Citation Nr: 1124059 Decision Date: 06/24/11 Archive Date: 06/29/11 DOCKET NO. 07-37 553 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to an initial rating in excess of 30 percent for migraine headaches. 3. Entitlement to an initial rating in excess of 10 percent for left hip osteoarthropathy. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD K. Osegueda, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1976 to July 2006. This matter comes before the Board of Veterans' Appeals (Board) from a September 2006 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The issue of entitlement to an initial rating in excess of 30 percent for migraine headaches is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. For the full period from August 1, 2006 forward, the Veteran's PTSD is approximated by findings of occupational and social impairment with reduced reliability and productivity, in this case due to symptoms such as such as difficulty in establishing and maintaining effective work and social relationships, impairment of short-term memory, and disturbance of motivation and mood. 2. The Veteran's left hip disability is manifested by X-ray evidence of osteoarthritis and flexion to 100 degrees. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating of 50 percent, but no more, are approximated. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b), 4.130, Diagnostic Code 9411 (2010). 2. The criteria for an initial rating in excess of 10 percent for left hip osteoarthritis are not met. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5250 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist As provided by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 510(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) VA must ask the claimant to provide any evidence in his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ), as was done in this case. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the VCAA duty to notify was satisfied by way of undated correspondence sent to the Veteran, which fully addressed all notice elements. The Veteran acknowledged receipt of the notice in June 2002. Correspondence dated in March 2006 informed the Veteran about disability ratings and effective dates. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In compliance with the duty to notify the Veteran of what information would substantiate his claim, the Veteran was advised that VA used a Schedule for Rating Disabilities (Schedule) that determined the rating assigned and that evidence considered in determining the disability rating included the nature and symptoms of the condition, the severity and duration of the symptoms, and the impact of the condition and symptoms on employment. VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's service treatment records and private medical records. Additionally, the Veteran was afforded a VA QTC examinations in March 2006. The Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim. See Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). PTSD The Veteran was granted service connection for PTSD by a rating decision in September 2006, which assigned a 30 percent evaluation effective August 1, 2006, the day after he was discharged from service. He expressed disagreement with the assigned rating in statements dated in September and October 2006. The Veteran contends that the symptoms of his psychiatric disabilities are more severely disabling than is reflected by the currently assigned rating. After review of the evidence, the Board finds that the severity of the Veteran's service-connected PTSD approximates findings of a rating of 50 percent, and the claim will be granted to this extent. Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Schedule). 38 C.F.R. Part 4 (2010). The percentage ratings contained in the 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 the residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2010). Separate diagnostic codes identify the various disabilities. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2010). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is the propriety of the initial disability rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). 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 (2010). The criteria for rating psychiatric disability are contained in the General Rating Formula. 38 C.F.R. § 4.130. Under the General Rating Formula, a 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, or recent events.) 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted when there is total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Symptoms listed in VA's General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In evaluating psychiatric disabilities, the Board has adopted the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., American Psychiatric Association (DMS-IV). That manual includes a Global Assessment of Functioning (GAF) scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). A GAF score of 31-40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family, relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up young children, is defiant at home, and is failing at school). See Diagnostic and Statistical Manual of Mental Disorders, 4th ed., American Psychiatric Association (DSM-IV). A GAF score of 41 to 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. A GAF score of 51 to 60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or coworkers.) Id. A GAF score of 61 to 70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Id. During a March 2006 pre-discharge VA QTC PTSD examination, the Veteran reported problems sleeping almost every night for 15 years. He lay awake or woke up frequently and was unable to fall back asleep. He had nightmares one or two times per week and woke up feeling anxious. Sometimes he felt afraid and got up to check the windows and doors in his home to see if anyone was around the house or in the yard. He left the lights on at night because he was afraid that a sniper was outside. During the day, he was anxious, tense, hypervigilant, and had some startle response. He was isolated and withdrawn, and he thought about dead people a lot. He did not appear to have a lot of depression. The Veteran acknowledged problems handling stress and had poor concentration. His wife noticed a change in his attitude, decreased trust, and increased irratibility since the Persian Gulf War. She said he was very irritable, displayed a lot of avoidance, and was opinionated and argued with people too much. The Veteran was able to independently perform activities of daily living, including: bathing, dressing, feeding himself, cooking, and cleaning. He liked to fish and hunt, read, and watch television. The Veteran and his wife socialized with friends, went to church, and went out to restaurants together. He appeared to get along with other people fairly well. He had minimal functional impairment caused by psychiatric symptoms at work. He was a little more irritable and had some concentration problems, but he could generally get along with people and follow complex instructions. Mental status examination revealed neat grooming and dress. The Veteran behaved normally and expressed a pleasant, cooperative, and polite attitude. He was not hostile or belligerent. Speech was normal in rate and tone, with good grammar and vocabulary. He was spontaneous and logical, and he was not inhibited or vague. Pressured speech, flight of ideas, or loose associations were not present. He denied hallucinations, delusions, paranoia, or ideas of reference. He was not homicidal or suicidal, and his self-confidence was fairly good. He complained of poor sleep, isolation, nightmares, intrusive memories, an increased startle response, and hypervigilance. The Veteran presented some mild depression and mild anxiety, but he demonstrated no psychomotor retardation, his impulse control was good, and he denied panic attacks. He acknowledged irritability and tended to minimize his difficulties. He was alert and oriented in all spheres and his fund of information and judgment were good. His insight was noted as poor. The diagnosis was PTSD, and a GAF score of 65 was assigned. The examiner noted mild social and occasional industrial impairment. In a May 2006 pre-discharge report of medical history, the Veteran acknowledged nervous trouble (including anxiety or panic attacks), frequent trouble sleeping, and depression or excessive worry. He reported paranoia, problems with crowds, and difficulty sleeping due to excessive worry about things at home and worrying about "the worst that could happen." During a July 2006 psychological assessment at the Goldsboro Psychiatric Clinic, the Veteran reported he had nightmares twice a week which began in 1991. He woke in a panic for 30 minutes to an hour. He had panic attacks twice per week which lasted "all day." He averaged four hours of sleep per night and woke twice per night. He indicated a startle response, hypervigilance, and intrusive thoughts. He rarely socialized and indicated he had memory trouble. The Veteran reported that he had the following symptoms 25 percent of the time: decreased interest level, thoughts of suicide, and "racing" thoughts. He had the following symptoms 50 percent of the time: sudden anger, sadness and fear; depression, decreased energy level, agitation, anger, hopelessness, difficulty learning new things, and mood swings. He indicated he felt helpless 75 percent of the time and he worried all of the time. When questioned about hallucinations, the Veteran acknowledged he heard his name or cars drive up once per week or less, and he saw shadows moving many times per day. The diagnosis was PTSD and major depression, and a GAF score of 40 was assigned. In correspondence dated August 2006, Edwin W. Hoeper, M.D., from the Goldsboro Clinic, wrote that he diagnosed the Veteran with chronic PTSD and chronic major depression after evaluating him in July 2006. The Veteran provided that he began having nightmares in 1990 and continued to have them twice per week. He woke in a panicked and sweating for 30 to 60 minutes, and averaged four hours of sleep per night. He had flashbacks with reminders and panic attacks twice per week, which sometimes lasted all day. He had intrusive thoughts; startled easily; was hypervigilant; and could not tolerate anyone behind him. He occasionally socialized with family members, and had severe impairment of his recent memory. He could not remember what he read and got lost while traveling. Dr. Hoeper quantified the Veteran's working memory as 50 percent impaired. He noted that the Veteran had unprovoked anger, sadness, and fear 50 percent of the time. He indicated he heard his name called once per week, heard vehicles drive up to his residence once per week, and saw shadows moving out of the corners of his eyes many times per week. The hallucinations and illusions occurred when no one or anything was there. The Veteran stated he felt depressed with no energy and had little interest in things 50 percent of the time. He angered and agitated easily and felt helpless and suicidal at times. However, Dr. Hoeper opined that the Veteran's PTSD moderately compromised his ability to sustain social relationships and moderately compromised his ability to sustain work relationships, and assigned a GAF score of 35. In a December 2006 follow-up psychological assessment report from the Goldsboro Clinic, the Veteran reported he had nightmares twice per week but reported that he rarely had flashbacks. He denied panic attacks and averaged five hours of sleep "on a good night." He woke two or three times per night and indicated he was anxious "all the time." He acknowledged hypervigilance, but reported it had lessened in severity since his July 2006 evaluation. He rarely socialized with friends and family, and noted some memory loss. The Veteran denied feeling hopeless and suicidal, and stated he rarely felt sadness and sudden fear. He acknowledged the following symptoms 25 percent of the time: sudden anger, depression, agitation, anger, helplessness, difficulty learning new things, mood swings, and jumping thoughts. He indicated he felt had racing thoughts 75 percent of the time and he always had a decreased energy level, decreased interest level, and worried. When questioned about hallucinations, the Veteran acknowledged he saw shadows moving once per week or less. He denied hearing his name, cars drive up, footsteps or noises in the house, or seeing animals. A diagnosis was not provided, but a GAF score of 40 was assigned. The Board finds that for the full period from August 1, 2006 forward, the evidence is at least in approximate balance as to whether the criteria for a 50 percent rating for PTSD are met. Although some VA QTC examination evidence indicates that the Veteran had minimal functional occupational impairment caused by psychiatric symptoms and he socialized with friends, there is additional evidence to indicate that the Veteran had occupational and social impairment with reduced reliability and productivity due to symptoms such as "difficulty in establishing and maintain effective work and social relationships," one of the criteria for a 50 percent rating. See 38 C.F.R. § 4.130, Diagnostic Code 9411. During a July 2006 Goldsboro Clinic psychological assessment, the Veteran reported he rarely socialized. In August 2006 correspondence, Dr. Hoeper opined the Veteran's PTSD "moderately compromised his ability to sustain social relationships and moderately compromised his ability to sustain work relationships." Additionally, there was evidence of panic attacks more than once per week; impairment of short-term memory; and disturbances of motivation and mood. See 38 C.F.R. § 4.130, Diagnostic Code 9411. During the March 2006 VA QTC examination, the Veteran acknowledged that he was isolated and withdrawn, and he thought about dead people a lot. He also acknowledged problems handling stress and poor concentration. During a July 2006 Goldsboro Clinic psychological assessment, he reported panic attacks twice per week that lasted "all day," memory trouble, decreased interest in activities, decreased energy level, and he saw shadows moving many times per day. However, the criteria for the next higher rating of 70 percent are not met or approximated for any period from August 1, 2006, the effective date of service connection for PTSD, forward. Although the Veteran reported he felt suicidal at times, one of the criteria for a 70 percent rating, during a July 2006 Goldsboro Clinic psychological assessment, the Board finds this testimony to be not probative of a sustained symptomatology. The Board finds more reliable and of greater probative weight repeated statements by VA examiners that the Veteran did not have signs of suicidal ideation, specifically at a VA QTC examination in March 2006, at which the examiner related that the Veteran did not have any suicidal or homicidal ideation, and the December 2006 Goldsboro Clinic psychological assessment, at which the Veteran denied feeling hopeless or suicidal. Accordingly, and particularly in light of the inconsistencies of record and the findings of medical examiners, the Board finds that the preponderance of the evidence indicates that the Veteran does not have suicidal ideation. Occasional hallucinations in the form of hearing his name being called, cars driving up to his home, and seeing shadows moving out of the corners of his eyes, were noted during the July 2006 and December 2006 Goldsboro psychological assessments and the August 2006 correspondence from Dr. Hoeper. However, as these were noted to be once per week or less (see July 2006 report) and were not present on examination, the Board finds that these are not "persistent delusions or hallucinations" as contemplated in one of the criteria for a 100 percent rating. Thus, the Board finds that while the Veteran may have had "difficulty in establishing and maintaining effective work and social relationships," and has related additional symptoms such as panic attacks more than once a week, and disturbances of motivation and mood, thus meeting or approximating the criteria for a 50 percent rating, the comparable criteria for a 70 percent rating are not met, which include "inability to establish or maintain effective relationships, or difficulty in adapting to stressful circumstances (including work or a worklike setting)." Also, the Board has reviewed the treatment and examination records and finds no evidence at any time during the pendency of the Veteran's claim of the majority of the criteria for a 70 percent rating, including obsessional rituals which interfere with routine activities (the Veteran's accomplishment of activities of daily living was found to be intact); speech intermittently illogical, obscure or irrelevant (speech was generally normal and the Veteran was oriented to person, place and time); near-continuous panic or depression affecting the ability the ability to function independently, appropriately, and effectively (the Veteran was noted to have panic attacks two times per week); spatial disorientation (the Veteran was oriented to all spheres); or neglect of personal appearance and hygiene (the Veteran was neatly groomed and dressed at the March 2006 VA QTC examination). Based on the July 2006 and December 2006 Goldsboro Clinic psychological assessments, the Board is persuaded that the Veteran's condition has worsened, but still, as discussed at length above, the criteria for the next higher rating of 70 percent are not met or approximated. As the criteria for a 70 percent are not met or approximated for any period during the pendency of the Veteran's claim, a staged rating in excess of 50 percent is not warranted for any period pertinent to this appeal. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). The Board has considered whether this case should be referred to the Director, Compensation and Pension Service, for extraschedular consideration for rating of the veteran's service-connected PTSD. Although the Board has no authority to grant an extraschedular rating in the first instance, it may consider whether the RO's determination with respect to that issue was proper. See VAOPGCPREC 6-96; Floyd v. Brown, 9 Vet. App. 88, 95 (1996) (Board may consider whether referral to "appropriate first-line officials" for extraschedular rating is required); see also Bagwell v. Brown, 9 Vet. App. 337, 339 (1996) (Board may affirm an RO conclusion that a claim does not meet the criteria for submission pursuant to 38 C.F.R. § 3.321(b)(1)). The governing norm in such exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b). In Thun v. Shinseki, F.3d 1366 (Fed. Cir. 2009), the Court articulated a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation is found inadequate because it does not contemplate the claimant's level of disability and symptomatology, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the disability picture requires the assignment of an extraschedular rating. There is no objective evidence that the disability picture presented is exceptional or that schedular criteria are inadequate. The Board finds there is no evidence of any unusual or exceptional circumstances, such as marked interference with employment or frequent periods of hospitalization related to his PTSD, that would take this case outside the norm so as to warrant the assignment of an extraschedular rating during the appeal period. Thus, it is concluded that the Veteran's impairment is contemplated by the schedular rating assigned, particularly when the symptoms of the disability falls squarely in the 30 percent evaluation. In light of the foregoing, the Board finds that for the full period from August 1, 2006 forward, the preponderance of the evidence shows that a higher initial rating of 50 percent, but no higher, for service-connected PTSD, is warranted. Left Hip Osteoarthropathy In evaluating disabilities of the musculoskeletal system, additional rating factors include functional loss due to pain supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Inquiry must also be made as to weakened movement, excess fatigability, incoordination, and reduction of normal excursion of movements, including pain on movement. 38 C.F.R. § 4.45. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability so that actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. When assigning a disability rating, it is necessary to consider functional loss due to flare-ups, fatigability, incoordination, and pain on motion. See 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.49; DeLuca v. Brown, 8 Vet. App. 202, 204-06 (1995). 38 C.F.R. § 4.40 notes that disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence of part or all of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 (2010). 38 C.F.R. § 4.45 provides that factors of disability involving a joint reside in reductions of its normal excursion of movements in different planes of motion and therefore, inquiry will be directed to such considerations as weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; and incoordination (impaired ability to execute skilled movements smoothly). 38 C.F.R. § 4.45 (2010). The Court has held that when a Diagnostic Code provides for compensation based upon limitation of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 must also be considered, and that examinations upon which the rating decisions are based must adequately portray the extent of functional loss due to pain "on use or due to flare-ups." DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Colayong v. West, 12 Vet App 524 (1999) (citing DORLAND'S ILLUSTRATED MEDICAL DICTIONALRY (28TH Ed. 1994) at 86). Under Diagnostic Code 5250, a 60 percent evaluation is warranted for favorable ankylosis of the hip in flexion at an angle between 20 degrees and 40 degrees, and slight adduction or abduction. See 38 C.F.R. § 4.71a, Diagnostic Code 5250 (2010). A 70 percent evaluation is warranted for intermediate ankylosis of the hip. Id. A 90 percent evaluation is warranted for extremely unfavorable ankylosis of the hip where the foot does not reach the ground and crutches are necessitated. Id. Diagnostic Code 5003 states that degenerative arthritis will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, x-ray evidence of involvement of 2 or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations warrants a 20 percent evaluation. X-ray evidence of involvement of 2 or more major joints or 2 or more minor joints warrants a 10 percent evaluation. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2010). In the selection of diagnostic codes assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With injuries and diseases, preference is to be given to the number assigned to the injury or disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27 (2010). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. See Butts v. Brown, 5 Vet. App. 532 (1993). During a March 2006 VA QTC examination, the Veteran complained of pain and tightness in his left hip, which continued to worsen since its onset in 2003, following knee surgery. The hip stiffened and swelled. There was constant, locking pain which caused the Veteran to limp. The pain traveled down his leg intermittently. He described the pain as "aching," "sticking," "cramping," and "burning," and rated it as an eight out of ten in severity. The pain was elicited with physical activity and when he woke from sleep, but it was alleviated by anti-inflammatory medication. The Veteran indicated he could function with medication and there were no prosthetic implants. He denied incapacitation and indicated the pain caused no time lost from work. The Veteran reported he was able to perform routine activities of daily living, except climbing stairs, gardening, or pushing a lawnmower because of his left hip pain, coupled with back and knee pain. On physical examination, an abnormal gait was noted. The Veteran limped on his left thigh, but he did not require any device for mobilization. Examination of the left hip revealed no edema, effusion, weakness, tenderness, redness, heat, abnormal movement, guarding movement, or sublaxation. His left hip joint was not in a fixed position, and range of motion measurements were as follows: flexion to 90 degrees without pain and 100 degrees with pain (normal flexion was noted as 125 degrees); extension to 25 degrees (normal extension was noted as 30 degrees); adduction to 20 degrees (normal adduction was noted as 25 degrees); abduction to 40 degrees (normal abduction was noted as 45 degrees); external rotation to 50 degrees (normal external rotation was noted as 60 degrees); and internal rotation to 30 degrees (normal internal rotation was noted as 40 degrees). The examiner noted that after repetitive use or during flare-ups, pain had a major limiting impact on the left hip. Fatigue, weakness, and lack of endurance also contributed to limiting the left hip function, but not incoordination. The examiner was unable to determine the additional limitation in degrees. Lower extremity motor function was normal on neurological examination. Diagnostic tests revealed osteoarthritic change in the left hip on an X-ray. The diagnosis was left hip strain and osteoarthritis of the left hip. After review of the evidence, the Board finds the Veteran's service-connected left hip disability approximates the criteria for the currently assigned 10 percent rating. In order for a rating of 60 percent to be awarded for favorable ankylosis of the hip, flexion must be limited at an angle between 20 degrees and 40 degrees, and there must be slight adduction or abduction. Here, this is not the case. The Veteran's left hip flexion was to 90 degrees without pain and 100 degrees with pain. Therefore, he does not warrant a 60 percent rating for ankylosis of the left hip. See 38 C.F.R. § 4.71a, Diagnostic Code 5250. Under Diagnostic Code 5003 for degenerative arthritis, when limitation of motion of the left hip is noncompensable under the appropriate diagnostic code (in this case, Diagnostic Code 5250), a rating of 10 percent is for application for the major joint. A 20 percent evaluation is warranted in the absence of limitation of motion when there is X-ray evidence of the involvement of two or more major joints, with occasional incapacitating episodes. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. Here, X-ray evidence revealed osteoarthritis in the left hip and the Veteran denied incapacitation. In fact, he indicated his pain was alleviated by anti-inflammatory medication. The Veteran is competent to report his left hip pain symptoms. His complaints are credible. The Veteran's complaints have been considered; however, evaluations for VA purposes have not shown the severity required for a higher, schedular, rating as discussed above. There is no objective evidence that the disability picture presented is exceptional or that schedular criteria are inadequate. The Board finds there is no evidence of any unusual or exceptional circumstances, such as marked interference with employment or frequent periods of hospitalization related to his left hip pain, that would take this case outside the norm so as to warrant the assignment of an extraschedular rating during the appeal period. The Veteran expressly denied incapacitation and indicated the pain caused no time lost from work. Thus, it is concluded that the Veteran's impairment is contemplated by the schedular rating assigned, particularly when the symptoms of the disability falls squarely in the 10 percent evaluation. ORDER A higher initial rating for PTSD of 50 percent, but no higher, is granted. An initial rating in excess of 10 percent for left hip osteoarthropathy is denied. REMAND Further development is required in order that VA may comply with its duty to assist the Veteran in his claim for entitlement to an initial rating in excess of 30 percent for migraine headaches. See 38 U.S.C.A. § 5103A. The VA examinations of record do not include medical evidence as to necessary criteria used to rate migraine headaches. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (When the medical evidence of record is insufficient, in the opinion of the Board, or of doubtful weight or credibility, the Board must supplement the record by seeking an advisory opinion, ordering a medical examination, or citing recognized medical treatises that clearly support its ultimate conclusions). In its September 2006 rating decision which granted service connection for migraine headaches, the RO assigned a 30 percent rating pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8100. Under this code, a 30 percent rating is provided for migraine with characteristic prostrating attacks occurring on an average once a month over last several months. A 50 percent rating for migraine with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The rating criteria do not define "prostrating." According to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), in which "prostration" is defined as "extreme exhaustion or powerlessness." In the rating decision, the RO relied on a June 2006 in-service neurology consultation. The consultation report documented complaints of headaches occurring twice per month, preceded by an aura with photo and phonophobia. He reported he had to lie down in a dark, quiet room until the headache subsided. There was no inquiry made into the Veteran's economic adaptability. VA must obtain a retrospective medical opinion to fully develop the claim. See Chotta v. Peake, 22 Vet. App. 80 (2008); see also Vigil v. Peake, 22 Vet. App. 63 (2008) (holding that the duty to assist may include development of medical evidence through a retrospective medical evaluation where there is a lack of medical evidence for the relevant time period). Accordingly, the case is REMANDED for the following actions: 1. The RO/AMC must ask the Veteran to identify all records of VA and non-VA health care providers who have treated him for migraine headaches. After obtaining any appropriate authorizations for release of medical information, the RO/AMC must obtain all relevant and previously unobtained records from each health care provider the Veteran identifies. a. The Veteran should also be advised that, with respect to private medical evidence, he may alternatively obtain the records on his own and submit them to the RO/AMC. b. In particular with regard to his claim for a higher initial rating for migraine headaches, the Veteran should submit, or notify the RO/AMC where records could be obtained, supporting any asserted interference with employment, including but not limited to employer's records of his absences due to the disability. 2. After waiting an appropriate time period for the Veteran to respond, the RO/AMC must schedule the Veteran for a VA examination by a physician with appropriate expertise in general medicine. The purpose of the examination is to determine the current level of disability due to migraine headaches, including whether prostrating attacks occur and how often. The following considerations must govern the examination: a. The claims file and a copy of this remand must be made available to the physician, who must acknowledge receipt and review of these materials in any report generated as a result of this remand. b. The physician must consider all medical evidence of record. In particular, the Board calls the physician's attention to service treatment records concerning complaints of migraine headaches in a May 2006 report of medical history and a June 2006 neurology consultation. c. All indicated tests and studies must be performed. d. The examiner should opine as to the current level of disability due to migraine headaches, including whether and how often these headaches are accompanied by prostrating attacks supported by clinical evidence if any. e. In all conclusions, the physician must identify and explain the medical bases of his or her opinions with reference to the claims file. If the physician is unable to render the requested opinions without resort to speculation, he or she must so state; however, a complete rationale for such a finding must be provided. 3. If the benefits sought remain denied, the RO/AMC must provide the Veteran and his representative with a supplemental statement of the case and an appropriate period of time for response. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is hereby notified that it is his responsibility to report for any examination and to cooperate in the development of the claim. The consequences of failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2010). In the event that the Veteran does not report for any scheduled examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any sent notice was returned as undeliverable. By this remand, the Board intimates no opinion as to the final disposition of any unresolved issue. The RO and the Veteran are advised that the Board is obligated by law to ensure that the RO complies with its directives, as well as those of the appellate courts. It has been held that compliance by the Board or the RO is neither optional nor discretionary. Where the remand orders of the Board or the Courts are not complied with, the Board errs as a matter of law when it fails to ensure compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs