Citation Nr: 1803140 Decision Date: 01/17/18 Archive Date: 01/29/18 DOCKET NO. 08-25 848 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a low back disorder. 2. Entitlement to service connection for a left knee disorder. 3. Entitlement to service connection for a right knee disorder. 4. Entitlement to service connection for bilateral hearing loss. 5. Entitlement to an initial rating in excess of 10 percent for costochondritis. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARINGS ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD T. Hal Smith, Counsel INTRODUCTION The Veteran served on active duty from February 1974 to December 1975. These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Waco, Texas, Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran and his wife testified at a Decision Review Officer hearing in January 2009. A hearing transcript is associated with the Veteran's claims file. In May 2016, the Veteran and his wife also testified at a videoconference hearing before the undersigned Veterans Law Judge, and a hearing transcript has been incorporated into the evidence of record. These matters were remanded by the Board in August 2016 for additional evidentiary development. The claims for service connection were denied in an October 2017 supplemental statement of the case (SSOC). However, in an October 2017 rating decision, a 10 percent rating for costochondritis was granted, effective May 20, 2010, the date that the claim was initially filed. The claims have now been returned to the Board for further appellate consideration. This appeal was processed using the Veterans Benefits Management System (VBMS). Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. In addition to the VBMS file, there is a Legacy Content Manager paperless claims file associated with the Veteran's claims. FINDINGS OF FACT 1. The most probative evidence of record does not establish that a low back disorder (lumbar degenerative disc and joint disease, status post fusion, and stabilization) was manifested during service or until many years thereafter, and is not etiologically related to his military service in any way. 2. The most probative evidence of record does not establish that the Veteran has a left knee disability (tendonitis/tendinosis), which manifested in service, arose within one year of separation from service, or was the result of any injury, disease, or event during active service. 3. The most probative evidence of record does not establish that the Veteran has a right knee disability (tendonitis/tendinosis), which manifested in service, arose within one year of separation from service, or was the result of any injury, disease, or event during active service, nor was it shown to have been caused or aggravated by a service-connected disability. 4. The most probative evidence of record does not establish that bilateral hearing loss was manifested during service or until many years thereafter or is causally or etiologically related to the Veteran's military service, to include noise exposure therein. 5. For the period on appeal, the Veteran's costochondritis has been manifested by pain, and, during flare-ups, difficulty breathing and performing certain activities, such as exercise. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 2. The criteria for service connection for a left knee disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 3. The criteria for service connection for a right knee disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 4. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2017). 5. The criteria for an initial rating in excess of 10 percent for costochondritis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.59, 4.71a, Diagnostic Code (DC) 5321 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Neither the Veteran nor his representative has raised any issue with the duty to notify or duty to assist. See Scott v. McDonald, 789 F3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed Cir. 2016) (applying Scott to a duty to assist argument). Initial Considerations As reported above, the Board remanded the claims in August 2016 for additional medical opinions on the issues of service connection. Moreover, the claim for an initial rating for costochondritis was remanded for a contemporaneous examination to determine the current severity of that condition for rating purposes. In the body of that remand, a detailed summarization of all medical records available at that time was provided. It will not be repeated here. In the decision below, all pertinent medical documents added to the record since the remand decision will be summarized. Those records and all previously summarized records will be discussed, when appropriate, in the decision below. Service Connection - In General Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2017). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2017). In addition, certain chronic diseases (e.g., arthritis, sensorineural hearing loss) may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). The chronicity provisions are applicable where evidence, regardless of its date, show that a veteran had a chronic condition, as defined in 38 C.F.R. § 3.309(a) (2017), in service, or during an applicable presumptive period, and still has that disability. That evidence must be medical unless it relates to a condition as to which lay observation is competent. 38 C.F.R. § 3.303(b) (2017). This rule does not mean that any manifestations in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time as distinguished from merely isolated findings or a diagnosis including the word "chronic". When the disease entity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2017). The United States Court of Appeals for Veterans Claims has held that, in order to prevail on the issue of service connection, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed inservice disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v West, 12 Vet. App. 341, 346 (1999). Hearing loss will be considered to be a disability (for VA purposes) when the threshold level in any of the frequencies 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater; or the thresholds for at least three of these frequencies are 26 decibels or greater; or speech recognition scores are less than 94 percent. 38 C.F.R. § 3.385 (2017). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. Additionally, when aggravation of a veteran's nonservice-connected condition is proximately due to or the result of a service-connected condition, the veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). 38 C.F.R. § 3.310 (2017). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a) (2012); 38 C.F.R. § 3.303(a) (2017); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The United States Court of Appeals for the Federal Circuit has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Analysis Low Back The Veteran contends that he hurt his back during active service. He argues that any current back condition is related to this inservice injury. Records added to the record since the Board's August 2016 remand decision include private and VA records showing treatment through 2017 for various conditions. Primarily, treatment has been for the Veteran's service-connected posttraumatic stress disorder (PTSD). It is noted that Social Security Administration (SSA) records added to the claims file include documents showing back surgery (two level transverse lumbar interbody disk space fusion, L3-4 and L4-5, with pedicle screw stabilization), was performed in 2009. This surgery was not specifically reported in the Board's August 2016 remand. In the August 2016 remand, the Board requested that medical opinion be obtained regarding whether it was at least as likely as not (probability of 50 percent or greater) that a low back disorder was caused by or aggravated by military service. The examiner was to discuss the Veteran's lay statements regarding continuous low back symptoms since active service and continuing until current diagnosis. The examiner was also to comment on the medical history of record which reflected injury to the back in the mid-1980s. The requested VA examination was conducted in October 2016. The examiner noted that the claims file was reviewed prior to the in-person examination. It was also noted that the Veteran claimed that he had experienced back pain since an inservice fall in 1976. His pertinent medical history included five back surgeries, with little pain relief. The final diagnoses were lumbar degenerative disc and joint disease, status post fusion and stabilization. The VA examiner opined that the Veteran's back condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed inservice injury, event, or illness. For rationale, he pointed to the service treatment records (STRs) which are negative for complaints associated with the low back. This included a separation examination report from December 1975 which showed normal spine findings. The examiner also noted that he was unable to find lay statements in the record referencing the Veteran's low back condition. The weight of the evidence is against a finding that the low back disorder is causally or etiologically related to service. The earliest indication of low back problems after service is in the early 1990s, approximately 15 years after service separation and with medical history given at that time of injury in the mid-1980s. A second back injury was reported in 1991. The approximate 10-year period between complaint of symptoms of low back disorder and service is one factor in this case, in the context of other factors (that include denial of back symptoms at service separation, negative clinical findings at service separation, and post-service back injury at the time of the onset of current back symptoms) that weighs against a finding of service incurrence, to include on a chronic disease presumptive basis. See Buchanan v. Nicholson, 451 F.3d 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor to consider as evidence against a claim of service connection). Further, after review of the record and interview and examination of the Veteran, the October 2016 VA examiner opined that the current low back disorder was not related to service. The examiner reasoned that actual objective evidence of a back condition was not reflected in the record until approximately 10 years after service. Moreover, there was no continuity of symptoms after service indicating any alleged inservice back injury which caused ongoing back symptoms post discharge as alleged. Because the examiner had adequate facts and data on which to render an informed opinion, acknowledged that the Veteran reported back symptoms since service discharge, and relied on accurate facts that included recognition of post service back injuries in the mid-1980s and 1991, and provided adequate rationale for the medical opinion, the October 2016 VA medical opinion is of significant probative value. There is no competent medical opinion to the contrary of record. Although the Veteran has asserted that the current low back disorder was related to service, he is a lay person and does not have the requisite medical expertise to diagnose degenerative disease or render a competent medical opinion regarding its cause where the facts show initial treatment following post service back injuries. Degenerative disc/joint disease is complex, involves unseen systems processes and disease processes that are not observable by the five senses of a lay person, and is diagnosed only by X-ray or similar specific specialized clinical testing; therefore, under the facts presented in this case, the Veteran is not competent to diagnose degenerative disc disease or opine as to its etiology. For these reasons, the Veteran's lay opinion is of lesser probative value and is outweighed by the negative October 2016 VA medical opinion. Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (holding that anterior cruciate ligament injury is too "medically complex" for lay diagnosis); King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2009) (holding that it was not erroneous for the Board to find that a lay veteran claiming service connection for a back disorder and his wife lacked the "requisite medical training, expertise, or credentials needed to render a diagnosis" and that their testimony "could not establish medical causation nor was it a competent opinion as to medical causation"); Clyburn v. West, 12 Vet. App. 296, 301 (1999) (holding that a veteran is not competent to relate currently diagnosed chondromalacia patellae or degenerative joint disease to the continuous post-service knee symptoms); Savage v. Gober, 10 Vet. App. 488, 496-97 (1997) (requiring that a veteran present medical nexus evidence relating currently diagnosed arthritis to in-service back injury). In consideration of the foregoing, the preponderance of the lay and medical evidence weighs against the claim of service connection for a low back disorder; therefore, the appeal must be denied. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017). Left and Right Knee Disorders The Veteran also contends that he hurt his left knee during service, and that any current left knee condition is related to that event. As for the right knee, he argues that he has right knee disability due to favoring his left knee. VA examination was conducted in October 2016 to address the medical questions raised. The examiner noted that the claims file was reviewed. The bilateral knee diagnoses were tendonitis/tendinosis. The examiner opined in a July 2017 addendum report that the left knee condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed inservice injury, event or illness. For rationale, it was noted that while the Veteran was seen for one week during service for a "slight strain," there were no reported residuals and no chronic left knee disorder was diagnosed, to include at time of separation examination. It was further noted that a knee strain refers to damage or tearing of a muscle tendon unit associated with the knee joint. Full recovery from strains could be expected after treatment. As to the right knee, that condition was also found to be less likely than not (less than 50 percent probability) incurred in or caused by the claimed inservice injury, event, or illness. For rationale, there was no report of right knee symptoms during service or until many years thereafter. Based on the evidence of record, it is determined that there is no evidence of any chronic left or right knee disorder until many years after service (approximately 2007 for complaints of bilateral knee pain with actual chronic knee disorders several years thereafter). See Maxson, Mense, and Kahana, supra. Further, after review of the record and interview and examination of the Veteran, the October 2016 VA examiner opined that the current left and right knee disorders were not related to service. The examiner reasoned that the left knee strain resolved, and it was many years later before the knee showed a chronic disorder. Moreover, there was no continuity of symptoms after service indicating any ongoing left knee symptoms post discharge as alleged. Also, there was no report of right knee problems in service, and as the left knee condition was unrelated to service, any secondary right knee disorder was also unrelated to that period. Because the examiner had adequate facts and data on which to render an informed opinion, acknowledged that the Veteran reported symptoms since service discharge, and relied on accurate facts that included recognition of post service knee complaints, and provided adequate rationale for the medical opinions rendered, the October 2016 VA medical report is of significant probative value. There is no competent medical opinion as to either knee to the contrary of record. Although the Veteran has asserted that the current knee disorders are related to service, he is a lay person and does not have the requisite medical expertise to diagnose knee tendonitis/tendinosis or render a competent medical opinion regarding its cause where the inservice records are negative for any chronic knee disorders until many years after discharge. Bilateral Hearing Loss As to the Veteran's claim that he has bilateral hearing impairment due to inservice noise exposure, VA audiometric examination was conducted in October 2016. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 35 45 40 40 45 LEFT 40 45 40 40 45 The average pure tone threshold loss was 43 decibels in each ear. Speech audiometry revealed speech recognition ability of 88 percent in both ears. Bilateral sensorineural hearing loss was diagnosed. It was the examiner's opinion that the Veteran's hearing loss was less likely than not (less than 50 percent probability) caused by or a result of inservice noise exposure. For rationale, it was noted that inservice hearing examinations revealed hearing within normal limits. There were no significant decibel threshold shifts during service. Moreover, the Institute of Medicine (IOM) stated that there was an insufficient scientific basis to conclude that permanent hearing loss was directly attributable to noise exposure that developed long after noise exposure. The IOM panel concluded that based on their current understanding of auditory physiology, a prolonged delay in the onset of noise-induced hearing loss was "unlikely." Based on the above, the Board finds that a preponderance of the evidence is against the claim. The VA examination opinion was provided by a VA audiologist and is supported by a reasoned opinion that is consistent with the evidence of the record. The Board affords it to be of significant probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). "Where findings of material fact by the Board are properly supported and reasoned, and the Board concludes that a fair preponderance of the evidence weighs against the claim of a veteran, it would not be error for the Board to deny the veteran the benefit of the doubt." Gilbert, supra. Taking the totality of the Veteran's private and VA examinations into account along with the Veteran's STR's showing no complaints, diagnosis, or symptomology of bilateral sensorineural hearing loss, based on a preponderance of all the evidence, the Veteran's bilateral sensorineural hearing loss does not meet the nexus to service connection element required to grant entitlement to disability compensation. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2017). Moreover, the Board concludes that there is no basis to grant service connection for bilateral sensorineural hearing loss on a presumptive basis, as there is no evidence that bilateral sensorineural hearing loss manifested to a compensable degree within one year of discharge from active duty. 38 U.S.C. §§ 1101, 1112, 1113, 1137, 5107 (2012); 38 C.F.R. §§ 3.303, 3,307, 3.309, 3.385 (2017). The Veteran's bilateral sensorineural hearing loss was not incurred or aggravated by active service, to include as result of inservice noise exposure. The medical opinion of record as to the Veteran's claim provided thorough and persuasive rationale. Thus, the preponderance of the most probative evidence weighs against the claim. In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the appellant's claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b) (2012); Gilbert, supra. Increased Ratings - In General Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). 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 (2017). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2017). When an unlisted condition is encountered it will be permissible to rate 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 (2017). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings may be appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See e.g. Hart v. Mansfield, 21 Vet. App. 505 (2007). Initial Rating in Excess of 10 Percent for Costochondritis The record reflects that the Veteran's costochondritis has been assigned a 10 percent rating by analogy under 38 C.F.R. § 4.71(a), DC 5021. See the November 2011 rating decision wherein service connection was granted, and a noncompensable rating was assigned, effective May 20, 2010. More recently, and during the appeal process, the RO determined a 10 percent rating was warranted, also from May 20, 2010. This increase was based upon findings made in the October 2016 examination which was conducted pursuant to the Board's August 2016 remand request. Pursuant to DC 5321, applicable to injury to muscles of the thoracic group, affecting respiration, a 10 percent rating is assigned for moderate disability, and the maximum 20 percent schedular rating is warranted for severe or moderately severe disability. 38 C.F.R. § 4.73, DC 5321 (2017). Factors for consideration in the rating of muscle disabilities are set forth in 38 C.F.R. § 4.56 (2017), which 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) (2017). A moderate muscle injury results in some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lower threshold of fatigue when compared to the sound side. Id. A moderately-severe muscle injury contemplates palpation of loss of deep fascia, muscle substance or normal firm resistance of muscles compared with the sound side. Tests of strength and endurance demonstrate positive evidence of impairment. Id. Finally, a severe muscle injury contemplates swollen and hardened muscles in contraction with severe impairment of muscle strength, endurance or coordinated movements. Id. At the October 2016 examination, the examiner noted that the claims file was reviewed, and there was an in person examination. It was noted that the Veteran did not have a penetrating or a non-penetrating muscle injury. There injury was located to muscle group (Group XXI) in the torso and/or neck. There was no history of rupture of the diaphragm with herniation. There was no history of an extensive muscle hernia of any muscle, without other injury to the muscle. There were no associated scars. His muscle injury did not affect muscle substance or function. Symptoms attributable to the muscle injury included fatigue-pain. Strength testing was normal, and there was no muscle atrophy. The examiner noted that the Veteran had no objective evidence of injury to the chest, but the Veteran reported that as a result of injury to the sternum in 1974, he had constant pain on inspiration. On exam, the Veteran did not take deep breaths because "it hurts." He also reported tenderness on palpation of the chest wall. There was no warmth, redness, or swelling. Based on the evidence described above, the Veteran has not exhibited symptoms analogous to a moderately-severe disability of the respiratory muscles. 38 C.F.R. § 4.73, DC 5321. In this respect, there has been no evidence of muscle atrophy or loss, as listed in the findings for a moderately severe muscle injury. Further, other than fatigue, pain, and tenderness, there were no other objective abnormalities indicated on the VA examinations or in the outpatient treatment records. For these reasons, the Board finds that the overall disability picture for the Veteran's costochondritis does not more closely approximate a 20 percent rating for moderately severe or severe muscle injury under the applicable DC. While the Board has also considered other potentially applicable DCs, the Veteran's costochondritis has not resulted in a loss of ribs, and as such 38 C.F.R. § 4.71(a), DC 5297 is not applicable in this case. Further, the Veteran's disability is not shown to involve other body systems. Therefore, this disability does not warrant an evaluation under any other provisions of the rating schedule. Accordingly, the Board finds an initial rating in excess of 10 percent for costochondritis is not warranted. Consideration has been given to assigning a staged rating for the disability decided herein; however, as explained above, the disability has been relatively consistent throughout the entire appeal period and does not warrant a rating in excess of 10 percent. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart, supra. ORDER Entitlement to service connection for a low back disorder is denied. Entitlement to service connection for a left knee disorder is denied. Entitlement to service connection for a right knee disorder is denied. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to an initial rating in excess of 10 percent for costochondritis is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs