Citation Nr: 1031245 Decision Date: 08/19/10 Archive Date: 08/24/10 DOCKET NO. 06-34 365A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to a rating in excess of 10 percent for residuals from stress fractures of the right ankle. 2. Entitlement to a rating in excess of 10 percent for residuals from stress fractures of the left tibial plateau. 3. Entitlement to a rating in excess of 10 percent for residuals from stress fractures of the right tibial plateau. 4. Entitlement to a rating in excess of 10 percent for residuals from stress fractures of the left hip/pelvis. 5. Entitlement to a rating in excess of 10 percent for residuals from stress fractures of the right hip/pelvis. 6. Entitlement to service connection for migraine headaches. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Heather M. Gogola, Associate Counsel INTRODUCTION The Veteran served on active duty from June 2003 to December 2003. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The Board notes that the Veteran's original claim was previously remanded to the RO via the Appeals Management Center (AMC) for further development per a Board decision dated October 2008. The Board has reviewed the record and finds that there was substantial compliance with that remand. Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. Prior to January 22, 2007, the Veteran has no more than moderate limitation of motion of the right ankle, without ankylosis or instability. 2. From January 22, 2007, the Veteran has no more than marked limitation of motion of the right ankle, without ankylosis or instability. 3. Throughout the rating period on appeal, the Veteran's residuals of a stress fracture to the left tibial plateau results in flexion ranging from 70 to 130 degrees and full extension. 4. Throughout the rating period on appeal, the Veteran's residuals of a stress fracture to the right tibial plateau results in flexion ranging from 70 to 130 degrees and full extension. 5. Throughout the rating period on appeal, the Veteran's residuals of a stress fracture to the left hip/pelvis results in flexion ranging from 90 to 120 degrees and abduction ranging from 10 to 20 degrees. There was no evidence of malunion with a moderate knee or hip disability. 6. Throughout the rating period on appeal, the Veteran's residuals of a stress fracture to the right hip/pelvis results in flexion ranging from 90 to 120 degrees and abduction ranging from 10 to 20 degrees. There was no evidence of malunion with a moderate knee or hip disability. 7. The Veteran has a headache disorder that is not related to her active service. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for residuals of stress fractures to the right ankle, prior to January 22, 2007, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.71a, Diagnostic Codes 5015, 5271 (2009). 2. From January 22, 2007, the criteria for a 20 percent rating, but no higher, for residuals of stress fractures of the right ankle have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.71a, Diagnostic Codes 5015, 5271 (2009). 3. The criteria for a rating in excess of 10 percent for residuals of stress fractures to the left tibial plateau have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.71a, Diagnostic Codes 5015, 5260, 5261 (2009). 4. The criteria for a rating in excess of 10 percent for residuals of stress fractures to the right tibial plateau have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.71a, Diagnostic Codes 5015, 5260, 5261 (2009). 5. The criteria for a rating in excess of 10 percent for residuals of stress fractures to the left hip/pelvis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.71a, Diagnostic Codes 5015, 5260, 5255 (2009). 6. The criteria for a rating in excess of 10 percent for residuals of stress fractures to the right hip/pelvis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.71a, Diagnostic Codes 5015, 5260, 5255 (2009). 7. A headache disorder was not incurred in, or aggravated during active service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2009), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2009), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The Court further held that VA failed to demonstrate that "lack of such a pre-AOJ-decision notice was not prejudicial to the appellant, see 38 U.S.C.A. § 7261(b)(2) (as amended by the Veterans Benefits Act of 2002, Pub. L. No. 107-330, § 401, 116 Stat. 2820, 2832) (providing that '[i]n making the determinations under [section 7261(a)], the Court shall...take due account of the rule of prejudicial error')." The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the Veteran was provided VCAA notice by letter mailed in March 2006, prior to the initial adjudication of the claim. In a separate communication sent that same month, the Veteran was provided with notice with respect to the disability rating or effective date element of his claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In addition, the Veteran's service treatment records and pertinent post-service treatment records have been obtained. Also, adequate VA examinations were provided. The Veteran has not identified any outstanding evidence that could be obtained to substantiate her claim. The Board is also unaware of any such evidence. Therefore, the Board is satisfied that the VA has complied with the duty to assist requirements of the VCAA and the pertinent implementing regulation. In sum, the Board is satisfied that any procedural errors in the development and consideration of the claim by the originating agency were insignificant and non-prejudicial to the Veteran. I. Increased ratings A. Background By a rating decision dated March 2004, the RO granted service connection for stress fractures of the right ankle, bilateral tibial plateau and pelvis (bundled together as one disability), and a noncompensable evaluation was assigned, effective December 11, 2003. In February 2006, the Veteran submitted a claim for an increased rating. A May 2006 rating decision continued the Veteran's noncompensable rating and the Veteran appealed that determination. A May 2007 rating decision granted an increased rating of 10 percent effective February 28, 2006. Finally, a December 2009 rating decision granted five separate 10 percent ratings for residuals of stress fractures of the right ankle, the left tibial plateau, the right tibial plateau, the left pelvis/hip, and the right pelvis/hip, effective from February 28, 2006. A February 2006 VA treatment record noted complaints of bilateral hip pain. Examination showed tenderness over the left sacroiliac joint but straight leg raising was negative and strength reflexes were normal. X-rays were negative. An assessment of bilateral hip pain was provided. The Veteran was afforded a VA examination in April 2006. The examiner noted a history of stress fractures of the tibial plateau, pelvis, and right ankle. The Veteran complained of pain in the areas in question, which she described as 8 out of 10 in intensity and "unrelenting" in duration. She denied stiffness, swelling, heat, redness, instability, or locking. Aggravating factors were prolonged standing, lifting, bending and weather change. Objectively, the Veteran had right ankle dorsiflexion to 10 degrees and plantar flexion to 40 degrees. There was pain on the end range of motion and diffuse tenderness over the right ankle. Repetitive motion did not decrease range of motion or increase in pain. Examination of the bilateral knees showed full extension and flexion to 130 degrees bilaterally. There was no pain on repetitive motion. Lachmans, anterior and posterior drawer tests were normal and McMurrays was negative. Knees were diffusely tender. Examination of the pelvis revealed flexion to 120 degrees bilaterally and extension to 30 degrees bilaterally, both without pain. Repetitive motion did not decrease range of motion or change the level of pain. There was no pain on internal or external rotation bilaterally, and the trochanter was not tender and there was no other tenderness in the pelvis. There was no evidence of joint warmth, effusion, erythema, or ligamentous laxity in any of the joints in question. The examiner noted that in all joints in question, range of motion was not limited by pain, fatigue, weakness, or lack of endurance. X-rays of the bilateral hips, bilateral knees including the tibial plateau, pelvis, and right ankle were normal. The examiner provided a diagnosis of healed stress fractures of the hip, bilateral knees, and right ankle. An April 2006 VA treatment report noted complaints of bilateral hip pain, bilateral lower leg pain, and bilateral ankle pain. The Veteran reported continued symptoms of pain going from her hips to her ankles, which occurred with prolonged standing. A diagnosis of a history of stress fractures was provided. A June 2006 VA treatment record referenced a May 2006 bone scan showing inflammation of the shins and lower femur. VA treatment records dated August 2006 noted continued complaints of leg and pelvic pain. The Veteran was afforded another VA examination in January 2007. She reported constant pain in the pelvis, legs and right ankle. The Veteran denied weakness, stiffness, swelling, heat, redness, drainage, instability, locking or abnormal motion. She was treated with medications with poor response. The examiner stated that the Veteran had no constitutional symptoms of bone disease. Examination noted no evidence of deformity, angulation, false motion, shortening or intraarticular involvement of the hips, tibial plateaus or the right ankle. There was no evidence of malunion, nonunion, loose motion or false joint. There was tenderness throughout the locations without drainage, edema, weakness, redness, or heat. The Veteran had painful motion throughout. There were no callosities, breakdown or unusual shoe pattern wear, and there was no ankylosis. A diagnosis of stress fractures of the tibial plateaus, right ankle, and pelvis. A separate January 2007 VA examination of the joints noted that the Veteran complained of pain that had increased in severity, frequency, and duration in both hips, which render her unable to perform her work duties. Range of motion testing of the hips revealed extension from 0 to 4 degrees bilaterally, flexion to 90 degrees bilaterally, abduction to 10 degrees bilaterally, adduction to 4 degrees bilaterally, internal rotation to 8 degrees, bilaterally, and external rotation with pain to 8 degrees bilaterally. There was pain on all ranges of motion and motion was not additionally limited following repetitive use. However the examiner noted bilateral trochanter tenderness. Range of motion testing of the right ankle revealed dorsiflexion to 0 degrees midline with pain, and plantar flexion to 40 degrees. Range of motion was additionally limited with repetitive use due to pain, resulting in a 12 degrees further reduction in dorsiflexion to midline. There was tenderness to palpation throughout. Stability and strength were normal. Range of motion testing of the bilateral knees revealed flexion to 70 degrees with pain and extension to 0 degrees midline. The knees were stable with anterior, posterior, varus-valgus, and lachman's testing. McMurray's was negative and there was no edema. Diagnoses of stress fractures of the pelvic/hips, right ankle, and bilateral tibial plateaus were provided. VA treatment records dated March 2007 showed continued complaints of pain in the lower pelvis when sitting. It was noted that a bone density test revealed osteopenia. A March 2008 treatment record noted complaints of pain in both legs from the mid thigh to the ankle. The Veteran reported symptoms of aching, tightness, and sporadic cramping with no edema. Examination noted that the tibia was very tender to palpation along the posterior calf. The Veteran was afforded a final VA examination in December 2008. At that time, she stated that as a result of stress fractures, she was having increased pain, decreasing mobility and range of motion of both knees due to injuries. The Veteran reported constant moderate pain with intermittent swelling, instability, and locking. Range of motion testing of the knees revealed extension to 0 degrees and flexion to 130 degrees with pain. Knees were stable but had a positive grade II moderate crepitus. Range of motion testing of the bilateral hips revealed abduction and adduction to 20 degrees with pain, internal and external rotation to 10 degrees with pain, and extension to 10 degrees with pain. There was bilateral trochanteric tenderness to palpation. Range of motion testing of the right ankle revealed dorsiflexion of -10 degrees with pain, plantar flexion to 10-20 degrees, with pain, and inversion and eversion to 10 degrees with pain. Range of motion for each joint was not additionally limited following repetitive use. The examiner provided diagnoses of bilateral moderate chondromalacia of the knees related to stress fracture; bilateral chronic bursitis of the hips; and recurrent ankle sprains. VA treatment records dated February to July 2009 reflected continued complaints of pain in the right ankle, bilateral legs, and hips. A July 2009 treatment examination of the right ankle showed no soft tissue swelling, negative drawer test, and good flexion and extension. B. Legal Criteria The present appeal involves the Veteran's claim that the severity of her service-connected stress fractures of the right ankle, bilateral tibial plateau, and bilateral hips/pelvis warrant a higher disability rating. Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet.App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet.App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. In cases of functional impairment, evaluations are to be based upon lack of usefulness, and medical examiners must furnish, in addition to etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification, a full description of the effects of the disability upon the person's ordinary activity. 38 C.F.R. § 4.10. The factors of disability regarding joints reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight- bearing are related considerations. 38 C.F.R. § 4.45. 1. Entitlement to a rating in excess of 10 percent for residuals of stress fractures of the right ankle Throughout the rating period on appeal, the Veteran has been evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5015-5271, at 10 percent for benign new growths of bones. Diagnostic Code 5015 directs that diseases under this Diagnostic Code should be rated on limitation of motion of the affected parts, as degenerative arthritis. Limitation of motion of the ankle is rated under Diagnostic Code 5271. Under Diagnostic Code 5271, a 10 percent rating is warranted for moderate limitation of ankle motion, and a 20 percent rating is warranted for marked limitation of ankle motion. Normal range of motion for the ankle is 20 degrees for dorsiflexion and 45 degrees for plantar flexion. 38 C.F.R. § 4.71, Plate II. Again, a VA examination in April 2006 showed right ankle dorsiflexion to 10 degrees and plantar flexion to 40 degrees, with no additional limitation with repetitive movement due to factors such as pain, weakness, or fatigability. X-rays were normal and there was no evidence of ankylosis, effusion, instability, or ligamentous laxity. As such, the Board finds that prior to January 2007, there is no evidence of marked limitation of motion, and a higher rating of 20 percent is not warranted for the right ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5271. However, the January 2007 VA examination revealed dorsal flexion to 0 degrees and plantar flexion to 40 degrees with pain resulting in a further loss of 12 degrees of dorsiflexion on repetitive motion. The ankle was tender throughout. The December 2008 VA examination showed dorsiflexion to -10 degrees with pain and plantar flexion from 10-20 degrees with pain with no additional limitation of motion on repetitive testing. Overall, the right ankle was stable, with no evidence of instability, effusion, crepitus, or ligamentous laxity. Given these findings, and considering the Veteran's credible complaints of pain, the Board finds that a higher rating of 20 percent for marked limitation of motion of the right ankle is warranted from January 22, 2007. As, there is no evidence of ankylosis of the ankle, ankylosis of the subastragalar or tarsal joint, or malunion of os calcis or astragalus, higher ratings are not warranted under 38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5272, or 5273.) The Board is aware of the Veteran's complaints of pain in her right ankle. However, as noted above, there is no objective evidence that pain on use of the joint results in limitation of motion to a degree which would support a higher rating. 38 C.F.R. §§ 4.40, 4.45; Deluca v. Brown, 8 Vet. App. 202 (1995). Additionally, the Veteran's current evaluations of her stress fractures of the right ankle disability as noted herein address any the Deluca concerns of pain, fatigability, weakness, and incoordination. 2. Entitlement to a rating in excess of 10 percent for residuals of stress fractures of the left and right tibial plateau Throughout the rating period on appeal, the Veteran has been in receipt of separate 10 percent evaluations under 38 C.F.R. § 4.71a, Diagnostic Code 5015-5260, for benign new growths of bones of both the left and right tibial plateaus. Diagnostic Code 5015 directs that diseases under this Diagnostic Code should be rated on limitation of motion of the affected parts, as degenerative arthritis. Limitation of motion of the leg is rated under Diagnostic Codes 5260 and 5261. Under 38 C.F.R. § 4.71a, Diagnostic Code 5260, a 10 percent rating is warranted for flexion limited to 45 degrees, a 20 percent rating is warranted for flexion limited to 30 degrees, and a 30 percent rating is warranted flexion limited to 15 degrees. In this case, the evidence shows flexion ranging from 70 to 130 degrees in the right leg. As there is no evidence of flexion limited to 30 degrees, a rating in excess of 10 percent is not warranted for residuals of stress fractures of the right tibial plateau. Likewise, the evidence shows that the Veteran had flexion ranging from 70 to 130 degrees in the left leg. As there is no evidence of flexion limited to 30 degrees, a rating in excess of 10 percent is not warranted for residuals of stress fractures of the left tibial plateau. Under 38 C.F.R. § 4.71a, Diagnostic Code 5261, a 10 percent rating is warranted for extension limited to 10 degrees, a 20 percent rating is warranted for extension limited to 15 degrees, a 30 percent rating is warranted for extension limited to 20 degrees, a 40 percent rating is warranted for extension limited to 30 degrees, and a 50 percent rating is warranted for extension limited to 45 degrees. The evidence regarding the right leg shows that the Veteran has full extension, and there is no evidence that pain results in limitation of motion which would result in a rating in a compensable rating. Therefore, a rating in excess of 10 percent is not assignable under diagnostic code 5261 for residuals of stress fractures of the right tibial plateau. Similarly, the evidence regarding the left leg shows that the Veteran has full extension, and there is no evidence that pain results in limitation of motion which would result in a rating in a compensable rating. Therefore, a rating in excess of 10 percent is not assignable under diagnostic code 5261 for residuals of stress fractures of the left tibial plateau. Finally, as there is no evidence of any impairment of the tibia or fibula, a rating in excess of 10 percent is not warranted under 38 C.F.R. § 4.71a, Diagnostic Code 5262 for residuals of stress fractures of the right or left tibial plateau. The Board is aware of the Veteran's complaints of pain in her bilateral legs. There is, however, no objective evidence that pain on use of the joint results in limitation of motion to a degree which would support a higher rating. 38 C.F.R. §§ 4.40, 4.45; Deluca v. Brown, 8 Vet. App. 202 (1995). Additionally, the Veteran's current evaluations of her stress fractures of the bilateral tibial plateau disability as noted herein address any the Deluca concerns of pain, fatigability, weakness, and incoordination. 3. Entitlement to a rating in excess of 10 percent for residuals of stress fractures of the left and right hips/pelvis Throughout the rating period on appeal, the Veteran has been in receipt of separate 10 percent ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5015-5255, 10 percent for benign new growths of bones of the left and right pelvis/hip. Diagnostic Code 5015 directs that diseases under this Diagnostic Code should be rated on limitation of motion of the affected parts, as degenerative arthritis. The Veteran is in receipt of separate 10 percent ratings for the left and right hip/pelvis under Diagnostic Code 5255. Under Diagnostic Code 5255, a 10 percent rating is warranted for impairment of the femur, malunion with slight knee or hip disability, a 20 percent rating is warranted for malunion with a moderate knee or hip disability, and a 30 percent rating is warranted for malunion with marked knee or hip disability. As noted above, there is no evidence of a moderate knee or hip disability. As such, a rating in excess of 10 percent for the right hip/pelvis is not warranted. Similarly a rating in excess of 10 percent for the left hip/pelvis is not warranted Under Diagnostic Code 5252, a 10 percent rating is warranted for flexion limited to 45 degrees; a 20 percent rating is warranted for flexion limited to 30 degrees; a 30 percent rating is warranted for flexion limited to 20 degrees, and; a 40 percent rating is warranted for flexion limited to 10 degrees. The medical evidence showed that the Veteran's flexion in the right hip ranged from 90 to 120 degrees. Thus, there is no showing of flexion limited to 30 degrees. Accordingly, a higher rating of 20 percent is not warranted under 38 C.F.R. § 4.71a, Diagnostic Code 5252 for residuals of stress fractures of either the right hip/pelvis. Similarly, the medical evidence showed that the Veteran's flexion in the left hip ranged from 90 degrees to 120 degrees. Thus, as the medical evidence does not show flexion limited to 30 degrees, a higher rating of 20 percent is not warranted under 38 C.F.R. § 4.71a, Diagnostic Code 5252 for residuals of stress fractures of either the left hip/pelvis. Under Diagnostic Code 5253, impairment of the thigh, a 20 percent rating is warranted for limitation of abduction, with motion lost beyond 10 degrees. However, the medical evidence revealed that the Veteran did not have limitation of abduction of the thigh with motion lost beyond 10 degrees, bilaterally. Rather the medical evidence showed abduction of the right hip ranging from 10 to 20 degrees and abduction of the left hip ranging from 10 to 20 degrees. Additionally, a higher rating is not warranted under Diagnostic Code 5250, for ankylosis of the hip; or under Diagnostic Code 5254, flail hip joint, as there is no evidence that the Veteran has these disorders. The Board is aware of the Veteran's complaints of pain in her hips/pelvis. There is, however, no objective evidence that pain on use of the joint results in limitation of motion to a degree which would support a higher rating. 38 C.F.R. §§ 4.40, 4.45; Deluca v. Brown, 8 Vet. App. 202 (1995). Additionally, the Veteran's current evaluations of her stress fractures of the bilateral hip/pelvis disability as noted herein address any the Deluca concerns of pain, fatigability, weakness, and incoordination. 4. Conclusion In light of the foregoing, the Board finds that the preponderance of the evidence is against the claims for ratings in excess 10 percent for residuals of stress fractures of the right tibial plateau; the left tibial plateau; the right hip/pelvis; the left hip/pelvis; and the right ankle prior to January 22, 2007. In making this determination, the Board considered the benefit-of- the-doubt doctrine but finds that it is inapplicable. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board does find that a rating of 20 percent, but no higher, is warranted for residuals of stress fractures of the right ankle from January 22, 2007. 5. Extraschedular considerations The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Shinseki, F.3d 1366 (Fed. Cir. 2009). Here, as discussed above, the rating criteria for the disability at issue reasonably describe the Veteran's disability level and symptomatology. Thus, as the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral for an extraschedular evaluation is required. Id. Finally, the Board notes that the record is negative for evidence that the Veteran is currently unemployable due to her service- connected residuals of stress fractures to the right ankle, bilateral tibial plateaus, and bilateral hips/pelvis. Therefore, remand or referral of a claim for a total rating due to individual unemployability (TDIU) is not necessary under the Court's ruling in Rice v. Shinseki, 22 Vet. App. 447 (2009). Indeed, VA examination in December 2008 clearly indicated that the Veteran was working. II. Service connection- headaches. The Veteran contends that she had migraine headaches related to her active service. Specifically, she alleges that she developed headaches after a gas chamber exercise during active duty. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2009); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Service treatment records showed a normal examination in October 2002, upon entrance into active duty. In August 2003, the Veteran was treated for a migraine headache in the forehead. Service treatment records are otherwise silent to any treatment for any other headaches. The first post service-documentation of headaches is shown in an April 2006 VA treatment record where the Veteran complained of headaches with dizziness, throbbing pain, and some nausea. The Veteran reported self treatment with Tylenol and sleep. A diagnosis of headaches was provided. August 2006 VA treatment records noted complaints of headaches that started suddenly with throbbing pain over the entire head and occasional blurred vision. The Veteran reported no nausea but some light sensitivity. A diagnosis of headaches, suspected to be tension-related, was provided. The Veteran was afforded a VA examination in January 2007. At that time, she reported having headaches after going through a gas chamber in basic training. She stated that the headaches have continued and that they currently occur on a daily basis. Headaches had a sudden onset of throbbing stabbing pain over the head that is so severe that the Veteran could not function. Examination of the cranial nerves showed no abnormality, and there was no evidence of any paraspinal, upper trapezius, or sternomastoid muscle dysfunction. A diagnosis of chronic daily headaches that did not fit the syndrome of migraine was provided. The examiner noted that there was no evidence that the headaches were impairing or disabling when the Veteran was on active duty. Subsequent VA treatment records showed continued complaints of headaches with occasional nausea and dizziness, with no vision changes. In December 2008, the Veteran was afforded another VA examination. The examiner noted that the Veteran complained with a headache across the front of her head on one occasion and a diagnosis of migraine was provided with no corroboration information. The examiner noted that the Veteran was vague in giving a history of headaches but simply called them migraines because they give her bad pain. The Veteran denied any other associated symptoms with her headaches and denied that the headaches were prostrating. Physical examination demonstrated no abnormalities of mental status, cranial nerves, motor system, or reflexes. The diagnosis was nonmigrainous, nonprostrating headaches, occurring with variable frequency. In February 2009, the December 2008 VA examiner reviewed the Veteran's claims file as well as his previous VA examination. The examiner found that the Veteran's service treatment records showed one occasion in which the Veteran complained of frontal head pain in association with an upper respiratory infection. While the word migrainous frontal headache was used, there was no description, and there was no further treatment or diagnosis of headaches while the Veteran served on active duty. Thus, the examiner opined that the Veteran's current headache disorder was unrelated to her active military service because there was no particular activity in which she engaged that would lend itself to the induction of headaches. Further, the headaches were so nonspecific that they were not classifiable. The examiner noted that headaches are the most common clinical disorder encountered, and etiologies or related causative factors are many and varied. Thus, the examiner concluded that since there was no chronic headache condition identified and treated during active duty, the Veteran's military service bore no relation to the Veteran's headaches. While the Veteran currently has headaches, there is no indication that such current headaches are the result of any incident of service. Service records showed only one acute complaint of headaches during active service in August 2003. The record was silent to any complaints of headaches until April 2006, nearly 3 years after discharge from service. In this regard, evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Further, upon examination and subsequent review of the claims file, the VA examiner stated that the Veteran had only one occasion of treatment for headaches associated with an upper respiratory infection during active service and there was no indication of any activity in which she engaged during active service that would lend itself to the induction of headaches. Moreover, her current headache disorder was so nonspecific as to not be classifiable. As such, the examiner opined that as there was no chronic headache disorder identified and treated while on active duty, the Veteran's military service bore no relation to the Veteran's current headaches. The Board notes that the Veteran has submitted her own statements in support of her claim. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Whether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board. The Board notes that the Veteran would be competent to report that she has had headaches since her active service. However, as noted above, service treatment records do not show treatment or diagnosis of any chronic headache disorder hip disability during active service. Moreover, while the Veteran's statements as to continuous headache symptoms since service are competent, they are not deemed credible here. Indeed, if she had been experiencing such headaches continuously since service, it would be reasonable to expect that she would have raised a claim for service connection earlier than 2006. While the Veteran has asserted that her headaches are due to a gas chamber exercise during basic training, there is no competent medical evidence showing that the Veteran has a headache disorder due to active service. Accordingly, the claim must be denied. As there is no evidence showing that the Veteran incurred a migraine headache disorder during her active service, the Board must find that the preponderance of the evidence is against entitlement to service connection for migraine headaches. As there is not an approximate balance of positive and negative evidence regarding the merits of the appellant's claim that would give rise to a reasonable doubt in favor of the appellant, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5170(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to a rating in excess of 10 percent for residuals of stress fractures to the right ankle prior to January 22, 2007, is denied. A rating of 20 percent for residuals of stress fractures to the right ankle from January 22, 2007, is granted, subject to the regulations applicable to the payment of monetary benefits. Entitlement to a rating in excess of 10 percent for residuals of stress fractures of the left tibial plateau is denied. Entitlement to a rating in excess of 10 percent for residuals of stress fractures of the right tibial plateau is denied. Entitlement to a rating in excess of 10 percent for residuals of stress fractures of the left hip/pelvis is denied. Entitlement to a rating in excess of 10 percent for residuals of stress fractures of the right hip/pelvis is denied. ____________________________________________ ERIC S. LEBOFF Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs