Citation Nr: 18113167 Decision Date: 06/21/18 Archive Date: 06/21/18 DOCKET NO. 15-12 978 DATE: June 21, 2018 ORDER A 20 percent rating, but not higher, for left foot (great toe) metatarsophalangeal joint arthritis is granted subject to the laws and regulations governing the award of monetary benefits. An initial 10 percent rating for bilateral costochondritis of the 5th and 6th ribs is granted, subject to the laws and regulations governing the award of monetary benefits. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran’s left foot great toe metatarsophalangeal joint arthritis has been manifested by pain on movement and weight-bearing and flare-ups resulting in limited range of motion and interference with walking, which results in moderately severe impairment. 2. Throughout the period on appeal, the Veteran’s service-connected costochondritis of the 5th and 6th ribs have been manifested by rib cage pain that has resulted in no more than moderate impairment to Muscle Group XXI. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for a 20 percent rating, but no higher, for left foot great toe metatarsophalangeal joint arthritis are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Codes (DCs) 5003, 5010, 5284 (2017). 2. Resolving reasonable doubt in favor of the Veteran, the criteria for a disability rating of 10 percent, but no higher, for bilateral costochondritis have been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.56, 4.73, Diagnostic Codes (DC) 5297, 5321 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from May 1989 to July 2012. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a Department of Veterans Affairs (VA) Regional Office (RO) rating decision in September 2012. The Veteran has perfected an appeal. See October 2013 Notice of Disagreement (NOD); March 2015 Statement of the Case (SOC); April 2015 VA Form-9. A March 2015 rating decision granted an increased evaluation of 10 percent for left foot (great toe) metatarsophalangeal joint arthritis from August 1, 2012. As this grant does not represent a total grant of benefits sought on appeal, the claim for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). Accordingly, the Veterans VA claims folder has been returned to the Board for further appellate proceedings. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has 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). Here, the relevant evidentiary window begins one year before the Veteran filed her claim for an increased rating, and continues to the present time. The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id. When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). In making all determinations, the Board must fully consider the lay assertions of record. A Veteran is competent to report on that of which he or she has personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). 1. Left foot (great toe) metatarsophalangeal joint arthritis The Veteran’s left foot (great toe) metatarsophalangeal joint arthritis is currently assigned a 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5284. Diagnostic Code 5284 provides rating criteria for other foot injuries. A moderate foot injury warrants a 10 percent disability evaluation; a moderately severe foot injury warrants a 20 percent disability evaluation; and a severe foot injury is assigned a 30 percent disability evaluation. A 40 percent disability evaluation will be assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a, DC 5284. VA's General Counsel has determined that DC 5284 is a general diagnostic code under which a variety of foot injuries may be rated; that some injuries to the foot, such as fractures and dislocations for example, may limit motion in the subtalar, midtarsal, and metatarsophalangeal joints; and that other injuries may not affect range of motion. Thus, General Counsel concluded that, depending on the nature of the foot injury, DC 5284 may involve limitation of motion. VAOPGCPREC 9-98. The words "moderate," "moderately severe," and "severe" as used in the various DCs are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2017). The use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2017). Service treatment records (STRs) document that the Veteran’s left foot was “smashed” by a trailer hitch in-service in June 1990. The Veteran was placed on a five-day profile and STRs document continued pain and tenderness in June and July 1990. January and March 2012 STRs document “joint pain in toes” under the list of the Veteran’s active problems. Service connection for left foot great toe metatarsophalangeal joint arthritis (claimed as arthritis) was granted in a September 2012 rating decision and assigned a noncompensable rating, effective August 1, 2012. The Veteran filed a notice of disagreement with the noncompensable rating in October 2013. A February 2014 private treatment record documents that the Veteran presented with left big toe-pain. The Veteran reported chronic severity with considerable pain ranging between 4 to 8 on a scale of 1 to 10. He described throbbing achy pain of about 3 years duration. He reported pain with shoes that was aggravated by activity such as walking and running. The Veteran indicated that the condition improved with rest. On examination, the physician noted mild hammering of the left hallux at the interphalangeal joint (IPJ) and slight limping. Dorsiflexion, plantarflexion, inversion, and eversion of the feet were noted as displaying normal range of motion and muscle strength. The examiner noted painful and limited range of motion of the IPJ of the left foot only. X-rays revealed no fractures or stress fractures and good bone stock. Degenerative changes were noted in the first metatarsophalangeal joints of both feet with joint space narrowing. The assessment was localized osteoarthritis of the left hallux IPJ with pain. The Veteran was advised not to go barefoot. There was a notation of a post-op shoe to immobilize acute arthritic flare up. The physician recommended surgery to clean up the joint to decrease pain if it was affecting the Veteran’s quality of life significantly. She further indicated that a fusion might be needed down the road and that given the Veteran’s history and intermittent pain, surgery might be the best option for him. See February 2014 Private Treatment Record. In a March 2014 statement, the Veteran asserted that he was experiencing daily left foot, great toe pain. He stated that on a good day, the pain level was a 4. He reported that on bad days, the pain was so intense that he was not able to wear a shoe or do normal activities. See March 2014 Statement in Support of Claim. During a January 2015 VA examination, a diagnosis of left great toe metatarsophalangeal (MTP) joint osteoarthritis was noted with an onset sometime around 2008. The examiner noted that he had not reviewed the Veteran’s file. The Veteran reported that he had left toe pain in service that was so severe that he had a limp, which had gotten somewhat better and was partially relieved by a special shoe. The Veteran reported flares of pain in both the distal and proximal left great toe MTP joints. The pain was characterized as aching and sharp. The Veteran further reported that flare-ups impacted the function of the foot through intermittent episodes of the above-described pain. The examiner noted that the Veteran did not exhibit symptoms of flat foot; Morton’s neuroma and metatarsalgia; hammer toe; hallux valgus; hallux rigidus; claw foot; or malunion/nonunion of the tarsal or metatarsal bones. The examiner indicated that the Veteran’s left foot condition was of “moderate” severity and required the use of arch supports, custom orthotic inserts or shoe modifications, but did not chronically compromise weight bearing. No left foot pain was observed on physical examination, but pain on movement and weight-bearing were noted as factors contributing to functional loss or impairment. It was noted that flare-ups caused pain that, in turn, caused a limp and interfered with walking. The Veteran did not require the use of any assistive devices as a normal mode of locomotion and there were no other pertinent physical findings. The examiner noted that the condition impacted the Veteran’s ability to perform occupation tasks in that pain flares limited walking ability which in turn interfered with long workdays requiring extensive walking. See January 2015 Foot Conditions Disability Benefits Questionnaire. The evidence shows that the Veteran's left foot great toe injury has manifested by symptoms including left great toe pain, throbbing, and aching. Furthermore, the Veteran has described experiencing daily left foot, great toe pain that at times is so intense that he is unable to wear a shoe or perform normal activities. He reported general pain with shoes that was aggravated by activity such as walking and running. He further reported flare-ups with sharp, aching left foot great toe pain that produced a limp. Objective evidence on the February 2014 private examination noted painful and limited range of motion of the IPJ on the left foot and mild hammering of the left hallux. The doctor indicated the potential need for surgery to decrease pain if the Veteran’s symptoms continued to affect quality of life. The January 2015 VA examiner indicated that the Veteran’s left foot condition was “moderate” and noted the required use of a special shoe. The examiner noted that the condition did not chronically compromise weight bearing but indicated that pain on movement and weight-bearing were factors contributing to functional impairment. Flare-ups were noted to cause a limp and interfere with walking and would impact the Veteran’s ability to perform occupational tasks. Based on the above evidence, including VA and private examination and treatment records, as well as the Veteran's own description of left foot great toe pain with resulting limitation in functioning, including in the performance of occupational tasks, the Board finds that a 20 percent rating, indicative of "moderately severe" disability under DC 5284, is warranted. The Board further notes that the Veteran's reports of left foot great toe pain, aching, throbbing, and functional impairment are specifically encompassed in the Board's assignment of the 20 percent disability rating. As described above, DC 5284 provides for ratings based on the overall severity of the disability. Overall, the Board finds that the Veteran's left foot great toe symptomatology more nearly approximates that of a moderately severe disability. In reaching this conclusion, the Board finds probative the fact that the Veteran experiences left foot great toe pain, aching, and throbbing, with intermittent, but intense flare-ups, which impacts his ability to walk for prolonged periods. He experiences some form of left foot great toe pain daily and requires the use of a special shoe to alleviate symptoms. Moreover, he has had difficulty walking and running with flare-ups producing a limp and limited range of motion of the IPJ. Thus, the Board finds that the Veteran's disability picture more nearly approximates a 20 percent disability rating for the entire period under DC 5284. See 38 C.F.R. § 4.7. The Board finds that a rating greater than 20 percent is not warranted, based on lack of evidence showing severe impairment of the left foot. For example, upon physical examination of the left foot, the February 2014 private examiner found normal range of motion on the remaining areas of the left foot, good bone stock, and no X-ray evidence of fractures or stress fractures. The January 2015 VA examiner noted no left foot pain on physical examination and indicated that the condition did not chronically compromise weight-bearing, despite evidence of pain on weight-bearing. Further, although the Veteran requires the use of a special shoe, he does not require the use of a cane or any other assistive device. Moreover, the evidence fails to suggest that the Veteran's left foot great toe metatarsophalangeal joint osteoarthritis is analogous to actual loss of use of the foot, as the Veteran's left foot is functional. See 38 C.F.R. § 4.71a, DC 5284, Note. Thus, the Board finds that the symptoms have not more nearly approximated a rating greater than 20 under DC 5284. In addition, a separate rating under DCs 5010 or 5003, which pertains to degenerative and traumatic arthritis, would violate the rule against pyramiding as the Veteran's pain on use of the left foot is already compensated under DC 5284, and a rating greater than 10 percent is not available under Diagnostic Code 5003. See 38 C.F.R. § 4.14. The Board further finds that a separate rating or a higher is not warranted under any other applicable provision of the rating schedule. 38 C.F.R. § 4.71a, DCs 5276-5284. To this end, the Veteran does not have a diagnosis of or symptoms approximating pes planus, weak foot, claw foot, hammer toe, hallux valgus, metatarsalgia, or hallux rigidus. 38 C.F.R. § 4.71a, DCs 5276-5278, 5279, 5280-5282. The Board notes that the February 2014 private examination report included a finding of mild hammering of the left hallux at the IPJ. However, the January 2015 VA examination found no evidence of hammer toe on the more recent examination. In any event, a rating greater than 10 percent is not available under Diagnostic Code 5282 and there is no evidence that the Veteran displays hammer toe of all toes, unilateral without claw foot, as required by the rating criteria for a 10 percent rating under DC 5282. Even assuming the Veteran displayed hammer toe of the left great toe, single toes displaying hammer toe are afforded a noncompensable rating under Diagnostic Code 5282. Moreover, the Board finds that any hammering of the left foot great toe is encompassed in the Board’s assignment of a 20 percent rating for a moderately severe foot injury under DC 5284. Accordingly, a separate evaluation under Diagnostic Code 5282 is not warranted. In addition, the record contains no evidence of any malunion or nonunion of the left foot. No other pathology of the left foot has been diagnosed. As the preponderance of the evidence is against a rating higher than 20 percent for the Veteran's left foot great toe injury, the benefit of the doubt doctrine is not for application in this regard. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102 2. Bilateral costochondritis of the 5th and 6th ribs The Veteran’s bilateral costochondritis of the 5th and 6th ribs is currently assigned a noncompensable rating under 38 C.F.R. § 4.71a, Diagnostic Code 5297. Although the Veteran’s condition is rated under Diagnostic Code 5297, the Board observes that the AOJ has evaluated the condition under Diagnostic Code 5321, which pertains to a muscle injury to Group XXI, the muscles of respiration. The Board’s analysis will discuss evaluation under both diagnostic codes. Costochondritis is not listed in the rating schedule. Where a particular disability is not listed, it may be rated by analogy to a closely related disease in which not only the functions affected, but also the anatomical area and symptomatology, are closely analogous. 38 C.F.R. §§ 4.20, 4.27 (2017); Lendenmann v. Principi, 3 Vet. App. 345, 349-50 (1992); Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Here, because there is no specific diagnostic code for costochondritis, the Veteran's condition is rated by analogy under Diagnostic Code 5297, which governs rib removal. Costochondritis is an "inflammation and associated tenderness of the cartilage (i.e., the costochondral joints) that attaches the front of the ribs to the breastbone." Gale Encyclopedia of Medicine (4th ed. 2012). Accordingly, 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. Diagnostic Code 5297, under which the Veteran is currently rated, states that removal of one rib or resection of two or more ribs without regeneration warrants a 10 percent disability rating. A 20 percent rating requires removal of two ribs. Removal of three or four ribs warrants a 30 percent rating. A 40 percent rating is assigned for removal of five or six ribs. Removal of more than six ribs warrants a 50 percent rating.38 C.F.R. § 4.71a, Diagnostic Code 5297 (2017). The Veteran’s condition could also be rated by analogy as an injury to Muscle Group XXI, the muscles of respiration of the thoracic muscle group. Under that code, a slight injury warrants a noncompensable evaluation. A moderate injury warrants a 10 percent rating. A moderately severe or severe injury warrants a 20 percent rating. 38 C.F.R. § 4.73, DC 5321. Factors for consideration in the rating of muscle disabilities are set forth in 38 C.F.R. §4.55 and 4.56. For VA rating purposes, 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). The type of injury associated with a slight muscle disability is a simple wound of muscle without debridement or infection. A history regarding this type of injury should include service department record of superficial wound with brief treatment and return to duty, healing with good functional results, and no cardinal signs or symptoms of muscle disability. Objective findings should include minimal scar, no evidence of fascial defect, atrophy, or impaired tonus, no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56 (d)(1). The type of injury associated with a moderate muscle disability is a 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. A history regarding this type of injury should include service department record or other evidence of in-service treatment for the wound and record of consistent complaints of one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use affecting the particular functions controlled by the injured muscles. Objective findings should include entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue and some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56 (d)(2). The type of injury associated with a moderately severe muscle disability is a through-and-through or deep penetrating wound by a small high-velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. A history regarding this type of injury should include service medical record or other evidence showing prolonged hospitalization for treatment of wound, record of consistent complaints of cardinal signs and symptoms of muscle disability, and, if present, evidence of inability to keep up with work requirements. Objective findings should include entrance and (if present) exit scars indicating the track of the missile through one or more muscle groups, and indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side. Tests of strength and endurance compared with sound side should demonstrate positive evidence of impairment. 38 C.F.R. § 4.56 (d)(3). The type of injury associated with a severe disability of muscles is a through-and-through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. A history consistent with this type of injury would include service department record or other evidence showing hospitalization for a prolonged period for treatment of wound, record of consistent complaint of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Objective findings of a severe disability would include ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track; palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area; muscles swell and harden abnormally in contraction; tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. 38 C.F.R. § 4.56 (d)(4). Turning to the evidence of record, service treatment records (STRs) document “chest pain made worse by breathing” as early as June 2011. In October 2011, the family practice clinic at Ireland Army Hospital referred the Veteran to Dr. M.S., a physician specializing in arthritis and connective tissue disorder, for evaluation of left ribcage pain. It was noted that the Veteran had been experiencing such pain for the past year intermittently, although occurring daily without proceeding injury or unusual exertion. The Veteran endorsed similar pain on the right side. The Veteran’s discomfort was described as burning to aching without any shooting pain. He denied any precipitating factors and had no significant relief with local heat or cold. The Veteran had not used topicals and had avoided NSAIDs due to a clotting disorder. He reported that Vicodin and Tylenol helped some. Ribcage pain was rated as 0-6 on a scale of 1-10. The assessment was left chest wall pain with no specific etiology evident. He had chronic spinal pain with restriction of movement raising the possibility of spondyloarthropathy. In November 2011, the Veteran reported experiencing pain for a year, with the onset of pain occurring gradually over time. He described his pain as constant, aching, hot-burning, and sharp. He reported pain between 3-6 on a scale of 1-10, averaging 4 out of 10. He reported pain improvement with medications. Examination of the thoracic spine revealed no evidence of atrophy or asymmetry. There was tenderness at the thoracic paraspinal muscles and tenderness at the facet joint lines. Hyperextension of the thoracic spine caused increased pain. Aching, burning, and shooting was noted on the left thorax anterior. The diagnosis was chronic chest wall pain along anterior cost-chondral junction with features suggestive of costochondritis versus thoracic radiculitis. It was noted that unlikely differential might include slipping rib syndrome. The Veteran was seen about two weeks later in November 2011 for follow-up. The Veteran reported right rib cage pain that occurred continuously. He described the pain as aching, hot-burning, and radiating to the right lower rib cage. Current pain level was 3 out of 10. He indicated that his pain was relieved by 60 percent by taking medications. He reported waking two times during the night due to pain. It was noted that pain was now more episodic than constant. An MRI was reviewed. There was no thoracic spine pathology suggestive of inciting cause so it was noted that the diagnosis may be more in line with local cause, slipping rib syndrome as opposed to costochondritis, thus it was determined that they would attempt a local block. The Veteran was seen for subsequent follow-up for constant left chest wall and intermittent right wall pain. X-ray of the thoracic spine from September 2011 was normal and MRI was unremarkable. The assessment was left chest wall pain and spinal pain with restriction of range of motion. It was noted that the Veteran would continue with pain management and might get local injection of nerve block as necessary. See November 2011 Report of Dr. M.S. A December 2011 record from Avicenna Pain Relief, PLLC, noted that the Veteran presented with “slipping rib syndrome” and was there for a steroid small joint injection to his left side. It was noted that previous conservative measures had failed to relieve pain. January and February 2012 treatment notes document costochondritis and chest pain made worse by breathing under the “problems” section. However, it should be noted that review of symptoms on these treatment notes indicate no findings of chest pain, discomfort, or palpitations. Review of lungs revealed normal respiratory movements, rhythm, and depth. A March 2012 treatment note and accompanying report of medical examination document tenderness to palpitation over the left anterior lower ribs with increased prominence on the left versus the right rib cage. In the summary of defects and diagnoses, it was noted that the Veteran experienced chest pain in the left anterior rib. The Veteran was seen again at Avicenna Pain Relief, in February 2012 for a costochondral junction block. The Veteran reported missing work due to pain. It was noted that he was doing extremely well until the effect of the block wore off. The Veteran was advised that he would likely get extended relief by efforts to break the cycle of pain with costochondral junction blocks in quick succession, weekly up to 4-5 times. An April 2012 examination diagnosed left side chronic intercostal muscle strain and bilateral 5th and 6th rib costochondritis. The condition was noted to effect muscle group XXI, the muscles of respiration in the thoracic muscle group. The Veteran had tenderness on palpation at the right and left 5th and 6th costochondral junctions and was also tender at the left 6th and 7th intercostal muscles near the mid-clavicular line. Imaging studies were performed and X-ray revealed normal ribs bilaterally. Functional impact was noted as limits on heaving lifting, pulling, or pushing. See April 2012 Examination. Service connection for bilateral costochondritis of the 5th and 6th ribs with intercostal muscle strain was granted in a September 2012 rating decision and assigned a noncompensable rating, effective August 1, 2012. See September 2012 Rating Decision. The Veteran filed a notice of disagreement with the noncompensable rating in October 2013. In a March 2014 statement in support of claim, the Veteran reported that he experienced pain on the left side of his rib cage. He stated that he had been prescribed different pain medications to help with the pain, as well as injections which were not effective. He asserted that he experienced pain every day and that some days the pain was so great that he could not function. See March 2014 Statement in Support of Claim. The Veteran underwent a VA examination for muscle injuries in January 2015. The examiner reported a diagnosis of bilateral costochondritis of the 5th and 6th ribs and noted that the Veteran had a non-penetrating muscle injury. The Veteran reported the onset of bilateral rib pain which his medical providers believe was due to some kind of trauma, although the Veteran reported that he could not remember any specific injury preceding the condition. The Veteran saw pain management for the condition while in service and received cortisone injections which were not particularly helpful. He was also placed on Neurontin and Lyrica for this and other chronic pain issues and had recently been prescribed T3, which caused him to fall asleep and awaken still in pain. Pain was sometimes so severe that it prevented him from going to work. The Veteran reported that pain was worse on the left side and ranged in character from aching to burning and stabbing, and felt like it was originating from deep within the rib cage. Pain was aggravated by pressure, twisting, and extension. The Veteran reported that extensive imagery had been done but found no abnormalities. See January 2015 VA Examination. On examination, the examiner did not document an effect on the muscles of Group XXI. It was noted that torso strength was symmetrical and intact, measured by resisted twisting, and resisted lateral spinal flexion, however these motions did not result in increased pain. In describing the functional impact of the Veteran’s condition, the examiner noted that pain resulted in interference with concentration and in poor sleep which led to fatigue, both of which led to poor tolerance for long workdays and impaired executive function. Id. As noted above, although the Veteran’s disability is currently assigned under Diagnostic Code 5927, the September 2012 rating decision and the March 2015 SOC indicate that the condition was evaluated under the criteria for Diagnostic Code 5321 for a Group XXI muscle injury. The Board finds that the Veteran’s costochondritis is most appropriately rated by analogy under DC 5321. In evaluating this claim, the Board initially notes that, because the Veteran's disability is assigned by analogy to a muscle injury, the exact characteristics of a muscle injury, as described in the rating criteria (i.e., penetrating wounds) are not adequate descriptors of the Veteran's overall disability picture. Nevertheless, the Board is mindful of 38 C.F.R. § 4.40, which states that, with respect to disabilities of the musculoskeletal system, "functional loss . . . may be due to pain." In this context, the Board notes that, while no associated bone or joint abnormalities have been identified as related to the Veteran's costochondritis, the service and post-service evidence reflect that he has consistently complained of fatigue-pain, a cardinal sign and symptom of muscle disability, which is incurred and worsened with movement, including pressure, twisting, and extension. He further indicated that he would frequently awake with such pain. The January 2015 VA examiner noted that such pain interfered with sleep and concentration. Given the evidence of in-service treatment for costochondritis and consistent complaints of one of the cardinal signs and symptoms of muscle disability, and after resolving all reasonable doubt in favor of the Veteran, the Board finds the Veteran's service-connected disability has more nearly approximated a moderate disability throughout the pendency of this appeal. Accordingly, a 10 percent rating is warranted under DC 5321. The Board has considered whether a rating in excess of 10 percent is warranted under DC 5321; however, the evidence does not show symptoms that are consistent with a moderately severe or severe impairment, including prolonged treatment or hospitalization during service or evidence of impaired respiratory function or decreased strength and endurance in the upper extremities. In this regard, the Board notes the Veteran has consistently reported pain and some fatigue with his condition, but has not asserted that he experiences weakness and loss of muscle power as a result of his costochondritis; a complete review of the lay and medical evidence of record shows that his costochondritis is manifested by aching, burning, and stabbing pain that impairs his ability to perform certain movements, when present, as opposed to weakness, loss of muscle power or strength, or other functional loss in the costochondral junctions or upper extremities. Therefore, the Board finds that the Veteran's costochondritis is moderate, at best, and warrants no more than a 10 percent rating under DC 5231. The Board has also considered whether a rating in excess of 10 percent is warranted under other potentially applicable diagnostic codes. As noted above, costochondritis involves the rib and its cartilage. See Gale Encyclopedia of Medicine (4th ed. 2012), supra. As a result, the Veteran's costochondritis has previously been rated under DC 5297, for removal of the ribs; however, the evidence of record does not show that the Veteran has ever had a removal of one rib or resection of two or more ribs without regeneration, meaning that he would not meet the criteria for even a 10 percent evaluation, much less a 20 percent rating under DC 5297, which requires the removal of at least two ribs. The Board finds that these criteria are not analogous to the Veteran's primary symptom of chronic pain. The Veteran's costochondritis could also be evaluated as arthritis or bursitis under DCs 5003 and 5019, respectively; however, those disabilities are evaluated based upon limitation of motion of the affected parts. The evidence does not show that the Veteran experiences limitation of motion in any affected area, including his chest and upper extremities, that is related to his costochondritis; here, the Board notes the Veteran does experience arthritis and upper extremity limitation of motion that is addressed and appropriately compensated by separate service-connected disability ratings. Thus, the Board finds that Diagnostic Codes 5003 and 5019 do not assist the Veteran in obtaining a rating higher than 10 percent with respect to his costochondritis. Finally, the Board finds there is no basis for staged rating of the Veteran's costochondritis pursuant to Hart, as the lay and medical evidence shows the Veteran's costochondritis has been consistently manifested by symptoms that more nearly approximate a 10 percent rating throughout the appeal period. Therefore, for the reasons and bases set forth above, the Board finds the preponderance of the evidence supports the award of an initial 10 percent rating, but no higher, for service-connected bilateral costochondritis of the 5th and 6th ribs. In making this determination, all evidence has been considered and all reasonable doubt resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Lewis, Associate Counsel