Citation Nr: 1337740 Decision Date: 11/19/13 Archive Date: 12/06/13 DOCKET NO. 10-32 556 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a neck condition. 2. Entitlement to service connection for a disability manifested by numbness in the right leg. 3. Entitlement to service connection for a left knee condition. 4. Entitlement to service connection for a bilateral ankle condition. 5. Entitlement to an initial compensable rating for residuals of traumatic brain injury (TBI). 6. Entitlement to service connection for a disability manifested by numbness in the left leg. 7. Entitlement to service connection for a bilateral hip condition. 8. Entitlement to service connection for a right knee condition. 9. Entitlement to an initial compensable rating for allergic rhinitis. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from October 2005 to November 2008. His discharge is characterized as General (Under Honorable Conditions) due to misconduct (drug abuse). This matter comes before the Board of Veterans' Appeals (Board) on appeal of a May 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida that in relevant part denied service connection for a neck condition; for numbness of the right leg; for compression neuropathy of the left leg; and, for disorders of the bilateral hips, knees and ankles. Also on appeal is a June 2009 RO rating decision that granted service connection for headaches as residual to TBI and for allergic rhinitis. The rating decision assigned initial noncompensable (0 percent) ratings for both disabilities effective from November 19, 2008. In his Substantive Appeal the Veteran requested a hearing before the Board at the RO ("Travel Board") hearing, and such a hearing was duly scheduled in April 2013 but the Veteran failed without explanation to attend. His request for a hearing before the Board is accordingly deemed to be withdrawn. 38 C.F.R. § 20.704(d) (2013). The issues of entitlement to service connection for a condition claimed as numbness in the left leg, a bilateral hip condition, and a right knee condition; and entitlement to a higher initial evaluation for service-connected allergic rhinitis are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. The Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War. 2. The Veteran's complaints of right leg numbness, and left knee and bilateral ankle pain, have not been associated with any underlying diagnoses, and are not otherwise accompanied by objective indications of qualifying chronic disabilities. 3. The Veteran has a diagnosed disorder of the cervical spine, but there is no evidence of injury or symptoms in service and no competent evidence that the current disorder is etiologically related to service. 4. From November 19, 2008, the residuals of the Veteran's TBI have been manifested by a level "2" impairment in the facet of subjective symptoms. CONCLUSIONS OF LAW 1. A neck condition is not due to or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2013). 2. A disability manifested by numbness in the right leg is not due to or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2013). 3. A left knee condition is not due to or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2013). 4. A bilateral ankle condition is not due to or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2013). 5. The criteria for initial rating of 40 percent, but not more, for residuals of TBI are met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.124a, Diagnostic Code 8045 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Before addressing the merits of the claim on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2013). The VA is required to assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The VA is required to notify a claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006) (notice of the elements of the claim). The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The RO provided pre-adjudication VCAA notice by letter dated in March 2009. As for the content of the VCAA notice, the document complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370, 374 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004) (to the extent of pre-adjudication VCAA notice); and of Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006) (notice of the elements of the claim). Neither the Veteran nor his representative has alleged or demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009 (reversing prior cases law imposing a presumption of prejudice on any notice deficiency and clarifying that the burden of showing harmful or prejudicial error normally falls on the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The record also reflects that the Veteran has been afforded appropriate assistance in developing his claim. Service treatment records, service personnel records, Social Security Administration disability records and all available post-service medical evidence identified by the Veteran have been obtained. The Veteran has been afforded appropriate medical examinations to address the issues on appeal. As noted in the Introduction, the Veteran was scheduled to testify before the Board, at his request, but he failed without good cause to appear at the hearing. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal, and has not argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced him in the adjudication of this appeal. Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issue to be decided herein is available and not part of the claims file. See Mayfield, 499 F.3d 1317. Therefore, the Board finds that duties to notify and assist have been satisfied and will proceed to the merits of the issues on appeal. I. Entitlement to Service Connection Legal Principles Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Where a veteran served for at least 90 days during a period of war or after January 1, 1947, and manifests arthritis to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In the case of a veteran who engaged in combat with the enemy in a period of war, lay evidence of in-service incurrence or aggravation of a disease or injury shall be accepted if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the lack of official record of such incurrence or aggravation. 38 U.S.C.A. § 1154(b); Libertine v. Brown, 9 Vet. App. 521, 524 (1996); Collette v. Brown, 82 F.3d 389, 392-94 (Fed. Cir. 1996). The provisions of 38 U.S.C.A. § 1154(b) do not provide a substitute for medical nexus evidence, or evidence of current disability, but rather serve only to reduce the evidentiary burden on combat veterans with respect to submission of evidence regarding the incurrence or aggravation of an injury or disease while in service. Kessel v. West, 13 Vet. App. 9, 16-19 (1999) (en banc). A veteran must still establish his claim through competent medical evidence showing a current disability and a nexus between that disability and those service events. Gregory v. Brown, 8 Vet. App. 563, 567 (1996); Clyburn v. West, 12 Vet. App. 296, 303 (1999). Because the Veteran served in the Southwest Asia Theater of operations since August 2, 1990, service connection may also be established under 38 C.F.R. § 3.317. Under 38 C.F.R. § 3.317, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War. For a disability due to undiagnosed illness and medically unexplained chronic multisymptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2016. See 76 Fed. Reg. 81834 (Dec. 29, 2011) (codified at 38 C.F.R. § 3.317(a)(1)). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. at 8-9. A medically unexplained chronic multisymptom illnesses is one defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness. A "medically unexplained chronic multisymptom illness" contemplates a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities." Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). For purposes of 38 C.F.R. § 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Evidence Service treatment records (STRs) show no indication of any injury to or disorder of the neck, legs, knees or ankles during service. The only musculoskeletal abnormality noted during service was "lumbago," a low back disorder for which the Veteran has been granted VA disability benefits (currently characterized as degenerative disc disease of the lumbar spine). He had a separation physical examination in September 2008 in which the only musculoskeletal abnormality noted was low back pain; all other musculoskeletal systems, including the upper and lower extremities, were noted to be "normal" on examination. The Veteran had a VA general medical examination in April 2009, performed by a physician who reviewed the claims file. The Veteran complained that his neck was painful and tender and always felt tight. The Veteran also complained of generalized achy joints, with painful ankles and popping of the knees. Although he denied any history of injury; he reported intermittent symptoms and denied current or past treatment. Examination of the neck/cervical spine was normal, as was examination of all muscles. Examination of the knees showed clicking during range of motion but no instability, swelling, effusion or laxity. Neurological examination showed no sensory loss or motor loss in either lower extremity. Although the Veteran complained of joint pains, there were no objective abnormalities of the left knee or bilateral ankles. X-ray of the ankles was unremarkable. The examiner diagnosed normal cervical spine, normal left knee, and normal bilateral ankles. A neurological disability of the right leg was not diagnosed. The Veteran had an MRI of the cervical spine at VA in June 2009 due to a complaint of worsening neck pain. The impression was posterolateral disc protrusion/herniation at C5-6. In January 2010 the Veteran presented to a VA physical therapy clinic, at which he had been receiving treatment for his lumbar spine disability, complaining of neck pain that had been present since Iraq but was previously untreated. Examination of the neck showed tightness of the paraspinal muscles, tenderness to palpation and decreased range of motion due to pain. No diagnosis was entered, and the Veteran was referred to physical therapy. The Veteran returned to the VA physical therapy clinic in February 2010 for treatment of his neck pain, which he reported as having been present for the last few years but without specific injury. The clinical impression, consistent with previous MRI, was posterolateral disc protrusion/herniation at C5-6. The Veteran subsequently had a series of therapy sessions for his neck pain; no opinion was rendered in regard to the etiology of the disorder. The Veteran presented to the VA polytrauma/TBI clinic in April 2010 complaining of continued neck pain. Musculoskeletal examination of the lower limbs was grossly normal; similarly, neurological examination of the lower limbs showed no sensory deficiency. Examination of the cervical spine showed tenderness and decreased range of motion associated with pain. The Veteran was referred to the VA pain clinic for follow-up. The Veteran presented to the VA pain clinic in May 2010 complaining of various musculoskeletal pains in Iraq as well as neck pain. Examination showed the cervical spine to be somewhat restricted in range of motion. The clinical impression was PTSD, apparently severe, that appeared to be at least partially responsible for the Veteran's chronic musculoskeletal and possibly headache complaints. The Veteran had a VA examination of the lumbosacral spine in November 2010, during the course of which the examiner determined there was no sensory or motor impairment of either leg. Analysis Right leg, Left Knee, and Bilateral Ankles Review of the evidence above shows the Veteran has no diagnosed neurological disorder of the right leg that manifests as numbness and, no diagnosed musculoskeletal disorders of either ankle or the left knee that manifest as joint pain. Neither numbness nor joint pain is a disease or injury that may be considered a disability for VA compensation purposes; rather, they are merely symptoms. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). An exception applies if numbness or joint pain is due to a qualifying chronic disability, to include an undiagnosed illness or a medically unexplained multi- symptom illness after Persian Gulf service. 38 U.S.C.A. § 1117(g)(1); 38 C.F.R. § 3.317(b)(1). The regulations clarify that there must be objective indications of a qualifying chronic disability, which include signs or symptoms in the medical sense, of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(1) and (3). While the Veteran's reports of right leg numbness and bilateral ankle and left knee joint pain are credible, all clinical evaluations have shown no actual sensory deficit in the right leg and no actual impairment of the left knee or either ankle. The Veteran has not been diagnosed with fibromyalgia. In other words, there are no objective indications of a qualifying chronic disability, so the Board has no basis on which to conclude that service connection under 38 C.F.R. § 3.317 is warranted. There is no indication of complaints in service related to the right leg, left knee or either ankle, and there is no competent evidence of current chronic disabilities affecting the right leg, left knee or either ankle. While the Veteran believes he has current disorders of the right leg, left knee and bilateral ankles, and that they are related to service, his lay opinion on this matter is not competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Rendering a diagnosis of chronic neurological and musculoskeletal disorders, and determining the etiology of such disorders, are complex medical questions, particularly when the record demonstrates there are no specific injuries or symptoms during service. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). No factual foundation has been established to show the Veteran is qualified through specialized education, training, or experience to diagnose such conditions, or to offer an opinion on the causal relationship or nexus between such disorders and his period of active service. For these reasons, his lay opinion is not competent evidence. The Veteran otherwise has not provided any medical evidence to establish that he currently has chronic disorders of the left knee, right leg, or bilateral ankles. Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability ... in the absence of a proof of present disability there can be no claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the absence of competent evidence of a current disability manifested by right leg numbness and bilateral ankle and left knee joint pain during the course of the appeal, service connection cannot be granted for those disorders. Because the preponderance of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. Cervical Spine The Veteran has been diagnosed with disc protrusion/herniation of the cervical spine. Accordingly, the first element of service connection - competent evidence of a current disability - is met in regard to this disability. However, neither the second element of service connection (an injury or event in service) nor the third element of service connection (relationship between the current disability and service) is shown. In this case, there is no indication of a cervical spine injury or chronic cervical spine disorder in service. The Board acknowledges that the Veteran has a Combat Infantryman Badge (CIB) demonstrating personal participation in combat that warrants consideration of lay evidence of injury in service under 38 U.S.C.A. § 1154(b). However, the Veteran has not asserted that he sustained an in-service neck injury. The Veteran suggests his neck complaints may be related to wearing body armor, but he has not suggested a combat-related injury to the neck or cervical spine. Accordingly, the "combat presumption" under 38 U.S.C.A. § 1154(b) is not raised. Although the file shows evidence of a current disability, there is no evidence that the current cervical spine disability is etiologically related to service (i.e., the third element of service connection- a relationship between the current disability and service). A veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000); Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998). Where an opinion is used to link the current disability to a cause during service, a competent opinion of a medical professional is required. Caluza, 7 Vet. App. 498. The Veteran's representative submitted an Informal Hearing Presentation in August 2013 asserting that the Veteran's cervical spine disorder is degenerative disc disease (DDD), which is equivalent to degenerative joint disease (DJD) and should accordingly be considered for presumptive service connection as "arthritis" under the provisions of 38 C.F.R. § 3.309(a). The Board disagrees. The Veteran is shown to have a herniated disc, which is not in any way synonymous with degenerative arthritis. There is nothing in 38 C.F.R. § 3.309(a) that suggests the presumption is intended to apply to a herniated disc. Evidence of continuity of symptoms is for consideration in regard to disorders recognized as "chronic" under 38 C.F.R. § 3.309(a); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As none of the claimed disabilities are listed in that regulation, lay evidence of chronicity is not for consideration. Because this disorder has a clear diagnosis, consideration under 38 C.F.R. § 3.317 for an undiagnosed illness or chronic multisymptom illness is not applicable. Service connection may be granted for disability shown after service, when all of the evidence shows that it was incurred in service. 38 C.F.R. § 3.303(d). In this case, there is no competent evidence, lay or medical, that shows the Veteran's current cervical spine disorder is otherwise related to service. While the Veteran believes his current neck condition is related to service, his lay opinion on this matter is not competent evidence. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Determining the etiology of a cervical spine disc protrusion/herniated disc is a complex medical question, particularly when the record demonstrates there are no specific neck injuries or symptoms during service. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). No factual foundation has been established to show the Veteran is qualified through specialized education, training, or experience to offer an opinion on the causal relationship or nexus between a cervical spine disc protrusion/herniated disc and his period of active service. For these reasons, his lay opinion is not competent evidence. The Veteran otherwise has not provided any medical evidence to establish that his current neck condition is related to service. The Veteran's representative also asserts the file should be remanded for the purpose of providing the Veteran an examination to determine the etiology of his current cervical spine disorder. The Board disagrees. The file does not show, and the Veteran does not assert, that he had an injury during service to the cervical spine. He has accordingly not shown a prima facie case of entitlement to service connection, and VA examination is not required. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). See also Wells v. Principi, 326 F. 3d. 1381, 1384 (Fed. Cir. 2003); Duenas v. Principi, 18 Vet. App. 512 (2004) (per curiam). In short, there is no competent evidence in favor of the claim for a cervical spine disorder, and the preponderance of the evidence is against the claim under the applicable theories of service connection. Because the preponderance of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. II. Evaluation of the Service-Connected Traumatic Brain Injury Legal Principles Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2013). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. The RO has rated this disability under the provisions of 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8045 (brain injuries due to trauma) and also under the provisions of DC 8100 (migraines). The rating criteria for those DCs are set forth below. The Board notes at this point that the rating criteria for DC 8045 were revised effective from October 23, 2008, immediately prior to the Veteran's grant of service connection. The old criteria are not for consideration. Revised DC 8045 states that there are three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. "Cognitive impairment" is defined as decreased memory, concentration, attention, and executive functions of the brain. "Executive functions" are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day-to-day. Evaluate cognitive impairment under the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified. Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified. However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Ménière's disease, even if that diagnosis is based on subjective symptoms, rather than under the Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified table. Evaluate emotional/behavioral dysfunction under § 4.130 (Schedule of ratings--mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified. Evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. Consider the need for Special Monthly Compensation (SMC) for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. Evaluation of Cognitive Impairment and Subjective Symptoms: The table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified contains 10 important facets of TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled "total." However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than "total," since any level of impaired consciousness would be totally disabling. Assign a 100- percent evaluation if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. For the facet memory, attention, concentration, executive functions a "0" level of impairment is assigned with no complaints of impairment. A "1" level is assigned with complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, finding words or often misplacing items), attention, concentration or executive functions, but without objective evidence on testing. A "2" level is assigned with objective evidence on testing of mild impairment. A "3" level is assigned with objective evidence on testing of moderate impairment. A "total" level is assigned with objective evidence on testing of severe impairment. For the facet judgment a "0" level of impairment is assigned for normal judgment. A "1" level is assigned with mildly impaired judgment; for complex or unfamiliar decisions, occasionally unable to identify, understand and weigh the alternatives, understand the consequences of choices, and make a reasonable decision. A "2" level is assigned with moderately impaired judgment; for complex or unfamiliar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, although has little difficulty with simple decisions. A "3" level is assigned with moderately severely impaired judgment; for even routine and familiar decisions, occasionally unable to identify, understand, weigh the alternatives, and make a reasonable decision. A "total" level is assigned with severely impaired judgment; for even routine and familiar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision; for example, unable to determine appropriate clothing for current weather conditions or judge when to avoid dangerous situations and activities. For the facet social interaction a "0" level of impairment is assigned when social interaction is routinely appropriate. A "1" level is assigned when social interaction is occasionally inappropriate. A "2" level is assigned when social interaction is frequently inappropriate. A "3" level of impairment is assigned when social interaction is inappropriate most or all of the time. For the facet orientation a "0" level of impairment is assigned when always oriented to person, time, place and situation. A "1" level is assigned when occasionally disoriented to one of the four aspects of orientation. A "2" level is assigned when occasionally disoriented to one of the four aspects of orientation or often disoriented to one aspect of orientation. A "3" level is assigned when often disoriented to two or more of the four aspects of orientation. A "total" level is assigned when constantly disoriented to two or more of the four aspects of orientation. For the facet motor activity (with intact motor and sensory system) a "0" level of impairment is assigned for normal motor activity. A "1" level is assigned for motor activity that is normal most of the time but mildly slowed at times due to apraxia (inability to perform previously-learned motor activities despite normal motor function). A "2" level is assigned for motor activity mildly decreased or with moderate slowing due to apraxia. A "3" level is assigned for motor activity moderately decreased due to apraxia. A "total" level is assigned for motor activity severely decreased due to apraxia. For the facet visual spatial orientation a "0" level of impairment is assigned when normal. A "1" level is assigned when mildly impaired: occasionally gets lost in unfamiliar surroundings; has difficulty reading maps or following directions; is able to use assistive devices such as GPS (global positioning system). A "2" level is assigned when moderately impaired: usually gets lost in unfamiliar surroundings; has difficulty reading maps, following directions and judging distance; has difficulty using assistive devices such as GPS. A "3" level is assigned when moderately severely impaired: gets lost even in familiar surroundings; unable to use assistive devices such as GPS. A "total" level is assigned when severely impaired: may be unable to touch or name own body parts when asked by the examiner, identify the relative position in space of two different objects, or find the way from one room to another in a familiar environment. For the facet subjective symptoms a "0" level of impairment is assigned for subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family of other close relationships (examples are mild or occasional headaches or mild anxiety). A "1" level is assigned with three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family of other close relationships (examples of findings that might be seen at this level of impairment are intermittent dizziness, daily mild-to-moderate headaches, tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light). A "2" level is assigned with three or more subjective symptoms that moderately interfere with work; instrumental activities of daily living; or, work, family of other close relationships (examples of findings that might be seen at this level of impairment are marked fatigability, blurred or double vision, headaches requiring rest periods during most days). For the facet neurobehavioral effects a "0" level of impairment is assigned for one or more neurobehavioral effects that do not interfere with workplace interaction or social interaction. Examples of neurobehavioral effects are: irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, physical aggression, belligerence, apathy, lack of empathy, moodiness, lack of cooperation, inflexibility, and impaired awareness of disability. Any of these effects may range from slight to severe, although verbal and physical aggression are more likely to have a more serious impact on workplace interaction and social interaction than some other effects. A "1" level is assigned with one or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them. A "2" level is assigned with one or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them. A "3" level is assigned with one or more neurobehavioral effects that interfere with or preclude workplace interaction, social interaction, or both on most days or that occasionally require supervision for safety of self or others. For the facet communication a "0" level of impairment is assigned when able to communicate by spoken or written language (expressive communication) and to comprehend spoken and written language. A "1" level is assigned when comprehension or expression, or both, of either spoken or written language is only occasionally impaired; can communicate complex ideas. A "2" level is assigned with inability to communicate either by spoken language, written language, or both, more than occasionally but less than half the time, or to comprehend spoken language, written language, or both, more than occasionally but less than half the time; can generally communicate complex ideas. A "3" level is assigned with inability to communicate either by spoken language, written language, or both, at least half the time but not all the time, or to comprehend spoken language, written language, or both, at least half the time but not all the time; may rely on gestures or other alternative modes of communication; able to communicate basic needs. A "total" level is assigned for complete inability to communicate either by spoken language, written language, or both, or to comprehend spoken language, written language, or both; unable to communicate basic needs. For the facet consciousness a "total" level of impairment is assigned for persistently altered state of consciousness, such as vegetative state, minimally responsive state, and coma. Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4): The terms "mild," "moderate" and "severe" TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under diagnostic code 8045. Note (5): A veteran whose residuals of TBI are rated under a version of § 4.124a, diagnostic code 8045, in effect before October 23, 2008 may request review under diagnostic code 8045, irrespective of whether his or her disability has worsened since the last review. As this Veteran was not service-connected until November 2008, Note (5) does not apply. Headaches are rated under the provisions of DC 8100. A rating of 50 percent is assigned with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A rating of 30 percent is assigned with characteristic prostrating attacks occurring on an average once per month over the last several months. A rating of 10 percent is assigned with characteristic prostrating attacks averaging one in 2 months over the last several months. A noncompensable rating is assigned with less frequent attacks. The rating criteria do not define "prostrating," nor has the Court. See Fenderson v. West, 12 Vet. App. 119 (1999), in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack. By way of reference, the Board notes that according to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), in which "prostration" is defined as "extreme exhaustion or powerlessness." In any claim for higher ratings, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). As this is an initial rating claim, the period under review begins on November 19, 2008, the effective date of service connection. Fenderson, 12 Vet. App. 119. Evidence Historically, the Veteran's original claim for service connection, received in February 2009, did not specifically request compensation for residuals of TBI; rather, he requested service connection for migraines and for sensitivity to bright light. Photophobia (sensitivity to light) is not a recognized disability under VA criteria, absent some diagnosed underlying disorder, but headaches are recognized as a disability rateable under DC 8100 as cited above. The RO combined both claims into the award for service connection for residuals of TBI. The Veteran had a VA eye examination in March 2009 in which he complained of sensitivity to bright light, which he stated was a cause for his headaches. On examination, the optometrist was unable to find any retinal or ocular cause for the Veteran's symptoms and recommended follow-up by a neuro-opthalmologist with possible electro-diagnostic testing. The Veteran had a VA general medical/TBI examination in April 2009, performed by a physician who reviewed the claims file. The Veteran complained of migraines, and stated his headaches had started several months after being exposed to blasts in Iraq; he also stated he developed severe sensitivity to light after returning home. The examiner noted that STRs documented complaints of headaches and photophobia in service. The Veteran reported his headaches had gotten progressively worse since onset; he endorsed current treatment with medication (ibuprofen) but only "fair" response to treatment. The Veteran reported having to wear dark glasses outdoors and having to keep the light dim indoors. He also complained of sleep disturbance due to bad dreams and constant fatigue. During examination the Veteran denied a history of angina, syncope, dyspnea, fatigue or dizziness. He denied any neurologic symptoms such as weakness or paralysis, paresthesias, numbness, memory loss, poor coordination, vision loss or speech difficulties; however, he endorsed psychiatric symptoms of difficulty with interpersonal relationships, depression, panic attacks, substance abuse, anxiety and sleep impairment. In the field of "cognitive impairment and other residuals" the Veteran had no complaints of impairment of memory, attention, concentration or executive function. His judgment was considered normal, although social interaction sometime inappropriate. He was always oriented times four. Motor activity and visual/spatial orientation were both normal. Communication was normal, as was consciousness. The examiner diagnosed "headaches of undetermined etiology" and stated the possible etiology of the Veteran's headaches was intertwined between PTSD, residuals of mild TBI, history of drug use and a psychological overlay; it would be impossible to identify the real cause of his headaches until the psychological and psychosocial issues stabilize. The examiner noted severe photosensitivity with no ocular pathology, which would need further workup to determine etiology. The examiner stated the Veteran was not employed, so there was no occupational impairment, but the headaches and photosensitivity caused a significant functional impairment of the Veteran's usual daily activities. The Veteran subsequently had a VA TBI/headaches examination in May 2009, again performed by an examiner who reviewed the claims file. The Veteran complained of headaches, severe light sensitivity that caused him to wear dark glasses most of the time, and neck pain sometimes radiating to the head. In regard to overall TBI symptoms the Veteran endorsed cognitive symptoms of short-term memory loss, work-finding difficulties, slower speed of thinking and disorganized or confused thinking. He endorsed physical symptoms of blurry or double vision, ringing in the ears, headaches, sensitivity to bright lights and loud noise and tingling or numbness in the legs or arms. Emotionally the Veteran endorsed feelings of sadness or depression, decreased emotion, decreased appetite, difficulty getting to sleep and staying asleep, irritability/easy frustration and feelings of anxiety or fear. The examiner continued the previous diagnosis of "headaches of unknown etiology but stated it was doubtful the Veteran's headaches could be attributed to the TBI alone. The Veteran's mother submitted a lay statement in November 2009 that primarily addressed the psychiatric manifestations of the Veteran's PTSD, but she also stated the Veteran had demonstrated night vision problems, extreme sensitivity to bright lights and frequent migraine headaches. The Veteran presented to the VA pain clinic in May 2010 complaining of chronic headaches unresponsive to medication. These headaches appeared to be intertwined with his daily sinus complaints and also with anxiety. The Veteran had a VA TBI/headaches examination in November 2010, performed by a Doctor of Osteopathy (D.O.) who reviewed the claims file. The Veteran reported weekly migraine headaches, less than half of which were prostrating. The headaches were not treated with continuous medication and usually resolved within hours. The examiner diagnosed chronic headaches and stated the occupational impairment associated with this disorder was increased tardiness and absenteeism, decreased concentration, inappropriate behaviour, poor social interaction, problems with lifting and carrying, lack of stamina, weakness or fatigue, and pain. There were no effects on the Veteran's usual daily activities other than to preclude sports or recreation. The examiner stated the Veteran's headaches do interfere with his ability to perform physical or sedentary types of employment. Analysis The Board notes at the outset that the Veteran is service-connected for posttraumatic stress disorder (PTSD), rated as 70 percent disabling under 38 C.F.R. § 4.130, DC 9411. Certain impairments cited in the rating criteria for TBI, such as memory loss and sleep impairment, are also specifically incorporated into the rating criteria for PTSD. The evaluation of the same manifestation under various different diagnoses is to be avoided; see 38 C.F.R. § 4.14; see also Brady v. Brown, 4 Vet. App. 203 (1993), holding that the rating schedule may not be employed as a vehicle for compensating a claimant twice or more for the same symptomology because such a result would overcompensate the claimant for the actual impairment of his earning capacity and would constitute pyramiding. Applying the criteria of DC 8045 (brain damage due to trauma), the Board finds the Veteran's disability picture most closely approximates criteria for a rating of 40 percent. For the facet memory, attention, concentration, executive functions, a level "1" impairment is appropriate. Memory loss is a symptom that is incorporated into the Veteran's 70 percent rating for PTSD, and may not be considered as a basis for evaluation under another DC. Brady, 4 Vet. App. 203. However, the TBI examination in November 2010 found that an impairment associated with the Veteran's TBI is "decreased concentration," which is not one of the symptoms enumerated in the rating schedule for mental disorders and may accordingly be considered under DC 8045. In terms of severity, during PTSD examination in November 2010 the Veteran's attention was intact and he was able to do serial 7s and to spell words forwards and backwards, albeit slowly. Thus, his impairment of concentration is a complaint and is not clinically shown, and level "1" is appropriate. For the facet judgment a "0" level of impairment is appropriate. TBI examination in April 2009 found the Veteran's judgment to be normal and the VA PTSD examiner in November 2010 stated the Veteran understood the outcome of his behavior. In sum, there is no clinical evidence of record showing impaired judgment. Further, impairment of judgment is one of the specific criteria cited in the schedule of ratings for mental disorders as a symptom warranting the Veteran's current 70 percent evaluation for PTSD. Brady, 4 Vet. App. 203. For the facet social interaction a "1" level of impairment is appropriate. The TBI examiner in April 2009 stated the Veteran's social action was "sometimes inappropriate" and TBI/headaches examination in November 2010 stated the Veteran's disability was manifested in relevant part by inappropriate behaviour and poor social interaction. There is no evidence that such behaviour occurs "frequently" or "most or all of the time" so level "1" is assigned. For the facet orientation a "0" level of impairment is appropriate. During every examination of record the Veteran was consistently oriented in all four aspects. For the facet motor activity a "0" level of impairment is appropriate since the Veteran's motor and sensory systems are consistently shown to be intact on examination. For the facet visual spatial orientation a "0" level of impairment is appropriate as the Veteran is not shown to have any impairment in this area. For the facet subjective symptoms a "2" level of impairment is appropriate. The Veteran complained in May 2009 of three or more symptoms that moderately interfere with work; i.e., photophobia, blurry or double vision, ringing in the ears, headaches, sensitivity loud noise and tingling/ numbness in the legs. Further, the VA examiner in November 2010 stated the Veteran's headaches interfere with his ability to perform physical or sedentary types of employment. Thus, a level "2" is appropriate, which is the highest level available in this facet. For the facets neurobehavioral effects, communication and consciousness a "0" level of impairment is assigned because the Veteran demonstrates no impairment in these areas. Thus, the Veteran's highest level of impairment in any facet is "2" in the subjective symptoms facet. An initial rating of 40 percent is accordingly warranted under DC 8045. Turning to the criteria of DC 8100 (migraines), a 50 percent rating requires very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability. The Veteran does not assert, and the medical evidence of record does not suggest, that these criteria are met. The next lower evaluation under DC 8100 is at the 30 percent level, so alternative rating under DC 8100, versus DC 8045, presents no benefit to the Veteran. The Board has found no discrete time period during the period under review in which the criteria for evaluation higher than 40 percent were met. Accordingly, "staged" initial rating is not warranted. Fenderson, 12 Vet. App. 119. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the Veteran's service-connected TBI disability. The schedular rating criteria incorporate all of the Veteran's reported symptoms, and also provide for higher rating if increased severity is shown. For these reasons, the Board concludes the Veteran's level of such occupational and social impairment is adequately reflected by the current schedular rating, and the manifestations of the Veteran's TBI disability are accordingly contemplated in the rating criteria. There is no indication of any exceptional or unusual disability picture. The rating criteria are therefore adequate to evaluate the Veteran's service-connected residuals of TBI and referral for consideration of extraschedular rating is not warranted. The Veteran is in receipt of a TDIU, based on his service-connected PTSD, so no further consideration of TDIU is warranted. In sum, based on the evidence and analysis above, the Board finds that during the period under review the disability picture associated with the Veteran's TBI residuals has approximated the criteria for a rating of 40 percent, but not more. His appeal is granted to that extent. Benefit of the doubt on this issue has been resolved in the Veteran's favor. Gilbert, 1 Vet. App. 49, 54-55. ORDER Service connection for a neck condition is denied. Service connection for a disability manifested by numbness in the right leg is denied. Service connection for a left knee condition is denied. Service connection for a bilateral ankle condition is denied. An initial rating of 40 percent for residuals of TBI is granted, subject to the criteria applicable to the payment of monetary benefits. REMAND The Veteran seeks service connection for a condition claimed as numbness in the left leg, a bilateral hip condition, and a right knee condition. The Veteran had a VA general medical examination in April 2009. He reported intermittent left leg numbness began during service after an improvised explosive device (IED) detonated in camp, causing him to fall down. The examiner noted that VA clinical records had categorized the Veteran as having intermittent compression neuropathy of the left leg. The Veteran also complained of generalized achy joints, with painful hips and popping of the knees. He denied any history of injury. X-ray showed an area of scoliosis in the right knee that was nonspecific but possibly related to a bone infarct or to an underlying enchondroma; other etiologies could not be excluded and magnetic resonance imaging (MRI) study was recommended. Following the clinical examination, the examiner provided pertinent diagnoses of mild sclerosis of the sacroiliac joints of the bilateral hips, enchondroma of the right knee, and intermittent compression neuropathy of the left leg, with no current objective findings. The examiner did not provide any opinion regarding the etiology of these disorders. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, remand is required for a medical opinion regarding any nexus to service. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McClendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran also seeks a higher initial rating for his service-connected allergic rhinitis. Further development is required before this issue can be adjudicated. The Veteran's representative submitted an Informal Hearing Presentation in August 2013 asserting that the Veteran's disability has increased in severity since the last VA examination in November 2010. A new VA examination is accordingly required in order to document the current level of the Veteran's disability. See 38 C.F.R. § 3.159(c)(4); see also VAOPGCPREC 11-95 (holding that although the Board is not required to direct a new examination simply because of the passage of time, a new examination is appropriate when the claimant asserts that the disability in question has undergone an increase in severity since the time of the last examination). Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and his representative and request that they provide sufficient information, and if necessary, authorization, to enable the RO to obtain any additional evidence pertinent to the claims on appeal. After securing the necessary authorizations for release of this information, obtain copies of all records referred to by the Veteran not already of record, including any pertinent VA treatment records since June 2010. Any negative response must be in writing and associated with the claim file. 2. Schedule the Veteran for a VA examination by an appropriate medical professional. The entire claim file (i.e., the paper claim file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claim file so they can be available to the examiner for review. The examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the compression neuropathy in the left leg, the sclerosis of the sacroiliac joints of the bilateral hips, and the right knee enchondroma manifested during service, or are otherwise related to service; or, are caused or aggravated by any service-connected disability. The examiner is advised that the term "aggravation" means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 3. Afford the Veteran an examination by an examiner with sufficient expertise to determine the current severity of his service-connected allergic rhinitis. The claims folder must be made available to and reviewed by the examiner, and any indicated studies should be performed. The examiner should document the Veteran's respiratory symptoms in terms conforming to the rating schedule. In addition to dictating objective test results, the examiner's report should fully describe the effects of the Veteran's disability on his occupational functioning and daily activities. The examiner should provide a complete rationale for all opinions provided. 4. After undertaking any other development deemed warranted, readjudicate the issues on appeal. Then, readjudicate the appeal. If the benefits sought remain denied, issue a Supplemental Statement of the Case and return the case to the Board. By this remand, the Board intimates no opinion regarding any final outcome warranted. The Veteran has the right to submit additional evidence and argument on the matter or matters 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ D. JOHNSON Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs