Citation Nr: 1314263 Decision Date: 04/30/13 Archive Date: 05/15/13 DOCKET NO. 07-33 788 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for a cervical spine disability. 2. Entitlement to service connection for a lumbar spine disability, to include as secondary to residuals of a right ankle fracture. 3. Entitlement to service connection for a headache disability, to include as secondary to a cervical spine disability. 4. Entitlement to service connection for a psychiatric disability, to include as secondary to a service-connected disability. 5. Entitlement to an initial rating in excess of 10 percent for a right ankle disability. REPRESENTATION Veteran represented by: David L. Huffman, Attorney WITNESSES AT HEARING ON APPEAL Veteran and Spouse ATTORNEY FOR THE BOARD J. W. Kim, Counsel INTRODUCTION The Veteran served on active duty from January 1985 to January 1989. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. In September 2009, the Board remanded the appeal to afford the Veteran an opportunity to present testimony during a Board hearing at the RO. In March 2011, the Veteran testified during a hearing before the undersigned Veterans Law Judge at the RO. Stegall v. West, 11 Vet. App. 268 (1998). In October 2011, the Board remanded the appeal to obtain any outstanding medical evidence and to provide the Veteran examinations to determine the etiology of his claimed disabilities and the severity of his service-connected right ankle disability. The Veteran was scheduled for his examinations in October 2012. However, he did not report to those examinations. In November 2011, the RO asked the Veteran to identify all providers who have treated or examined him for the disabilities on appeal. The Veteran did not reply. The Board finds that the RO has substantially complied with the remand directives. Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. A cervical spine disability did not have its onset in service or within one year thereafter and it is not causally related to any incident of service. 2. A lumbar spine disability did not have its onset in service or within one year thereafter and it is not causally related to any incident of service or a service-connected disability. 3. A headache disability did not have its onset in service or within one year thereafter and it is not causally related to any incident of service or a service-connected disability. 4. A psychiatric disability did not have its onset in service or within one year thereafter and it is not causally related to any incident of service or a service-connected disability. 5. The Veteran's residuals of a right ankle fracture do not more nearly approximate marked limited motion of the ankle. 6. The Veteran failed, without stating good cause or adequate reason, to report for a VA medical examination in October 2012 which was scheduled to evaluate his service-connected residuals of a right ankle fracture. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical spine disability are not met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.655 (2012). 2. The criteria for service connection for a lumbar spine disability, to include as secondary to a service-connected disability, are not met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.655 (2012). 3. The criteria for service connection for a headache disability, to include as secondary to a service-connected disability, are not met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.655 (2012). 4. The criteria for service connection for a psychiatric disability, to include as secondary to a service-connected disability, are not met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.655 (2012). 5. The criteria for an initial rating in excess of 10 percent for residuals of a right ankle fracture have not been met and the claim is denied because the Veteran failed to report for a scheduled VA examination. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.655, 4.71a, Diagnostic Code 5271 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Proper notice must inform the claimant and his or her representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice requirements apply to all five elements of a service-connection claim, including Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's right ankle claim arises from an appeal of the initial rating following the grant of service connection. Once service connection is granted the claim is substantiated. Therefore, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Thus, no further notice is needed. With respect to the service connection claims, neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. The Veteran was notified in a November 2005 letter of the criteria for establishing service connection, the evidence required, and his and VA's respective duties for obtaining evidence. This letter predated the initial adjudication by the RO in May 2006 of the claims for service connection for neck and headache disabilities. In a March 2006 letter, he was notified of how VA determines disability ratings and effective dates if service connection is awarded. The claims were readjudicated in a September 2007 statement of the case. The above letters addressed all notice elements and predated the adjudication by the RO in September 2006 of the claims for service connection for back and psychiatric disabilities. VA also has a duty to assist a Veteran in the development of claims. That duty includes assisting him in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). The Board finds that all necessary development has been accomplished and appellate review may proceed without prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service medical records, and post-service reports of VA and private treatment and examination. The Veteran's statements in support of the claims are of record. The Board has carefully reviewed the statements and concludes that no available outstanding evidence has been identified. The Board has also reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the claims. VA provided the Veteran with examinations in September 2006 to determine the nature and etiology of his back and psychiatric disabilities. 38 C.F.R. § 3.159(c)(4) (West 2002 & Supp. 2012). When VA undertakes to provide an examination or obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds the examination reports to be thorough and adequate upon which to base decisions on the claims. The VA examiners personally interviewed and examined the Veteran, including eliciting a history from the Veteran, and provided the information necessary to decide the claims. Brief but relevant and important opinions were provided. The Board finds the opinions to be adequate, as they were based on a full reading of the private and VA medical records in the claims file as well as the Veteran's own statements. VA provided the Veteran with examinations in May 2006 and September 2010 to determine the nature and severity of his right ankle disability. The Board finds the examination reports to be thorough and adequate upon which to base a decision on the claim. The VA examiners personally interviewed and examined the Veteran, including eliciting a history from the Veteran, and provided the information necessary to evaluate the disability under the applicable rating criteria. The Veteran's claims file contains documentation showing that VA scheduled the Veteran for examinations in October 2012 to determine the etiology of his claimed disabilities and the severity of his service-connected right ankle disability. However, the Veteran failed to appear for those examinations. A September 2012 letter from the RO indicated that the Veteran would receive notice of the time and place of his examinations. The letter also informed the Veteran that failure to report to an examination without good cause would result in the claim being rated on the basis of the evidence of record, or could result in a denial of the claim. October 2012 VA examination reports and the February 2013 supplemental statement of the case show that the Veteran failed to report for his examinations. The Veteran has not indicated that he did not receive notice of his examinations, nor has he advanced any other arguments regarding scheduling the examinations. The presumption of administrative regularity states that it is presumed that government officials have properly discharged their official duties. Ashley v. Derwinski, 2 Vet. App. 307 (1992). There is no requirement that a copy of the notice letter VA sent to the Veteran informing him of his scheduled examination be contained in the record for the presumption of regularity to apply. Kyhn v. Shinseki, 23 Vet. App. 335 (2010). The Veteran has submitted no evidence to rebut the presumption of regularity. Thus, the Board concludes that the Veteran was properly notified of the date and time of his examinations. VA's duty to assist a claimant is not a one-way street. A claimant seeking help cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining evidence. Wood v. Derwinski, 1 Vet. App. 190 (1991). When entitlement or continued entitlement to a benefit cannot be established or confirmed without a current VA examination or reexamination, and a claimant, without good cause, fails to report an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. 38 C.F.R. § 3.655 (2012). When the examination was scheduled in conjunction with any other original claim, a reopened claim for a benefit which was previously disallowed, or a claim for increase, the claim shall be denied. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. 38 C.F.R. § 3.655(a) (2012). The Board finds that entitlement to the benefits sought cannot be established without a current VA examination. The current evidence of record contains only lay evidence regarding a nexus between the Veteran's current disabilities and events in service. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran does not have the medical expertise to establish that his current disabilities are related to his service. Therefore, a medical opinion is required to establish a nexus and entitlement to benefits and the regulation applies. 38 C.F.R. § 3.655(a) (2012). The Veteran did not attend scheduled examinations. He did not offer an explanation for his absence or request that his examinations be rescheduled. The Board finds that the Veteran has not provided good cause for his failure to attend the examinations. Accordingly, the claims shall be rated based on the evidence of record and the Veteran is not entitled to another examination. 38 C.F.R. § 3.655(a) (2012). The Board finds that VA has fully satisfied the duty to assist. Additional efforts to assist or notify the Veteran would serve no useful purpose. Soyini v. Derwinski, 1 Vet. App. 540 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied the duty to inform and assist the Veteran at every stage in this case, and any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). Service connection may also be granted for any chronic disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. §§ 3.303(d), 3.309(a) (2012); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a chronic disease in service or continuity of symptoms after service, the disease shall be presumed to have been incurred in service. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a disorder noted during service is not shown to be chronic, then generally a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b) (2012). Where a veteran served for 90 days or more of active service, and certain chronic diseases, such as arthritis or psychosis, become manifest to a degree of 10 percent or more within one year from the date of separation of such service, the disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. The presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). Service connection requires competent evidence of (1) a current disability; (2) the in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be granted for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (2012). Service connection is permitted not only for a disability caused by a service-connected disability, but also for the degree of disability resulting from aggravation to a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439 (1995). The Board reiterates that the Veteran failed to report for his scheduled examinations and did not offer good cause for that failure to report. As a result, the Board must come to a determination solely on the basis of information included in the record. 38 C.F.R. § 3.655 (2012). Cervical Spine Disability The Veteran claims that he experienced a neck injury at the same time as his documented in-service right ankle fracture. He reports that, while he did not complain about the neck injury at the time, he experienced neck symptoms continuously from the time of his right ankle fracture. The Veteran's service medical records do not show any problems with his neck. A July 1987 treatment note shows that he was playing rugby when he fell onto his flexed right knee and felt a snap and sharp pain in the right ankle. He was found to have a fracture of the distal tibia. After service, the first documentation of neck pain appears in an October 1991 private treatment note showing complaints of neck pain and a diagnosis of an acute cervical strain. Then, a May 1994 treatment note shows complaints of pain in the cervical spine that the Veteran reported started while playing football in high school and was aggravated by an injury in service. A November 1994 MRI showed a disc herniation at C5-C6. A December 1994 treatment note shows a history of neck pain since the spring of 1994. He underwent surgery in January 1995 for cervical disc herniation at C5-C6 and cervical spondylosis. He underwent a second surgery in January 2003 for cervical radiculopathy secondary to C4-C5 and C6-C7 degenerative herniated discs with foraminal stenosis and central spinal stenosis. Current VA treatment notes show a diagnosis of neck pain. As the Veteran's claimed traumatic incident was documented in the service treatment records, he had a current diagnosis of a neck disability, and there was competent lay evidence of continuity of symptomatology from that claimed traumatic incident to the present, the Board requested a VA examination to determine the etiology of his currently diagnosed neck disability. However, the Veteran failed to report to the scheduled examination. Thus, the record does not contain a competent medical opinion as to whether his cervical spine disability is related to service, to include the in-service incident. The Veteran's lay statements are competent to report that he experienced neck pain from the time of his in-service right ankle injury to the present. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 21 Vet. App. 191 (2007). As indicated above, there is evidence of a current disability of the cervical spine. The remaining inquiry is whether his neck disability diagnosed after service is related to the documented in-service incident. The only medical evidence that addresses a nexus between the Veteran's neck disability and the in-service incident is a May 1994 private treatment note in which the physician noted the Veteran's complaints of neck pain that started while playing football in high school and was aggravated by an injury in service. However, that statement simply repeated the contentions of the Veteran and, therefore, is not probative as to etiology. Leshore v. Brown, 8 Vet. App. 406 (1995) (transcriptions of lay history unenhanced by any medical comment by an examiner are not transformed into competent medical evidence merely because the transcriber happens to be a medical professional). The only other evidence of record addressing a nexus between the Veteran's neck disability and the in-service incident are his own lay statements and that of a fellow serviceman. On his August 2005 claim for benefits, the Veteran asserted that he injured his neck at the same time as he fractured his right ankle in service. He also stated that he has had problems with his neck since that incident. In September 2006, he again asserted that he injured his neck in service. In a statement received in March 2006, a fellow former servicement stated that he served with the Veteran and the Veteran complained of neck pain after the incident in which the Veteran injured his ankle. He noted that the Veteran did not tell the service physician about his neck because the Veteran thought that it would heal over time without treatment. The former fellow serviceman further stated that the Veteran thereafter complained of neck pain during the remainder of his own service which ended in 1988 and over the years as they had kept in touch. The Board finds that the question regarding the potential relationship between the Veteran's neck disability and 1987 in-service incident is medically complex in nature. Although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Although the Veteran was diagnosed with a cervical strain in 1991, that was described as acute and almost two years after discharge from service with no further documentation for over two years until 1994 with the eventual diagnosis of cervical disc herniation at C5-6 and cervical spondylosis that lead to the surgery in 1995. Disc herniation and spondylosis are diagnosed by medical tests and there is no evidence that the Veteran has the requisite medical knowledge to administer medical tests or interpret the results. Furthermore, he does not possess the medical knowledge to attribute those diagnoses to any specific instance of service, to include documented incident. Therefore, the Board finds that there is no competent medical evidence of record showing that any current cervical spine disability is related to the Veteran's service. While the Veteran is competent to describe his in-service incident and neck pain, the Board accords his statements regarding the etiology of his disc herniation and spondylosis no probative value as he is not competent to opine on that complex medical question and has only offered conclusory statements. To the extent that the Veteran is claiming to have experienced continuous neck pain since active service, that assertion is not found to be credible. He did not complain of neck pain during service and his discharge examination revealed a normal neck and spine. There is no medical evidence of a neck disability until October 1991, almost two years after discharge, and then no further complaint of record until the spring of 1994. The Board finds of great probative value his reported history of neck pain since early 1994 as it was made during the receipt of medical care. Lastly, if he had experienced neck problems since service, it would be reasonable to expect that he would have filed a disability claim sooner than in August 2005. Thus, the Board finds that the statements alleging or implying continuity of symptoms are not credible in this case. Therefore, continuity of symptomatology is not established by either the competent evidence or the lay statements by the Veteran and the fellow serviceman. The Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a cervical spine disability. Therefore, the claim must be denied. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Lumbar Spine Disability The Veteran claims that he has a low back disability secondary to his service-connected residuals of a right ankle fracture. Specifically, he asserts that it is due to the altered gait due to the right ankle disability. A September 2006 VA spine examination report shows that the Veteran's low back disability was not related to his residuals of a right ankle fracture because he had a normal posture and gait. The examiner noted that for an ankle disability to cause a back problem it needed to be significant enough to alter posture and gait. During the March 2011 hearing before the Board, the Veteran's spouse stated that she had witnessed the Veteran limping regularly for the previous 12 years. As her testimony was competent to demonstrate that she witnessed the Veteran limping on a regular basis over that time period, the Board requested a VA examination to determine the etiology of his low back disability. However, the Veteran failed to report to that scheduled examination. Thus, the record does not contain a competent medical opinion on whether his cervical spine disability is related to service, to include a service-connected disability. Thus, the only medical evidence addressing a nexus between the Veteran's low back disability and his service-connected right ankle fracture is that of the above VA examiner, who provided a negative opinion. The only other evidence of record addressing a nexus between the Veteran's low back disability and his service-connected right ankle fracture are his own lay statements and those of his spouse. On his August 2005 claim for benefits, he asserted that he had a lumbar spine disability secondary to his broken right ankle. The Board reiterates that although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In this case, the question of causation extends beyond an immediately observable cause-and-effect relationship and therefore the Veteran is not competent to address etiology. The medical evidence shows that his low back disability is not related to his right ankle disability. Although not claimed by the Veteran, the Board notes that his service treatment records show that he was treated for his back on two occasions in 1986. In May 1986, he complained of low back pain for the past two days and was diagnosed with rule out back strain. In June 1986, he complained of low back pain for the past one day and was diagnosed with mechanical low back pain. His January 1989 discharge examination showed a normal evaluation of the spine. After service, the first documentation of back pain appears in a May 1994 private treatment note showing complaints of pain in the upper and middle portions of the back that the Veteran stated started while playing football in high school and was aggravated by an injury in service. The Veteran also complained of an occasional sore low back. The only medical evidence that addresses a nexus between the Veteran's low back disability and service is a May 1994 private treatment note in which the physician noted the Veteran's complaints of upper and middle back pain that started in high school and was aggravated by an injury in service. However, that statement simply repeated the contentions of the Veteran and, therefore, is not probative as to etiology. Leshore v. Brown, 8 Vet. App. 406 (1995) (transcriptions of lay history unenhanced by any medical comment by an examiner are not transformed into competent medical evidence merely because the transcriber happens to be a medical professional). In a statement received in March 2006, a former fellow serviceman stated that he served with the Veteran and the Veteran complained of back pain after the incident in which the Veteran injured his ankle. He noted that the Veteran did not tell the service physician about the back because the Veteran thought that it would heal over time without treatment. The former fellow serviceman further stated that the Veteran thereafter complained of back pain during the remainder of his own service which ended in 1988 and over the years as they had kept in touch. To the extent that the Veteran is claiming to have experienced continuous back pain since active service, that assertion is not found to be credible. The Veteran's discharge examination revealed a normal spine. The Board has considered the statement of the former fellow serviceman that the Veteran did not report his back in service because of the belief that it would heal over time without treatment. However, the Board finds the absence of in-service complaints to be especially probative as it indicates that a chronic back disability did not develop in service. There is no medical evidence of a back disability until May 1994, over five years after discharge. Lastly, if he had experienced back problems since service, it would be reasonable to expect that he would have filed a disability claim sooner than in August 2005. Thus, the Board finds that the statements alleging or implying continuity of symptoms are not credible in this case. Therefore, continuity of symptomatology is not established by either the competent evidence or the lay statements by the Veteran and the fellow serviceman. There is no competent evidence of record showing that any current lumbar spine disability is related to the Veteran's service or to any service-connected disability. The Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a lumbar spine disability, to include as secondary to service-connected residuals of a right ankle fracture. Therefore, the claim must be denied. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Headache Disability The Veteran claims that he has a headache disability secondary to his neck disability. Initially, the Board notes that the Veteran does not contend, and the record does not show, that his headache disability had its onset in or is related to service. Furthemore, the evidence does not show any headache disability in service. Therefore, the Board finds that direct service connection is not warranted. There is no competent medical evidence of record linking any current headache disability to the Veteran's service or to any service-connected disability. As the Board has found that service connection for a cervical spine disability is not warranted, service connection for a headache disability on a secondary basis is also not warranted. The Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a headache disability, to include as secondary to a cervical spine disability. Therefore, the claim must be denied. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Psychiatric Disability The Veteran claims that he has a psychiatric disability secondary to his service-connected right ankle disability and the other disabilities on appeal. Initially, the Board notes that the Veteran does not contend, and the record does not show, that his psychiatric disability had its onset in or is related to service. The evidence does not show any psychiatric disability during service or any psychosis within one year following separation from service. Therefore, direct service connection and presumptive service connection are not warranted. An August 2006 private psychiatric report stated that the Veteran's psychiatric disabilities resulted from injuries sustained while serving in the Marine Corps. The report listed the Veteran's in-service injuries as involving his ankle, neck, and back. However, the examiner did not provide a rationale. Therefore, that opinion is of little probative value. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). As the above private psychiatric report indicated a link between the claimed psychiatric disability and a service-connected disability, the Veteran was afforded a VA examination in September 2006. The examiner stated that the Veteran's depressive symptoms seemed to be caused by or a result of severe sleep apnea rather than the ankle injury, based on the type of symptoms the Veteran reported. The Board finds the opinion to be of great probative value as it was based on examination of the Veteran and his documented medical history. Hayes v. Brown, 5 Vet. App. 60 (1993); Wood v. Derwinski, 1 Vet. App. 190 (1992). As the VA examiner did not address the relationship between the Veteran's psychiatric disability and neck and back disabilities, claims for service connection for which were then pending, the Board requested an examination to determine the etiology of any psychiatric disability. However, the Veteran failed to report to that scheduled examination. The Board finds that the weight of the probative medical evidence addressing a nexus between the Veteran's psychiatric disability and his service-connected right ankle disability is against the claim. The only other evidence of record addressing a nexus between the Veteran's psychiatric disability and his service-connected residuals of a right ankle fracture are his own lay statements. On his August 2005 claim for benefits, he asserted that he had depression due to the pain from his service-connected right ankle disability. The Board reiterates that although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In this case, the question of causation extends beyond an immediately observable cause-and-effect relationship and, as such, he is not competent to address etiology. Diagnosing and determining the etiology of mental disorders requires medical training. The most persuasive medical evidence of record shows that the psychiatric disability is not related to his right ankle disability. As the Board has found that service connection for a cervical spine disability, lumbar spine disability, and a headache disability is not warranted, service connection for a psychiatric disability secondary to those disabilities is also not warranted. The Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a psychiatric disability, to include as secondary to a service-connected disability. Thus, the claim must be denied. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Initial Rating for Right Ankle Disability Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). A veteran's entire history is to be considered when assigning disability rating. 38 C.F.R. § 4.1 (2012); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). When the veteran has disagreed with the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of the assignment of different ratings for distinct periods of time, based on the facts found, is required. Fenderson v. West, 12 Vet. App. 119 (1999). The Board's analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. From the August 24, 2005 effective date of service connection, the Veteran's residuals of a right ankle fracture have been rated 10 percent under Diagnostic Code 5271. 38 C.F.R. § 4.71a (2012). Under Diagnostic Code 5271, used for rating limitation of motion of the ankle, a 10 percent rating is assigned for moderate limitation of motion; and a 20 percent rating is assigned for marked limitation of motion. That is the maximum schedular rating. Normal range of motion of the ankle is 20 degrees of dorsiflexion and 45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II (2012). After a careful review of the record, the Board finds that a higher initial rating is not warranted for the Veteran's residuals of a right ankle fracture. A May 2006 VA joints examination report shows complaints of constant aching in the right ankle and also of popping, cracking, weakness, stiffness, giving way, fatigability, and lack of endurance. The Veteran reported flare-ups of moderately severe pain of varying frequency and duration, requiring him to rest. Examination showed no obvious deformity, edema, or tenderness of the ankle. Posture and gait were normal. There was 20 degrees of dorsiflexion that remained unchanged after repetition. There was 35 degrees of plantar flexion that was further reduced to 30 degrees after repetition due to increased pain. There was pain with inversion and eversion stressing but no instability. X-rays were normal. A September 2010 VA joints examination report shows complaints of persistent aching in the right ankle that became severe with flare-ups and also of locking, popping, giving way, swelling, instability, stiffness, and weakness. The Veteran described his flare-ups as severe, occurring weekly and lasting three to seven days, requiring him to sit and rest. Examination showed tenderness of the ankle but no instability, tendon abnormality, or angulation, and 10 degrees of dorsiflexion and 45 degrees of plantar flexion. The examiner noted the presence of objective evidence of pain on active motion and repetitive motion. However, the examiner did not state at which degree the pain began. The examiner noted there was no additional limitation after repetitive motion and no ankylosis. X-rays were normal. VA and private medical records show complaints of right ankle pain but contain no range of motion findings. However, they do not indicate any ankylosis or malunion of the ankle. The May 2006 examination showed normal dorsiflexion and at worst 30 degrees of plantar flexion, indicative of slight to moderate limitation of plantar flexion. Taken together, the Board finds that the Veteran's disability was not reflective of marked limited motion of the ankle. The September 2010 examination showed 10 degrees of dorsiflexion, indicative of moderate to severe limitation of dorsiflexion, and normal plantar flexion. Although the examiner noted evidence of pain on active motion and repetitive motion, the examiner did not state at which degree the pain began. Thus, the Board is left with the above findings, which fail to show that the Veteran's disability was reflective of marked limited motion of the ankle. Accordingly, the Board finds that the Veteran's residuals of a right ankle fracture do not more nearly approximate marked limited motion of the ankle. Thus, the criteria for a higher 20 percent rating are not met. The Board has considered functional loss due to pain and other factors, to the extent shown by the evidence of record, in making this determination. Without evidence of ankylosis or malunion of the ankle, the Board finds that no other diagnostic code provides for a higher or separate rating. In the October 2011 remand, the Board noted the inadequacy of the September 2010 examination and requested that the Veteran be afforded another examination. However, the Veteran failed to report to the scheduled examination. The Veteran has not suggested or provided any reason for missing the October 2012 examination. Thus, the Board finds that good cause has not been shown and the claim for increase must be denied. 38 C.F.R. § 3.655 (2012). The Board finds that the claim for an initial rating in excess of 10 percent for residuals of a right ankle fracture must be denied. The preponderance of the evidence is against a finding that an increased rating is warranted based on the evidence of record. In addition, the Veteran failed to report for a scheduled examination and has not offered good cause for that failure to report. Therefore, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.655 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a cervical spine disability is denied. Service connection for a lumbar spine disability, to include as secondary to residuals of a right ankle fracture, is denied. Service connection for a headache disability, to include as secondary to a cervical spine disability, is denied. Service connection for a psychiatric disability, to include as secondary to a service-connected disability, is denied. An initial rating in excess of 10 percent for a right ankle disability is denied. ____________________________________________ HARVEY P. ROBERTS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs