Citation Nr: 1803427 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 07-03 538 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to a disability rating in excess of 40 percent for undiagnosed illness involving chest pain, joint pain, muscle ache, fatigue, sleep disturbance, headaches, and irritable bowel symptoms, to include entitlement to separate ratings for irritable bowel symptoms (diagnosed as irritable bowel syndrome (IBS)), headaches and joint pain. REPRESENTATION Veteran represented by: James A. Bunker, Private Agent WITNESSES AT HEARING ON APPEAL The Veteran & his Wife ATTORNEY FOR THE BOARD C. Boyd Iwanowski, Counsel INTRODUCTION The Veteran served on active duty from October 1989 to October 1993. He received a Combat Action Ribbon in recognition of his service in Saudi Arabia. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. Following a July 2012 remand, the claim was denied in a January 2015 Board decision. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In a November 2016 Memorandum Decision, the Court vacated the January 2015 decision and remanded the claim to the Board for further proceedings. In July 2017, the Board remanded the claim to schedule the Veteran for a hearing before the Board. In October 2017, the Veteran and his wife testified at a hearing before the undersigned Veterans Law Judge. A transcript of the proceeding is associated with the electronic claims file. At the hearing, the Veteran waived initial RO consideration of evidence added to the file since the most recent supplemental statement of the case (SSOC). The Board notes there are a number of other issues in appellate status. At his October 2017 hearing, the Veteran indicated that he had testified at a Decision Review Officer hearing on those issues and was awaiting a supplemental statement of the case. Once a supplemental statement of the case is issued, the issues that remain in appellate status will be addressed by the Board in a later decision if necessary. FINDINGS OF FACT 1. During the appeal period, the Veteran's IBS has resulted in a moderate disability with frequent episodes of bowel disturbance with abdominal distress, but without more severe symptomatology more nearly approximating more or less constant abdominal distress. 2. During the appeal period, headaches were very frequent, sometimes multiple times per week, and associated with sensitivity to light, nausea and a need to lie down or take Butalbital; resolving all doubt in the Veteran's favor, given the very frequent need for Butalbital, the severity of his headaches is analogous to prolonged, completely prostrating attacks capable of producing severe economic inadaptability. 3. The Veteran's undiagnosed illness, characterized as fibromyalgia, results in such symptoms as widespread musculoskeletal pain and stiffness in the joints; Diagnostic Code 5052 is the most appropriate for rating such disability and ratings for each painful joint would constitute prohibited pyramiding. CONCLUSIONS OF LAW 1. The criteria for a separate rating of 10 percent (but not higher) for irritable bowel symptoms, diagnosed as IBS, are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.114, Diagnostic Code 7319 (2017). 2. The criteria for a separate rating of 50 percent for headaches are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2017). 3. The criteria for a rating in excess of 40 percent for undiagnosed illness involving chest pain, joint pain, muscle ache, fatigue, sleep disturbance, headaches, and irritable bowel symptoms, to include separate ratings for each painful joint, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.14, 4.71a, Diagnostic Code 5025 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran is currently receiving a 40 percent rating for symptoms arising from his service in Saudi Arabia, which include chest pain, joint pain, muscle aches, fatigue, sleep disturbance, headaches, and irritable bowel symptoms. These were regarded as symptoms of an undiagnosed illness, and rated by analogy to fibromyalgia. See 38 C.F.R. § 4.71, Diagnostic Code (DC) 5025 (2017) (providing for a maximum disability rating of 40 percent). In his appeal to the Court, the Veteran argued that the Board erred in denying him separate disability ratings for IBS and headaches under 38 C.F.R. § 4.114, DC 7319 and 38 C.F.R. § 4.124a, DC 8100 respectively, and in failing to consider separate ratings for each painful joint under 38 C.F.R. § 4.59. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 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). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). When there is an approximate balance of evidence for and against an issue, all reasonable doubt will be resolved in the Veteran's favor. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Ratings Generally Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id.; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes the Veteran's representative's contentions regarding a 2002 rating decision and statement of the case. Notably, the Veteran did not file a substantive appeal of the decisions made in 2002 and they are considered final. The Veteran filed a new claim seeking a higher rating for his undiagnosed illness that was received by VA on January 31, 2006. The evidence that will be considered by the Board in the context of this appeal will begin January 31, 2005; one year prior to the receipt of the Veteran's increased rating claim. See 38 C.F.R. §3.400(o)(2) (2017). IBS The Veteran argues that he is entitled to a separate rating for his irritable bowel symptoms because he meets the criteria for a compensable rating under DC 7319 and has a longstanding diagnosis of IBS. Under 38 C.F.R. § 4.14, DC 7319 (irritable colon syndrome), a 10 percent rating is assigned for moderate disability with frequent episodes of bowel disturbance with abdominal distress. A 30 percent rating is warranted for severe disability with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. By way of background, in a March 2006 gastroenterology consult, the Veteran reported excessive foul smelling gas, constipation alternating with diarrhea and that bowel movements required strain. The gastroenterologist opined that the Veteran had "chronic constipation with possible constipation predominant IBS." At a March 2006 VA examination, the Veteran indicated having loose stools alternating with constipation. During another VA examination in September 2006, the Veteran reported bloating of the stomach, foul smelling gas and that his bowels were frequently constipated. In a July 2007 treatment record, he again indicated alternating constipation and diarrhea and that he had a lot of gas and sometimes stained his underwear. In a September 2008 statement, the Veteran's employer indicated that his co-workers made reference to his excessive flatulence on a few occasions. In an August 2010 VA examination report, the Veteran was diagnosed with IBS based on symptoms including "intermittent diarrhea, constipation, bloating, foul smelling gas, symptoms relieved by bowel movement and crampy abdominal pain." The examiner concluded after review of the record and examination of the Veteran that the Veteran's IBS is at least as likely as not a result of Gulf War exposures. He met the diagnostic criteria for IBS and it was noted there was documentation in the service treatment records indicating the Veteran was treated for gastrointestinal complaints consistent with IBS. In July 2012, the Board remanded the claim to "obtain a more current and comprehensive examination." At a September 2012 examination, the examiner rejected the previous diagnosis of IBS and diagnosed "functional bowel dysfunction." The Veteran reported onset in 1990 when he experienced "horrible gas" with constipation or diarrhea. At the examination, he indicated having about one bowel movement a day either loose or firm and bloating every day with occasional pain. In a February 2014 Disability Benefits Questionnaire (DBQ), the Veteran's IBS symptoms were noted to include constipation alternating with diarrhea and lots of gas. It was indicated the Veteran had tried many diet changes and medications without relief. He stated that every 2 to 3 months he would have diarrhea for half a day, but most of the time was constipated. At a February 2016 VA examination, the examiner noted a diagnosis of IBS. The Veteran indicated he alternated between constipation for two to three days, diarrhea for two days, and bloating. He indicated the condition had stayed the same since onset. The examiner indicated abdominal distension and that the Veteran felt better after passing gas. To the question as to whether the Veteran had episodes of bowel disturbance with abdominal distress, the examiner noted frequent episodes. More or less constant abdominal distress was not noted. In the November 2016 Memorandum Decision, the Court questioned the adequacy of the 2012 examination noting that the evidence considered did not include the March 2006 and April 2007 VA reports referenced in the August 2010 VA examination report as supporting the diagnosis of IBS and several other medical reports that dealt with bowel symptoms and IBS. The Court found that the Board erred in its reliance on the 2012 VA examination which counseled a remand. At his hearing before the Board in October 2017, the Veteran indicated daily abdominal problems, to include constipation and diarrhea. He also complained of minor fecal incontinence. Overall, the Board finds that assignment of a separate rating for IBS is warranted. The evidence suggests the Veteran's irritable bowel symptoms are related to exposures in the Gulf War and the evidence throughout the appeal period suggests such symptoms are compensably disabling under DC 7319. In addition, DC 5025 allows for rating musculoskeletal pain "with or without associated . . . irritable bowel symptoms . . ." As such, assigning a separate rating for these symptoms does not constitute prohibited pyramiding contrary to 38 C.F.R. § 4.14. As to the severity of the Veteran's symptoms, the Board finds the record most closely supports a finding of moderate disability. Between 2006 and 2008, records and examination reports indicated frequent constipation that alternated with diarrhea and excessive gas. No symptoms were noted to occur constantly or nearly constantly. On examination in 2010, the Veteran's symptoms were noted to be intermittent and in 2012, he noted daily bloating with occasional pain and one bowel movement daily. Upon examination in 2014, it was noted he was mostly constipated and the 2016 VA examiner noted frequent episodes of bowel disturbance with abdominal distress, but that abdominal distress was not more or less constant. Given the relative frequency of reported episodes of IBS symptoms throughout the appeal period, the Board finds that the criteria for a 10 percent disability rating, and no higher, are approximated under DC 7319 and a separate rating is warranted. The preponderance of the evidence, however, is against the assignment of a rating greater than 10 percent. In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55. Headaches The Veteran argues that he is entitled to a separate rating for his headaches because many of his headaches are prostrating and thus, he meets the criteria for a compensable rating under DC 8100. Pursuant to DC 8100, a 10 percent rating is assigned for migraines with characteristic prostrating attacks averaging 1 in 2 months over the previous several months. A 30 percent rating is assigned for migraines with characteristic prostrating attacks occurring on an average once a month over the previous several months. A maximum 50 percent rating is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. See 38 C.F.R. § 4.124a, DC 8100; see also Pierce v. Principi, 18 Vet. App. 440, 445 (2004) (finding rating criteria do not define "severe economic inadaptability," but nothing in DC 8100 requires that Veteran be completely unable to work to qualify for 50 percent rating; "productive of economic inadaptability" can be read as either "producing" or "capable of producing.") Although DC 8100 does not provide a definition for "prostrating," prostration is defined as "extreme exhaustion or powerlessness." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1531 (32nd ed. 2012). In the November 2016 Memorandum Decision, the Court found that the Board erred in failing to consider a statement in a medical document that the Veteran takes a drug known as Butalbital for headaches at a frequency varying from 2 per month to 2 per week. The Court pointed out that in an addendum to earlier medical notes, a VA examiner opined that "if [the Veteran] takes Butalbital for a headache it is a headache severe enough to cause him to stop work." This demonstrated that the Veteran would be experiencing headaches of sufficient severity to miss work at a frequency in excess of that required for a compensable rating under or by analogy to DC 8100, but for the ameliorative effects of the Butalbital. See Jones v. Shinseki, 26 Vet. App. 26, 63 (2012) (holding the Board erred when denying entitlement to a higher disability rating based on the ameliorative effects of medication when the rating criteria does not provide for such consideration). Turning to the evidence, at a September 2006 VA examination, the Veteran reported frequent headaches "three to four times in two weeks," and that he had lost one or two weeks of work due to headaches in the last year. In a January 2007 statement, the Veteran indicated severe headaches weekly that required him to lie down. He also indicated he had cut his work hours back and had been showing up late due to sleep impairment. In a June 2007 VA treatment record, he indicated his headaches were frequent. In September 2008, the Veteran's employer stated that his "fatigue, obvious lack of sleep, and migraines" had "taken a toll on his performance and reliability." In a January 2011 VA mental health record, the Veteran reported headaches if he missed his medication. In May 2011, the Veteran reported headaches several days a week with up to three headaches on those days. In an October 2011 VA treatment record, the Veteran again indicated headaches several times a week. In a February 2012 treatment record, the Veteran indicated that he "might as well take" his headache medication "every day." He indicated continuing to work, but that he struggled to make the quotas. Following a remand by the Board in July 2012, the Veteran underwent a VA examination in September 2012. He endorsed headaches associated with nausea and that the pain lasted less than one day. He had reportedly missed six work days due to anxiety/headaches over the past year, although he took 4 to 6 doses of Butalbital per week. He related that he was working around 55 hours per week. The examiner diagnosed tension headaches with prostrating attacks of non-migraine headache pain less than once every two months. In February, March and July 2013 VA treatment records, it was noted the Veteran's need for migraine medication varied from two per month to two per week. The record noted that the Veteran was able to function during the most severe headaches and only approximately once a year did he have a more severe headache that prevented work. However, it was also noted that if he had a headache bad enough to take Butalbital, he would lay down until the headache was gone and if he was taking Butalbital, it was a severe enough headache to cause him to stop work. In a February 2014 DBQ, the examiner noted one to two day long migraine headaches two to three times per month. It was noted the Veteran took Butalbital and used caffeine as needed to alleviate his headaches. Nausea, vomiting, sensitivity to light and sound were noted to be associated with the headaches along with pain on both sides of the head. Characteristic prostrating attacks of migraine headache pain were identified. In February 2016, the Veteran underwent another VA examination and migraines were diagnosed. He indicated experiencing 2 to 3 migraines per month when he felt a squeezing sensation at the occiput. It was noted the Veteran continued to take Butalbital. He reported pain on both sides of the head that worsened with physical activity and that sensitivity to light and nausea were associated with his headaches. Typical head pain was noted to last less than one day, but to occur more frequently than once a month. It was indicated the Veteran had very frequent prostrating and prolonged attacks of migraine headache pain and missed work an average of two times per month. At the hearing before the Board in October 2017, the Veteran indicated experiencing 2 to 3 headaches per month. He stated some were regular headaches and some were migraines that sometimes caused him to vomit. He indicated his headaches typically lasted up to a day, but could last two days; a couple had lasted three. Overall, the Board finds that assignment of a separate rating for headaches is warranted. The evidence suggests the Veteran's headaches are related to exposures in the Gulf War and the evidence throughout the appeal period suggests such symptoms are compensably disabling under DC 8100. In addition, DC 5025 allows for rating musculoskeletal pain " with or without associated . . . headache . . ." As such, assigning a separate rating for these symptoms does not constitute prohibited pyramiding contrary to 38 C.F.R. § 4.14. The Veteran has requested a 50 percent rating for his headaches. Therefore, the Board has undertaken a thorough review of the lay and medical evidence of record pertaining to headaches with an eye to determining whether it can be said that the Veteran had very frequent attacks of extreme exhaustion or powerlessness productive of severe economic inadaptability during the appeal period. The evidence suggests that throughout the appeal period, the Veteran has taken Butalbital for his headaches as often as twice per week or as little as twice per month. A treatment provider has opined that when he takes this medication, the headache is of such a magnitude that he would need to stop work but for taking the medication. Throughout the appeal period, the Veteran has complained of headaches at least monthly, if not weekly and that at times, he feels the need to take his headache medication every day. Overall, the Board finds that the evidence is at least in equipoise as to whether a 30 percent or 50 percent rating is warranted. The Veteran's ability to work long hours goes against a finding of headaches that cause extreme exhaustion or powerless; however, the evidence suggests that the Veteran's ability to work has been aided by very frequently taking Butalbital and that without the medication, he would not have been able to work nearly as much. If two disability evaluations are potentially applicable, the higher evaluation will be assigned. 38 C.F.R. § 4.7. Resolving all doubt in the Veteran's favor, the Board finds the evidence demonstrates very frequent headaches capable of producing severe economic inadaptability and a 50 percent rating is granted. In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55. Painful Joints The Veteran argues he is entitled to separate compensable ratings for each afflicted painful joint pursuant to 38 C.F.R. § 4.59 in light of evidence that he experiences significant joint pain in his feet, knees, back, shoulders, and neck. See September 2017 Brief of Appellant. Pursuant to 38 C.F.R. § 4.59, the intent of the Rating Schedule is "to recognize actually painful motion with joint or periarticular pathology as productive of disability." The regulation also states that "[i]t is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint." Id. In the November 2016 Memorandum Decision, the Court determined that the Board is required to consider the Veteran's joint pain under 38 C.F.R. § 4.59 and DC 5002, as addressed in Pettiti v. McDonald, 27 Vet. App. 415, 427 (2015). The Pettiti Court found that "[o]bservations from a lay person who witnesses a veteran's painful motion satisfies the requirement of objective and independent verification of a veteran's painful motion" which is required under DC 5002, the diagnostic code for rating rheumatoid arthritis. The Court in this case pointed to independent lay evidence confirming the Veteran's description of his joint pain, to include from his co-workers and his wife. In Pettiti, the Court acknowledged that the application of 38 C.F.R. § 4.59 with regard to DC 5002 requires objective evidence of painful motion, but was "unpersuaded" that such confirmation is limited to a doctor's finding, specifically involving range-of-motion tests. Pettiti, 27 Vet. App. at 428. The Court stated that lay statements by others of a Veteran's difficulty undertaking activity "falls within the scope of 'satisfactory evidence of painful motion' that has been 'objectively confirmed.'" Id. The Court also noted that such lay testimony could consist of the Veteran's own testimony, but that because "DC 5002 requires that 'satisfactory evidence of painful motion' be 'objectively confirmed', a [V]eteran's testimony, alone, is not enough." Id. Turning to the evidence in this case, in a March 2005 statement, the Veteran indicated his joints were "almost like lock jaw" if he stopped for a while either sitting or walking. He stated he was really stiff and it was "really bad" to get moving again. A March 2006 rheumatology record revealed a history of body aches and one hour of joint stiffness each morning. The Veteran indicated he felt his feet "curl in a ball" every morning and his joint pain was 9/10 in the morning, compared to 3/10 the rest of the day. All the fibromyalgia tender points were active. At a September 2006 VA examination, the Veteran complained of generalized muscle aches and joint pains. He complained that his whole body was stiff when he woke up or sat too long. In January 2007, the Veteran reported body aches, particularly in the morning or after being still for 45 minutes. In a June 2007 VA treatment record, the Veteran was assessed with fibromyalgia and complained of increased "stiffness". He reported morning joint stiffness that lasted all day. In an April 2008 VA treatment record, the Veteran indicated pain in "all joints" that was "achy, crampy, miserable, numb, shooting, tender and unbearable at times." In an October 2008 statement in support of claim, the Veteran indicated chronic joint pain throughout his body that was worse after sitting. In a June 2009 VA treatment record, the Veteran complained of increased "stiffness and pain all over." He complained of morning joint stiffness that lasted "all day." Fibromyalgia tender points were active. At an August 2010 VA examination, the Veteran's joint symptoms included pain, stiffness and swelling. Joints affected were noted to include the bilateral shoulders, knees and ankles. It was noted these were not related to Gulf war exposures as the Veteran had old injuries to the right knee, ankle and Achilles tendon. It was noted he had cramping in the mid foot and that he was already service connected for a foot disability. Following July 2012 remand by the Board, the Veteran underwent a VA examination in September 2012. He reported "stiffness/tightness" in all joints. It was noted that small and large joint and all muscle groups were palpated with no complaint of pain or objective evidence of pain. In a February 2014 DBQ, fibromyalgia was assessed. It was noted the Veteran had tender points for pain due to fibromyalgia, to include in the back and knees. In February 2016, the Veteran underwent another examination. Widespread musculoskeletal pain was described in the extremities and torso along with stiffness. The Veteran complained of waking up very sore and very stiff and that his back and neck hurt a lot. These symptoms were noted to be nearly constant and refractory to therapy. At his hearing before the Board in October 2017, the Veteran indicated he was always stiff and sore and tight. Upon careful consideration, the Board finds that this case can be distinguished from Pettiti because DC 5002, at issue in Pettiti, specifically contemplates separate ratings based on limitation of motion where there is painful motion whereas DC 5025 does not have a provision for rating residuals and already specifically accounts for rating musculoskeletal pain of multiple joints. More specifically, DC 5002 allows for rating rheumatoid arthritis either (1) as an active process or (2) for chronic residuals. For chronic residuals such as limitation of motion, DC 5002 specifically indicates that ratings should be under the appropriate diagnostic codes for the specific joints involved and that a separate rating is contemplated where limitation of motion of the specific joint or joints involved is noncompensable. In that context, it is noted that limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. The Board recognizes that 38 C.F.R. § 4.59 applies whether or not arthritis is present. See Burton v. Shinseki, 25 Vet. App. 1 (2011). However, DC 5025, which already accounts for musculoskeletal pain, does not specifically allow for providing additional ratings for pain under various other diagnostic codes as DC 5002 does. Pursuant to Diagnostic Code 5025, symptoms of widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud's-like symptoms are contemplated. A maximum 40 percent rating is assigned for symptoms which are constant, or nearly constant, and refractory to therapy. 38 C.F.R. § 4.71a, Diagnostic Code 5025. Here, the Veteran has widespread musculoskeletal pain and stiffness that is nearly constant and worse in the morning or after a period of cessation of activity. This has remained true within records throughout the appeal period. DC 5025 contemplates the Veteran's situation and is the most appropriate diagnostic code under which to rate his symptomatology. Specifically, he has musculoskeletal pain and stiffness that is episodic and there is evidence that other diagnosed disabilities, such as plantar fasciitis and chondromalacia in the knees are causing some symptoms, to include pain. Notably, the Veteran is service connected for plantar fasciitis and receiving a 10 percent rating for that disability and he is not service connected for a specific disability in the knees. Overall, the Board finds that the 40 percent rating under DC 5025 is the appropriate rating and compensates for the joint pain and stiffness the Veteran feels. Separate ratings for each painful joint would not be appropriate because the Veteran is specifically being compensated at the maximum level for his widespread musculoskeletal pain under DC 5025. The assignment of separate ratings for the same manifestation of disability, specifically pain, under multiple diagnostic codes, would constitute prohibited pyramiding contrary to the provisions of 38 C.F.R. § 4.14. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55. ORDER Entitlement to separate rating of 10 percent (but no higher) for IBS is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a separate rating of 50 percent for headaches is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a rating in excess of 40 percent for undiagnosed illness involving chest pain, joint pain, muscle ache, fatigue, sleep disturbance, headaches, and irritable bowel symptoms, to include separate ratings for each painful joint, is denied. ____________________________________________ Nathan Kroes Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs