Citation Nr: 21002423 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 17-15 082 DATE: January 13, 2021 ORDER Entitlement to an increased rating of 20 percent, but no higher, for left Achilles tendonitis with plantar heel spurs is granted, effective March 15, 2014, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an increased rating of 20 percent, but no higher, for right Achilles tendonitis with plantar heel spurs is granted, effective March 15, 2014, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an increased rating of 50 percent, but no higher, for major depressive disorder is granted, effective March 15, 2014, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an increased rating of 10 percent, but no higher, for migraine headaches is granted, effective March 15, 2014, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an increased rating higher than 0 percent for costochondritis with strain of muscle group XXI is denied. REMANDED Entitlement to an increased rating higher than 10 percent for right knee strain with degenerative arthritis is remanded. FINDINGS OF FACT 1. Considering the Veteran’s lay reports of symptoms and functional loss, the Veteran’s left and right Achilles tendonitis with plantar heel spurs more nearly approximates marked limited motion. 2. The Veteran’s major depressive disorder is more closely approximated by social impairment with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. 3. Resolving all doubt in the Veteran’s favor, during the appeal period, the Veteran experienced migraines with characteristic prostrating attacks occurring on average once every two months. 4. During the period on appeal, the Veteran’s costochondritis with strain of muscle group XXI most closely approximated a slight muscle disability; the evidence of record does not demonstrate that the Veteran’s costochondritis with strain of muscle group XXI approximated a moderate, moderately severe, or severe muscle disability. CONCLUSIONS OF LAW 1. The criteria for a rating of 20 percent, but no higher, for left Achilles tendonitis with plantar feel spurs have been met, effective March 15, 2014. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.71a, Diagnostic Codes 5015-5271. 2. The criteria for a rating of 20 percent, but no higher, for right Achilles tendonitis with plantar feel spurs have been met, effective March 15, 2014. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.71a, Diagnostic Codes 5015-5271. 3. The criteria for a disability rating of 50 percent, but no higher, for major depressive disorder have been met, effective March 15, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9434. 4. The criteria for a disability rating of 10 percent, but no higher, for migraine headaches have been met, effective March 15, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8100. 5. The criteria for a compensable evaluation for costochondritis with strain of muscle group XXI have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.56, 4.73, Diagnostic Code 5321. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from March 2010 to March 2014. This matter comes to the Board of Veterans’ Affairs (Board) on appeal from a May 2014 rating decision from the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ), which, in pertinent part, granted service connection for major depressive disorder, assigning a 30 percent rating; left Achilles tendonitis and right Achilles tendonitis, assigning separate 0 percent ratings; migraine headaches, assigning a 0 percent rating; right knee strain with degenerative arthritis, assigning a 0 percent rating; and costochondritis with strain, muscle group XXI, assigning a 0 percent rating. All ratings are effective on March 15, 2014, the day after the Veteran’s separation from service. In a July 2019 rating decision, the AOJ granted separate increased ratings of 10 percent for left and right Achilles tendonitis with heels spurs; and granted an increased rating of 10 percent for the right knee strain. All ratings are effective March 15, 2014. Increased Rating 1. Entitlement to an increased rating higher than 10 percent for left Achilles tendonitis with plantar heel spurs 2. Entitlement to an increased rating higher than 10 percent for right Achilles tendonitis with plantar heel spurs The Veteran contends that he is entitled to higher ratings because he cannot do any physical activity for exercise or ride bikes with his kids. See August 2020 Board hearing transcript, p. 14. He noted that he cannot really go for a run and had been dealing with the pain since 2010. Id. He noted that the examinations provided did not capture the limitation of motion in his ankles because just sitting he was fine but after limping around, he does have limitation of motion. Id. at 15. He indicated that he had been an auto mechanic prior to service but could not go back to that type of job because of the walking around all day long. Id. He noted that the symptoms in the both ankles were about the same, but the left sometimes hurt more. Id. at 17. The Veteran’s left and right Achilles tendonitis with heel spurs is rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5015-5271. Under Diagnostic Code 5015, benign new bone growths are rated on limitation of motion of the affected parts as degenerative arthritis. Diagnostic Code 5271 addresses limitation of motion of the ankle. Under Diagnostic Code 5271, a 10 percent rating is warranted for moderate limited motion of the ankle. A maximum 20 percent rating is warranted for marked limited motion of the ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5271. According to Merriam Webster, “moderate” means “tending toward the mean or average amount or dimension”. See www.merriam-webster.com/dictionary/moderate. “Marked” means “having a distinctive or emphasized character”. See www.merriam-webster.com/dictionary/marked. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. A March 2014 VA examination report shows that the Veteran had the onset of symptoms in 2011 during physical training as pain in the Achilles tendons. It was noted to be the result of wear and tear from hiking, running, and ruck marches. His left ankle reportedly started to hurt in 2011. By 2013, during physical therapy for the left ankle, he started to notice the same pain in the right ankle. The condition had gotten worse over time. He described flare-ups impacting his ankle as a sharp pain in both heels causing a limp. The pain was intermittent. Range of motion studies showed right and left ankle plantar flexion to 45 degrees or greater, and right and left dorsiflexion to 20 degrees or greater. There was no additional loss of motion after repetitive use studies. There was pain on palpation of the joints/ soft tissue of both ankles. Joint stability testing was normal. There was no ankylosis. The Veteran was diagnosed with having Achilles tendonitis or Achilles tendon rupture on both sides. The Veteran reported symptoms of pain and tightness in the back of the ankles. X-ray examination also showed very small plantar heel spurs on both sides. The impact of the Veteran’s ankle condition on his ability to work was that the Veteran had to be on his feet all day as a car mechanic at a car dealership and sometimes had to squat or crouch, which aggravated his tendonitis. There were no contributing factors of weakness, fatigability, incoordination, or pain during flare-ups or repeated use over time that could additionally limit the functional ability of the ankle joint. A May 2019 VA examination report shows the Veteran was diagnosed with bilateral Achilles tendonitis and bilateral heel spurs. The Veteran reported that ankle pain had become worse over time. He was provided with inserts for his shoes, which provided some relief of the pain, but as soon as he was barefoot, the symptoms returned immediately. He had constant pain at a 4 to 5 out of 10 in both heels and ankles off and on. His pain was worse when on his feet or walking for prolonged periods of time. He also had intermittent stiffness to the bilateral ankles. Functional loss included that he did not run anymore and tried to stay off of his feet in general. Range of motion studies showed 0 to 20 degrees of dorsiflexion and 0 to 45 degrees of plantar flexion in the right and left ankles, which was found to be normal. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissues. There was pain noted on examination, but it did not result in or cause functional loss. There was pain on weight-bearing in the right and left ankles. The impact of the Veteran’s disability on his work was that he was unable to stand or walk for prolonged periods of time due to pain from the bilateral heel spurs and bilateral Achilles tendonitis. It was noted that the Veteran was not being examined after repetitive use over time or during a flare-up. There was objective evidence of pain on passive range of motion testing and when the joint was used in non-weight bearing in both ankles. As noted, the Veteran testified that in spite of the examinations showing full range of motion in the ankles, after he had been on his feet for a while, he had limitation of motion in the ankles. He noted that the examinations were taking place when he was sitting down and his ankles were fine but that after being on his feet, he had painful motion in the ankles. This is consistent with the April 2014 VA examination noting that he described flare-ups impacting his ankle as a sharp pain in both heels causing a limp; and the May 2019 VA examination noting pain on weight-bearing and with passive range of motion testing. The examiners did not state that the Veteran’s range of motion was limited by the pain; however, resolving all doubt in the Veteran’s favor, the Board finds that the Veteran’s limitation of motion in the ankles is more marked than moderate. The Veteran described pain in the ankles that limited his motion and caused a limp, which is more consistent with a distinct or emphasized character. See www.merriam-webster.com/dictionary/marked (“Marked” means “having a distinctive or emphasized character.”). Thus, the Board finds that the evidence more closely approximates the criteria for 20 percent ratings for left and right Achilles tendonitis with plantar heel spurs. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain during flare-ups, and pain during repetitive use over time. In considering the Veteran’s lay reports of symptoms and functional loss, the Veteran’s left and right Achilles tendonitis more nearly approximates marked limited motion. The Board has considered whether any other Diagnostic Codes related to disabilities of the ankle would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. The medical evidence shows that there was no ankylosis or malunion in the left and right ankles. There also had been no surgeries, including an astragalectomy. In conclusion, the Board finds that the evidence more closely approximates the criteria for 20 percent ratings, but no higher, for the left and right Achilles tendonitis with plantar heel spurs. 3. Entitlement to an increased rating higher than 30 percent for major depressive disorder The Veteran contends that he should be rated higher based on the impairment associated with his major depression. He testified at the August 2020 Board hearing that he had to take a lot of time off from work because of his down moods and difficulties being around a lot of people. See Board hearing transcript, pp. 3-4. He also noted that he was put on restrictions because of his coming in late so that he could not be promoted for a year. Id. at 4. He mentioned that some days he could not maintain focus for his technical job. Id. at 9. He testified that he and his wife argue a lot and he had lost his temper and damaged their home. Id. at 5. He further noted that he did not have friends or maintain relationships with anyone. Id. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 50 percent or higher. The Board concludes that the Veteran’s symptoms more closely approximated the symptoms associated with a 50 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. An April 2014 VA examination report shows the Veteran began having symptoms of depression late in his career in the military. The examiner noted that the Veteran was unhappy with what was going on at his duty station, but also was having concentration difficulties. It was noted that he likely had his first onset of depression when he had sleep difficulties in Afghanistan and eventually developed more symptoms, which led to a diagnosis of depression. The examiner noted that the Veteran was not reporting symptoms of significant anxiety, though the depressive symptoms continued. The examiner found that the best summary of the Veteran’s occupational and social impairment was that he had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior. On the mental health evaluation, the Veteran had complaints of decreased concentration and memory. He also had depressed mood and decreased interest in usual enjoyable activities, withdrawal, and detachment in social relationships, as well as anxiety about getting out and returning to school. It was noted that the Veteran’s anxiety appeared to be situational. He also had symptoms of depressed mood lasting more than two weeks, anhedonia, sleep disturbance, decreased energy, appetite disturbance, and decreased concentration with indecisiveness. Socially, the examiner found that he was impaired by mild depression leading to some withdrawal and a sense of being distanced from others. Occupationally, the examiner found that the Veteran’s employment had not been impacted by his psychiatric issues, as he had finished his tour of active duty and had worked full-time since then. An April 2015 VA intake assessment notes that the Veteran described difficulties in readjusting to civilian life following deployment. He reported depression, social anxiety, anger, disorganization, and relationship difficulties. His symptoms were negatively affecting his relationship with his spouse. He noted that he had a history of suicidal thoughts, but no plan or history of prior attempts. He reported homicidal thoughts but no plans. On mental status evaluation, the Veteran had an anxious affect with tense motor activity. He also had sleep disturbance. A May 2019 VA examination report shows that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran noted that he had been married since 2010 and described the relationship as “unstable, poor” related to poor communication and stress. He noted that there were daily fights. He had three children, ages 2, 6, and 10, and the relationship with the children was described as “pretty good.” He also had chronic sleep impairment with average of four to five hours of sleep per night. He noted that he occasionally awoke with anxiety. Occupationally, the Veteran had recently been placed on probation due to repeatedly being late to work. He stated that he sometimes slept late due to sleeping in his car after a fight with his wife. He also stated that a prior prescription of Mirtazapine interfered with the ability to wake up. Socially, the Veteran maintained one close friendship and engaged in a social activity once every couple of months. He spent his free time taking care of his children and completing tasks around the house. He reported experiencing a recurrent sad mood on most days. He rarely experienced happiness. His low moods were attributed to marital strain, current dissatisfaction with his job, and chronic back pain. His brother had passed away unexpectedly in 2016. He stated that he had no goals or excitement. He endorsed low motivation and low energy. He reported anhedonia and decreased enjoyment in activities over the past three to four years. He had a decreased desire for social interactions and reported a history of passive suicidal ideation after fights with his wife. He denied any history of active suicidal ideation. He reported difficulty focusing and irritability with losing his temper at home on most days. He also had anxiety and described acute anxiety during meetings at work and at large social events. He felt nervous in crowds and went shopping during off hours. He experienced difficulty breathing racing heart in unfamiliar and crowded settings. He would take Propranolol when he believed he would feel anxious. It was noted that a January 2018 medication management note showed that the Veteran and his wife were participating in marital counseling through their church. He had residual depression exacerbated by back pain and marital discord. A prior VA examination in April 2014 indicated sleep impairment since deployment to Afghanistan. Onset of depressive symptoms was in 2013 related to dislike of job, relationship issues, and financial issues. The symptoms for the Veteran’s major depression included depressed mood, anxiety, and chronic sleep impairment. In May 2019, a VA medication management note shows that the Veteran planned to restart Mirtazapine; he had been using it sporadically as it made him too tired during the day. He was advised to continue marital counseling and to hold restarting Adderall as it did not aid attention. He continued to have little pleasure in life but denied that he would be a danger to himself or others. The Board finds the level of impairment caused by the Veteran’s symptoms more closely approximates the level associated with a 50 percent rating. While some of the Veteran’s major depression is manifested by symptoms associated with a 30 percent rating, including panic attacks, anxiety, and chronic sleep impairment, he also has symptoms associated with a 50 percent rating, including occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. His major depression was shown to cause occupational impairment with reduced reliability and productivity as he testified that he was missing work and having disciplinary problems at work related to the marital discord that affected his sleep and his trouble with concentrating at work. He had social impairment in that he had a poor relationship with his wife and his anger problems affected his marriage and resulted in property damage to their home. He also had at most one friend and would have anxiety attacks in crowds or unfamiliar areas. He had disturbances of motivation and mood as he had little pleasure in life anymore and had a history of passive suicidal ideation. These symptoms also demonstrate difficulty in establishing and maintaining effective work and social relationships. In addition, he had symptoms that are not listed with a specific rating, such as poor appetite and low energy. The Board notes that the Veteran expressed suicidal ideation, which is contemplated by the 70 percent criteria and is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). He also reportedly had homicidal thoughts. However, the severity, frequency, and duration of the Veteran’s suicidal ideation and homicidal thoughts had not risen to the level contemplated by the 70 percent or 100 percent disability ratings. The Veteran reported experiencing only passive suicidal and homicidal ideation on occasion, particularly after arguing with his wife, with no active plan. In addition, the Veteran was not shown to have deficiencies in most areas or total social and occupational impairment. He still was able to work on a full-time basis and helped to care for his children at home. He also remained married and living with his wife, though the relationship was strained. He reportedly had at least one friend and was seeking marital counseling with his wife through their church. In short, the criteria for a 50 percent rating, but no higher, for major depressive disorder are met. 4. Entitlement to an increased rating higher than 0 percent for migraine headaches The Veteran contends that he is entitled to a higher rating because he sometimes has to stop what he is doing and go to a dark room and sit down and wait for the headache to pass. See August 2020 Board hearing transcript, p. 10. He also submitted a headache log to show the number of attacks he had and the severity of them. Id. at 11. The headache log submitted by the Veteran noted headaches on average once per month from September to August of the next year with several entries, with a severity of 8 or 9 out of 10. Migraine headaches are rated pursuant to 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8100, for migraine. Under DC 8100, a noncompensable rating is warranted for migraines with less frequent attacks. A 10 percent rating is warranted for migraines with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months. The rating criteria of DC 8100 are considered successive, meaning that a claimant cannot fulfill the criteria of the higher rating without fulfilling those of the next lower rating. Johnson v. Wilkie, 30 Vet. App. 245, 252 (2018). This renders 38 C.F.R. §§ 4.7 and 4.21 inapplicable. Johnson, 30 Vet. App. at 252. The phrase “characteristic prostrating attacks” is used in the criteria corresponding to 10 percent and 30 percent ratings under DC 8100 to describe the nature and severity of migraines, but it is not defined in the regulation. Pursuant to Dorland’s Illustrated Medical Dictionary 1531 (32d ed. 2012), prostration is defined as “extreme exhaustion or powerlessness.” Thus, the phrase “characteristic prostrating attacks” is understood to describe migraine attacks that typically produce extreme exhaustion or powerlessness. The Board concludes that the Veteran’s migraines have occurred with characteristic prostrating attacks averaging one in 2 months over the last several months throughout the appeal period, corresponding to the criteria for a 10 percent rating under DC 8100. An April 2014 VA examination report shows that the Veteran was diagnosed with migraine headaches in 2013. He reported daily headaches that would last 30 minutes on average. He indicated that the headaches would start as pulsating and become sharp. The pain was about a 6 out of 10 lasting for an hour. He took acetaminophen. He described pulsating or throbbing head pain and pain localized to one side of the head. He also had non-headache symptoms associated with the headaches including sensitivity to light and sound. Typical head pain lasted for less than one day and typically was located on the right side of the head. The Veteran did not have characteristic prostrating attacks of migraine headache pain. The headaches impacted his ability to work in that he had to stop what he was doing, take medications, and wait until the headache went away before he could return to work. A May 2019 VA examination report shows the Veteran started having headaches in 2013, which would last for about 30 minutes at a time. There was no particular injury or illness which precipitated the headaches as far as the Veteran could recall. He currently had symptoms a few times per week, which lasted anywhere from two hours to half a day. The pain was pulsing or throbbing on the right side/ front of head. He also would become sensitive to light and sound and needed to take Tylenol and sit in the dark until the symptoms subsided. In addition to sensitivity to light and sound, other non-headache symptoms associated with headaches included changes in vision. The Veteran did not have characteristic prostrating attacks of migraine headache pain. It also was noted that the Veteran’s headache condition did not impact his ability to work. As noted, the Veteran testified that while the examinations of record noted that he did not have any characteristic prostrating attacks, he found this to be incorrect on the basis of his episodes where he had to sit in a dark room until his headaches subsided. See August 2020 Board hearing transcript, p. 10. He also submitted a headache log, which documented headaches for about a year and included several entries of headaches rated at level 8 to 9 out of 10. The Veteran is competent to report his readily observable symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). There is no reason shown to doubt the Veteran’s credibility, in this regard. Considering all relevant evidence of record, the Board finds the Veteran’s reports of experiencing headaches that require him to find a dark room and sit until they pass are consistent with the rating criteria noting characteristic prostrating attacks of headache pain. Notwithstanding the examinations of record noting no characteristic prostrating attacks, not being able to do anything other than sit in a dark room is consistent with Dorland’s Illustrated Medical Dictionary 1531 (32d ed. 2012), definition of prostration as “extreme exhaustion or powerlessness.” As he has stated that the most severe attacks occur several times per year, resolving all doubt in the Veteran’s favor, the Board concludes that the Veteran’s migraine headaches occurred with characteristic prostrating attacks averaging one in 2 months over the last several months throughout the appeal period, corresponding to the criteria for a 10 percent rating under DC 8100. A higher 30 percent rating under DC 8100 is not warranted unless there are migraines with characteristic prostrating attacks occurring on average once a month over the last several months. The Veteran does not state in his headache logs, nor does the evidence show headaches that are prostrating on average once a month. Thus, the Board concludes that the Veteran meets the criteria for a 10 percent rating, but no higher, for migraine headaches under DC 8100. 5. Entitlement to an increased rating higher than 0 percent for costochondritis with strain of muscle group XXI The Veteran contends that he is entitled to a compensable evaluation for costochondritis with strain of muscle group XXI because he had a mild pain with a cough or sneeze; and with any sort of activity like a push-up he had a very sharp pain in the arm and chest. See August 2020 Board hearing transcript, p. 18. He noted that when he was a mechanic, he experienced sharp pain working under a vehicle that was lifted in the air. Id. The Veteran’s representative also argued that based on the finding in Saunders v. Wilkie, the Veteran should have at a minimum a 10 percent rating for the pain. Id. at 19. The Veteran’s costochondritis with strain of muscle group XXI is currently rated by analogy to a disability of the thoracic muscle group responsible for respiration under 38 C.F.R. § 4.73, Diagnostic Code (DC) 5321. Under DC 5321, a noncompensable rating is warranted for a slight disability, a 10 percent rating is warranted for a moderate disability, and a 20 percent rating is warranted for a severe or moderately severe disability. For VA ratings purpose, 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. A slight muscle disability is defined as a simple wound of the muscle without debridement or infection. Such a wound should have a history of brief treatment and return to duty, exhibiting healing with good functional results, and no cardinal signs and symptoms. Residuals include minimal scar, no impairment of function, no retained metallic fragments, and no evidence of fascial defect, atrophy, or impaired tonus. 38 C.F.R. § 4.56 (d)(1). A moderate muscle disability is defined as 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. Such a wound should result in consistent complaint of one or more of the cardinal signs and symptoms, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Residuals 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). A through and through injury with muscle damage shall be evaluated at no less than a moderate disability. 38 C.F.R. § 4.56 (b). A moderately severe muscle disability is defined as a through and through or deep penetrating wound by a small high velocity missile or a large low velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. Such a wound should have a record of prolonged hospitalization for treatment, a record of consistent complaint of cardinal signs and symptoms, and, if present, evidence of inability to keep up with work requirements. Residuals include entrance and (if present) exit scars indicating track of missile through one or more muscle groups, indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side, and tests of strength and endurance with positive evidence of impairment compared with the sound side. 38 C.F.R. § 4.56 (d)(3). A severe muscle disability is defined as a through and through or deep penetrating wound due to a high velocity missile or large and 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. Such a wound should have a record of prolonged hospitalization for treatment, a record of consistent complaint of cardinal signs and symptoms worse than those shown for a moderately severe disability, and, if present, evidence of inability to keep up with work requirements. Residuals include ragged, depressed, and adherent scars indicating wide damage to muscle groups in missile track; palpation showing loss of deep fascia or muscle substance, or soft flabby muscles in the wound area; abnormal swelling and hardening in muscle contraction; and tests of strength, endurance, or coordinated movements indicating severe impairment of function compared to the sound side. A severe disability can also be shown by x-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; adhesion of scar to bone; diminished muscle excitability to pulsed electrical current; visible or measurable atrophy; adaptive contraction of an opposing muscle group; atrophy of muscle groups not in the track of the missile; or induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56 (d)(4). An open comminuted fracture with muscle or tendon damage will be evaluated as severe unless muscle damage is minimal. 38 C.F.R. § 4.56 (a). Ratings under muscle disability codes generally require reference to the STRs for the type of wound that gave rise to the disability. The Veteran reported the onset of muscle pain in the chest in August 2012, a week after he began doing martial arts. The Veteran underwent a VA examination for his costochondritis of muscle group XXI in April 2014. It was noted that the Veteran did not have a penetrating muscle injury. He also did not have a non-penetrating muscle injury, such as muscle strain. It was noted that the Veteran’s muscle injury had been to muscle group XXI, which affects the muscles of respiration: thoracic muscle group. The Veteran did not have any known fascial defects or evidence of fascial defects associated with the muscle injury. The muscle injury also did not affect muscle substance or function. He had no cardinal signs or symptoms of a muscle disability. In addition, there was no muscle atrophy. A May 2019 VA examination report shows the Veteran reported a constant, dull aching pain at a 2-3 out of 10 that was worse with picking things up, sneezing, push-ups, any anything else requiring chest muscles that made the pain go up to an 8 out of 10. It was noted that the Veteran did not have a history of injury to the fascial muscles. There were no fascial defects or evidence of fascial defects associated with the muscle injury. The muscle injury did not affect the muscle substance or function. There was no muscle atrophy. It was noted that the muscle injury did not impact the Veteran’s ability to work. The Board has carefully reviewed the remaining record from the appeal period in its entirety but finds no other probative evidence of record showing that the Veteran’s costochondritis with strain of muscle group XXI is more severe for compensation purposes than demonstrated on the VA evaluation discussed above. The evidence of record demonstrates that the Veteran’s costochondritis with strain of muscle group XXI symptoms are overall shown to be slight under the standards required in 38 C.F.R. § 4.56. During the period on appeal, the symptoms of Veteran’s costochondritis with strain of muscle group XXI were never shown to be more than slight. See also 38 C.F.R. § 4.73, DC 5321. The evidence of record does not demonstrate that the Veteran has had a moderate, moderately severe, or severe disability of the thoracic muscle group, as required for a compensable evaluation under DC 5321. The Veteran did not exhibit a through and through or deep penetrating wound or related scars; and he did not exhibit any of the cardinal signs and symptoms or other symptoms such as loss of deep fascia or muscle substance or impairment of muscle tonus, as would be required for a 10 percent evaluation under DC 5321. 38 C.F.R. § 4.56. The Veteran did not have prolonged hospitalization for treatment or evidence of inability to keep up with work requirements; and he did not exhibit symptoms such as loss of normal firm resistance of the muscles, loss of muscle strength and endurance, soft flabby muscles in the wound area, minute multiple scattered foreign bodies, severe impairment of function, or muscle atrophy, as would be required for a 20 percent evaluation under DC 5321. 38 C.F.R. § 4.56. The Board acknowledges the Veteran’s assertions that his costochondritis with strain of muscle group XXI warrants compensable evaluation. The Veteran’s representative also argued that the Veteran’s complaints of pain should be considered compensable under Saunders. In Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), the U.S. Court of Appeals for the Federal Circuit (Court) determined that pain alone can qualify as a disability if it amounts to functional impairment of earning capacity. See also 38 C.F.R. § 4.10. However, the VA examination provided in May 2019 noted that the Veteran’s costochondritis did not have any impact on his work. While the Veteran testified that he experienced a sharp pain associated with his muscle injury while working as a mechanic, there is no evidence to support that the Veteran has suffered any functional impairment in earning capacity solely because of the costochondritis with strain of muscle group XXI. Moreover, the evidence does show that his costochondritis with strain of muscle group XXI has exhibited the type of symptoms required for a moderate, moderately severe, or severe muscle disability under 38 C.F.R. § 4.56 and § 4.73, DC 5321. Based on the above, the preponderance of the evidence is against the assignment of a compensable evaluation for the Veteran’s costochondritis with strain of muscle group XXI. Therefore, the Veteran’s claim of entitlement to a compensable evaluation for costochondritis with strain of muscle group XXI must be denied. See 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.73, DC 5321. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. REASONS FOR REMAND 1. Entitlement to an increased rating higher than 10 percent for right knee strain with degenerative arthritis is remanded. The Veteran testified that his right knee disability had worsened in the past six to eight months where he could not do anything because of his right knee. See August 2020 Board hearing transcript, p. 20. He also noted that he used a wrap for instability in his right knee. Id. at 22. The last VA examination in May 2019 noted no instability or use of a brace. The Veteran also did not report any instability on the examination. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his right knee disability. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from May 2019 to present. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his right knee strain with degenerative arthritis. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In so doing, the examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner also must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sarah B. Richmond, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.