Citation Nr: 1333458 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 10-39 519 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to a compensable evaluation for right ear hearing loss. 2. Entitlement to an evaluation in excess of 10 percent for tinnitus. 3. Entitlement to a compensable evaluation for lumbar strain with levoscoliosis prior to May 4, 2009. 4. Entitlement to a rating in excess of 10 percent for lumbar strain with levoscoliosis since May 4, 2009. 5. Entitlement to an evaluation in excess of 10 percent for costochondritis (claimed as chest pain and shortness of breath). 6. Entitlement to an evaluation for hypertensive heart disease, associated with hypertension, in excess of 60 percent prior to August 26, 2009. 7. Entitlement to an evaluation for hypertensive heart disease, associated with hypertension, in excess of 30 percent since August 26, 2009. 8. Entitlement to service connection for a cervical spine disorder, claimed as a neck disorder. 9. Entitlement to service connection for a gastrointestinal disorder, claimed as left stomach problems. 10. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder. 11. Whether there is new and material evidence to reopen a claim of entitlement to service connection for sleep apnea. 12. Whether there is new and material evidence to reopen a claim of entitlement to service connection for gout of both hands. 13. Whether there is new and material evidence to reopen a claim of entitlement to service connection for both lower extremities, to include the knees. 14. Entitlement to a rating in excess of 20 percent for hypertension. 15. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD A. Barner, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1979 to April 1993. This appeal comes before the Board of Veteran's Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. A Substantive Appeal for the issue of entitlement to service connection for a dental condition of teeth 22, 34, and 36 was not filed, and the Veteran was so informed in a February 2013 Supplemental Statement of the Case. The issue has, however, been addressed in an April 2013 rating decision, and the representative included it in his July 2013 brief, but was not listed as an issue. As such, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. In addition, the Board observes that the Veteran has claimed hearing loss, and VA examiners have noted that the Veteran's diagnosis of bilateral hearing loss is related to service, yet only his right ear hearing loss is service connected at this time. As such, the issue of entitlement to service connection for left ear hearing loss has been raised by the record, but has not been adjudicated by the AOJ. Therefore, the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action. Finally, the Board observes that the Veteran's claim of entitlement to service connection for memory problems was withdrawn according to an April 2013 decisional letter by the RO, which followed a report of contact in which the Veteran indicated that his memory problems were part and parcel of his claim of entitlement to service connection for posttraumatic stress disorder. That letter also indicated that if the Veteran filed the same claim within a year of the date of the letter, the effective date for any grant of benefits for the same claim would be awarded as if the claim were not withdrawn. The Veteran has since, in a statement received by the Board in October 2013 indicated that he would like to continue an appeal regarding his memory problems. There has not been a separate adjudication regarding memory problems. As such, the Board does not currently have jurisdiction over it, and it is referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to service connection for a cervical spine disorder, gastrointestinal disorder, and posttraumatic stress disorder, and the claim of new and material evidence to reopen claims of entitlement to service connection for sleep apnea, for left and right hand gout, and for right and left lower extremities (to include the knees), and the claim for a rating in excess of 20 percent for hypertension, and for entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran has demonstrated no worse than Level III hearing in the right ear. In the absence of complete deafness the left ear is considered normal for rating purposes. 2. The 10 percent rating for tinnitus is the maximum scheduler rating available for tinnitus. 3. The Veteran's lumbar spine disability prior to May 4, 2009, was not limited to greater than 30 degrees but less than 60 degrees forward flexion or with combined range of motion not greater than 170 degrees, or with spinal spasm or guarding severe enough to result in abnormal gait or spinal contour. It was, however, characterized by localized tenderness with no evidence it resulted in abnormal spinal contour or gait. 4. The Veteran's lumbar spine disability was not limited to greater than 30 degrees but less than 60 degrees forward flexion or with combined range of motion not greater than 170 degrees, or with spinal spasm or guarding severe enough to result in abnormal gait or spinal contour. 5. During the appeal period, there were no physician-prescribed periods of bedrest due to back impairment. 6. The Veteran's service-connected costochondritis, chest pain, is presently manifested by episodes of subjective pain at various times, without objective evidence of limitation of motion, including as a result of pain and dysfunction. There is tenderness along the bilateral costosternal sides, productive of a moderate level of impairment. 7. From February 14, 2008 to March 10, 2009, the Veteran's hypertensive heart disease was manifested by an estimated workload of 3 METs, with no evidence of cardiomegaly, and ejection fraction of 40 percent. 8. From March 11, 2009 to August 25, 2009, the Veteran's hypertensive heart disease was manifested by an estimated workload of 7 METs, and ejection fraction of 40 percent. 9. Since August 26, 2009, the Veteran's hypertensive heart disease was manifested by an estimated workload of 5 to 7 METs, with no evidence of cardiomegaly, and ejection fraction of 56 percent. CONCLUSIONS OF LAW 1. The schedular criteria for a compensable rating for the Veteran's right ear hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.85, 4.86, Diagnostic Code 6100 (2013). 2. There is no legal basis for the assignment of a schedular rating higher than 10 percent for tinnitus. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. § 4.87, Diagnostic Code 6260 (2013). 3. Resolving reasonable doubt in favor of the Veteran, criteria for a rating of 10 percent, but no higher, for a lumbar spine disability have been met prior to May 4, 2009. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.16, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5237 (2013). 4. The criteria for a rating in excess of 10 percent for a lumbar spine disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.16, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5237 (2013). 5. The criteria for an evaluation in excess of 10 percent for costochondritis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.71a, 4.73, Diagnostic Codes 5099-5010, 5321 (2013). 6. The criteria for an evaluation of 100 percent for hypertensive heart disease, associated with hypertension, from February 14, 2008 to March 11, 2009, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7007 (2013). 7. The criteria for an evaluation in excess of 60 percent for hypertensive heart disease, associated with hypertension from March 11, 2009 to August 25, 2009 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7007 (2013). 8. The criteria for an evaluation in excess of 30 percent for hypertensive heart disease, associated with hypertension since August 26, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7007 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met with regard to the issues decided herein. There is no issue as to providing an appropriate application form or completeness of the application. In February 2008, prior to the rating decision in question, VA notified the Veteran of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain. This letter also provided notice of how disability ratings and effective dates are assigned. VA has fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. Although the representative has suggested that the November 2012 examination for costochondritis did not properly address the Veteran's pain and symptoms, the Board finds that the examiner reviewed the Veteran's history to include "Chest pain around the breast and sternum. . .rib cage severe pain." There was extensive discussion describing the factors that caused the pain, its location and severity, as well as symptoms such as swelling and abnormal motion resulting from his bone condition. As such, the Board finds that this examination is adequate. In Martinak v. Nicholson, 21 Vet. App. 447 (2007), the United States Court of Appeals for Veterans Claims (Court) noted that, unlike the rating schedule for hearing loss, extraschedular provisions do not rely exclusively on objective test results to determine whether referral for an extraschedular rating was warranted. The Court held that in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in the final report. Id. at 455. The Board finds that the VA audiological examinations are in compliance with Martinak and are adequate for rating purposes. Id. Although the Veteran was provided the opportunity to attend a Board hearing, he declined to do so. In sum, there is no evidence of any VA error in notifying or assisting him that reasonably affects the fairness of this adjudication. 38 C.F.R. § 3.159(c). Indeed, the Veteran has not suggested that such an error, prejudicial or otherwise, exists. The case is ready for adjudication. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule). Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 (2013). The factors of disability affecting joints are reduction of normal excursion of movements in different planes, and include consideration of weakened movement, excess fatigability, incoordination, swelling and pain on movement. 38 C.F.R. § 4.45 (2013). The 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 (2013). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). In cases in which a reasonable doubt arises as to the appropriate degree of disability to be assigned, such doubt shall be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where there is a question as to which of the 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. Hearing loss Evaluations of defective hearing are based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination testing together with the average hearing threshold level as measured by pure tone audiometric tests in the frequencies 1,000, 2,000, 3,000 and 4,000 Hertz. 38 C.F.R. § 4.85, Diagnostic Code 6100. To evaluate the degree of disability from defective hearing, the rating schedule requires assignment of a Roman numeral designation, ranging from Level I for essentially normal acuity to Level XI for profound deafness. Other than exceptional cases, VA arrives at the proper designation by mechanical application of Table VI, which determines the designation based on results of standard test parameters. Id. Table VII is then applied to arrive at a rating based upon the respective Roman numeral designations for each ear. Id. The assignment of a disability rating for hearing loss is a "mechanical" process of comparing the audiometric evaluation to the numeric designations in the rating schedule. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1993). In the present case, the Board notes that the Veteran has been granted service connection for only one ear. As such, VA regulations require that the non-service-connected ear be rated at Roman Numeral Level I. See 38 C.F.R. §§ 3.383, 4.85(f). After reviewing the evidence of record the Board finds that a compensable rating for right ear hearing loss is not warranted. 38 C.F.R. §4.85, Diagnostic Code 6100. The Veteran reports that his hearing is very poor, and that he has to ask others to repeat themselves. He has indicated that at times he is unable to hear anything from his right ear, and he experiences right ear pain. The Veteran was afforded a July 2008 VA audiological examination. He reported experiencing sharp pain in his right ear, but no dizziness, vertigo, difficulty balancing, or discharge. The Veteran had not received any treatment for his hearing loss. He reported that he had not been hospitalized or undergone surgery for his ear. Auricle and external ear examinations were within normal limits. Hearing loss was present bilaterally. No ear disease was present. Tympanic membrane and mastoid examinations were within normal limits. There was no active infection or disturbance of balance. Cerumen impaction was greater on the right than on the left; however, it was removed. Although air and bone conduction testing was performed, the examiner indicated that air conduction study better reflected the Veteran's hearing loss. An audiogram revealed air conduction pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 30 30 40 45 LEFT 15 25 25 30 30 The average pure tone threshold from 1000 to 4000 Hertz was 36dBs in the right ear and 28dBs in the left ear. Speech audiometry revealed speech recognition ability of 96 percent in the right ear, and of 96 percent in the left ear. Diagnosis was of bilateral sensorineural hearing loss, shown by audiometric findings, and reported by the Veteran. Hearing loss affected the Veteran's usual occupation in causing difficulty hearing customers and staff at work. It affected his daily activities in causing difficulty hearing people. The left ear is considered normal. The Veteran was afforded an August 2009 audiological examination. The Veteran reported significantly worse hearing loss in his right ear than in the left ear. The Veteran described experiencing symptoms to include extreme headaches, poor vision and difficulty performing job duties. He reported his hearing loss contributed to poor work performance, difficulty understanding, and difficulty hearing normal conversational speech at work, and in noisy situations. Auricle and external ear examinations were within normal limits. Pure tone threshold levels, in decibels were determined both on air conduction and bone conduction at the examination. Air conduction was again noted to better reflect the Veteran's hearing loss. An audiogram revealed pure tone air conduction thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 35 30 35 40 LEFT 20 25 30 30 30 The average pure tone threshold from 1000 to 4000 Hertz was 35dBs in the right ear and 29dBs in the left ear. Speech audiometry revealed speech recognition ability of 76 percent in the right ear, and of 96 percent in the left ear. The examiner indicated that diagnosis was changed to bilateral mild sensorineural hearing loss, slightly worse in the right ear. The Veteran reported difficulties hearing at work and at home, and the conduction results revealed mild sensorineural hearing loss. A complete otologic evaluation to rule out retrocochlear disorder was recommended in light of differences in word understanding between the right and the left ears. The examiner indicated that the Veteran's hearing loss affected his work by causing difficulty understanding. It affected his daily activities by causing difficulty understanding normal conversational speech. The Veteran was afforded an August 2009 VA audiological examination to follow-up with retrocochlear evaluation. An audiogram revealed pure tone air conduction thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 40 45 40 45 50 LEFT 30 35 35 45 50 The average pure tone threshold from 1000 to 4000 Hertz was 45dBs in the right ear and 41dBs in the left ear. Speech audiometry revealed speech recognition ability of 96 percent in the right ear, and of 92 percent in the left ear. There was no pathology to render a diagnosis of retrocochlear disorder. The diagnosis was of bilateral sensorineural hearing loss. The Veteran was afforded a November 2012 VA audiological examination. He indicated that his hearing loss caused difficulty hearing and understanding in large crowds of people. An audiogram revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 30 30 40 50 LEFT 25 30 30 40 45 The average pure tone threshold from 1000 to 4000 Hertz was 38dBs in the right ear, and 36dBs in the left ear. Speech audiometry revealed speech recognition ability of 80 percent in the right ear, and of 88 percent in the left ear. The examiner indicated that there was bilateral hearing loss. The evidence of record, as detailed above, preponderates against entitlement to a compensable schedular rating. The evidence of record simply does not allow for a compensable disability rating under the schedular criteria. The audiometric thresholds do not meet the exceptional pattern of hearing impairment under 38 C.F.R. § 4.86. Therefore, the Veteran's audio threshold and speech recognition scores will be applied to Table VI and not Table VIA. Applying the values of the audiological examinations to the rating criteria results in a numeric designation no greater than Level III in the right ear. See 38 C.F.R. § 4.85, Table VI. Application of this level of hearing impairment to Table VII at 38 C.F.R. § 4.85 produces a noncompensable rating. To the extent that the Veteran contends that his hearing loss is more severe than currently evaluated, the Veteran, while competent to report symptoms such as difficulty hearing, is not competent to report that his hearing acuity is sufficient to warrant a compensable evaluation under VA's tables for rating hearing loss disabilities. Such an opinion requires medical expertise which he has not been shown to have. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Even after considering the Veteran's reports as to the effects of the disability on his daily life, to include difficulty hearing others the evidence shows that the rating criteria for a compensable rating are not met. Lendenmann. With regard to extraschedular consideration, the threshold determination is whether the disability picture presented in the record is adequately contemplated by the rating schedule. Thun v. Peake, 22 Vet. App. 111 (2008). The Veteran's disability picture is not so unusual or exceptional in nature as to render his schedular rating inadequate. The Veteran's right ear hearing loss has been evaluated under the applicable diagnostic code that specifically contemplates the level of occupational impairment caused by this level of disability. In reaching this decision the Board considered the doctrine of reasonable doubt; however, the preponderance of the evidence is against the claim, and the doctrine is not otherwise for application. Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Staged ratings are not appropriate under the circumstances. Tinnitus Tinnitus is evaluated under Diagnostic Code 6260 and assigns a single 10 percent schedular rating, whether tinnitus is perceived as being in one ear or each ear or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260, Note 2 (2013). In Smith v. Nicholson, 451 F.3d 1344, 1350-51 (Fed. Cir. June 19, 2006), the Federal Circuit affirmed VA's long-standing interpretation of Diagnostic Code 6260 that only a single 10 percent schedular rating for tinnitus is assignable, whether or not the tinnitus is perceived unilaterally or bilaterally. In light of the foregoing, the Board concludes that the initial rating of 10 percent for tinnitus is the maximum schedular rating assignable under Diagnostic Code 6260. As such, the Veteran is not entitled to any higher schedular rating for his tinnitus. Here, disposition of the claim is based on interpretation of the law, and not the facts of the case, and the claim must be denied based on a lack of entitlement under the law. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The Board is cognizant that in his November 2012 audiological examination, the Veteran reported that his tinnitus caused headaches and made it more difficult for him to hear. The Veteran's report of symptomatology is competent and credible, however his report as to the etiology of his headaches and attempt to relate them to his tinnitus is not competent, and as such, is not afforded probative value. The evidence of record indicates that the Veteran's symptomatology to include ringing in the ears is fully contemplated by the schedular rating, such that his disability picture is not so unusual or exceptional in nature as to render his schedular rating inadequate. Thun v. Peake, 22 Vet. App. 111 (2008). Staged ratings are not appropriate under the circumstances. Lumbar strain with levoscoliosis Under 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5010, traumatic arthritis is rated as degenerative arthritis which in turn is rated based upon the nature and extent of any limitation of motion. If the limitation of motion of the joint involved is noncompensable, a rating of 10 percent is applicable. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. With any form of arthritis, painful motion is an important factor. It is the intent of the rating schedule to recognize actually painful, unstable or mal-aligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The criteria for evaluating disabilities of the spine are contained in a General Rating Formula for Diseases and Injuries of the Spine. The 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 for disability of the thoracolumbar spine: 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 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 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a (2013). Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V) 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. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5242 (2013). In addition to the General Rating Formula for Diseases and Injuries of the Spine, intervertebral disc syndrome may be evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation. See 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2013). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that when intervertebral disc syndrome is productive of incapacitating episodes having a total duration of at least one week but less than two weeks during the past twelve months, a 10 percent rating is assigned. When incapacitating episodes have a total duration of at least two weeks but less than four weeks during the past twelve months, a 20 percent rating is assigned. When incapacitating episodes have a total duration of at least four weeks but less than six weeks during the past twelve months, a 40 percent rating is assigned. When incapacitating episodes have a total duration of at least six weeks during the past 12 months, a maximum 60 percent rating is assigned. Note (1) following 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2013) provides that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2) following 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2013) provides that if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever results in a higher evaluation for that segment. The Veteran's lumbar spine disability was service connected and rated as noncompensably disabling effective February 14, 2008, and as 10 percent disabling effective May 4, 2009. The Veteran contends that his lumbar spine disability warrants higher evaluations. During this appeal, the Veteran has reported that he experiences symptoms such as pain, stiffness, fatigue, spasm, decreased motion, paresthesia, and numbness related to lumbar strain. In an August 2008 VA examination the Veteran indicated that he experienced stiffness of his spine. He denied visual disturbances, weakness, numbness, fevers, bladder complaints, malaise, bowel complaints, and dizziness. He reported that he had not lost any weight due to his lumbar spine disorder. He reported experiencing pain in his low back for more than nine years. The pain occurred five times per day and lasted for a week. The pain traveled down his legs and hips, and was characterized by aching, at a level of six on a scale with 10 as the worst pain. Pain was elicited with physical activity, and relieved by rest. The Veteran reported that he required bed rest during the pain. He did not receive any treatment for his condition, and reported that it had not resulted in any incapacitation. The Veteran reported that he did not experience any functional impairment from this condition. On examination, the Veteran's posture was within normal limits, as was his gait. He did not require any assistive device for ambulation. Inspection of the spine revealed a normal head position with symmetry in appearance, and symmetry of spinal motion with normal curvatures of the spine. There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement. There was no evidence of radiating pain on movement and muscle spasm was absent. There was tenderness noted on examination of the left lumbar area. There was a negative straight leg raising test bilaterally. There was no ankylosis of the spine. Range of motion testing revealed flexion to 90 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees, and right and left rotation to 30 degrees. Joint function of the spine was additionally limited by pain following repetitive motion. Pain had a major functional impact; however, pain did not limit the motion in degrees. The Veteran was not additionally limited by fatigue, weakness, lack of endurance and incoordination following repetitive motion. Neurological examination of the upper and lower extremities was within normal limits, as was sensory function. Upper extremity reflexes were 1+, and lower extremity reflexes were 2+. Diagnosis was of levoscoliosis and lumbar strain. Subjective factors were based on the Veteran's history and objective factors were lumbar back pain and X-ray evidence showing levoscoliosis. The Veteran experienced difficulty lifting. In August 2009 the Veteran reported that he experienced spine stiffness, aching, unfavorable ankylosis of the entire spine, bowel and bladder impairment, and his spinal segment was in a neutral position. He suggested that the thoracic, lumbar, and cervical spine segments should be used to determine the combined range of motion. The Board refers the Veteran to the regulations which explain in 38 C.F.R. § 4.71a, Note (6) that the thoracolumbar and cervical spine segments are separately evaluated, except when there is unfavorable ankylosis of both segments. A July 2008 addendum opinion indicated that an emergency intravenous pyelogram from March 1985 showed levoscoliosis of the lumbosacral spine, which was during service, such that his current levoscoliosis with lumbar strain was more likely than not related to earlier diagnosis. The Veteran was afforded a VA examination for lumbar strain with levoscoliosis in September 2009. The Veteran reported that he was able to walk approximately one kilometer in an hour. He did not have a history of falls. The Veteran reported experiencing stiffness, fatigue, spasms, decreased motion, paresthesia, and numbness. He also reported experiencing weakness of the spine, leg, and foot. He denied experiencing bowel or bladder problems. He also denied experiencing erectile dysfunction. The Veteran reported that he experienced pain that was constant and severe, and traveled down both legs. The pain was exacerbated by activity and alleviated with rest. The Veteran was able to function with medication while experiencing the pain. During flare-ups he experienced functional impairment described as pain and incoordination, and pain with limited motion when bending forward or rotating the spine. The Veteran was not receiving any treatment for his spine, and reported that he had never been hospitalized or received surgery for it. The Veteran reported functional impairment in limited sitting and standing. On examination, his posture and gait were within normal limits. Walking was steady, and an assistive device was not required. Examination of the thoracolumbar spine revealed no evidence of radiating pain on movement. Muscle spasm was absent. No tenderness was noted. Guarding of movement, described as apprehension of moving the spine for fear of experiencing pain, was present. Spinal contour was preserved, in spite of the guarding. Guarding did not produce an abnormal gait. The examination did not reveal any weakness. Muscle tone and musculature were normal. There were negative straight leg raising tests bilaterally. Lasegue's sign was negative. There was no atrophy of the limbs. There was no ankylosis of the thoracolumbar spine. Flexion of the lumbar spine was to 70 degrees, with pain at 70 degrees. Extension was to 20 degrees. Right and left lateral flexion were each to 20 degrees, with pain. Right and left rotation were each to 30 degrees. Following repetitive motion, there was no additional limitation in degree of motion. The joint function of the spine was additionally limited by pain, fatigue, weakness, and lack of endurance following repetitive motion. Of these, weakness had the greatest functional impact. Incoordination was not an additional limitation following repetitive motion. Inspection of the spine revealed normal head position with symmetry in appearance. There was also symmetry of spinal motion with abnormal curves of the spine, scoliosis, present. Lumbar X-ray showed minimal scoliosis. Diagnosis was of lumbar strain with levoscoliosis, and active condition with subjective factors as reported. Objective factors were mild tenderness associated with limited range of motion, and X-ray evidence of scoliosis in the lumbar spine. Neurological examination of the lumbosacral spine, using pin prick and feather testing, revealed no sensory deficits from L1 to L5, or S1. There was no lumbosacral motor weakness. The right lower extremity reflexes revealed knee jerk 2+ and ankle jerk 2+. Left lower extremity testing revealed knee reflexes. There were no signs of lumbar intervertebral disc syndrome with chronic and permanent nerve root involvement. There were no non-organic physical signs. Effects on the Veteran's daily activities were nil, and the Veteran worked in the restaurant industry. At his November 2012 VA examination for lumbar strain with levoscoliosis the Veteran reported that his condition had worsened over time, and limited his daily physical activities. He reported that the lumbar area was in constant pain and discomfort, and that he had requested to wear a back brace, and struggled daily with severe pain while standing or bending. Range of motion testing revealed flexion to 85 degrees, with objective evidence of painful motion beginning at the same. Extension ended at 30 or greater degrees, with no objective evidence of painful motion. Right and left lateral flexion, and right and left lateral rotation ended at 30 or greater degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive use testing with three repetitions, and post-test flexion, extension, right and left lateral flexion and lateral rotation were the same as reported on initial testing. There was no additional limitation of motion of the thoracolumbar spine following repetitive use testing. There was functional loss or impairment to include less movement than normal, and pain on movement of the thoracolumbar spinal. There was no localized tenderness or pain to palpation for joints and or soft tissue of the spine, and no guarding or muscle spasm. Muscle strength testing was all normal for hip flexion, knee extension, ankle plantar flexion and ankle dorsiflexion and great toe extension. There was no muscle atrophy. Reflex and sensory examinations were all normal. Straight leg raising tests were normal, and there was no radicular pain or symptoms of radiculopathy. There were no neurologic abnormalities. The Veteran did not have intervertebral disc syndrome. The Veteran did not use assistive devices. Imaging did not reveal arthritis or vertebral fracture. It did, however, reveal levocurvature of the spine. The Veteran's spine condition did not impact his ability to work. The Veteran's posture and gait were within normal limits. The Veteran's lumbar levoscoliosis was active. A November 2012 X-ray showed that there was mild levoscoliosis of the thoracolumbar junction. The evidence prior to May 2009 showed that the Veteran experienced tenderness of the left lumbar area noted on examination, had levoscoliosis, and had a normal gait. There is no indication that the tenderness resulted in abnormal spinal contour or abnormal gait. As such, resolving reasonable doubt in the Veteran's favor, he is entitled to a 10 percent rating for his lumbar spine disability prior to May 4, 2009. The Veteran is not, however, entitled to a rating in excess of 20 percent for any time period on appeal. The Veteran throughout the appeal has had levoscoliosis, and September 2009 examination showed guarding of movement; however the evidence has indicated that muscle spasms were absent, and gait was normal. There was no indication that the abnormal spinal contour was caused by muscle spasm or guarding, and in September 2009 the examiner indicated that guarding did not produce an abnormal gait. The Veteran's forward flexion of the lumbar spine was, at its worst, limited to 70 degrees with pain, and the combined range of motion ranged from 190 to 240. This range of motion is consistent with the rating criteria for a 10 percent rating. There is no evidence of forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, combined range of motion not greater than 120 degrees, or muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour to warrant a rating of 20 percent. As such, the preponderance of the evidence is against a rating in excess of 10 percent. The Board has considered the rating criteria related to IVDS and finds that the Veteran is not entitled to a rating of 20 percent based upon incapacitating exacerbations. Although in August 2008 the Veteran reported that he required bedrest during periods of pain, the record does not reflect doctor-prescribed bed rest during the relevant period to warrant a higher rating under the rating criteria for IVDS. The Board has also considered whether the Veteran is entitled to a separate rating for radiculopathy or sciatica of the lower extremities during any period on appeal. The Board finds that although the Veteran has reported some radiating pain in the lower extremities, the Veteran's neurologic examinations of the lower extremities have been within normal limits. Although the Veteran reported experiencing bowel problems in August 2009, he denied having any bowel or bladder problems at his September 2009 examination. As such, a separate rating for neurologic disability of the lower extremities is not warranted. The Board has also considered the Veteran's lay statements that his lumbar spine disability is worse than currently evaluated. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's lumbar spine disability has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which this disability is evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective complaints of increased symptomatology. As such, resolving reasonable doubt in the Veteran's favor a 10 percent rating, but no higher, is awarded prior to May 4, 2009. The preponderance of the evidence is against a rating in excess of 10 for his lumbar strain with levoscoliosis for the entire time on appeal. The Board has considered whether to assign staged ratings, but finds them not appropriate under the circumstances. With regard to extraschedular consideration, the threshold determination is whether the disability picture presented in the record is adequately contemplated by the rating schedule. Thun v. Peake, 22 Vet. App. 111 (2008). The Veteran's disability picture-to include lumbar spine pain, limitation of motion, and levoscoliosis-is not so unusual or exceptional in nature as to render his schedular rating inadequate. The Veteran's lumbar strain with levoscoliosis has been evaluated under the applicable diagnostic code that specifically contemplates the level of occupational impairment caused by this level of disability. Costochondritis The current 10 percent rating accounts for the Veteran's complaints of pain, and considers the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59. Although the Veteran has reported pain attributed to his costochondritis, pain is taken into account in the scheduler rating. The rating schedule does not include criteria for the evaluation of costochondritis; however, the schedule provides for analogous ratings under 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, 4.27. In consideration of the nature of the disability at issue, musculoskeletal codes pertaining to the chest region can therefore be applied to determine the applicable rating. As such, the most appropriate Diagnostic Code for the Veteran's costochondritis appears to be 5321, for muscle group XXI, muscles of respiration, because of the similar anatomical location and symptomatology. The Veteran's costochondritis is currently rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Codes 5399-5321. When a disability is not specifically listed, the Diagnostic Code will be "built up," meaning that the first 2 digits will be selected from that part of the schedule most closely identifying the part of the body involved, and the last 2 digits will be "99." 38 C.F.R. § 4.27 (2013). For example, Diagnostic Code 5099 is used to identify unlisted diseases of the musculoskeletal system. Additionally, in the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With diseases, preference is to be given to the number assigned to the disease itself. If the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27 (2013). The hyphenated diagnostic code in this case therefore indicates that an unlisted disorder under Diagnostic Code 5399 is the service-connected disorder, and that the disorder at issue is being rated under Diagnostic Code 5321. As noted, costochondritis may be rated as a musculoskeletal disability under 38 C.F.R. § 4.71a, or alternatively as a muscle disability under 38 C.F.R. § 4.73. As will be discussed, musculoskeletal disabilities are rated on limitation of motion. Diagnostic Code 5010 pertains to arthritis due to trauma substantiated by X-ray findings and is to be rated as degenerative arthritis. Traumatic arthritis (Diagnostic Code 5010) is evaluated according to Diagnostic Code 5003, which pertains to degenerative arthritis. Under Diagnostic Code 5003, arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint involved. If, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic codes, a 10 percent rating will be applied if limitation of motion is established by X-ray findings and objective evidence of limitation of motion, such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2013). Here, although the Veteran has reported limited motion, the objective evidence does not demonstrate the same. As such, no higher disability rating under 38 C.F.R. § 4.71a for musculoskeletal ratings could be assigned than the 10 percent already awarded according to 38 C.F.R. § 4.73 for a muscle disability. Consequently, the Board will continue its evaluation according to 38 C.F.R. § 4.73. Diagnostic Code 5321 addresses muscle injuries to Group XXI muscles of respiration: Thoracic muscle group. The function of these muscles is for respiration. Under Diagnostic Code 5321, a 0 percent evaluation is assigned for a slight muscle disability; a 10 percent evaluation is assigned for moderate muscle disability; and a 20 percent evaluation is assigned for a moderately severe or severe disability. 38 C.F.R. § 4.73, Diagnostic Code 5321 (2013). 38 C.F.R. § 4.56 provides guidance for the evaluation of muscle disabilities as slight, moderate, moderately severe, or severe. The cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c) (2013). Slight disability of muscles results from a simple wound of muscle without debridement or infection. 38 C.F.R. § 4.56(d)(1) (2013). Moderate disability of the muscles results from through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. 38 C.F.R. § 4.56(d)(2) (2013). Moderately severe disability of muscles results from through and through or deep penetrating wound with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. It requires indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side demonstrating positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). Severe disability of the muscles results from through and through or deep penetrating wound with extensive debridement, prolonged infection, sloughing of soft parts, and intermuscular scarring and binding. It requires ragged, depressed and adherent scars; loss of deep fascia or muscle substance or soft flabby muscles in the wound area; and severe impairment on tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side. 38 C.F.R. § 4.56(d)(4). In a March 2009 rating decision the RO granted entitlement to service connection for costochondritis, and evaluated it as 10 percent disabling since February 14, 2008 according to Diagnostic Code 6843. In a November 2009 rating decision the Diagnostic Code was changed to 5399-5321 without explanation. Nevertheless, for the reasons discussed, Diagnostic Codes 5399-5321 are most appropriate to evaluate the Veteran's costochondritis. During the course of this appeal, the Veteran reported that he experienced discomfort in his chest, and his lungs hurt his ribs, breastbone, and costochondral area. He described experiencing symptoms such as a sharp, sticking, aching, crushing, burning sensation in his ribs and chest. He reported that there was inflammation in his chest, with sharp pains in the front of his chest wall, and pain on deep breaths. In March 2009 the Veteran was afforded a VA examination for chest condition, costochondritis. By history, the Veteran reported he was hit in the chest with a machine gun in 1989. He reported experiencing pain in his chest that occurred constantly, and traveled with movement of his trunk to the left side of his ribs. The pain was described as squeezing, aching and sharp, at a level 10 of 10. He reported that pain was elicited by physical activity, and relieved by rest. At the time of pain, the Veteran could function without medication. The Veteran described experiencing additional symptoms of dyspnea and swelling. The bone condition had never been infected, and he had not been hospitalized or had surgery for it. The Veteran was not receiving treatment for his condition. The Veteran reported functional impairment in that he was required to rest for long periods of time. He was able to brush his teeth, shower, vacuum, drive a car, cook, climb stairs, dress himself, take out the trash, walk, shop, perform gardening activities, and push a lawn mower. He had worked in food service for 11 years, and was employed. On examination, breath sounds were symmetric, with no rhonchi or rales, and expiratory phase was within normal limits. Examination of the ribs showed tenderness to palpation of the bilateral costosternal function, due to injury. Rib X-ray findings were within normal limits. Diagnosis was of costochondritis with subjective factor of chest wall pain, and objective factors noted on examination. The examiner indicated that there was no effect of the condition on the Veteran's usual occupation or daily activities. An addendum opinion indicated that pulmonary function test (performed because of report of dyspnea) was abnormal. It showed a diagnosis of restrictive lung disease, which could be consistent with costochondritis. Corresponding X-ray of the left unilateral ribs was unremarkable, and showed no evidence of discrete fracture or osseous destructive lesion. X-ray of the chest gave an impression of no acute process in the chest. Lungs were free of pleural effusion, pneumothorax or air space consolidation. Pulmonary vasculature was within normal limits. There were unremarkable cardiac and mediastinal silhouette. There was minimal uncoiling of the thoracic aorta. There was faint nodular density measuring subcentimeter in size projecting just inferior to the left fifth rib, not definitely appreciated on lateral projection and possibly reflecting a shadow. Osseous structures demonstrated no acute abnormalities. The Veteran was afforded an August 2009 VA examination for costochondritis. He reported that the central part of his chest wall was involved, and that this was where he experienced pain constantly. He also reported that pain traveled from the left ribs to his neck, and that his pain was crushing, burning, aching, oppressing, sharp and sticking. He indicated that his pain was an 8 of 10. He reported that physical activity, food and stress could exacerbate his pain, while it was relieved spontaneously. He found that he could rest while he experienced pain. The bone condition had never been infected, and the Veteran reported that he had not been hospitalized or received surgery for it. The Veteran did not receive treatment for his condition. His overall functional impairment was evident in limited prolonged sitting and standing. Examination of the lungs showed breath sounds were symmetric, and examination was normal. Expiratory phase was within normal limits. On palpation of the ribs, there was pain at the junction of the ribs and the sternum. Rib X-ray findings were within normal limits. The examiner indicated that there was no change in diagnosis of costochondritis, and the subjective factors were as reported. The objective factors were physical examination showing tenderness in the costochondral area of the 3rd, 4th, and 5th ribs bilaterally. Effects on daily activity were nil. The Veteran worked in the restaurant industry. At his November 2012 VA examination for costochondritis the Veteran reported that he experienced a bone condition due to trauma/injury and disease. He indicated that he experienced severe chest pain around the breast, sternum, and rib cage. He reported that there was daily swelling, and painful areas of Tietze's syndrome, with his shoulder and arm swelling. The chest, ribs, belly, back and arms were involved. The Veteran reported experiencing flare-ups daily lasting all day, with severity a nine of 10. Physical activity precipitated the flare-ups, while rest alleviated them. Functional impairment was described as pain all over the body, occurring constantly, characterized as localized, squeezing, burning, and sharp. The Veteran reported that he experienced weakness, stiffness, giving way, swelling, abnormal motion, and heat as a result of his condition. He was able to function with the pain, without medication. He indicated that he had limitations on his ability to stand because of his bone condition. He reported that on average he could stand for 10 minutes, and was unable to walk because of his bone condition. The Veteran indicated that the bone condition had never been infected, and he had not been hospitalized for it. The Veteran had not had surgery for such condition, and was not receiving any treatment for it. He reported experiencing limited daily physical activities. Examination of the ribs revealed tenderness to palpation of the bilateral costosternal junction, of unknown cause, involving ribs three through six. Rib X-ray was within normal limits. The examiner indicated that the Veteran's condition did not affect his occupation or daily activities, and that there was no change in diagnosis of costochondritis. The Veteran's costochondritis was active, with subjective factors of chest wall pain, and objective factors of "tenderness to palpation, chest wall." It was noted that critical diagnostic test results included chest X-ray demonstrating slight infiltrate in the right lung base. Based upon the evidence of record, the Veteran's service-connected costochondritis, chest pain, is presently manifested by symptoms to include intermittent episodes of subjective pain weakness, stiffness, giving way, swelling, abnormal motion, and heat, and without objective evidence of limitation of motion, in spite of reports, including as a result of pain and dysfunction and some tenderness shown on examination. Therefore, the Board finds a compensable rating under 5099-5010, for the Veteran's service-connected costochondritis, chest pain, is not warranted. The Board finds, however, that the Veteran's costochondritis is manifested by pain and decreased strength which is most appropriately described as "moderate" and not "moderately severe" or "severe" under the criteria of Diagnostic Code 5321 for Group XXI muscle injuries, and that a 10 percent disability rating is therefore warranted. Pertinently, the examiner also noted that the Veteran's daily activities are at the most mildly affected by the costochondritis. Furthermore, although heart and pulmonary examinations were not normal, the Veteran is in receipt of a separate rating for hypertensive heart disease, and he has a separate diagnosis for lung disease with respiratory failure and pulmonary hypertension which has not been service connected. As such, while the Board does not doubt that chest pain and decreased strength exist, in the absence of any evidence to the contrary, the Board cannot characterize the Veteran's costochondritis disability as "moderately severe," or "severe." Accordingly, based on the evidence of record, the Board finds that the Veteran's costochondritis is properly described as "moderate" under the criteria of Diagnostic Code 5321 for Group XXI muscle injuries. To the extent that the Veteran may contend otherwise, his self-reports are outweighed by the medical evidence, which does not indicate that there is moderately severe or severe symptoms associated with the costochondritis. As such, the preponderance of the evidence is against a rating in excess of 10 percent for costochondritis. The doctrine of reasonable doubt was considered, but is not applicable here. The Board has considered whether to assign staged ratings, but finds them not appropriate under the circumstances. With regard to extraschedular consideration, the threshold determination is whether the disability picture presented in the record is adequately contemplated by the rating schedule. Thun v. Peake, 22 Vet. App. 111 (2008). The Veteran's disability picture, to include pain, and tenderness to palpation is not so unusual or exceptional in nature as to render his schedular rating inadequate. Hypertensive Heart Disease The Veteran's hypertensive heart disease is currently evaluated under Diagnostic Code 7007 as 60 percent disabling from February 14, 2008 to August 25, 2009, and as 30 percent disabling since August 26, 2009. 38 C.F.R. § 4.104. The criteria for hypertensive heart disease are based upon METs, which are "metabolic equivalents," or the energy cost of standing quietly at rest, representing an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. Id.; Note (2). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or snow shoveling) that result in dyspnea, fatigue, angina, dizziness, or syncope may be used. Id. Under Diagnostic Code 7007, a 30 percent evaluation is warranted when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation is warranted when there is more than one episode of acute congestive heart failure in the past year, or; a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent evaluation is warranted for chronic congestive heart failure; or work load of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7007 (2013). In April 2010 the RO awarded entitlement to service connection for hypertensive heart disease, evaluated as 10 percent disabling, effective May 4, 2009. In August 2011 the RO corrected its decision, to award a 60 percent evaluation for hypertensive heart disease effective February 14, 2008, and a 30 percent evaluation from August 26, 2009. During the course of this appeal the Veteran indicated that he experienced symptoms such as chest pain and palpitations during ordinary activities discomfort even during rest, weakness, nausea, fatigue, angina, and dizziness. He has reported that his heart problems have kept him from working. In July 2008, VA examination of the heart revealed no heaves or thrills. There was regular sinus rhythm. There were no murmurs or gallops. Examination of the heart did not reveal evidence of congestive heart failure, cardiomegaly or cor pulmonale. Diagnosis was of hypertension, and the electrocardiogram (EKG) was abnormal with voltage criteria for left ventricular hypertrophy. Ejection fraction was at 40 percent, with estimated METs of 3. The examiner indicated that because of the Veteran's high blood pressure he would not recommend a stress test. At a March 11, 2009 VA examination, the Veteran's heart showed normal S1 and S2, no S3, and S4 of regular rate and rhythm. There were no heaves or thrills, and no murmurs or gallops. The chest X-ray was within normal limits; however, there was a sub-centimeter nodular density, which might represent a shadow. An addendum opinion considered an EKG that showed left ventricular hypertrophy or ischemia. An earlier EKG showed diagnoses of mild left ventricular enlargement with mild left ventricular systolic function, mild concentric left ventricular hypertrophy; abnormal pattern of left ventricular diastolic function, mild left atrial enlargement, mild mitral and tricuspid regurgitation, with ejection fraction of 40 percent. METs was estimated at 7, which corresponded to climbing stairs slowly, walking uphill less than 5 miles per hour, and bicycling less than 13 miles per hour. At an August 26, 2009 VA examination the Veteran reported symptoms of headaches and dizziness associated with hypertension, for which he did not receive treatment. He indicated that he did not experience any overall functional impairment from his hypertension. Examination of the heart indicated normal S1 and S2, no S3, and S4, regular rate and rhythm. There were no heaves or thrills, murmurs or gallops. Diagnostic tests revealed sinus rhythm, left ventricular hypertrophy with nonspecific st-t changes. EKG showed signs of left ventricular hypertrophy. Chest X-ray showed cardiomegaly. As such, there was evidence of hypertensive heart disease because of cardiomegaly seen in the chest X-ray and EKG, also showing left ventricular hypertrophy. The Veteran's usual occupation was in the restaurant industry and the effect of his condition on daily activities was nil. An addendum provided additional blood pressure readings, with diagnosis of hypertension remaining. The Veteran was advised to follow-up with his provider to receive treatment. A stress test using Bruce protocol was performed on September 30, 2009. Impression of indeterminate high level stress EKG to peak heart rate of 159, moderate functional aerobic impairment, with completion of only 6 1/2 minutes, increase in resting EKG abnormalities of uncertain significance. There were no arrhythmias. There was no chest pain. The Veteran's cardiac functions fit in to a 7.7 METs level as he was able to walk 3.5 miles per hour, stair climbing at slow speed, and dish. Also, the examiner opined that the Veteran should be able to do household jobs like gardening, and carrying about 30 to 40 pounds. The examiner advised that the Veteran's provider might want to perform further evaluation such as nuclear isotope imaging. The examiner indicated that the stress test results were not very clear. At his November 2012 VA examination for hypertensive heart disease, the Veteran reported experiencing daily symptoms, to include fatigue, hypertension, shortness of breath, irregular pulse, nausea, headaches, chest pain, vision problems and congestive heart failure. He experienced angina, shortness of breath, dizziness, and fatigue. The examiner indicated that the Veteran's heart conditions did not qualify within the generally accepted medical definition of ischemic heart disease. Nor had the Veteran ever had a myocardial infarction. The examiner indicated that the Veteran did not have congestive heart failure, arrhythmia, heart valve conditions, infectious heart conditions or pericardial adhesions. The Veteran had not experienced any non-surgical or surgical procedures for the treatment of a heart condition, and he had not been hospitalized for a heart condition. On physical examination, his heart rate was 98, with regular rhythm, and the point of maximal impact was in the 5th intercostal space. Heart sounds were normal, and there was no jugular-venous distension. Auscultation of the lungs was clear. Peripheral pulses were normal. There was no peripheral edema. Blood pressure readings were 118/84, 129/74, and 128/79. There was no evidence of cardiac hypertrophy or cardiac dilatation. An EKG was conducted and revealed left ventricular hypertrophy. Chest X-ray was abnormal as the lungs demonstrated slight infiltrate in the right lung base. EKG revealed left ventricular ejection fraction of 56 percent, and normal wall motion and wall thickness. An interview-based MET's test indicated that symptoms such as dyspnea, fatigue, angina, and dizziness were evident between greater than 5 to 7 METs. This METs level was consistent with activities such as walking a flight of stairs, golfing (without a cart), mowing lawn (push mower), or heavy yard work (digging). The METs level limitation was due solely to the heart condition. The examiner indicated that for the VA diagnosis of hypertensive heart disease, there was no change in diagnosis. There was no evidence of cardiac hypertrophy, as the EKG showed normal wall thickness. The examiner concluded that the Veteran's condition was quiescent. In sum, July 2008 VA examination revealed an ejection fraction of 40 percent and METs estimated at 3, which corresponds to a 100 percent rating. Then, on March 11, 2009 VA examination revealed ejection fraction of 40 percent, and METs of 7, which corresponds to a 60 percent rating. The August 26, 2009 VA examination revealed METs of 7.7, but will not be considered to reduce the Veteran's rating where the examiner did not provide the ejection fraction. For that time the RO has awarded a 30 percent rating. The November 2012 VA examination revealed an ejection fraction of 56 percent, and estimated METs of greater than 5 to 7, which corresponds with a 30 percent rating. The Veteran's reports of symptomatology are considered competent and credible. Although the Veteran asserts that higher ratings should be assigned for hypertensive heart disease, his statements have less probative value than the objective findings on examination, because the diagnostic criteria requires specialized knowledge regarding METs and ejection fractions. As such, the medical evidence is given the greatest probative value. The Board concludes that the evidence supports an initial rating of 100 percent from February 14, 2008 to March 10, 2009, because the examination revealed estimated METs of 3. From the date of a March 11, 2009 VA examination revealing METs of 7, with an ejection fraction of 40 percent, a 100 percent evaluation is no longer supported, but rather the evidence supports a 60 percent rating. The RO awarded a 60 percent rating through August 25, 2009, which the Board will not disturb. Since August 26, 2009, the date from which the RO awarded a 30 percent evaluation, the evidence supports a 30 percent evaluation. The preponderance of the evidence, which shows Mets from 5 to 7 at minimum, and ejection fraction of 56 percent is against an award greater than 30 percent since August 26, 2009, such that there is no doubt to resolve. Staged ratings have been considered and appropriately applied. With regard to extraschedular consideration, the threshold determination is whether the disability picture presented in the record is adequately contemplated by the rating schedule. Thun v. Peake, 22 Vet. App. 111 (2008). The Veteran's disability picture, to include limited activities due to cardiac functions is not so unusual or exceptional in nature as to render his schedular rating inadequate. ORDER A compensable rating for right ear hearing loss is denied. A rating in excess of 10 percent for tinnitus is denied. A rating of 10 percent for lumbar spine disability prior to May 4, 2009, is granted subject to the laws and regulations governing the award of monetary benefits. A rating in excess of 10 percent for lumbar spine disability is denied. A rating in excess of 10 percent for costochondrosis is denied. A rating of 100 percent from February 14, 2008 to March 10, 2009 for hypertensive heart disease is granted, subject to the laws and regulations governing the award of monetary benefits. A rating in excess of 60 percent for hypertensive heart disease from March 11, 2009 to August 25, 2009, is denied. A rating in excess of 30 percent for hypertensive heart disease since August 26, 2009 is denied. REMAND A March 2009 rating decision denied, among other issues, entitlement to service connection for a neck disorder and for gastrointestinal disorder. Although the Veteran filed an August 2009 (signed July 2009) statement construed as a Notice of Disagreement as to other issues discussed, the RO did not address the Veteran's statements of "gastrotintestinal symptoms" and "cervical spine segments." The Board construes these statements as the Veteran's Notice of Disagreement with the denial of entitlement to service connection for a neck disorder and gastrointestinal disorder, and finds that these issues should be adjudicated in a Statement of the Case. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 19.26, 19.29, 19.30 (2013); Manlincon v. West, 12 Vet. App. 238 (1999). A November 2009 rating decision denied, among other issues, entitlement to a rating in excess of 20 percent for hypertension. Although the Veteran filed a May 2010 statement construed as a Notice of Disagreement, a Statement of the Case was not issued regarding this issue. Id. In April 2013 the RO issued a decision denying entitlement to service connection for posttraumatic stress disorder, for new and material evidence to reopen a claim of entitlement to service connection for sleep apnea, and to reopen claims for left hand and right hand gout, and for right and left lower extremities (to include the knees). In October 2013, subsequent to the transfer of the case to the Board, the Board received the Veteran's Notice of Disagreement regarding these issues. As such, these issues are remanded for issuance of a Statement of the Case. Id. Regarding the issue of entitlement to a total disability rating for individual unemployability, which is inherently part and parcel of an increased rating claim, as there are outstanding issues to be adjudicated that are intertwined, adjudication is deferred at this time. See Rice v. Shinseki, 22 Vet. App. 447 (2009). While on remand, obtain an examination to determine whether the Veteran's service-connected disabilities preclude him from performing substantially gainful employment. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). Expedited handling is requested.) 1. Furnish the Veteran a Statement of the Case on the claim for entitlement to service connection for a cervical spine disorder, claimed as neck disorder, gastrointestinal disorder, claimed as left stomach problems, for posttraumatic stress disorder, the claim for entitlement to a rating in excess of 20 percent for hypertension and claims for new and material evidence for, sleep apnea, gout of the hands and impairment of the lower extremities, including the knees. A substantive appeal has to be timely filed for these matters to be returned to the Board. Failure to do so with result in the RO/AMC closing the appeal. 2. Schedule the Veteran for an appropriate VA examination to determine the impact that his service-connected disabilities have on his ability to secure or follow substantially gainful employment. The claims folder should be made available to and reviewed by the examiner. All indicated studies should be conducted. If other development is need on this issue, it should be undertaken in accordance with applicable procedures. The examiner should describe all functional impairment caused by the Veteran's service-connected disabilities. All opinions must be supported by rationale. 3. After taking any further development deemed appropriate, readjudicate the claims. If any benefit sought on appeal is not granted, issue a statement of the case before returning the case to the Board. If appellant does not desire to appeal the unemployability issue, he should so indicate in writing to the RO. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs