Citation Nr: A25036070 Decision Date: 04/18/25 Archive Date: 04/18/25 DOCKET NO. 240331-429557 DATE: April 18, 2025 ORDER A rating in excess of 10 percent for a cervical strain is denied. A rating in excess of 10 percent for a lumbosacral strain is denied. A compensable rating for a cyst (low neck anterior chest) is denied. An effective date prior to February 21, 2024, for the grant of a 30 percent rating for migraines is denied. Service connection for a left knee disorder is denied. Service connection for a right knee disorder is denied. Service connection for costochondritis is granted. FINDINGS OF FACT 1. The Veteran served on active duty from December 2017 to December 2021. 2. A cervical strain has been manifested by subjective complaints of pain, stiffness, and numbness without flare-ups; objective findings include limitation of flexion and no intervertebral disc syndrome (IVDS) or degenerative arthritis. 3. A lumbar strain has been manifested by subjective complaints of stiffness and muscle spasms; objective findings include limitation of flexion and no IVDS or degenerative arthritis. 4. A low neck anterior chest cyst has not been shown to involve at least 5 percent of the entire body affected or of the exposed areas affected and has not required systemic therapy. 5. Prior to February 21, 2024, the evidence fails to show a factually ascertainable date of increased symptomatology for migraine headaches. 6. A left knee disorder, currently diagnosed as left knee strain, was not shown in service and is not causally or etiologically related to service. 7. A right knee disorder, currently diagnosed as right knee strain, was not shown in service and is not causally or etiologically related to service. 8. Costochondritis manifested by rib pain was shown in service. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for a cervical strain have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.321(b), 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5237. 2. The criteria for a rating in excess of 10 percent for a lumbosacral strain have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.321(b), 4.40, 4.45, 4.59, 4.71a, DC 5237. 3. The criteria for a compensable rating for a cyst (low neck anterior chest) have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, DC 7821. 4. The criteria for an effective date prior to February 21, 2024, for the grant of a 30 percent for migraine headaches have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.400, 4.124a, DC 8100 (2024). 5. A left knee disorder was not incurred in service. 38 U.S.C. §§ 1110, 5103(a), 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2024). 6. A right knee disorder was not incurred in service. 38 U.S.C. §§ 1110, 5103(a), 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2024). 7. Costochondritis was incurred in service. 38 U.S.C. §§ 1110, 5103(a), 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2024). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS This decision has been written under the guidelines of the Veterans Appeals Improvement and Modernization Act, also known as the Appeals Modernization Act (AMA). In March 2023, and January and February 2024, the agency of original jurisdiction (AOJ) denied the claims. In March 2024, the Veteran appealed to the Board via a VA Form 10182 and elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the AOJ decision on appeal. 38 C.F.R. § 20.301. Increased Rating Claims Turning to the relevant laws and regulations, disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. ? Cervical and Lumbosacral Strains Cervical and lumbosacral spine disabilities are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine (General Rating Formula). 38 C.F.R. § 4.71a, DCs 5237-5243. The Veteran has been rated under DC 5237 for the cervical and lumbosacral strains, but the Board will consider all relevant diagnostic codes to assess whether a high rating is appropriate. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, DC 5237, under which the Veteran's spine disabilities are rated, was not changed. Similarly, the regulations addressing arthritis have not been changed. Cervical Strain. The Veteran's neck disability has been rated at 10 percent under DC 5237 for a cervical strain effective December 5, 2021, which is the day following service separation. A rating in excess of 10 percent will be warranted when the objective medical evidence shows the following: o incapacitating episodes of IVDS having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months (20 percent); o forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees (20 percent); o combined range of motion of the cervical spine not greater than 170 degrees (20 percent); o muscle spasms or guarding that is severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis (20 percent); or, o degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations (20 percent). Turning to the evidence, the Veteran does not have a diagnosis of IVDS. An August 2022 VA examiner found no diagnosis of IVDS. The remainder of available medical records during the appeal period similarly fail to show a diagnosis of IVDS. Thus, the medical evidence does not support a higher rating due to IVDS. As to limitation of motion, the August 2022 VA examiner found that the cervical spine active, passive, and repetitive use ranges of motion (ROM) were "normal" and the Veteran did not report flareups. Of note, normal ROM of the cervical spine is flexion-extension from 0 to 45 degrees, lateral flexion from 0 to 45 degrees, and rotation from 0 to 80 degrees. With respect to repeated use over time, the examiner estimated a 5 degree decrease in motion for all ROM movements but noted pain with active, passive, and weight-bearing. Further, the examiner indicated objective evidence of crepitus and localized tenderness or pain on palpitation. The clinical records were reviewed to include physical therapy treatment notes, and there is no evidence inconsistent with the examiner's ROM findings. In sum, even at worse, the limitation of motion measurements for forward flexion of the cervical spine was 40 degrees (5 degrees less than normal) which does not support a higher rating. Further, the combined rating (even considering the estimated decrease due to pain) would be 40+40 (flexion-extension) plus 40+40 (lateral flexion) plus 75+75 (rotation) or a combine ROM of 310 degrees, which is well over the 170 degrees required for a higher rating. As such, the medical evidence does not support a higher rating due to limitation of motion. During the examination, the Veteran indicated he did not have flare-ups, and although the examiner indicated the Veteran had no guarding but had some localized tenderness and muscle spasms; however, neither were severe enough to result in an abnormal gait or spinal contour. Again, the clinical records were reviewed, and there is no evidence inconsistent with the examiner's findings. As such, the medical evidence does not support a higher rating due to either muscle spasms or guarding. Also, the examiner observed there were no diagnostic testing, specifically X-rays, documenting degenerative arthritis, and there were no X-ray results in the clinical records that indicate degenerative arthritis. As such, the medical evidence does not support a higher rating due degenerative arthritis. Thus, the medical evidence does not support a higher rating under any diagnostic code for the cervical spine disability. Lumbosacral Strain. The Veteran's low back disability has been rated at 10 percent under DC 5237 for a lumbosacral strain. A rating in excess of 10 percent will be warranted when the objective medical evidence shows the following: o incapacitating episodes of IVDS having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months (20 percent); o forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees (20 percent); o combined range of motion of the thoracolumbar spine not greater than 120 degrees (20 percent); o muscle spasms or guarding that is severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis (20 percent); or, o degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations (20 percent). Turning to the evidence, as with the cervical spine, the Veteran does not have a diagnosis of IVDS of the lower back. The August 2022 VA examiner found no diagnosis of IVDS. The remainder of available medical records during this portion of the appeal period similarly fail to show a diagnosis of IVDS. Thus, the medical evidence does not support a higher rating due to IVDS. As to limitation of motion, the August 2022 VA examiner found that the lumbosacral spine active, passive, and repetitive use ROM were normal, and the Veteran did not report flareups. Of note, normal ROM of the lumbosacral spine is flexion to 0 to 90 degrees, extension 0 to 30 degrees, lateral flexion 0 to 30 degrees, and rotation 0 to 30 degrees. With respect to repeated use over time, the examiner estimated forward flexion to 80 degrees (less 10 degree from normal) with other ROMs to 25 degrees (less 5 degree from normal); however, the examiner noted no pain with active, passive, weight-bearing, and nonweight-bearing. Further, the examiner indicated that there was no objective evidence of crepitus or localized tenderness or pain on palpitation. The clinical records were reviewed to include physical therapy treatment notes and there is no evidence inconsistent with the examiner's ROM findings. In sum, the limitation of motion measurements for forward flexion of the lumbosacral spine is not less than 60 degrees (it is at worse to 80 degrees), and the combined range of motion of the lumbosacral spine is not less than 120 degrees (it is at worse to 205 degrees). As such, the medical evidence does not support a higher rating due to limitation of motion. During the examination, the Veteran indicated he did not have flare-ups, and although the examiner indicated the Veteran had no guarding or localized tenderness, he had some muscle spasms, which were not severe enough to result in an abnormal gait or spinal contour. Again, the clinical records were reviewed, and there is no evidence inconsistent with the examiner's findings. As such, the medical evidence does not support a higher rating due to either muscle spasms or guarding. Also, the examiner observed there were no diagnostic testing, specifically X-rays, documenting degenerative arthritis, and there were no X-ray results in the clinical records that indicate degenerative arthritis. As such, the medical evidence does not support a higher rating on this basis. Thus, the medical evidence does not support a higher rating under any diagnostic code for the lumbosacral spine disability. Lower Neck/Anterior Chest Cyst The Veteran's skin disorder, diagnosed as a cyst on the lower neck anterior chest area, has been rated in accordance with the criteria under 38 C.F.R. § 4.118, DC 7821 - Cutaneous manifestations of collagen-vascular diseases not listed elsewhere, which directs evaluation under the General Rating Formula for the Skin. The cyst is currently rated at 0 percent disabling. Under DC 7821, the criteria for a higher rating, 10 percent rating, is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. For purposes of DC 7821, "systemic therapy," which is the type of therapy that creates compensability, is connected to the phrase "corticosteroids or other immunosuppressive drugs" by the phrase "such as," those drug types do not constitute an exhaustive list of all compensable systemic therapies, but rather serve as examples of the kind and degrees of treatments used to justify a particular disability rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Consequently, the types of systemic treatment that are compensable under DC 7821 are not limited to "corticosteroids or other immunosuppressive drugs." Compensation is warranted for all systemic therapies that are like or similar to corticosteroids or other immunosuppressive drugs. Warren v. McDonald, 28 Vet. App. 194 (2016). Turning to the medical evidence, the Veteran underwent a VA examination in May 2022. The examiner noted a cyst diagnosis in 2021 during service, which was also noted in the service treatment records (STRs). Further, the examiner indicated the Veteran had neither treated the cyst with medication in the previous 12 months nor undergone treatment or procedures to include phototherapy, photochemotherapy, electron beam therapy, intensive light therapy, or other similar treatments. Additionally, the examiner observed that the cyst's total body area was less than % percent, and there no total exposed body area. The clinical records were reviewed. There were no treatment records for a cyst in the VA treatment records, and a cyst was not listed in the Veteran's medical history when he initiated VA treatment. Based on the above, as the cyst is less than 5 percent of either the exposed area or the entire body and does not require systemic therapy or immunosuppressive drugs, the medical evidence does not support a compensable rating. As to the increase ratings claims for the cervical, lumbosacral, and cyst disabilities, the Board has considered the Veteran's lay statements that his disabilities are worse that currently rated. While he is competent to report symptoms because this requires only personal knowledge as it comes through the senses, he is not competent to identify a specific level of disability of these disorders according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's cervical, lumbosacral, and cyst disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which this disability is evaluated. Moreover, as the examiner has the requisite medical expertise to render a medical opinion regarding the degree of impairment caused by the disability and had sufficient facts and data on which to base the conclusion, the Board affords the medical opinion great probative value. As such, these records are more probative than the Veteran's subjective complaints of increased symptomatology. In sum, after a careful review of the evidence of record, the benefit of the doubt rule is not applicable, and the appeals are denied. Earlier Effective Date for the Grant of a 30 Percent Rating for Migraines The Veteran argues the effective date for the grant of a 30 percent rating for migraine disability should be earlier than February 21, 2024. Instead, he contends the appropriate effective date is the date of the original grant of service connection: December 5, 2021. Turning to the relevant laws and regulations, unless specifically provided otherwise in the statute, the effective date of an award based on an original claim for compensation benefits shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. The effective date of an award of disability compensation shall be the day following separation from service or the date entitlement arose if the claim is received within one year of separation, otherwise the date of claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(b); 38 C.F.R. § 3.400(b)(2). Historically, in April 2022, within one year of discharge, the Veteran filed a claim for, among other things, chronic headaches. The AOJ granted service connection for migraines February 2024 and assigned an initial noncompensable (0%) rating effective December 5, 2021, the day after discharge, and a 30 percent rating effective February 21, 2024, the date that a VA examination identified symptoms consistent with a higher rating. As noted, he contends the 30 percent rating should be effective to December 5, 2021. The Veteran's headaches have been rated under DC 8100 for migraine headaches. In order to warrant a higher rating, the evidence must show: " headaches with less frequent attacks (0 percent); " headaches with characteristic prostrating attacks averaging one in two months, over the last several months (10 percent); " headaches with characteristic prostrating attacks occurring on an average of once a month of the last several months (30 percent); or " headaches with very frequent, completely prostrating and prolonged attacks that are productive of severe economic inadaptability (50 percent). Turning to the evidence, the Veteran had two VA examinations for migraines during the period on appeal: May 2022 and February 2024. The May 2022 VA examiner reported the Veteran had been diagnosed with migraines in 2019 while on active duty. During the examination, the Veteran described the migraines as pulsating or throbbing head pain on both sides of the head. The migraines lasted for less than a day and he described other symptoms such as sensitivity to light and sound with changes in vision. During the migraine episodes, the Veteran related that he had difficulty focusing and required rest and medication for relief. He indicated he used over-the-counter medications such as Tylenol Extra Strength and Excedrin Headache. Significantly, the examiner found that the migraines did not result in characteristic prostrating attacks of headache pain or very prostrating and prolonged attacks of pain productive of severe economic inadaptability. These findings most closely approximate a noncompensable rating for migraines under DC 8100, consistent with the initial rating. Next, the February 2024 VA examiner confirmed the migraine diagnosis and noted the Veteran had two or three migraines weekly that lasted less than a day with pain on both side of the head with light and sound sensitivity. The February 2024 VA examiner described the migraines as characteristic prostrating attacks greater than once per month. The clinical records reflected that the Veteran reported migraines in June 2022 when he initiated VA treatment. At that time, he indicated he had twice weekly migraines that were relieved with Tylenol and ibuprofen. Otherwise, the treatment records are silent for any additional treatment for migraines or reflect symptoms greater than those reported by the VA examiners. Accordingly, the medical evidence does not support a compensable rating for the migraines until the February 2024 VA examination, i.e., the date entitlement arose. As to the effective date for the 30 percent rating, as noted above, there is no evidence indicative of an earlier point when it was factually ascertainable that the Veteran's symptoms more nearly approximated the 30 percent rating. As such, the appropriate effective date was the date the entitlement arose, i.e., the date of the VA examination, February 21, 2024, and the appeal is denied. Service Connection Claims Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Bilateral Knee Disorders The Veteran contends the bilateral knee disorders were incurred in service. As the analysis for the appeals are the same, they will be discussed together. Turning to the medical evidence, a May 2022 VA examiner diagnosed the Veteran with left and right knee strains. As such, current bilateral knee disorders are shown, and the first elements of direct service connection are met. Next, as to in-service incurrence, the STRs do not show complaints of, treatment for, or a diagnosis of bilateral knee disorders. Although, the Veteran sought treatment for other ailments or injuries, such as back pain, ear pain, allergies, rib pain, there are recorded in-service complaints related to either the left or right knee. As such, the medical evidence does not support the second elements of direct service connection. The Veteran's assertions as to in-service knee complaints is given less probative weight. Specifically, as the STRs appear to be complete, and as knee symptoms would be of medical significance, it is reasonable to assume that they would be recorded were they to have happened, particularly in light of other in-service orthopedic complaints such as back pain and rib pain. Therefore, the absence of evidence of a bilateral knee complaints during service is one factor in a finding that the current bilateral knee disorders were not incurred in service. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (VA may use silence in the STRs as evidence contradictory to a veteran's assertions if the STRs appear to be complete and the injury, disease, or symptoms involved would ordinarily have been recorded had they occurred) (Lance, J., concurring); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (citing Fed. R. Evid. 803(7) for the proposition that the absence of an entry in a record may be evidence against the existence of a fact that would ordinarily be recorded). To the extent that the Veteran asserts a nexus between the current complaints and service, no medical professional has opined that the current bilateral knee disorders are related to service. Accordingly, the medical evidence does not support service connection for bilateral knee disorders. The Board has considered the Veteran's lay statements that the current left and right knee disorders were caused by service. While he is competent to report symptoms as this requires only personal knowledge as it comes to through the senses, he is not competent to offer an opinion as to the etiology of the current disorders due to the medical complexity of the matter involved. Specifically, the lay statements about weakness and stiffness in the left and right knee do not describe symptoms of a particular disorder of the knee, including strains, or suggest a particular etiology of any such disorder. In sum, after a careful review of the record, the evidence weighs persuasively against the claim for service connection for the bilateral knee disorders, and there is no doubt to be resolved. As such, the appeals are denied. Costochondritis The Veteran claims he has a right rib disorder, which resulted from service. Turning to the evidence, a May 2022 VA examiner diagnosed costochondritis, which is inflammation of the cartilage that connects the ribs to the breastbone (sternum). Therefore, the first element of service connection is met. At to an in-service incurrence, a review of the STRs reflects several complaints of painful ribs on the right side beginning in 2018, including pain when breathing deep and shortness of breath. As such, the second element of direct service connection is met. As to the third element - a medical nexus between the two - although the Veteran underwent a VA examination in May 2022, no medical opinion was provided; however, he indicated ongoing rib pain since 2019. Moreover, VA treatment records note rib cage pain in June 2022 when he initiated care, which was within 6 months after separation. Given the in-service complaints of painful ribs, the competent and credible lay evidence of continuous symptoms since service, and resolving reasonable doubt in the Veteran's favor, service connection is established and the appeal is granted. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. 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). L. HOWELL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. J. Ferguson, Associate 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.