GOUT

Summary

The veteran, who served in the Army from October 1982 to July 1990, appeals the denial of service connection for right foot gout and seeks an increased rating for his service-connected left foot gout. The Board granted service connection for left foot gout and assigned a 30 percent rating, finding that the veteran's gout symptoms, including frequent and severe flareups causing incapacitation and an antalgic gait, met the criteria for severe impairment under Diagnostic Code 5284. The Board found the VA examiner's assessment of moderate impairment insufficient to warrant a higher rating, noting the absence of actual loss of use of the foot. For the right foot gout, the Board found the September 2024 VA examination adequate to establish service connection, noting the veteran's in-service onset of gout and the examiner's opinion that current episodes were likely a continuity of service-incurred symptoms. However, the Board remanded the increased rating claims for bilateral ankle gout due to an inadequate VA ankle examination, which contained internal inconsistencies regarding flareup reporting and functional limitation descriptions. The Board found the ankle examination inadequate because the examiner noted significant functional limitations due to pain but reported no change in range of motion after repetitive use, without explanation.

Rationale

Severe impairment warrants 30% rating under DC 5284.; Flareups cause incapacitation, antalgic gait, and functional limitations.; Evidence does not support actual loss of use of the left foot.

Full Decision Text

Citation Nr: A26040962
Decision Date: 04/30/26	Archive Date: 04/30/26

DOCKET NO. 250519-545372
DATE: April 30, 2026

ORDER

An initial rating of 30 percent for left foot gout is granted, subject to the statutes and regulations governing the payment of monetary benefits.

Service connection for right foot gout is granted.

REMANDED

The issue of entitlement to an initial rating greater than 10 percent for right ankle gout is remanded.

The issue of entitlement to an initial rating greater than 10 percent for left ankle gout is remanded.

FINDINGS OF FACT

1. Resolving reasonable doubt in his favor, the Veteran's left foot gout is manifested by severe symptoms but has not more nearly approximated loss of use of the left foot.

2. The Veteran's gout began during his active service.

CONCLUSIONS OF LAW

1. The criteria for an initial rating of 30 percent for left foot gout are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.10,4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5017-5284.

2. The criteria for service connection for right foot gout are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty training in the United States Army Reserve from June 1982 to July 1982 and in the United States Army on active duty from October 1982 to July 1990, with additional National Guard service.

This appeal is being processed under the modernized review system, commonly referred to as the "AMA," as established by the Veterans Appeals Improvement and Modernization Act of 2017. 115 Pub. L. No. 55, 131 Stat. 1105.

These matters come before the Board of Veterans' Appeals (Board) on appeal of an April 2025 decision issued by a Department of Veterans Affairs (VA) regional office, an agency of original jurisdiction (AOJ). The April 2025 rating decision was issued in response to a January 2025 VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), seeking review of an October 2024 decision. See 38 C.F.R. § 3.2601.

The Board received the Veteran's VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), in May 2025. The Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time the AOJ issued the October 2024 rating decision, which was subsequently subject to HLR in the April 2025 rating decision on appeal. 38 C.F.R. § 20.301. If evidence was submitted during the period after the AOJ issued the decision, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a VA Form 20-0995, Decision Review Request: Supplemental Claim, and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim(s), considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. However, because the Board is remanding the bilateral ankle gout increased rating claims, any evidence the Board could not consider will be considered by the AOJ in the readjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

Increased Rating

Disability evaluations (ratings) are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. § Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual disorders in civil occupations. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1.

Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability
.F.R. § 3.103(c)(2)(ii).

Increased Rating

Disability evaluations (ratings) are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. § Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual disorders in civil occupations. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1.

Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3.

When evaluating musculoskeletal disabilities, 38 C.F.R. § 4.40 recognizes that the primary concern is the inability to perform the normal working movements of the body with normal excursion, strength, speed coordination, or endurance. VA must also consider factors such as: more or less movement than normal; weakened movement; excess fatigability; incoordination; and pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing are related considerations as well. 38 C.F.R. § 4.45. 

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 Sharp v. Shulkin, 29 Vet. App. 26 (2017), the United States Court of Appeals for Veterans Claims (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 flareup is not observable at the time of examination.

In Jones v. Shinseki, the Court held that "the Board may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria." 26 Vet. App. 56, 63 (2012). If the rating criteria do not specifically contemplate the effects of medication, the ameliorative effects of medication must be addressed. See Ingram v. Collins, 38 Vet. App. 130 (2025).

"Staged" ratings may be assigned when the evidence shows distinct periods during the evaluation period when manifestations of the disability warranted varied ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2009).

The issue of entitlement to an initial rating greater than 10 percent for left foot gout.

The Veteran contends that his left foot gout symptoms are worse than the minimum evaluation. See January 2025 VA Form 21-4138, Statement in Support of Claim.

At the outset, the Board notes that it is reviewing the AOJ's initial evaluation of the Veteran's left foot gout as 10 percent disabling in the October 2024 rating decision, which was subsequently subject to HLR.

The Veteran's left foot gout is currently rated under 38 C.F.R. § 4.71a, DC 5017-5284. Hyphenated DCs are used when a rating under one DC requires use of an additional DC to identify the basis for the rating assigned. 38 C.F.R. § 4.27. The additional DC, shown after the hyphen, represents the basis for the rating, while the primary DC indicates the underlying source of the disability. DC 5017 for gout directs that the gout is to be rated based on limitation of the affected parts. 38 C.F.R. § 4.71a. DC 5017-5284 indicates that gout (DC 5017) is rated pursuant to the criteria for other foot injuries (DC 5284).

Under DC 5284, a
-5284. Hyphenated DCs are used when a rating under one DC requires use of an additional DC to identify the basis for the rating assigned. 38 C.F.R. § 4.27. The additional DC, shown after the hyphen, represents the basis for the rating, while the primary DC indicates the underlying source of the disability. DC 5017 for gout directs that the gout is to be rated based on limitation of the affected parts. 38 C.F.R. § 4.71a. DC 5017-5284 indicates that gout (DC 5017) is rated pursuant to the criteria for other foot injuries (DC 5284).

Under DC 5284, a 10 percent rating is warranted for moderate impairment. A 20 percent rating is warranted for moderately severe impairment. A 30 percent rating is warranted for severe impairment. 38 C.F.R. § 4.71a, DC 5284. A Note to DC 5284 indicates that a maximum 40 percent rating is assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a, DC 5284, Note.

The terms "moderate," "moderately severe," and "severe" are not defined in VA regulations or in DC 5284. In the absence of an express definition, words are given their ordinary meaning. Prokarym v. McDonald, 27 Vet. App. 307, 310 (2015) (citations omitted). In this context, the Board understands the term "moderate" to mean tending toward the mean or average amount and the term "severe" to mean very painful or harmful or of a great degree. See Merriam-Webster's Online Dictionary. "Moderately severe" is not a precisely defined term because moderately, as an adverb, modifies severe. Moderately means to a moderate degree or extent. Id. Thus, the Board finds that moderately severe indicates a condition that is more than the mean or average amount or dimension but less than very painful or harmful, although it may encompass symptoms associated with either a moderate or severe condition.

The Court held that a "severe" disability under DC 5276 (pes planus) is not equivalent to a "severe" disability under DC 5284 (other foot injury); that is, what is classified as "severe" can be dependent on the DC used. See Breniser v. Shinseki, 25 Vet. App. 64, 76-77 (2011).

Rather than applying a mechanical formula, the Board must evaluate all of the evidence. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of the issue of severity. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6.

Upon review, the Board finds that an initial 30 percent rating is warranted for left foot gout under DC 5284. 

At a September 2024 VA examination, the Veteran reported flareups related to gout attacks once every three months that lasted one to two weeks. Flareups were rated in severity as 10/10 and characterized by erythema, swelling, and warmth. During a flareup of left foot gout symptoms, the Veteran was unable to ambulate and remained on bed rest or otherwise remained seated. The Veteran also reported overall functional impairment as an antalgic gait, slow pace of locomotion and disturbance due to pain, and difficulty with walking more than one half mile, prolonged standing, ascending stairs, and walking on an incline. The examiner noted physical examination findings, including tenderness to palpation of the left great toe. The examiner found the severity of the Veteran's left foot gout was moderate. See September 2024 VA Foot Conditions Examination Report.

Contributing factors of disability are noted as swelling, deformity, disturbance of locomotion, interference with standing, and pain. The examiner found that the procured evidence suggested that pain, fatigability, weakness, lack of endurance, or incoordination significantly limited functional ability during flareups and/or after repeated use over time. The examiner described this functional loss as the Veteran reported that he remained on bedrest during flareups and otherwise reported an antalgic gait, slow pace of locomotion and disturbance due to pain, and difficulty with walking more than one half mile, prolonged standing, ascending stairs, and walking on an incline. The examiner opined that functional impairment was not so diminished that amputation with prosthesis would equally serve the Veteran. The examiner described functional impact similarly
, deformity, disturbance of locomotion, interference with standing, and pain. The examiner found that the procured evidence suggested that pain, fatigability, weakness, lack of endurance, or incoordination significantly limited functional ability during flareups and/or after repeated use over time. The examiner described this functional loss as the Veteran reported that he remained on bedrest during flareups and otherwise reported an antalgic gait, slow pace of locomotion and disturbance due to pain, and difficulty with walking more than one half mile, prolonged standing, ascending stairs, and walking on an incline. The examiner opined that functional impairment was not so diminished that amputation with prosthesis would equally serve the Veteran. The examiner described functional impact similarly: that the Veteran reported that he remained on bedrest during flareups and otherwise reported an antalgic gait, slow pace of locomotion and disturbance due to pain, and difficulty with walking more than one half mile, prolonged standing, ascending stairs, and walking on an incline. The examiner further remarked on the Veteran's gout condition, including that the Veteran experienced incapacitating exacerbations four of more times per year, lasting one to two weeks; that the most recent incapacitating exacerbation was in May 2024 and lasted two weeks; and described incapacitating exacerbations as the Veteran remained on bedrest due to pain, swelling, malaise, weakness, and anorexia. Id.

The Board notes that VA and non-VA treatment records of record do not show treatment for left foot gout and finds that the September 2024 VA examination findings are representative of the severity of the Veteran's left foot gout throughout the rating period on review.

In support of his claim, the Veteran reported several flareups a month associated with gout that caused him to miss work during the required recouperation periods. See June 2024 Buddy/Lay Statement. A co-worker of over 30 years stated that the Veteran's gout reoccurred with greater frequency over that time. See June 2024 Buddy/Lay Statement. On examination, he reported constant sole and toe pain and that he walked on the lateral foot borders to avoid contact of his toes with the ground and that because of this, he developed calluses on the foot's lateral border. The Board finds that the lay statements, together with the findings of the September 2024 VA examination report, present a disability picture that is severe, i.e., of a great degree, and warrants an initial 30 percent rating. 38 C.F.R. § 4.71a, DC 5284.

However, the Board finds that the evidence of record persuasively weighs against an initial rating greater than 30 percent. The Board acknowledges the Veteran's lay reports of symptoms and that he remained on bedrest during flareups. However, even considering the Veteran's lay reports of symptoms and functional loss, the degree of additional limitation reflected by his statements of flareups of his left foot gout occurring approximately four times per year would not result in symptoms more nearly approximating actual loss of use of the left foot. The September 2024 VA examiner specifically found that the Veteran's left foot gout did not cause functional impairment such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Thus, the Board finds that actual loss of use of the left foot is not shown by the evidence of record.

The Board has also considered the other DCs pertaining to the foot. In Scott v. Wilkie, the United States Court of Appeals for the Federal Circuit (Federal Circuit) expressly adopted the Court's holding that disabilities specifically listed in the rating schedule may only be rated under DCs which specifically pertain to them. Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019) (citing Copeland v. McDonald, 27 Vet. App. 333, 336 (2015)). The Federal Circuit also expressly adopted the Court's holding that unlisted conditions may be rated by analogy to DCs that may not describe the unlisted disability but addresses disabilities that may be productive of similar symptoms. Scott, 920 F.3d 1375 (citing Yancy v. McDonald, 27 Vet. App. 484, 493 (2016). Finally, the Federal Circuit concluded that the Board must also consider assigning separate ratings under analogous DC, when rating an unlisted service-connected foot disability exhibiting distinct manifestations, even when service connection has also been granted for one of the eight foot conditions listed in the rating schedule. Id.

Here, the Veteran's disability (left foot gout) is unlisted in the foot regulations and is rated by analogy. In this regard, the only left foot diagnosis provided at the September 2024 VA examination was gout. The record does not document any other left
 productive of similar symptoms. Scott, 920 F.3d 1375 (citing Yancy v. McDonald, 27 Vet. App. 484, 493 (2016). Finally, the Federal Circuit concluded that the Board must also consider assigning separate ratings under analogous DC, when rating an unlisted service-connected foot disability exhibiting distinct manifestations, even when service connection has also been granted for one of the eight foot conditions listed in the rating schedule. Id.

Here, the Veteran's disability (left foot gout) is unlisted in the foot regulations and is rated by analogy. In this regard, the only left foot diagnosis provided at the September 2024 VA examination was gout. The record does not document any other left foot diagnoses upon which to apply another foot regulation to the facts of this Veteran's case. Further, the only two DCs pertaining to the foot that would allow the Veteran an initial rating in excess of 30 percent would be DC 5276 for flatfoot (pes planus) and DC 5278 for pes cavus. The Veteran does not allege, and the record does not document, that the Veteran has these diagnoses of his feet. Further, the Board does not find that left foot gout would be more appropriately rated under either DC 5276 or DC 5278. 

In sum, in consideration of the evidence as discussed above and resolving reasonable doubt regarding degree of disability in the Veteran's favor, the Board finds that the Veteran's left foot gout is shown to warrant an initial 30 percent rating, but not higher, under DC 5284. The appeal is granted to this extent.

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, to establish service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence persuasively favors one side or the other. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Veteran is entitled to the benefit of the doubt when the evidence is in approximate balance or "nearly equal," and does not require that the evidence be in exact equipoise. Id.; Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021).

The issue of entitlement to service connection for right foot gout.

As to the claim for service connection for right foot gout, the Board notes that in June 2024, the Veteran submitted a VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, for claims including bilateral foot gout. 

The October 2024 rating decision, which was subsequently subject to HLR in the April 2025 rating decision on appeal, awarded service connection for left foot gout, but did not address the Veteran's right foot gout.

A review of the record shows that a VA examiner diagnosed bilateral foot gout, in connection with which they issued a positive nexus opinion for bilateral foot gout. See September 2024 VA Foot Examination Report; September 2024 VA Medical Opinion Report. Upon review of service treatment records, the examiner found it evident that the Veteran displayed an onset of gout during service years, to include a surgical procedure for the right foot due to right tibial sesamoid bone malunion with crystalline deposit that was presumed to be gout in 1989 and opined that the Veteran's ongoing gout episodes are likely a continuity of the symptoms incurred during service. 

While the Veteran was only specifically service connected for gout of the left foot, right ankle, and left ankle by the AOJ, in view of the fact that gout is a condition that may affect multiple joints, the Board finds that determining an appropriate rating for gout generally necessitates consideration of service connection for gout of the right foot as gout is a condition that may affect multiple joints. See Bailey v. Wilkie, 33 Vet. App. 188, 203 (2021); see also Morgan v. Wilkie, 31 Vet. App. 162 (2019).

In doing so, the Board finds the September 2024 medical opinion adequately supports and is probative as to a nexus between the Veteran's right foot gout and his service. The opinions are adequate because
 foot, right ankle, and left ankle by the AOJ, in view of the fact that gout is a condition that may affect multiple joints, the Board finds that determining an appropriate rating for gout generally necessitates consideration of service connection for gout of the right foot as gout is a condition that may affect multiple joints. See Bailey v. Wilkie, 33 Vet. App. 188, 203 (2021); see also Morgan v. Wilkie, 31 Vet. App. 162 (2019).

In doing so, the Board finds the September 2024 medical opinion adequately supports and is probative as to a nexus between the Veteran's right foot gout and his service. The opinions are adequate because the examiner's rationale is logical, well-reasoned, and based on consideration of the entire record. Therefore, the Board therefore finds that the September 2024 medical opinion satisfies the nexus requirement for service connection.

In sum, the Board finds that the evidence of record persuasively supports the award of service connection for the Veteran's gout of the right foot.

REASONS FOR REMAND

The issue of entitlement to an initial rating greater than 10 percent for right ankle gout.

The issue of entitlement to an initial rating greater than 10 percent for left ankle gout.

The Veteran attended a VA examination in September 2024. However, for the following reasons, the Board finds that the September 2024 VA ankle examination is inadequate for rating purposes.

On examination, the Veteran reported gout flareups in the bilateral ankles once every three months that lasted one to two weeks and involved sharp 10/10 pain with swelling and warmth of the ankle joints. Range of motion (ROM) testing measurements are shown as right ankle plantar flexion to 20 degrees and dorsiflexion to 10 degrees, and left ankle plantar flexion to 15 degrees and dorsiflexion to 10 degrees. The Veteran was able to perform repetitive use testing with no additional loss of function or ROM after three repetitions. The examiner indicated that the Veteran was examined immediately after repetitive use over time and that the procured evidence suggested that pain, fatigability, and weakness significantly limited functional ability of both ankles with repeated use over time. The estimated ROM immediately after repeated use over time is shown as the same as the initial ROM measurements, i.e., right ankle plantar flexion to 20 degrees and dorsiflexion to 10 degrees, and left ankle plantar flexion to 15 degrees and dorsiflexion to 10 degrees. Section 3D. of the examination report regarding flareups shows that the examiner indicated that the Veteran denied flareups. See September 2024 VA Ankle Examination Report.

First, the September 2024 VA Ankle Examination Report is internally inconsistent as it shows that the Veteran reported gout flareups in the bilateral ankles once every three months that lasted one to two weeks and involved sharp 10/10 pain with swelling and warmth of the ankle joints, but the report later shows that the Veteran denied flareups. Second, the examiner indicated that pain, fatigability, and weakness significantly limited functional ability of both ankles with repeated use over time but estimated ROM after repeated use over time is shown as the same as the initial ROM measurements, with no explanation of how functional ability of either ankle was significantly limited by pain, fatigability, and weakness with repeated use over time. The Board finds that these deficiencies render the examination inadequate for rating purposes.

Providing the Veteran with an inadequate examination is a pre-decisional duty-to-assist error; and therefore, the matters must be remanded to provide the Veteran with an adequate examination to assess the current severity of his bilateral ankle gout. See Barr v. Nicholson, 21 Vet. App. 303 (2007). VA's "duty to assist includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim." Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (internal quotation omitted).

The matters are REMANDED for the following action:

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Schedule the Veteran for an examination to assess the current nature and severity of his gout of the right and left ankles. The examiner should provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran's disabilities under the rating criteria.

 

 

G.J. Suh

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	S. Battaile

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.