia, or fascial defects. She did exhibit symptoms such as pain, weakness, and a lowered threshold of fatigue. There was no atrophy or other pertinent physical findings, complications, signs or symptoms. The examiner indicated that the appellant's disability would not impact her ability to work or keep up with work requirements. At a June 2013 VA medical examination, the appellant's complaints included occasional left upper back pain which she described as a pressure like sensation without irradiation. She used pain medication and muscle relaxers with good results. She denied flare-ups which impacted function of her thoracolumbar spine. Range of motion testing showed forward flexion to 60 degrees, with pain beginning at 60 degrees; extension to 15 degrees, with pain beginning at 15 degrees; right and left lateral flexion to 20 degrees, with pain beginning at 20 degrees; right and left lateral rotation to 25 degrees, with pain beginning at 25 degrees. The appellant was able to perform repetitive testing with no additional loss of motion. The appellant exhibited muscle spasm to the left trapezius muscle. There was no guarding or muscle spasm of the thoracolumbar spine. Her strength and reflexes in the lower extremities were normal. There was no radicular pain and the appellant exhibited no other signs or symptoms of radiculopathy or other neurologic abnormalities. The examiner indicated that the appellant's disability did not impact her work. Applicable Law Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The basis of disability evaluations 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. Evaluations are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § 4.10. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where, as here, a claimant appeals the initial rating assigned following an award of service connection, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous . . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. The U.S. Court of Appeals for Veterans Claims (Court) has held that functional loss, supported by adequate pathology and evidenced by visible behavior of the Veteran undertaking the motion, is recognized as resulting in disability. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.10, 4.40, 4.45. The appellant's service-connected left mid scapular myositis is evaluated under the provisions of 38 C.F.R. § 4.71a, Diagnostic Codes 5021-5242, pertaining to myositis limiting motion of the spine. The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. As set forth in more detail below, the Board has considered the assignment of other diagnostic codes, but finds no more appropriate provision. The appellant's symptoms of left shoulder pain, limitation of left arm motion, and functional loss have been contemplated in assigning the current rating for her service-connected left shoulder bursitis. Therefore, evaluating her mid scapular myositis under the criteria for limitation of motion of the arm would constitute pyramiding prohibited by 38 C.F.R. 4.14. See Esteban v. Brown, 6 Vet. App. 259 (1994). Similarly, again as discussed below, the medical evidence establishes that the appellant's service-connected mid scapular myositis disability is not closely analogous in anatomic location or function to the cervical spine. Moreover, service connection for a cervical spine disability has been previously denied in a final rating decision. Thus, the appellant's cervical symptomatology, including neck pain, cervical spasm, and limitation of motion of the cervical spine, may not be considered in assigning the rating for her service-connected left mid scapular myositis because the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation must be avoided. 38 C.F.R. § 4.14. Finally, the Board considered rating the appellant's disability under the criteria for evaluating muscle injuries. The medical evidence of record, however, indicates that the symptoms which are part and parcel of the appellant's service-connected mid scapular myositis disability include spasms and tenderness to palpation in the dorsal, mid scapular and mid trapezius regions. Given the rating criteria set forth at 38 C.F.R. § 4.56 and 38 C.F.R. § 4.73, the Board finds that the appellant's medical history, diagnosis, and demonstrated symptomatology indicate that application of the specific rating criteria pertaining to myositis affecting motion of the dorsal area is more appropriate. As set forth below, the appellant has been expressly diagnosed as having myositis and her medical history contains no indication of findings such as a wound of the muscle, debridement, infection, loss of fascia or muscle substance, impairment of muscle tonus, intramuscular scarring, or loss of power or lowered threshold of fatigue when compared to the sound side. Diagnostic Code 5021 is the provision for rating myositis. That diagnostic code provides that myositis shall be rated on the basis of limitation of motion of the affected parts, as degenerative arthritis. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, degenerative arthritis, substantiated by X-ray findings, is rated based on limitation of motion for the specific joint involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate Diagnostic Code, 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. During the lengthy pendency of this claim, the criteria for evaluating limitation of motion of the spine were amended. See 68 Fed. Reg. 51,454 -56 (Aug. 27, 2003) (codified at 38 C.F.R. 4.71a (effective September 26, 2003) (General Rating Formula for Diseases and Injuries of the Spine)). The appellant is entitled to application of the version of the criteria which is more favorable to her, subject to applicable effective date limitations. See VA O.G.C. Prec. Op. No. 3-2000 (Apr. 10, 2000), 65 Fed. Reg. 33,421 (2000); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Under the criteria in effect prior to September 26, 2003, limitation of motion of the dorsal spine was evaluated under 38 C.F.R. § 4.71a, Diagnostic Codes 5291. Diagnostic Code 5291 provided a zero percent rating for slight limitation of motion of the dorsal spine. A 10 percent rating was warranted for moderate or severe limitation of motion of the dorsal spine. Words such as "slight," "moderate," and "severe" were not defined in the VA Schedule for Rating Disabilities as they applied to the Diagnostic Code discussed above. Rather than applying a mechanical formula, the Board was required to evaluate all of the evidence to the end that its decisions were "equitable and just." 38 C.F.R. § 4.6. Under the criteria in effect from September 26, 2003, disabilities of the spine are rated under a General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5242 (pertaining to degenerative arthritis of the spine). That formula provides that with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, the following ratings are assigned: A 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. Id. Several notes to the General Rating Formula for Diseases and Injuries of the Spine provide additional guidance. Note (2) provides that for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. In every instance where the minimum schedular evaluation requires residuals and the schedule does not provide for a zero percent evaluation, a zero percent evaluation will be assigned when the required symptomatology is not shown. 38 C.F.R. § 4.31. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C.A. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. 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(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis Applying the facts in this case to the criteria set forth above, the Board finds that the criteria for an initial 10 percent rating, but no higher, for the appellant's service-connected left mid scapular myositis have been met from June 20, 2001, but that the preponderance of the evidence is against the assignment of a rating in excess of 20 percent from April 13, 2004. As a preliminary matter, the Board notes that the RO has awarded service connection for both left shoulder bursitis and left mid-scapular myositis. As noted above, in its final November 2012 decision, the Board rated the appellant's service-connected connected left shoulder bursitis disability pursuant to 38 C.F.R. §§ 4.71a, Diagnostic Codes 5019-5201. Diagnostic Code 5019 provides that bursitis shall be rated on the basis of limitation of motion of the affected parts, as degenerative arthritis. Limitation of motion of the arm is rated under the provisions set forth in Diagnostic Code 5201. In its decision, the Board assigned the initial rating for left shoulder bursitis based on the appellant's complaints of left shoulder pain and limitation of flexion and abduction of the left arm, with no additional functional loss due to pain or additional range of motion loss due to any weakened movement, excess fatigability, or incoordination. See 38 C.F.R. §§ 4.40, 4.45 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board's decision in this regard is final, absent any indication that the appellant appealed. VA's Rating Schedule provides that the evaluation of the same disability under various diagnoses is to be avoided. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. The Court has emphasized that a claimant may not be compensated twice for the same symptomatology as such a result would overcompensate the claimant for the actual impairment of his earning capacity. Brady v. Brown, 4 Vet. App. 203 (1993). Notwithstanding the provisions of 38 C.F.R. § 4.14, VA is required to provide separate evaluations for separate manifestations of the same disability which are not duplicative or overlapping. See Esteban v. Brown, 6 Vet. App. 259, 261 (1994), 38 C.F.R. § 4.25 (2010). In light of these provisions, the Board finds that the symptomatology already considered in rating the appellant's service-connected left shoulder bursitis disability, i.e. left shoulder pain and limitation of left arm motion, may not be considered in assigning the rating for her left mid scapular myositis, as this would constitute pyramiding prohibited by 38 C.F.R. 4.14. See Esteban v. Brown, 6 Vet. App. 259 (1994). Similarly, the Board observes that the record shows that the appellant suffers from cervical symptomatology, including pain, spasm, and limitation of motion of the cervical spine. In a final December 2004 rating decision, however, the RO denied service connection for chronic cervical strain/cervical myositis, based on a November 2004 VA medical opinion which indicated that the appellant's cervical myositis was not related to her service-connected left mid-scapular myositis. Additionally, during the course of this appeal, the Board solicited a medical opinion in order to ascertain the appellant's left mid-scapular myositis symptoms, separate and distinct from her left shoulder bursitis symptoms. In a August 2011 VA medical examination report, the examiner explained that the symptoms associated with the appellant's service-connected mid scapular myositis were mild tenderness to palpation at the mid trapezius and left rhomboid major muscle bellies. He further explained that this disability was not analogous in anatomic location or function to rating the cervical spine. Rather, he explained that the mid trapezius and the rhomboids major were not part of the neck intrinsic muscles which permitted movement of the head. Under these circumstances, the Board further concludes that the appellant's cervical symptomatology, including neck pain, cervical spasm, and limitation of motion of the cervical spine, may not be considered in assigning the rating for her service-connected left mid scapular myositis. Again, the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation must be avoided. 38 C.F.R. § 4.14; see also Mittleider v. West, 11 Vet. App. 181, 182 (1998). The issue now before the Board on appeal involves the appellant's entitlement to a higher initial rating for her service-connected left mid scapular myositis under the applicable rating criteria. In that regard, VA's Rating Schedule provides that myositis is to be rated on the basis of limitation of motion of the affected part. 38 C.F.R. § 4.71a, Diagnostic Code 5019. During the period from June 20, 2001, to April 12, 2004, the evidence shows that the appellant reported that her left mid scapular myositis symptoms were on and off left scapular pain. She specifically denied experiencing any other symptomatology related to that disability. At the August 2001 VA medical examination, the appellant exhibited forward flexion of the spine to 95 degrees, backwards extension and rotation to 30 degrees, and lateral flexion to 40 degrees. There was no painful motion. These findings do not meet the criteria for a compensable rating under either the old or amended rating criteria for limitation of motion of the dorsal or thoracolumbar spine. Nonetheless, the Board observes that the examiner's findings in August 2001 also included mild scapular muscle spasm and mild tenderness to palpation in that area. The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent rating when symptoms of muscle spasm are present, despite noncompensable limitation of motion. Although these rating criteria were not in effect prior to September 26, 2003, the Board finds when the appellant is afforded the benefit of the doubt, her symptoms of muscle spasm and tenderness are the functional equivalent of moderate limitation of motion of the dorsal spine, also warranting a 10 percent disability rating under 38 C.F.R. § 4.71a, Diagnostic Codes 5291, as in effect prior to September 26, 2003. See 38 C.F.R. §§ 4.40, 4.45, 4.71a, Diagnostic Code 5003 (2002) (providing for the assignment of a 10 percent rating when the limitation of motion of the specific joint or joints involved is noncompensable but accompanied by objectively confirmed by findings such as muscle spasm). The Board finds, however, that absent evidence of additional symptomatology or objective functional loss, the criteria for a rating in excess of 10 percent for left mid scapular myositis were not met during the period from June 20, 2001, to April 12, 2004. Id. Similarly, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 20 percent from April 13, 2004, for the appellant's service-connected left mid scapular myositis. As set forth in more detail above, repeated examinations conducted since April 2004 have shown that the appellant did not exhibit limitation of motion of the dorsal or thoracolumbar spine of the degree necessary to meet the criteria for a rating in excess of 20 percent under the General Rating Formula for Diseases and Injuries of the Spine, nor did she ever exhibit ankylosis of the dorsal spine, as would be required for a rating in excess of 20 percent under the former rating criteria. The Board also finds that the most probative evidence establishes that the appellant's left mid scapular myositis disability is not objectively productive of additional range of motion loss due to pain or functional loss necessary to meet the Deluca factors for a rating in excess of 20 percent from April 13, 2004. For example, during a May 2004 VA medical examination, the appellant exhibited a normal gait and posture and no specific findings of functional loss were observed. At a November 2004 VA medical examination, the appellant reported pain in the dorsal region in the paravertebral muscles, with occasional flare-ups of pain for which she took Advil. She denied, however, experiencing any additional limitation of motion or functional impairment during flare-ups. At a VA medical examination in August 2011, the appellant exhibited mild tenderness over the mid trapezius and rhomboids major, but strength was normal and the examiner determined that her service-connected mid scapular myositis was not manifested by pain on motion, evidence of weakness, excess fatigability, or incoordination. The Board has reviewed the remaining evidence of record but concludes that the most probative evidence shows that additional functional loss factors do not restrict motion to such an extent that the criteria for a rating in excess of 20 percent would be justified. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.10, 4.40, 4.45. In reaching this decision, the Board has also considered whether an extraschedular rating is warranted with respect to the appellant's left mid scapular myositis. Bagwell v. Brown, 9 Vet. App. 157 (1996) (the question of extraschedular rating is a component of a claim for an increased rating). After reviewing the record, however, the Board finds that there is no basis for further action on this question as there is no indication of an exceptional or unusual disability picture such that the schedular criteria for the appellant's service-connected left scapular myositis are inadequate. As discussed above, the symptoms associated with the appellant's service-connected disability, including pain, spasm, limitation of motion, and functional loss are fully contemplated by the Rating Schedule. There is no objective evidence of record demonstrating that the appellant's service-connected left mid scapular myositis markedly interferes with her employment, beyond that contemplated by the rating schedule. Indeed, VA examiners have expressly concluded that the appellant's left mid scapular myositis does not have a significant impact on her occupation or activities of daily living. There is also no evidence of record showing that she has been frequently hospitalized due to her left mid scapular myositis. In fact, it does not appear that she has been hospitalized for this disability at all. Although the appellant reported that her disability prevented her from demonstrating certain physical skills to her students in her capacity as a physical education instructor, her occupational limitations have been contemplated in assigning the current rating, based on her functional loss. In recognition of the industrial impairment caused by her service-connected left mid scapular myositis, the appellant has been awarded a 10 percent disability rating from June 20, 2001, and a 20 percent from April 13, 2004. Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The record otherwise contains no indication that there are factors causing marked interference with employment beyond that contemplated by the schedular criteria. Under these circumstances, the Board finds no evidence to indicate referral for extraschedular consideration. Thun v. Peake, 22 Vet. App. 111 (2008). In reaching this determination, the Board has considered Mittleider v. West, 11 Vet. App. 181 (1998), but finds that the record does not show, nor has the appellant expressly contended, that an extraschedular rating is warranted based on consideration of all of her service-connected symptomatology. Finally, the Board has considered the Court's decision in Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). In this case, however, the record on appeal contains no indication that the appellant is unemployable as a result of her service-connected left mid scapular myositis and the appellant has not expressly contended otherwise. Rather, the record shows that she remained employed during the course of this appeal and is in the process of obtaining an advanced degree to allow her to work in a less physically demanding capacity. She has reported that she lost no significant time from work due to disability. Again, VA examiners have consistently concluded that the appellant's left mid scapular myositis does not have a significant effect on her occupation. Absent probative evidence of unemployability due to the left mid scapular myositis, consideration of a total rating based on individual unemployability due to service-connected disability is not warranted in connection with this claim. For the reasons and bases discussed above, the Board finds that an initial 10 percent disability rating is warranted for left mid scapular myositis from June 20, 2001. The preponderance of the evidence is against the assignment of an initial rating in excess of 10 percent from June 20, 2001, and in excess of 20 percent from April 13, 2004. To that extent, the benefit of the doubt doctrine is not for application as the weight of the evidence is against the claim. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). ORDER Entitlement to an initial 10 percent rating for left mid scapular myositis for the period from June 20, 2001, to April 13, 2004, is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 20 percent for left mid scapular myositis from April 13, 2004, is denied. ______________________________________________ Cheryl L. Mason Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs