Citation Nr: 1327664 Decision Date: 08/29/13 Archive Date: 09/05/13 DOCKET NO. 09-37 191A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected disabilities. 2. Entitlement to an initial rating in excess of 10 percent, prior to December 16, 2009, for muscle tension headaches. 3. Entitlement to an initial rating in excess of 30 percent, on and after December 16, 2009, for muscle tension headaches. 4. Entitlement to an initial rating in excess of 10 percent for gastroesophageal reflux disease. 5. Entitlement to an initial rating in excess of 20 percent for post-operative residuals of right foot trauma with calcaneal varus and pain. 6. Entitlement to an initial rating in excess of 20 percent for post-operative residuals of left foot trauma with calcaneal varus and pain. REPRESENTATION The Veteran is represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. Pflugner, Counsel INTRODUCTION The Veteran served on active duty from December 1979 to September 1992 and from August 1995 to August 2001. These matters are before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office in Baltimore, Maryland, on behalf of the VA Regional Office in Waco, Texas (RO), and September 2009 rating decisions by the VA Regional Office in Waco, Texas. The August 2008 rating decision granted service connection for muscle tension headaches, and assigned a 10 percent initial rating effective from April 16, 2008, and granted service connection for gastroesophageal reflux disease (GERD), and assigned a noncompensable initial rating effective from April 16, 2008. The September 9, 2009 rating decision denied entitlement to service connection for obstructive sleep apnea, and a September 28, 2009 rating decision granted service connection for post-operative residuals of right and left foot trauma with calcaneal varus and pain, and granted a 10 percent initial rating for each, effective from February 5, 2008. The September 28, 2009 rating decision also assigned a 10 percent (increased) initial rating for GERD, with an earlier effective of February 5, 2008, and assigned an earlier effective date of February 5, 2008 for the grant of service connection, and the assigned 10 percent initial rating, for muscle tension headaches. During the pendency of the appeal, a March 2012 rating decision assigned a staged initial rating of 30 percent for muscle tension headaches, effective December 16, 2009. A claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the Veteran has not argued, and the record does not otherwise reflect, that the disabilities at issue render him unemployable. Indeed, the evidence of record demonstrates that the Veteran is employed on a full-time basis. The Veteran has not asserted that such employment constitutes marginal employment. Accordingly, the Board concludes that a claim for TDIU has not been raised. During the pendency of this appeal, evidence associated with the claims file suggested that the Veteran experienced right and left ankle disabilities, as a consequence of his service-connected post-operative residuals of right and left foot trauma with calcaneal varus and pain, respectively. As right and left ankle disabilities were not contemplated in the grant of service-connection for the Veteran's right and left foot disabilities, nor were the symptoms associated with his right and left ankle disabilities considered in the ratings assigned to his right and left foot disabilities, the Board finds that claims of entitlement to service connection for right and left ankle disabilities have been reasonably raised by the record. As these claims have not been developed or adjudicated by the RO, the Board does not have jurisdiction to consider them herein. Consequently, the Board is referring these claims to the RO for the appropriate action. In May 2013, the Board received a claim of entitlement to a temporary total disability rating with respect to his service-connected right knee disability for surgery necessitating convalescence. In support of this claim, the Veteran also submitted several documents, including an operative report. As this claim has not been developed or adjudicated by the RO, the Board does not have jurisdiction to consider it herein. Consequently, the Board is also referring this claim to the RO for the appropriate action. Throughout the pendency of this appeal, the Veteran stated on numerous occasions that he was seeking a rating of 30 percent for each of his above-captioned service-connected disabilities, and that he would withdraw the respective claim should a 30 percent rating be assigned. The Board finds that these various statements do not represent a clearly expressed intent to limit the appeal to entitlement to specific disability ratings. Indeed, the Veteran has not withdrawn his appeal with regard to a higher initial rating for muscle tension headaches following the grant of a 30 percent staged initial rating for part of the appeal period. Accordingly, the Board will presume that the Veteran is seeking the maximum benefit allowed by law and regulation in each time period at issue herein. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The issue of entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected disabilities, is REMANDED to the RO via the Appeals Management Center in Washington, DC. VA will notify the Veteran if further action is required. FINDINGS OF FACT 1. Prior to September 12, 2008, the Veteran's muscle tension headaches were not manifested by characteristic prostrating attacks. 2. On and after September 12, 2008, the Veteran's muscle tension headaches were manifested by characteristic prostrating attacks that occurred on an at least once per month basis, but were not very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability. 3. Throughout the pendency of this appeal, the Veteran's GERD was manifested by pain, nausea, pyrosis, and regurgitation; however, said symptoms were not productive of a considerable impairment of health. 4. Throughout the appellate period, the Veteran's post-operative residuals of right and left foot trauma with calcaneal varus were manifested by pain on a daily basis that was increased during ambulation and standing; severe and significant calcaneal abnormalities in his heels; "mild" bunions; swelling; tenderness; a limping gait with obvious pain; a lateral wear pattern on his shoes; and hallux valgus of 15 degrees, bilaterally. Further, the Veteran used shoe inserts, custom made orthotics, and custom made ankle braces. Moreover, he has undergone four surgical procedures to treat these disabilities, including the insertion of metal plates and screws and to fuse bones. CONCLUSIONS OF LAW 1. Prior to September 12, 2008, the criteria for an initial rating in excess of 10 percent for muscle tension headaches were not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2012). 2. On and after September 12, 2008, the criteria for a rating of 30 percent, but not more, for muscle tension headaches were met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2012). 3. The criteria for an initial evaluation in excess of 10 percent for GERD have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.114, Diagnostic Code 7346 (2012). 4. The criteria for an initial evaluation of 30 percent, but not more, for service-connected post-operative residuals of right foot trauma with calcaneal varus and pain have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2012). 5. The criteria for an initial evaluation of 30 percent, but not more, for service-connected post-operative residuals of left foot trauma with calcaneal varus and pain have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the veteran of any information and 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 veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Because the August 2008 and September 2009 rating decisions granted the Veteran's claims for service connection for muscle tension headaches, GERD, post-operative residuals of right foot trauma with calcaneal varus and pain, and post-operative residuals of left foot trauma with calcaneal varus and pain, these claims are now substantiated. His filing of notice of disagreements as to the August 2008 and September 2009 determinations does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3) (2012). Rather, the Veteran's appeal as to the initial ratings assigned triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. Statements of the case, under the heading "Pertinent Laws; Regulations; Rating Schedule Provisions," set forth the relevant diagnostic codes for rating the disabilities at issue and included a description of the rating formulas for the current evaluations and for all other higher evaluations. The Veteran was, thus, informed of what was needed not only to achieve the next-higher schedular rating with respect to each disability, but also to obtain all schedular ratings above those already assigned. Therefore, the Board finds that the Veteran has been informed of what was necessary to achieve higher ratings for the service-connected disabilities at issue herein. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996). The duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's VA and private treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In April 2010, the Veteran submitted a notice response form wherein he indicated that he had no additional evidence to submit in support of his claims. Moreover, there is no indication in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini, 18 Vet. App. at 120. The Veteran underwent adequate VA examinations in order to ascertain the severity of his service-connected muscle tension headaches, GERD, and post-operative residuals of right and left foot trauma with calcaneal varus and pain. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The examiners considered the Veteran's statements and administered thorough clinical examinations, both of which allowed for fully-informed evaluations of the claimed disabilities. The Board acknowledges that, in July 2012 and May 2013 briefs, the Veteran's representative asserted that the January 2011 VA examinations were more than one year old and, thus, did not comply with VA's duty to afford the Veteran current examinations. Neither the Veteran nor his representative specifically alleged that any of the Veteran's service-connected disabilities worsened since the January 2011 VA examinations; rather, they contended that the January 2011 VA examinations were simply not contemporaneous. However, age alone is not sufficient to mandate the provision of a new VA examination when the previous examination is otherwise adequate. See VAOPGCPREC 11-95. As such, the Board finds that a remand in order to provide the Veteran with additional VA examinations is not warranted. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of these claims, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the official who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the April 2009 and December 2010 hearings before RO Decision Review Officers, the Veteran discussed the elements of the claims. The Veteran was assisted at the hearing by an accredited representative from Disabled American Veterans. The representative and the Decision Review Officer asked questions to ascertain the course and severity of the Veteran's disabilities. No pertinent evidence that might have been overlooked and that might substantiate the claims was identified by the Veteran or the representative. The hearings focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate the increased rating claims. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearings. Therefore, the Board finds that, consistent with Bryant, the Decision Review Officers complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). 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 (2012). 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). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. This involves a factual determination of the current severity of the disability. Staged ratings are appropriate whenever the factual findings show distinct periods in which a disability exhibits symptoms that warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In determining the applicable disability rating, pertinent regulations do not require that all cases show all findings specified by the Rating Schedule; rather, it is expected in all cases that the findings be sufficiently characteristic as to identify the disease and the resulting disability, and above all, to coordinate the impairment of function with the rating. 38 C.F.R. § 4.21 (2012). Therefore, the Board will consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). I. Muscle Tension Headaches Muscle tension headaches are rated by analogy under 38 C.F.R. § 4.124, Diagnostic Code 8100, which concerns migraine headaches. See 38 C.F.R. § 4.20 (2012) (permitting evaluation, by analogy, where the rating schedule does not provide a specific diagnostic code to rate the disability). Migraine headaches are assigned disability ratings based on the frequency of prostrating attacks. A 30 percent rating is provided for migraine headaches with characteristic prostrating attacks occurring on an average once per month over last several months. 38 C.F.R. § 4.124, Diagnostic Code 8100. A 10 percent rating is provided for migraine headaches with characteristic prostrating attacks averaging one in two months over last several months. Id. The Rating Schedule does not define "prostrating." "Prostration" has been defined as "complete physical or mental exhaustion." MERRIAM-WEBSTER'S NEW COLLEGIATE DICTIONARY 999 (11th ed. 2007). "Prostration" has also been defined as "extreme exhaustion or powerlessness." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st ed. 2007). In May 2008, the Veteran underwent a VA examination in order to ascertain the severity of his muscle tension headaches. The Veteran reported that he began experiencing headaches in 2002. In describing the onset of a headache, the Veteran stated that he felt pain and tenseness in his shoulders, which was followed by tenseness that went up his occipital area. He stated that this occurred four to five times each week, with each episode typically lasting about 30 minutes, but that the headaches were variable in both time and intensity. He denied precipitating factors, but endorsed the use of his shoulders as an aggravating factor. The Veteran stated that rest was an alleviating factor, and that over-the-counter Ibuprofen or Tylenol helped some. The Veteran stated that the use of these medications could give him an upset stomach. However, he denied other symptoms associated with his headaches and denied prostrating attacks, but stated that he would sit down and try to relax when he was experiencing a headache. After a physical examination, the diagnosis was headaches, likely secondary to muscle tension. In a September 12, 2008 statement, the Veteran asserted that his muscle tension headaches were productive of prostrating attacks. Specifically, the Veteran claimed that, when he was experiencing a headache, his "routine" was to isolate himself in a room at home, close the door, draw the curtains, recline in his chair, close his eyes, eliminate noise, and have no interpersonal contact. He stated that he was incapacitated during these episodes and that he isolated himself from his surroundings. In a November 2008 statement, the Veteran said that he informed the VA medical staff during the May 2008 VA examination that his muscle tension headaches were "a weekly occurrence." He then reiterated his assertion that his headaches were incapacitating. In April 2009, the Veteran provided testimony at a hearing before a RO Decision Review Officer. With respect to muscle tension headaches, the Veteran stated that he experienced said headaches "more than once a month." The Veteran asserted that his headaches were "incapacitating," that he was "essentially immobile[ized]," and that he would be "prostrated in a quiet area, quiet position." With respect to the duration of the headaches, the Veteran endorsed variable lengths, but stated that if one were to occur in the morning, he hoped that it would have resolved by noon. Even after the headache had resolved, the Veteran stated that he felt as though he was in a "fragile state." When a headache occurred, the Veteran stated that he experienced tension or pounding on the sides of his head and temples, which was made worse by moving his head or shoulders around, especially with quick motions. He then testified that he isolated himself, reclined in a chair, darkened the room, put on a sleep mask, and sat quietly. He also stated that he might take over-the-counter medication, such as Advil, and drink some water. During such times, the Veteran stated that his family knew not to disturb him. In a letter dated on December 11, 2009, the Veteran reiterated his assertion that he experienced prostrating headaches with varying frequencies, but that they occurred at least once or more per month. He then stated that he took over-the-counter analgesic medications, but also stated that he had been prescribed oxycodone from September or October 2001 until 2009. During that time, he claimed that he took five milligrams of oxycodone six times each day, which was eventually replaced by a generic medication. He claimed that he took this generic medication only when a headache was "coming on." Specifically, he stated that he would take two capsules, then two more every four hours for 12 hours (four doses total). He claimed that he would take this medication more than once per month. In December 2010, the Veteran submitted a hand-written "headache log." The first entry was dated on December 16, 2009 and was followed by 20 additional entries, the last of which was dated on November 30, 2010. The monthly average was approximately 1.7. The Veteran provided no description as to the severity or duration of the headaches. During a December 2010 Decision Review Officer hearing, the Veteran explained that each entry in the headache log represented a headache that had prostrating effects on him. During a headache, the Veteran endorsed taking prescribed medications, isolating himself, darkening the room, and sitting still in a chair or laying in a bed while wearing a sleep mask. During these episodes, the Veteran stated that he stayed quiet, did not interact with anyone, did not take phone calls, may not eat, did not watch television, and did not listen to the radio. He then said that he took 8 to 9 days of unscheduled sick leave from his job in the previous year due to his headaches, but that his job was not in jeopardy. In January 2011, the Veteran underwent a VA examination to ascertain the severity of his service-connected muscle tension headaches. The Veteran stated that his headaches started during his active duty service and that they increased in frequency since then. He was unable to identify any specific triggers for the headaches, saying that they were unpredictable. Prior to the onset of a headache, the Veteran endorsed becoming fatigued and irritable. The Veteran reported that his headaches occurred once per month, on one side of his head, usually along his temple, but occasionally along that back of his head. Generally, the Veteran said that these headaches lasted "hours to days." He then discussed what he did during a headache, which included self-isolation in a dark room and sitting in a recliner with his feet up. During these episodes, the Veteran stated that he was unable to engage in any activity, became nauseated, and could not eat. Further, the Veteran stated that fluorescent light exacerbated his symptoms. The examiner indicated that the Veteran's headaches had been stable since their onset; that medication was his only current treatment; and that his response to the medication was fair, without side effects. The examiner observed no history of neurologic related hospitalizations or surgery, no neurologic trauma, and no neurologic neoplasm. Physical examination revealed normal mental status, intact cranial nerves, and no evidence of chorea, among other clinical findings. The diagnosis was tension headaches. The examiner stated that the Veteran's headaches resulted in increased absenteeism from work; decreased concentration; weakness or fatigue; and pain. Moreover, the examiner reiterated that the Veteran withdrew from his family and his life and was unable to engage in household activities when experiencing a headache. The examiner then noted that the Veteran was employed full-time as a management analyst and had been so employed for the previous 5 to 10 years. Finally, the examiner noted that the Veteran lost about 2 weeks from work due to his headaches. Prior to September 12, 2008, the evidence of record demonstrated that the Veteran underwent a VA examination in May 2008. During that examination, the Veteran denied experiencing characteristic prostrating attacks associated with his service-connected muscle tension headaches. The Board acknowledges that, following the May 2008 VA examination, the Veteran asserted that he told the VA medical staff during the May 2008 VA examination that he experienced muscle tension headaches with characteristic prostrating attacks on at least a once per month basis. However, the VA examiner reported in detail the symptoms associated with the Veteran's muscle tension headache and their effect on the Veteran, specifically indicating that the Veteran denied prostrating attacks. It is reasonable to assume that, had the Veteran endorsed experiencing muscle tension headaches with characteristic prostrating attacks on a more than once per month basis, this would have been reflected in the examiner's report. As such, the Board finds that the May 2008 VA examiner's assessment that the Veteran's muscle tension headaches were not productive of characteristic prostrating attacks is more persuasive than the Veteran's later contradictory statements. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (noting that the credibility of statements may be impeached by inconsistent statements and consistency with other evidence); Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than history as reported by a veteran). The evidence of record was otherwise silent as to the frequency of the Veteran's service-connected muscle tension headaches with characteristic prostrating attacks prior to September 12, 2008. Accordingly, the Board finds that the criteria for an initial rating in excess of 10 percent, prior to September 12, 2008, for muscle tension headaches were not met and, thus, to this extent the claim is denied. Id. In March 2012, the RO issued a rating decision wherein the disability rating assigned to the Veteran's service-connected muscle tension headaches was increased to 30 percent, effective December 16, 2009. In explaining the decision, the RO indicated that the Veteran's December 2010 headache log served as the earliest evidence of record demonstrating that his muscle tension headaches were productive of the criteria associated with a 30 percent rating, that is, characteristic prostrating attacks occurring on an average once per month over last several months. As discussed above, this log was hand-written by the Veteran, and showed a series of headaches over the course of a 12-month period, with an average of approximately 1.7 per month. The log did not describe the severity or duration of each episode. However, during the December 2010 DRO hearing, the Veteran stated that each entry represented the occurrence of a headache with a characteristic prostrating attack. According to evidence dated prior to the date of the log's first entry (December 16, 2009), however, the Veteran asserted that his service-connected muscle tension headaches were productive of prostrating attacks. Specifically, in the September 12, 2008 letter, the Veteran asserted that, when he experienced one of his service-connected headaches, he had a routine that involved isolating himself, eliminating as much sound and light as possible, and resting in a reclining chair. In a November 2008 statement, the Veteran said that episodes such as this occurred on a weekly basis. VA has already accepted, via the March 2012 rating decision, the Veteran's headache log as competent and credible evidence of the frequency of the Veteran's service-connected headaches with characteristic prostrating attacks. See Chisem v. Gober, 10 Vet. App. 526, 527-8 (1997) (holding that, under the "law of the case" doctrine, appellate courts generally will not review or reconsider issues that have already been decided in a previous appeal of the same case). The Board is unable to distinguish between the Veteran's written assertions that he experienced headaches with characteristic prostrating attacks on a greater than once per month basis from a hand-written log that, in essence, amounted to the same assertion, just in an itemized form rather than in prose form. As such, the Board accepts the Veteran's assertion that he experienced muscle tension headaches with characteristic prostrating attacks on at least a once-per-month basis beginning September 12, 2008. Consequently, the Board finds that a 30 percent rating is warranted for the Veteran's service-connected muscle tension headaches on and after September 12, 2008. 38 C.F.R. § 4.124, Diagnostic Code 8100. The maximum rating of 50 percent on and after September 12, 2008 is not warranted because the evidence of record did not demonstrate muscle tension headaches manifested by very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability. Id. Words such as "very frequently" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2012). The evidence demonstrated that the Veteran's muscle tension headaches with characteristic prostrating attacks occurred on an at least once-per-month basis. According to his headache log, the Veteran experienced an average of approximately 1.7 muscle tension headaches, with completely prostrating attacks, per month. He stated that these episodes could last hours up to days. The Board finds that this does not more nearly approximate very frequent, completely prostrating and prolonged attacks. 38 C.F.R. §§ 4.6, 4.7. Further, the evidence of record demonstrated that the Veteran was employed full-time as a management analyst. Although he indicated increased absenteeism due to his headaches, amounting to approximately 2 weeks over a given 12-month period, he denied that his job was in jeopardy. The evidence of record was otherwise silent as to how the Veteran's service-connected muscle tension headaches were productive of severe economic inadaptability. As such, the maximum 50 percent rating for the Veteran's service-connected muscle tension headaches is not warranted on and after September 12, 2008. 38 C.F.R. § 4.124, Diagnostic Code 8100. II. GERD Throughout the pendency of this appeal, the Veteran's GERD has been evaluated by analogy under the provisions of 38 C.F.R. § 4.124a, Diagnostic Code 7346, for hiatal hernia. 38 C.F.R. § 4.20. Diagnostic Code 7346 indicates that hiatal hernia should be rated on the basis of symptoms such as recurrent epigastric distress with dysphagia, pyrosis, and regurgitation or, in more severe situations, vomiting, hematemesis, melena, or material weight loss. 38 C.F.R. § 4.114. The Board finds that rating the service-connected GERD under Code 7346 is appropriate, as these are the same manifestations or potential manifestations produced by the Veteran's disability. Under Diagnostic Code 7346, a 30 percent evaluation is assignable for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346. A 10 percent evaluation is assignable when there are two or more symptoms for the 30 percent evaluation of less severity. Id. A March 2008 private treatment record demonstrated that the Veteran complained of chronic GERD that he stated had been gradually worsening. The Veteran described pyrosis on a daily basis, which was worse at night, but without the "alarm symptoms" of weight loss, dysphagia, early satiety, or abdominal pain. The doctor recommended that the Veteran adhere to lifestyle and diet modifications, adjusting his sleep position, exercise, and lose weight. Further, the Veteran was scheduled for and underwent an esophagogastroduodenoscopy (EGD). The results of the EGD showed "minimal chronic gastritis" and "reflux esophagitis, moderate." In May 2008, the Veteran underwent a VA examination, during which the Veteran reported that he first experienced difficulties with reflux in 2001 and that his symptoms gradually worsened. The Veteran complained of a burning sensation in his epigastric area that continued up into his throat. He also endorsed waking up with a bitter, sour taste in his mouth. He stated that his symptoms "largely resolved" since he started taking medication. He denied dysphagia, hematemesis, melena, vomiting, and regurgitation. He also denied hospitalizations or surgery. Further, there was no history of neoplasm. He endorsed some nausea, but stated that it resolved with use of medication. There were no affects on his occupational function or activities of daily living. The Veteran then provided a description of the medications he was taking, which included oxycodone, acetaminophen, aspirin, and ibuprofen. A physical examination showed an alert, obese male in no acute distress. His abdomen was soft, non-tender, and distended. There were no hepatosplenomegaly, mass, or bruit. His bowel sounds were normal. The diagnosis was GERD. A September 2008 private treatment report showed that the Veteran appeared for a follow-up appointment. This report indicated that the Veteran was initially seen in March 2008 for GERD manifested by pyrosis and regurgitation without alarm symptoms. It was also observed that the Veteran's symptoms were improved by medication at the time of the last appointment, but that in the preceding 4 weeks, he complained of increasing symptoms of regurgitation and pyrosis, worse in the morning and early evening. The Veteran denied any alarm symptoms, such as dysphagia, odynophagia, abdominal pain, early satiety, or weight loss. The doctor then stated that the quality of the Veteran's life was "diminished again." After reviewing the Veteran's medical history, a review of his systems demonstrated no loss of appetite, weight gain or loss, fatigue, chest pain, abdominal pain, black tarry stools, bloating/gas, blood in stool, change in bowel habits, constipation, diarrhea, incontinence, nausea, swallowing difficulty, or vomiting. He endorsed regurgitation/pyrosis. A physical examination demonstrated that the Veteran weighed 278 pounds. He was well-developed, well-nourished, and in no acute distress. His bowel sounds were normoactive. His abdomen was soft, non-tender, non-distended, with no rebound/guarding, no masses, and no ascites. Ultimately, the assessment was GERD with Los Angeles grade B erosive esophagitis clinically with recurrent symptoms of regurgitation and pyrosis that was most likely due to under dosing of medication. In a September 2008 statement, the Veteran reiterated his private doctor's findings that his GERD was manifested by pyrosis and regurgitation. In April 2009, the Veteran provided testimony at a Decision Review Officer hearing. The Veteran stated that his treatment records clearly documented pyrosis and regurgitation associated with his GERD. The Veteran asserted that his pyrosis worsened to the point that he was unable to sleep. Further, he asserted that his pyrosis resulted in pain that was so severe that he thought he was having a heart attack on one occasion. The Veteran then described his regurgitation as a "really dry" burning sensation in the back of his mouth. He also stated that he took medication twice daily; once in the morning and once in the evening. The Veteran provided testimony about what normally triggers the symptoms associated with his GERD, which primarily involved the consumption of certain food and beverages. The Veteran later testified that he believed that his GERD was also productive of dental disabilities. Separate claims of entitlement to service connection have been developed and adjudication for dental disabilities and, thus, are not raised here. According to a December 2009 private treatment report, the Veteran underwent a follow-up appointment for GERD with erosive esophagitis. The Veteran reported experiencing pyrosis, middle chest epigastric discomfort, and non-exertional chest pressure, which have been reduced with the use of medication. The doctor noted that, if the Veteran did not take his medication as prescribed, he would promptly experience a recurrence of his symptoms, and that such recurrence adversely affected his quality of life. The Veteran denied alarm symptoms, such as dysphagia, odynophagia, abdominal pain, early satiety, or weight loss. After reviewing the Veteran's relevant medical history, a review of the Veteran's systems demonstrated no loss of appetite, weight gain, fatigue, or weight loss. He also denied chest pain, abdominal pain, black tarry stools, bloating/gas, blood in stool, change in bowel habits, constipation, diarrhea, heartburn/reflux, incontinence, nausea, swallowing difficulties, or vomiting. A physical examination demonstrated that he weighed 257 pounds. His bowel sounds were normoactive. His abdomen was soft, non-tender, non-distended, demonstrating no rebound or guarding, no masses, and no ascites. The assessment was GERD and esophagitis, reflux. In a December 2009 statement, the Veteran reiterated the findings from his previous medical examinations concerning his GERD in support of his assertion that a rating of 30 percent should be granted. In December 2010, the Veteran provided testimony at another Decision Review Officer hearing. The Veteran read into the record the findings from previous medical appointments. He asserted that his GERD was manifested by substernal chest pain, pyrosis, and regurgitation. He then stated that his medication did a "good job" at controlling these symptoms. Further, the Veteran stated that these symptoms had "subsided to the point that perhaps once a month I really feel a problem with...pyrosis, regurgitation, or the substernal[,] arm[,] or shoulder pain." Without the medication, the Veteran stated that his symptoms would be "much more common." The Veteran then described how his eating habits needed to be altered in order to avoid experiencing GERD symptoms. In January 2011, the Veteran underwent a VA examination to assess the severity of his service-connected GERD. The Veteran reported that he experienced substernal chest pain in the 1990s. After his symptoms continued, his principle care provider referred him to a gastrointestinal specialist. The Veteran reported that clinical testing administered by this specialist reveal the presence of Helicobacter pylori. The Veteran also reported experiencing reflux and difficulty swallowing certain foods, including coffee, chocolate, mints, citrus, and, spicy foods. The course of his GERD since its onset was described as "stable." The Veteran stated that he was currently taking a medication for his GERD and that there were no side effects to the medication. With respect to his relevant medical history, the Veteran denied hospitalizations and surgery, trauma, neoplasm, vomiting, dysphagia, esophageal distress, hematemesis, melena, and esophageal dilation. The Veteran endorsed a history of nausea occurring several times each week, which was brought on by certain foods and reclining position. Further, the Veteran endorsed daily pyrosis and daily regurgitation. With respect to regurgitation, the Veteran stated that it consisted of bile-stained fluid. A physical examination demonstrated that the Veteran's overall health was "good." Moreover, there were no signs of anemia. After the administration of laboratory testing, the examiner reviewed the Veteran's employment history, which indicated that he was employed on a full-time basis as a management analyst. The examiner then rendered a diagnosis of GERD and found that the symptoms associated therewith had "significant effects" on his usual occupation due to decreased concentration and pain. The examiner also stated that the Veteran must constantly monitor his diet, but that there was no impact on his ability to perform usual daily activities. In sum, to varying degrees, the evidence record supported the Veteran's assertions that his service-connected GERD was productive of pain, nausea, pyrosis, and regurgitation throughout the appellate period. Additionally, there was conflicting evidence as to whether the Veteran's GERD was manifested by substernal chest pain. Even assuming that the Veteran's GERD was manifested by substernal chest pain in addition to the other symptoms, in order for a rating in excess of 10 percent to be warranted, not only do symptoms such as these need to be present, they must also be productive of a considerable impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346. However, during the pendency of this appeal, the Veteran stated that the symptoms associated with his GERD were essentially resolved as a consequence of taking prescribed medication, with the exception of one episode of symptoms per month. The evidence did not demonstrate that the Veteran experienced weight loss, anemia, or any other "alarm symptom" due to his GERD. Further, as a consequence of a physical examination during the May 2008 VA examination, the Veteran was considered to be alert, obese, and in no acute distress. Significantly, the January 2011 VA examiner determined that the Veteran's overall health was "good." Based on the above, the Board finds the symptoms associated with the Veteran's service-connected GERD were not productive of a considerable impairment of health. Consequently, the Board finds that the disability picture associated with the Veteran's GERD throughout the appellate period did not more nearly approximate the criteria for a 30 percent rating. As such, the Board finds that a rating in excess of 10 percent rating is not warranted for the Veteran's service-connected GERD for any distinct period during the pendency of this appeal. 38 C.F.R. §§ 4.7, 4.114, Diagnostic Code 7346. III. Right and Left Foot The ratings assigned to the Veteran's post-operative residuals of right and left foot trauma with calcaneal varus and pain were assigned according to the criteria of 38 C.F.R. § 4.71a, Diagnostic Code 5284, concerning foot injuries. Pursuant to Diagnostic Code 5284, a foot injury that is moderately severe warrants a 20 percent disability rating. If the foot injury is severe, a maximum 30 percent disability rating is warranted. Words such as "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. A December 2007 private treatment report demonstrated that the Veteran appeared for a follow-up appointment regarding a left 3rd and 4th metatarsal fracture. He reported that the outside of his left foot "seemed" to be getting better, but that he had developed some pain in the insert of the arch along the heel, which was indicative of plantar fascia strain. He was instructed to engage in aggressive stretching exercises, toe curls exercises, and take anti-inflammatory medication. A February 2008 private treatment report showed that the Veteran complained of an enlargement of the 2nd toe with a plantar abscess. He also complained of a "considerable" amount of pain on the central lateral aspect of his right foot, overlying the lateral ankle and the central and mid-foot region. Regarding the right foot pain, a gait analysis revealed a severely deformed heel in the form of a bilateral calcaneal varus deformity with significant ankle instability. Upon forced inversion and anterior drawer, he experienced significant laxity in the anterior talofibular ligament and calcaneofibular ligament with subtalar joint instability. The doctor indicated that the Veteran had "severe" calcaneal abnormality in his bilateral heels. A radiological report revealed a "severe" varus attitude, approximately 18 degrees from the resting calcaneal stance position. The doctor then recommended that the Veteran would most likely need either corrective orthotic measures or permanent, surgical correction. A March 2008 private treatment report demonstrated that the Veteran appeared for a follow-up appointment concerning his left foot. The doctor reviewed magnetic resonance imaging results, which showed no signs of any osteomyelitic changes. There was considerable abnormality on the base of the 3rd and 4th metatarsals with exuberant abnormal tissue between the 3rd and 4th metatarsals, which exhibits low signal intensity on P1, P2. Radiological examination did not reveal any type of calcification in the soft tissue structures. A computed tomography scan was recommended. According to a May 2008 letter from a private doctor of podiatric medicine, M.W.C., the Veteran reported feeling a crack on the outside of his right foot. Upon examination, the Veteran had an edematous right foot with exquisite pain laterally. A radiological examination confirmed the presence of a fracture along the lateral cortex mid shaft right foot. The doctor recommended immobilization in a long leg fracture boot and a surgical procedure for ankle stabilization. In May 2008, the Veteran underwent a VA examination. The Veteran complained of swelling in both of his feet when ambulating, and pain in both feet at rest, while standing, and during ambulation. He stated that he underwent a previous fusion of the proximal interphalangeal joint in his 2nd toe in his left foot for hyper-mobility. The Veteran denied weakness, fatigability, and flare-ups. With respect to medication, the Veteran stated that he took ibuprofen and oxycodone, with partial relief of his symptoms. At the time of the examination, the Veteran was wearing a cam walker on his left foot, which he said helped with ambulation, but did not limit pain. The Veteran estimated that he missed 10 days of work over the past year due to his feet. The examiner stated that the Veteran's activities of daily living were affected to the extent that weight-bearing activities were "particularly painful." The examiner also stated that neoplasm was not an issue. A physical examination revealed a limping gait on the left in the cam walker. He exhibited painful fore- and hindfoot motion, bilaterally, with tenderness over the left 2nd toe and 1st metatarsophalangeal joint, bilaterally. There were no ulcerations, edema, callosities, instability, or abnormal shoe wear patterns. The Veteran had bilateral "mild" bunions, left greater than right. Pes planus was not an issue, but there were bilateral calcaneal varus deformities. With respect to functional limitations, the Veteran experienced "instantaneous pain" upon standing and walking. The diagnoses were bilateral calcaneal varus; left 2nd proximal interphalangeal arthrodesis for hyper-mobility of the joint; and fore- and hindfoot painful motion secondary to his calcaneal varus deformities, bilaterally. In a June 2008 statement, the Veteran stated that, on or about May 15, 2008, he experienced "more problems" with his feet. Specifically, the Veteran stated that he broke a bone in his right foot. In a September 2008 letter that was primarily concerned with an etiological opinion, Dr. M.W.C. described the Veteran's disabilities as bilateral calcaneal varus deformities with "significant" ankle instabilities. In a second letter, dated in August 2008, the doctor indicated that the Veteran experienced "chronic" fracturing of the right 5th metatarsal with subsequent nonunion as a result of the varus attitude of the calcaneals. Moreover, the Veteran exhibited similar symptoms in his left foot for which he was scheduled to undergo surgical correction. After discussing the Veteran inservice experiences, the doctor stated that, upon physical examination the Veteran had "significant" varus deformity in the heel. In April 2009, the Veteran testified at a Decision Review Officer hearing. The Veteran's testimony was geared toward establishing service connection for his right and left foot disabilities. In so doing, the Veteran read into the record the various medical opinions already of record. The Veteran then stated that he had undergone two surgeries on his right feet and one on his left foot. In January 2011, the Veteran underwent a VA examination to assess the severity of his post-operative residuals of right and left foot trauma with calcaneal varus and pain. After briefly discussing the onset and early course of these disabilities, the Veteran stated that, in 2008, he underwent four surgical procedures: (1 and 2) stabilization of the tendons of the lateral ankles, bilaterally; (3) open reduction internal fixation of a fracture of the right 5th metatarsal; and (4) fusion of a hammertoe on the left second toe. The Veteran reported that these operations resulted in "very little" improvement. At the time of the examination, the Veteran did not use an assistive device to walk beyond shoe inserts, custom made orthotics, and custom made ankle braces. He endorsed pain on a daily basis primarily over the lateral arch and over the ball of the foot on the plantar surface, bilaterally. At rest, the Veteran endorsed pain, which increased upon standing and with ambulation. To treat his pain, the Veteran stated that he had been prescribed Tramadol by his podiatrist. The Veteran stated that his occupation was sedentary and that he experienced "no difficulty" with his employment. Moreover, the Veteran did not have difficulties performing the activities of daily living. According to the examiner, the Veteran did not have inflammatory joint disorders or constitutional symptoms. The Veteran stated that his primary problems occur with standing longer than 10 minutes or walking further than one block, both of which caused increased foot pain, bilaterally. Radiological examination of the resulted in the following impression: Multiple surgeries have been performed on both feet. On the left side[,] there is a fusion of the interphalangeal joints of the second toe. Metal plates and screws are seen in the calcaneum for the treatment of fracture. The fracture line is not visualized as it is healed. On the right side[,] there are metal plates and screws in the calcaneum for the treatment of the calcaneal fracture. The fracture line is not visualized as a fracture has healed. There is a large plantar spur. Fracture of the fifth metatarsal bone has healed and has been internally fixed with a metallic plate and screws. Hallux valgus deformity is seen on both sides. A physical examination revealed a hallux valgus of 15 degrees, bilaterally. There was tenderness over the plantar surface of the right foot, laterally and across the ball of the foot. The Veteran's shoes showed a lateral wear pattern. No unusual calluses were present. A fused proximal interphalangeal joint of the left second toe was observed as being fused in an extended position. The Veteran endorsed tenderness over the plantar surface of the ball of the foot and over the lateral aspect of the arch, bilaterally. The Veteran's arches were high, bilaterally. His gait was antalgic, with a "quick component" to the right, and the examiner noted obvious pain upon ambulation. The active range of motion on the left and right metatarsophalangeal joints of the great toe was normal. There were no unusual calluses, breakdown of the skin, or skin or vascular changes, bilaterally. There were no hammertoes, clawfoot, or other deformities present, bilaterally. The Veteran's Achilles tendon alignment was normal, bilaterally, both in weight- and non-weight bearing. There was no valgus deformity, forefoot mal-alignment, or midfoot mal-alignment, bilaterally. Ultimately, the diagnoses were residuals of right foot trauma status post tendon realignment and open reduction and internal fixation of a stress fracture of the right fifth metatarsal and residual plantar fasciitis; and residuals of left foot trauma with tendon realignment laterally and fusion of the left second toe with residual plantar fasciitis and myofascial pain. The evidence of record demonstrated that the Veteran's post-operative residuals of right and left foot trauma with calcaneal varus and pain were manifested by pain on a daily basis that was increased during ambulation and standing; severe and significant calcaneal abnormality in his heels, bilaterally; "mild" bunions; swelling; tenderness; a limping gait with obvious pain; a lateral wear pattern on his shoes; and hallux valgus of 15 degrees, bilaterally. The Veteran used shoe inserts, custom made orthotics, and custom made ankle braces. Further, he has undergone four surgical procedures, including the insertion of metal plates and screws and the fusion of bones. Based on the disability picture associated with the Veteran's service-connected post-operative residuals of right and left foot trauma with calcaneal varus and pain, the Board finds that it more nearly approximated a severe foot injury such that separate evaluations of 30 percent are warranted throughout the pendency of this appeal. 38 C.F.R. §§ 4.6, 4.7, 4.71a, Diagnostic Code 5284. Under Diagnostic Code 5284, 30 percent is the maximum available rating. Id. Other diagnostic codes pertaining to the right and left foot have been considered. Schafrath, 1 Vet. App. at 595. However, the evidence of record does not show that the Veteran has weak foot, claw foot, hallux rigidus, hammertoe, or pes planus, bilaterally. The postoperative scars were noted to be asymptomatic. Further, a rating in excess of 30 percent is not available under the diagnostic codes associated with anterior metatarsalgia, hallux valgus, or malunion or nonunion of the metatarsal bones. Thus, Diagnostic Codes 5276-5283 are not for application. See 38 C.F.R. § 4.71a, Diagnostic Codes 5276-5283 (2012). Where the evaluation is based on limitation of motion, the question of whether pain and functional loss are additionally disabling must be considered. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012). However, where a diagnostic code is not predicated on a limited range of motion alone, the provisions of 38 C.F.R. §§ 4.40 and 4.45, with respect to pain, do not apply. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Inasmuch as Diagnostic Code 5284 is not based on limitation of motion, the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 do not apply. IV. Extraschedular Generally, evaluating a disability using either the corresponding or an analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). 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, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of a veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the veteran's disability level and symptomatology, the Rating Schedule contemplates then the veteran's disability picture, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability pictures are not so unusual or exceptional in nature as to render the assigned ratings inadequate. A. Muscle Tension Headaches Prior to and on and after September 12, 2008 The Veteran's service-connected muscle tension headaches are evaluated as a neurological condition analogous to migraine headaches pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8100, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by his disability. Id. Prior to September 12, 2008, the Veteran's muscle tension headaches were manifested by pain and tenseness, but not by characteristic prostrating attacks. On and after September 12, 2008, the Veteran's muscle tension headaches were manifested by characteristic prostrating attacks that occurred on an at least once per month basis, but not very frequently and did not result in severe economic inadaptability. When comparing these disability pictures with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's muscle tension headaches prior to September 12, 2008, and on and after September 12, 2008, are adequately contemplated by the 10 and 30 percent disability ratings, respectively. Ratings in excess of those already assigned are provided in the Rating Schedule for certain manifestations of muscle tension headaches, but the medical evidence of record does not demonstrate that such manifestations were present in this case for either period of time. The criteria for the already assigned ratings more than reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular evaluations are adequate. See 38 C.F.R. § 4.124a, Diagnostic Code 8100. B. GERD The Veteran's service-connected GERD is evaluated as a digestive system disability pursuant to 38 C.F.R. § 4.114 , Diagnostic Code 7346, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by his disability. Id. The evidence associated with the Veteran's claims file demonstrated that his service-connected GERD was productive of pain, nausea, pyrosis, and regurgitation. However, these symptoms did not produce a considerable impairment of his health, to include such symptoms as weight loss and anemia. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the symptoms associated with the Veteran's GERD are adequately contemplated by the 10 percent disability rating. Ratings in excess of 10 percent are provided for certain manifestations of GERD, but the medical evidence of record does not demonstrate that such manifestations are present in this case. The criteria for the initial 10 percent disability rating contemplate the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular evaluation is adequate. See 38 C.F.R. § 4.114, Diagnostic Code 7346. C. Right and Left Foot The Veteran's service-connected post-operative residuals of right and left foot trauma with calcaneal varus and pain are evaluated as a musculoskeletal disability under 38 C.F.R. § 4.71a , Diagnostic Code 5284, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by these disabilities. Id. Throughout the appellate period, the Veteran's post-operative residuals of right and left foot trauma with calcaneal varus and pain were manifested by pain on a daily basis that was increased during ambulation and standing; severe and significant calcaneal abnormalities in his heels; "mild" bunions; swelling; tenderness; a limping gait with obvious pain; a lateral wear pattern on his shoes; and hallux valgus of 15 degrees, bilaterally. Further, the Veteran used shoe inserts, custom made orthotics, and custom made ankle braces. Moreover, he has undergone four surgical procedures to treat these disabilities, including the insertion of metal plates and screws and to fuse bones. When comparing these disability pictures with the symptoms contemplated by the Rating Schedule, the Board finds that the symptoms associated with the Veteran's right and left foot disabilities are adequately contemplated by the separate 30 percent disability ratings assigned herein. Ratings in excess of 30 percent are provided for certain manifestations of foot disabilities, but the medical evidence of record does not demonstrate that such manifestations are present in this case with respect to either foot. The criteria for the separate initial 30 percent disability ratings adequately describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular evaluations are adequate. See 38 C.F.R. § 4.71a, Diagnostic Code 5284. In reaching these decisions, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the Veteran's claims of entitlement to rating in excess of those already assigned to his service-connected disabilities, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). ORDER An initial rating in excess of 10, prior to September 12, 2008, for percent for muscle tension headaches is denied. A rating of 30 percent, but not more, on and after September 12, 2008, for muscle tension headaches is granted, subject to the laws and regulations governing the payment of monetary benefits. An initial evaluation in excess of 10 percent for GERD is denied. An initial evaluation of 30 percent, but not more, for service-connected post-operative residuals of right foot trauma with calcaneal varus and pain is granted, subject to the laws and regulations governing the payment of monetary benefits. An initial evaluation of 30 percent, but not more, for service-connected post-operative residuals of left foot trauma with calcaneal varus and pain is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND Pursuant to his claim of entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected disabilities, the Veteran was provided a VA examination in August 2009. Ultimately, the examiner opined as follows: Sleep apnea diagnosed in 2008 (7 years since separation from active duty) is not caused by or result of service-connected or the non-service connected orthopedic conditions and/or his service-connected depression which are claimed to have contributed to weight gain. As rationale for the opinion, it was noted that: No documentation noted in literature, Up to Date, or Harrison Textbook that list orthopedic and/or depression conditions as etiology of sleep apnea. Weight gain is noted as one factor of contributing to sleep problems but difficult to correlate with the [V]eteran's history and no evidence of sleep apnea noted in [service treatment records]. Information is all now related 7 years after discharge. Although the examiner briefly discussed weight gain as a contributing factor to sleeping problems, the examiner did not provide an opinion addressing whether the Veteran's obstructive sleep apnea was aggravated beyond its natural course by the Veteran's service-connected disabilities. 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439, 448 (1995)(en banc). Consequently, the Board finds that the August 2009 VA examination is not adequate for the purpose of determining the Veteran's entitlement to service connection for obstructive sleep apnea. Once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, VA must provide an adequate one or, at a minimum, notify the veteran why one will not or cannot be provided. Barr, 21 Vet. App. at 311. Accordingly, the Board finds that a remand is required in order to afford the Veteran another VA examination. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be provided another VA examination to determine the nature and etiology of his obstructive sleep apnea. The claims file must be made available to and reviewed by the examiner. All necessary and appropriate tests must be performed and their results documented. The examiner must fully describe all manifestations of the Veteran's obstructive sleep apnea. After examining the Veteran and reviewing the service and post-service treatment records, the examiner is requested to provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that obstructive sleep apnea was incurred in or due to is active duty service or was aggravated by a service-connected disability. In rendering any etiological opinion, the examiner must address the Veteran's and his spouse's assertions that he experienced symptoms during service. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion, it must be so stated, and the examiner must provide the reasons why an opinion could not be provided. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 2. In providing answers to the questions posed, the examiner is advised that the term at least as likely as not does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the contended causal relationship; less likely weighs against the claim. Further, "aggravation" is defined as a permanent worsening beyond the natural progression of the disease or disability. 3. The RO must notify the Veteran that it is his responsibility to report for any examination scheduled and to cooperate in the development of his claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for a scheduled examination, documentation must be obtained and associated with his claims file that shows that notice scheduling the examination was sent to the last known address. Documentation must also be obtained and associated with his claims file indicating whether any notice that was sent was returned as undeliverable. 4. After undertaking all additional development that is deemed necessary, the RO must then adjudicate the Veteran's claim on appeal, to include consideration of all relevant evidence of record. If the benefit sought remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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. 2012). _________________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs