Citation Nr: 1338798 Decision Date: 11/25/13 Archive Date: 12/06/13 DOCKET NO. 13-23 060 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Togus, Maine THE ISSUES 1. Entitlement to service connection for a left hip disorder. 2. Entitlement to service connection for a left tibia disorder. 3. Entitlement to an initial evaluation in excess of 30 percent for tension headaches. 4. Entitlement to an initial evaluation in excess of 10 percent for left foot tendonitis. 5. Entitlement to an initial evaluation in excess of 10 percent for left knee patellofemoral syndrome. 6. Entitlement to special monthly compensation (SMC) based on need for aid and attendance. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Peters, Associate Counsel INTRODUCTION The Veteran had active duty service from September 1974 to September 1977 and from November 1985 to March 1986. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2013 and February 2013 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for tension headaches, left knee and left foot disorders, and assigned 30 percent, 10 percent and 10 percent evaluations for those disabilities, respectively, effective October 2, 2012-the date on which he filed his claim for service connection-and denied service connection for left tibia and hip disorders and entitlement to SMC, respectively. The Veteran timely appealed those two decisions. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Chronic left hip disability did not have its clinical onset in service and is not otherwise related to active duty. 2. Chronic left tibia disability did not have its clinical onset in service and is not otherwise related to active duty. 3. Tension headaches, throughout the appeal period, were not manifested by very frequent characteristic prostrating and prolonged attacks productive of severe economic inadaptability. 4. Throughout the appeal period, the Veteran's left foot tendonitis is not shown to be moderately severe in severity. 5. The patellofemoral syndrome of the left knee is shown throughout the appeal period to have objective findings of flexion to 100 degrees with pain and extension to 0 degrees; the evidence of record does not demonstrate any complaints of laxity, instability or recurrent patellar subluxation/dislocation, nor is there any evidence of dislocated semilunar cartilage of the left knee, frequent episodes of locking, or any effusion of the left knee. 6. The Veteran is not shown to have a need for aid and attendance due solely to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for a left hip disorder have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2013). 2. The criteria for establishing service connection for a left tibia disorder have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2013). 3. The criteria establishing an initial evaluation in excess of 30 percent for tension headaches have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Code 8100 (2013). 4. The criteria establishing an initial evaluation in excess of 10 percent for a left foot tendonitis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5024, 5284 (2013). 5. The criteria establishing an initial evaluation in excess of 10 percent for a left knee patellofemoral syndrome have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5257-5261 (2013). 6. The criteria for special monthly compensation based on the need for aid and attendance have not been met. 38 U.S.C.A. §§ 1114(l) (West 2002); 38 C.F.R. §§ 3.350, 3.352 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Proper notice from VA must inform the claimant 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 claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA 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). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). With regards to the increased evaluation claims for tension headaches, left foot and left knee disabilities, those claims arise from an appeal of the initial evaluations following the grants of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA as to those claims herein decided. With respect to the SMC and service connection claims for left hip and left tibia disorders, the Veteran was sent letters in November 2012 that provided information as to what evidence was required to substantiate those claims and of the division of responsibilities between VA and a claimant in developing an appeal. Those letters also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify as to those claims herein decided. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims herein decided. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Analysis The Board has reviewed all of the evidence in the Veteran's claims file. 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 Veteran or obtained on his 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). Service Connection Claims for Left Hip and Left Tibia Disorders Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). "[L]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as opposed to merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service (or during any applicable presumptive period) is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). However, 38 C.F.R. § 3.303(b) only applies to the list of chronic diseases/disabilities recognized by VA as being chronic and those chronic diseases/disabilities are listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that 38 C.F.R. § 3.303(b) only applies to the listed chronic disabilities in 38 C.F.R. § 3.309(a)). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2013). A review of the Veteran's service treatment records reveals that the Veteran's left hip and tibia were normal on enlistment in August 1974, though he did complain of cramps in his legs on enlistment in August 1974. The Veteran's left hip and tibia were normal on separation in July 1977, and no intervening treatment records show any complaint of, treatment for, or diagnosis of any left hip or tibia problems. In July 1985, on enlistment, the Veteran's left hip and tibia were again noted as normal, but he again complained of cramps in his legs at that time. In January 1986, the Veteran sought treatment for left leg symptoms that had been present for a week; he related that he did not have pain prior to that, that there was no precipitating trauma, and that his leg and joint were not swollen. It appears the Veteran was given crutches at that time. Approximately two weeks later, in February 1986, the Veteran complained of persistent distal left tibia pain; he was scheduled for a bone scan. The Veteran was diagnosed with "overuse secondary to using crutches to support his right" side three days later. Four days after that, the Veteran complained of left tibia, foot and knee pain after falling while using his crutches; on examination, the Veteran's left hip was normal and his left tibia was tender distally about half way along the posterior medial aspect. The Veteran was diagnosed with "multiple overuse of the bilateral lower extremities." Approximately a week later, the Veteran underwent a bone scan in February 1986, which was shown to be normal. He also had an orthopedic consultation which noted that he has questionable overuse of his bilateral lower extremities, with minimal objective findings and that his subjective complaints were greater than the objective findings. He was put on a profile for 14 days at that time. He was noted as having a full range of motion and his bone scan was normal. The Veteran was discharged from service approximately a month later. The Veteran underwent a VA examination in February 1987, at which time no left hip or tibia disorder was noted, though pain in his legs was noted. The Board has additionally reviewed the Veteran's Social Security Administration records which have been associated with the claims file. Generally, those records do not demonstrate any left hip or tibia disorders or problems. More specifically, however, a June 1995 treatment records from Dr. V.R. indicated that left hip and pelvis x-rays from that time did not reveal any evidence of fracture or subluxation. An April 2000 private orthopedic examination from Dr. J.R. indicated that the Veteran had an accident in 1994, and that since that time he has had lumbar spine pain and three surgeries. The Veteran's lower extremities were examined at that time and were unremarkable, with full ranges of motion in the hips shown. His left leg pain was related to radicular symptoms associated with his lumbar spine disorder. Other records confirm the Veteran's left sciatica secondary to his lumbar spine disorder which appears to be the result of a 1994 work-related accident throughout those records. The Board has reviewed the other private and VA treatment records associated with the claims file. Those records generally are for unrelated medical problems associated with his pancreatic cancer or his lumbar spine disorder, and do not demonstrate any left hip or tibia complaints or problems. In fact, in the Veteran's March 2007 initial treatment examination with VA, the Veteran denied pain with the exception of lumbar spine pain. The Veteran claimed service connection in October 2012, and he underwent a VA examination in January 2013. The examiner noted the above service treatment records regarding the left hip and tibia complaints from 1986. With respect to the left tibia, the Veteran reported that he had not had left tibia pain since service. During examination of the knee and tibia, the examiner noted that the Veteran had a history of "shin splits" (medial tibial stress syndrome) on the left side, but that such had completely resolved and that the bone scan in service was negative. The Veteran was not diagnosed with any left tibia disorder at that time; it was noted that he was unable for him to tolerate x-rays. Likewise, the examiner noted that the Veteran's left hip pain was due primarily to radiculopathy from his lumbar spine disorder. The Veteran reported that he has had left hip pain since service, but the examiner noted the severe lumbar spine degenerative disc disease and three surgeries since his work-related accident in 1994, which included radiating back pain into his buttocks, hip and down his left leg to his foot. After examination, the examiner opined that the Veteran's left hip disorder was less likely than not incurred in or caused by his military service. She noted that his service treatment records showed normal left hip examinations and that they disclosed no left hip diagnoses. She noted that the Veteran had a right hip strain in service that had resolved, and that the Veteran was currently complaining of left hip pain, not right hip pain. "Based on records, it appears that the pain in the left hip area is primarily due to his severe lumbar spine pain and radiculopathy." She additionally noted that the Veteran was in terrible diffuse pain now due to his terminal cancer as well. Based on the foregoing, the Board finds that service connection for left hip and left tibia disorders is not warranted because there are no current diagnoses of left tibia or left hip disability, and no showing of pertinent disability since the Veteran filed his compensation claim. Initially, the Board notes that while the Veteran is competent to relate that he has pain in his left hip and left tibia, he is not competent to render a diagnosis for any condition thereof. 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); see also Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). With respect to the left tibia, the Board notes that the Veteran does not even claim that he has current left tibia pain, but specifically denied having pain in his left tibia since service in his most recent VA examination. That examination did not demonstrate any left tibia disorder at that time. None of the other VA or private treatment records in the claims file, including the Social Security Administration documents, demonstrate any diagnosis of a left tibia disorder. Turning to the left hip disorder, in the most recent VA examination, the Veteran is shown to have left hip pain. The Board notes that pain, without an underlying malady, is not a service connectable disability. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), dismissed in part, vacated in part on other grounds sub. nom. Sanchez-Benitez v. Principi, 259 F.3d 1356, 1362 (Fed. Cir. 2001) (pain, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection can be granted). Indeed, that left leg and hip pain is shown in the records to be associated with the Veteran's lumbar spine disorder as a radicular symptom, rather than an independent left hip disorder. The Board notes again that the evidence, particularly the older evidence from 1995 and 2000 do not demonstrate any left hip disorders or problems at those times. The Veteran's private and VA treatment records, including the Social Security Administration documents, in the claims file do not demonstrate any diagnosis of a left hip disorder. In summary, while the Veteran may have had some left tibia and hip problems during his later period of service due to overuse, such problems appear to have resolved, and there are no current diagnosed issues with respect to his left tibia or left hip at this time. Accordingly, service connection for left tibia and left hip disorders is denied on the evidence of record at this time. See 38 C.F.R. § 3.102, 3.303; Brammer v. Derwinski, 3 Vet. App. 223 (1995) (Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability). In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Increased Evaluation Claims for Tension headaches, Left Foot and Left Knee Disorders Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2013); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2013); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2013); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2013). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the claimant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2013); see also 38 C.F.R. § 4.45 (2013). Tension headaches The Veteran's tension headaches have been evaluated as 30 percent disabling, effective October 2, 2012-the date on which he filed his claim for service connection. The Veteran's evaluation was assigned under 38 C.F.R. § 4.124a, Diagnostic Code 8100. Under Diagnostic Code 8100, a rating of 50 percent is warranted for migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability; a 30 percent rating is warranted for migraine headaches with characteristic prostrating attacks occurring on an average once a month over last several months; a 10 percent rating is warranted for migraine headaches with characteristic prostrating attacks averaging one in 2 months over the last several months; a noncompensable rating is warranted for less frequent attacks. See 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2013). Turning to the evidence of record, the Board notes that the Veteran's Social Security Administration records note complaints of headaches at that time, though those records document his symptomatology as documented in 2003 and prior. The Board notes that those records are nearly a decade old and hold very little probative value regarding the Veteran's symptomatology beginning in October 2012. The Board has reviewed those records, in order to get a sense of the history of his symptoms. The Board has also reviewed the Veteran's more recent VA and private treatment records, which do not demonstrate any treatment for his headache disorder. Instead, the Board finds the most probative evidence of record to be a statement from the Veteran's friend, R.M-O., in November 2012, the January 2013 VA headache examination, and the Veteran's lay statements with respect to his headache disability of record since filing his claim in October 2012. In the November 2012 statement from R.M-O., the Veteran's friend indicated that the Veteran's headaches can be so severe that even after maximizing his medications and lying in a darkened room, his headaches can take hours to subside. The Veteran underwent a VA examination of his headaches in January 2013; at that time he was diagnosed with tension headaches since 1986. The Veteran reported daily headaches for the past 20 years, and that he had sinus surgery to try and improve that condition, though it did not help; neither do nasal sprays or medications. His headaches are primarily on the top and left side of his head and he has seen many doctors without a diagnosis of migraines. He treats his condition with NSAIDs, which ease the headache within approximately one hour. The Veteran is now on morphine and other narcotics for his terminal cancer pain. The examiner noted that the Veteran was in terrible pain throughout the appeal period due to his terminal cancer pain and neuropathy associated with his chemotherapy regimen. On examination, the Veteran was shown to have pulsating or throbbing headache pain and pain localized on one side of the head. The duration of his headache pain was less than one day, though it can last hours; he responded to NSAID treatment within about an hour. The pain is located on the left side of his head. The examiner noted that he did not have the characteristic prostrating attacks of migraine headache pain, and there were no symptoms of nausea, vomiting, or sensitivity to sound or light. The Veteran was noted as having prostrating attacks of non-headache pain, however, that occurred more frequently than once per month; the examiner noted that such attacks were not "very frequent." The examiner noted that the Veteran's headache condition does not affect his ability to work. The examiner noted that she estimated the Veteran's migraine headaches due to his terminal cancer condition and the fact that he has pain all over his body, including his head, over the past year due to that condition. In his March 2013 notice of disagreement, the Veteran stated that he "continue[s] to suffer headaches daily." In his August 2013 statement submitted in connection with his substantive appeal, VA Form 9, the Veteran indicated that his headache episodes typically last 6-10 hours, during which he lays on his back with a cold compress on his head that his wife has to change regularly. The Veteran stated that his headaches were pulsating and throbbing headaches that occurred nearly every day, even prior to his terminal cancer diagnosis, and that they "prohibited [him] from functioning properly nearly every day, for hours on end." The Veteran additionally noted that his taking of NSAID medication only reduces his headache pain from a 9 to a 7 out of a scale of 10. He also indicated that if he has to travel in a car, he has to lay down in the back due to his headaches, as well as hip and back pain due to sitting. Based on the foregoing, the Board finds that a 50 percent evaluation is not warranted. In order to warrant that evaluation, the Veteran's headache attacks need to be "very frequent" and completely prostrating attacks, and productive of severe economic inadaptability. The Board notes that the Veteran reported that his history of headaches included daily headaches of pain that necessitated lying down for hours with a cold compress on his head. He further stated that his headaches were severe. The Veteran is competent to describe the frequency and severity of his headaches and the Board finds his descriptions credible. However, the examiner's findings specifically noted that the Veteran's headache attacks were not "very frequent" during the examination. In addition, the Veteran did not exhibit "characteristic" prostrating attacks; they were not accompanied by nausea, vomiting, or sensitivity to sound or light. The examiner indicated that the Veteran would not be impacted in his ability to work due to his tension headaches. While the Veteran has claimed frequent headaches, the examiner's findings are more probative as they distinguish the prostrating and non prostrating nature of the headaches and also note whether the headaches are "characteristic" prostrating or not. They also clarify that the headaches do not result in severe economical inadaptability. While the Veteran has stated that his headaches were severely economically inadaptive, the Board additionally notes that the overall evidence does not support this. The Veteran continued to work and participate in activities despite his history of "daily headaches" prior to his terminal cancer condition. The Board notes that R.M-O. indicated that the Veteran, prior to his cancer, helped him roof a geodesic dome barn. R.M-O. additionally noted that the Veteran's headaches can become so severe that he has to lie in a darkened room for hours without relief, but the implication of that statement is that such does not occur all the time or even very frequently. While the Board cannot specifically discount the Veteran's lay statements based on the lack of any treatment records, the Board can take that fact into account when assessing the validity of the Veteran's statements. In this case, the Board notes that the Veteran's claims file has several notations in his Social Security Administration documents which note that he has headaches, but he is shown to have been working throughout that time, and the Veteran was found to be unemployable due to his other medical conditions at that time-mainly his lumbar spine disorder which appears to be due to a 1994 work-related accident. In short, the Board acknowledges the Veteran's statements regarding the severity of his tension headaches prior to his cancer condition, but does not find that there is evidence that the Veteran's tension headaches are "very frequent," as noted by the January 2013 examiner, nor that such attacks are completely prostrating and prolonged attacks. Moreover, the VA examiner noted that the Veteran's ability to work would not be impacted by his headache condition, and R.M-O.'s statement appears to confirm that the Veteran was not severely economically inadaptive due to his headache condition, though admittedly, his headaches could sometimes be so severe that he needed to lay down in a darkened room for hours before relief. Thus, the Board concludes that the disability picture in this case regarding the Veteran's tension headaches since October 2, 2012, is more closely approximate to headaches with characteristic prostrating attacks occurring on an average once a month over last several months, rather than very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Accordingly, the Board must deny an increased evaluation for the Veteran's tension headaches on the evidence of record at this time. See 38 C.F.R. § 4.7, 4.124a, Diagnostic Code 8100. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Left Foot The Veteran's left foot tendonitis has been evaluated as 10 percent disabling, effective October 2, 2012-the date on which he filed his claim for service connection. The Veteran's evaluation was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5024-5284. The Board notes that Diagnostic Code 5024, tenosynovitis, redirects the evaluation to the limitation of motion of the affected body part. For the foot, the Board notes that those Diagnostic Codes are 5276 through 5284. Initially, the Board notes that the evidence of record, as discussed below, does not demonstrate any flatfeet (pes planus), pes cavus, metatarsalgia, hallux valgus, hallux rigidus, hammertoes, or any mal- or nonunion of his tarsal or metatarsal bones of his left foot. Thus, the Board finds Diagnostic Codes 5276-83 to be not applicable in this case. See 38 C.F.R. § 4.71a, Diagnostic Codes 5276-83 (2013). Likewise, the Board finds that Diagnostic Codes 5003 and 5010 are not applicable as the Veteran has already been assigned a compensable evaluation under the limitation of motion diagnostic codes. Moreover, a 20 percent evaluation under Diagnostic Codes 5003 and 5010 is not applicable as multiple major joints or minor joint groups are not involved in this case. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010 (2013). Under Diagnostic Code 5284, a 10 percent disability rating is assigned for symptomatology which is moderate in severity. A 20 percent disability rating is assignable for symptomatology which is moderately severe. A 30 percent disability rating is assignable for symptomatology which is severe. See 38 C.F.R § 4.71a, Diagnostic Code 5284 (2013). The note following that Diagnostic Code provides that a 40 percent evaluation is assigned for loss of use of the foot. Id. Turning to the evidence of record, the Board notes that the Veteran's Social Security Administration documents generally do not demonstrate any treatment for left foot tendonitis, and also generally address an attenuated time period from the current period on appeal. The Veteran's private and VA treatment records in the claims file also generally do not demonstrate any treatment for his left foot tendonitis. The Board notes that the Veteran's March 2007 VA treatment record demonstrates he denied any other significant muscle or joint pains, arthritis, gout, backaches, with the exception of back pain associated with his lumbar spine disorder; the examiner noted that there was no swelling, redness, pain, tenderness, stiffness, weakness or limitation of motion or activity at that time. The Veteran underwent a VA examination of his left foot disorder in January 2013. The examiner noted that the Veteran had left foot tendonitis diagnosed since 1986. The Veteran stated that he has had dorsal left foot pain since his second period of service. On examination, the Veteran's left foot did not have a Morton's neuroma, metatarsalgia, hammertoes, hallux valgus, hallux rigidus, pes cavus, mal- or nonunion of the tarsal and metatarsal bones, bilateral weak foot, or any other foot injuries. The examiner noted that the Veteran had tenderness that remained over the proximal dorsal aspect of the left foot, just as described in his service treatment records. There was no swelling or redness noted. The examiner noted that the Veteran was thin, weak, and because of his severe cancer pain and neuropathy due to his chemotherapy, he was in terrible pain during the examination, despite regular use of narcotic pain medication including morphine. She noted that the Veteran could not tolerate x-rays due to his extreme pain due to cancer; she did note, however, that the bone scan and x-rays from service were normal. The examiner additionally noted that the Veteran used a cane to assist in ambulation, though that was shown to be necessary as a result of his severe lumbar spine disorder and now his terminal cancer, and not his left foot disorder. The Veteran's left foot did not impact his ability to work. The Veteran avers on appeal in his August 2013 statement submitted with his substantive appeal, VA Form 9, that he should be evaluated as 20 percent disabling for his left foot tendonitis. The Veteran's statement, however, does not address his current symptomatology associated with his left foot tendonitis, but rather focuses on medical evidence as to why his lumbar spine and claimed left hip disorders should be service-connected. Based on the foregoing evidence, the Board finds an increased evaluation is not warranted on the evidence of record. The Board notes that in order to award a higher evaluation in this case, the evidence must demonstrate at least moderately severe symptomatology in the left foot. The Board notes that tenderness is shown in the left foot, but that the Veteran's extreme pain noted throughout the appeal period is shown to be due to his terminal cancer and not his left foot. The Board additionally notes that there is no limitation of motion or any other notation of pain shown in the March 2007 VA treatment record. The Board notes that it does not even appear, in the Board's judgment, that the Veteran's left foot symptomatology is moderate in severity throughout the appeal period. Accordingly, the Board finds that an evaluation in excess of 10 percent for his left foot tendonitis is not warranted on the evidence of record at this time. See 38 C.F.R. § 4.7, 4.71a, Diagnostic Code 5024-5284. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Left Knee The Veteran's left knee patellofemoral syndrome has been evaluated as 10 percent disabling, effective October 2, 2012-the date on which he filed his claim for service connection. The Veteran's evaluation was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5260. The Board notes that the normal range of motion of the knee is to 0 degrees (full extension) to 140 degrees (full flexion). See 38 C.F.R. § 4.71a, Plate II. When flexion of the knee is limited to 45 degrees, a 10 percent rating may be assigned. When flexion is limited to 30 degrees, a 20 percent evaluation may be assigned. A 30 percent rating may be assigned when flexion of the leg is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. When extension of the knee is limited to 10 degrees, a 10 percent evaluation may be assigned. When extension is limited to 15 degrees, a 20 percent evaluation may be assigned. When limited to 20 degrees, a 30 percent rating may be assigned. When extension is limited to 30 degrees, a 40 percent evaluation is assignable. A 50 percent evaluation may be assigned when extension of the leg is limited to 45 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. Slight recurrent subluxation or lateral instability warrants a 10 percent evaluation. A 20 percent rating requires moderate recurrent subluxation or lateral instability. A 30 percent rating requires severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Dislocation of the semilunar cartilage of the knee with frequent episodes of "locking," pain and effusion into the joint warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Initially, the Board notes that that Diagnostic Codes 5003 and 5010 are not applicable as the Veteran has already been assigned a compensable evaluation under the limitation of motion diagnostic codes. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010 (2013). Historically, the Board notes that the Veteran's left knee was shown to have flexion from 0 to 100 degrees in a Social Security Administration examination in March 1995. Generally, the other Social Security Administration documents do not demonstrate any treatment for his left knee patellofemoral syndrome; additionally, the Board notes that those documents are mostly attenuated from the relevant rating period on appeal at this time. The Board notes that the Veteran's March 2007 treatment record does not demonstrate any left knee complaints at that time. It further demonstrates he denied any other significant muscle or joint pains, arthritis, gout, backaches, with the exception of back pain associated with his lumbar spine disorder; the examiner noted that there was no swelling, redness, pain, tenderness, stiffness, weakness or limitation of motion or activity at that time. The Veteran's private treatment records in the claims file generally are related to other medical problems, mostly his terminal pancreatic cancer, and generally do not demonstrate any treatment for his left knee patellofemoral syndrome. The Veteran underwent a VA examination of his left knee in January 2013. The examiner diagnosed the Veteran with patellofemoral syndrome of the left knee since 1986. The Veteran reported knee pain in service and afterwards and thinks he had a steroid injection decades ago but was unable to recall the details. He reported that his pain was primarily in his left patellar tendon for years. He denied any flare-ups of his left knee condition. On examination, the Veteran had flexion to 130 degrees with pain beginning at 100 degrees; he had extensions to 0 degrees with pain beginning at 0 degrees. After repetitive testing, the Veteran's left knee had 110 degrees of flexion and still had 0 degrees of extension. The examiner noted that the Veteran had additional limitation of motion due to repetitive use, including less movement and pain on movement. The Veteran has slightly decreased muscle strength testing, with active movement against some resistance; his joint instability testing was normal, including the Lachman, Posterior Drawer, and Medial-lateral Instability tests. The examiner noted that there was no evidence or history of recurrent patellar subluxation/dislocation. The examiner noted that the Veteran did not have any meniscal conditions, including "locking" episodes. X-rays were not obtained at that time due to the Veteran's inability to handle them due to his terminal cancer condition. The Veteran was shown to use a wheelchair and cane to ambulate, but those assistive devices were necessary due to his lumbar spine disorder and terminal cancer condition. The examiner noted that the Veteran's left knee disorder would not impact his ability to work. She additionally noted that he would be unable to do repetitive squatting based on the history of his left knee condition. On appeal, the Veteran avers that he should be evaluated as 20 percent disabling for his left knee patellofemoral syndrome. In his August 2013 statement, submitted with his substantive appeal, VA Form 9, the Veteran additionally provides that during his examination in January 2013, he was taking oxycondone and oxycotin "which would have significantly reduced the pain severity caused by the examiner's range of motion flexion test." He also noted that his wife had to help him get into position for the test and then had to leave to retrieve pain medication from the car during the test due to the level of pain he was experiencing during the examination. Based on the foregoing evidence, the Board finds that an evaluation in excess of 10 percent is not warranted at this time for the Veteran's left knee patellofemoral syndrome. First, the Board notes that there is no lay complaints of locking of the knees, nor does there appear to be any evidence of record which demonstrates that the Veteran's left knee has frequent episodes of locking or any effusion of the left knee. Moreover, the Veteran is not shown to have any dislocation of the semilunar cartilage in the left knee throughout the appeal period. Thus, evaluation under Diagnostic Code 5258 is not applicable in this case. Additionally, throughout the appeal period, the Veteran's left knee is not shown to have recurrent subluxation or dislocation, nor does he complain of any laxity or instability of his left knee throughout the appeal period. The Board further notes that his instability testing in the January 2013 examination was normal, and the examiner specifically noted that there was no evidence or history of recurrent patellar subluxation/dislocation. In light of these facts, the Board finds that a separate evaluation is not warranted for instability of the left knee. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. Likewise, the Veteran's extension throughout the appeal period is shown to be to 0 degrees, which is normal. Thus, the Board finds that a separate evaluation for limitation of extension is not warranted on the evidence of record in this case. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. Thus, the Board is left with evaluation of the Veteran's left knee under Diagnostic Code 5260, for limitation of flexion. During the appeal period, the Veteran's pain during flexion is shown to begin at 100 degrees of flexion-which the Board notes is also the number of degrees that he was historically limited to in March 1995. The Board notes that such a limitation of motion in flexion is noncompensable. Based on the Veteran's inability to do repetitive testing and his amount of pain noted on examination, the Veteran has been assigned a 10 percent evaluation for his left knee on the basis of the noted Deluca factors present on examination. The RO assigned a 10 percent evaluation for a disability picture which more closely approximated limitation to 45 degrees of flexion in the left knee, which the Board finds contemplates the additional limitation of motion due to his pain and inability to do repetitive motion, when the objective findings clearly demonstrate that the Veteran has several more degrees of actual range of motion. The Board does not find convincing evidence, even including the Veteran's complaints of extreme pain and limitation of motion due to pain, that left knee patellofemoral syndrome is the equivalent of limitation of flexion to 30 degrees or less during the appeal period. Accordingly, the Board finds that an initial evaluation in excess of 10 percent for a left knee patellofemoral syndrome must be denied at this time on the evidence of record. See 38 C.F.R. § 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5260, DeLuca v. Brown, 8 Vet. App. 202 (1995). In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Other Considerations The Board must also determine whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2013). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluations are adequate. An evaluation in excess of that assigned is provided for certain manifestations of the service-connected tension headaches, left foot and left knee disorders, but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disorders. As the rating schedule is adequate to evaluate the disability, referral for extraschedular consideration is not in order. The Board has also considered whether a remand is necessary in order to determine whether the Veteran is entitled to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). In this case, the evidence of record does not indicate that the Veteran is currently unemployed due to his tension headaches, left foot and/or left knee disabilities, but rather that he is unable to work due to several other medical conditions, including diffuse pain associated with his terminal pancreatic cancer. Since there is not any evidence of record that the Veteran's tension headaches, left foot, and left knee disabilities cause him to be unable to secure and follow substantially gainful employment, the Board finds that a remand for such an opinion is not required in this case. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Finally, the Board does note that the VA examiner noted in the January 2013 VA examination report that future VA examinations of the Veteran would not be possible due to his terminally-ill pancreatic cancer condition; she noted that the Veteran made an excessive effort, which was medically unreasonable, in order to have the January 2013 VA examination performed. Based on this finding, the Board notes that it has evaluated the Veteran's service-connected tension headaches, left foot and left knee disabilities as best as possible given the information contained in the claims file and the January 2013 VA examination report. Entitlement to SMC based on the need for Aid & Attendance Special monthly compensation is payable to individuals who are permanently bedridden or are so helpless as a result of service-connected disability as to be in need of the regular aid and attendance of another person under the criteria set forth in 38 C.F.R. § 3.352(a). See also 38 U.S.C.A. § 1114(l); 38 C.F.R. § 3.350(b)(3). Determinations as to need for aid and attendance must be based on actual requirements of personal assistance from others. In making such determinations, consideration is given to such conditions as the following: Inability of the claimant to dress or undress himself or to keep himself ordinarily clean and presentable; the frequent need of the adjustment of any special prosthetic or orthopedic appliance which by reason of the particular disability cannot be done without aid; the inability of the claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352(a). "Bedridden" will be a proper basis for the aid and attendance determination and is defined as that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that the claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater-or-lesser part of the day to promote convalescence or cure will not suffice. In Turco v. Brown, 9 Vet. App. 222 (1996), the Court held that it was not required that all of the disabling conditions enumerated in the provisions of 38 C.F.R. § 3.352(a) be found to exist to establish eligibility for aid and attendance, but that such eligibility required at least one of the enumerated factors be present. The Court added that the particular personal function that a Veteran is unable to perform should be considered in connection with his or her condition as a whole. Also, it is only necessary that the evidence establish that a Veteran is so helpless as to need regular aid and attendance, not that there be a constant need. See Turco, supra; 38 C.F.R. § 3.352. Determinations that the Veteran is so helpless, as to be in need of regular aid and attendance will not be based solely on an opinion that the claimant's condition is such as would require him to be in bed. They must be based on the actual requirement of personal assistance from others. Id. The performance of the necessary aid and attendance service by a relative of the claimant or other member of his or her household will not prevent the granting of the additional allowance. 38 C.F.R. § 3.352(c). In this case, the Board finds that it is unquestioned that the Veteran is indeed in need of aid and attendance and is unable to attend to the wants of nature and necessitates care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment. The Board, however, is not able to award SMC for aid and attendance in this case, as the Veteran's inability to attend to the wants of nature and necessity of care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment does not stem from his service-connected disabilities. Currently, the Veteran's service-connected disabilities are: tension headaches, evaluated as 30 percent disabling; left foot tendonitis, 10 percent disabling; and, left knee patellofemoral syndrome, 10 percent disabling. Turning to the evidence in this case, the Veteran's private physician, Dr. F.P.G., examined the Veteran in September 2012. In that examination for aid and attendance report, the Veteran's complete diagnosis was noted as: "pancreatic cancer, diabetes mellitus, [chronic obstructive pulmonary disease], hypertension, coronary artery disease, depression, chronic low back pain status post surgery." He noted that the Veteran was unable to walk unaided and noted that he was a fall risk; the Veteran walked with a cane assist and wheelchair for transport to appointments. The Veteran was able to feed himself, but was unable to purchase or prepare his meals. He needed assistance bathing and with other hygienic needs. The Veteran was able to attend the wants of nature, so long as he had the added convenience such as a urinal or a commode. The Veteran was not confined to a bed, nor is he blind. He was also not able to drive and needed the ability to lie down to travel; he was assessed as not being able to travel. He was not assessed as being able to leave the house unattended, though he did not require nursing home care at that time. Dr. F.P.G. concluded that due to the severity of the current conditions, the Veteran "cannot be left unattended and requires assistance in all aspects of care." In a November 2012 statement from the Veteran's friend, R.M-O., stated that he had to help the Veteran's wife pick the Veteran up sometimes after he fell when his leg would give out and the cane was not in position to save a fall. He also noted that the Veteran needed help getting dressed and that 70-80 percent of any given day, the Veteran was "laying or, occasionally sitting-when attempting to stand he experiences severe balance issues, often resulting in near falls and causing more strain on weak joints that are forced to react strongly to the disequilibrium." She noted that the Veteran's wife rarely was able to be away from the Veteran, and that even when she was able to leave his side she was reluctant to except when absolutely necessary. He noted that in his opinion, without the wife's aid, the Veteran would need immediate outside assistance. In December 2012, that assessment was again submitted to VA, along with an "Authorized Plan for Home Care" from Eastern Maine Medical Center, which noted that the Veteran's wife assisted with all aspects of care throughout a 24-hour period. A VA aid and attendance examination, dated December 2012, which was completed by the Veteran's private physician, Dr. T.L.S., demonstrates that the Veteran was able to feed himself, but was unable to prepare his meals. He needed assistance in bathing and tending to other hygienic needs. He was not legally blind, and did not require nursing home care. The Veteran needed help managing his medications and could not manage his own financial affairs. The Veteran was noted as being slow and weak in his upper extremities, and his lower extremities were slow with peripheral neuropathy secondary to his chemotherapy regimen. The Veteran had limited range of motion due to his chronic pain. The Veteran also was noted as having significant weight loss within the last year and had ongoing abdominal and back pain. He was able to get out regularly with the help of his wife. The Veteran was noted as using a wheelchair and a cane and was limited to one block in walking. In his April 2013 notice of disagreement, the Veteran indicated that he was unable to do any household chores due to instability and massive pain and weakness in his legs, feet and hands. He noted that he needed assistance in attending basic wants of nature, including toileting, showering, and other basic hygienic needs, due to reduced mobility and stability. He noted that he has to lie down in order to travel/be transported and required assistance getting into and out of a vehicle. He reported using canes and a wheelchair for assistance in mobility. He also noted that "the large amounts of narcotics I have to take to alleviate the pain [he] suffer[ed] from [his] service-connected disabilities and from the pancreatic cancer, [he is] unable to handle [his] own finances, medications, meals or other essentials of living." He stated that he was dependent on his wife to handle all of his needs for living and to run their home; he stated he could not be trusted to be alone due to his conditions. In his August 2013 statement, submitted with his substantive appeal, VA Form 9, the Veteran stated, "My diagnosis of pancreatic cancer, though devastating, does not change the fact that I would need aid and attendance for reasons associated with my service-connected disabilit[ies]-lack of mobility, risk of falling, and pain resulting in me requiring assistance with skills of daily living based on what my service-connected disabilit[ies] should be." The record does not demonstrate the necessity of aid and attendance due solely to service-connected disability. As previously discussed, the headaches do not result in frequent and prolonged prostrating attacks and do not result in severe economic inadaptability. The left foot tendonitis is no more than moderate in degree. The left knee lacks full flexion and there is pain on motion, but the remaining function is quite good. Taken together, these disabilities would not preclude gainful employment and certainly would not require the aid and attendance of another. Dr. T.L.S. does not restrict the Veteran's assessment of the need for aid and attendance to his service-connected disabilities, nor is it clear from his assessment which medical problems cause the Veteran's need for aid and attendance, though it is clear that the Veteran's back pain and chemotherapy-induced neuropathy are major factors. Instead, the Board notes that Dr. F.P.G.'s assessment, which clearly demonstrates that the Veteran is a fall risk and has other reduced mobility problems and a clear need for aid and attendance, predicates all of his findings on the basis of nonservice-connected disabilities, to include his lumbar spine disorder and pancreatic cancer. In fact, Dr. F.P.G. does not even note on his aid and attendance examination that the Veteran even has headache, left foot, or left knee disabilities. The Veteran claims that even prior to his pancreatic cancer diagnosis, he required aid and attendance; however, the evidence reflects that the service-connected disabilities are in the moderate range and taken together are less severe than the Veteran asserts. The Veteran's condition prior to his pancreatic cancer diagnosis is not at issue in this case, as the earliest possible effective date assignable for SMC would be October 2, 2012-which is clearly after his diagnosis of pancreatic cancer. Regardless, there is no evidence either before or after the diagnosis of pancreatic cancer demonstrating that the Veteran was in need of aid and attendance for his service-connected tension headaches, left foot, and/or left knee disabilities. Finally, insofar as the Board notes that a VA examination for aid and attendance did not contemplate the "aggregate effects" of his service-connected disabilities, the Board finds that (a) Dr. T.L.S. did submit a VA examination worksheet; and (b) it appears to contemplate all of the Veteran's disabilities not just his service-connected disabilities. The Board additionally notes the extreme difficulty noted by the January 2013 examiner regarding future evaluation of the Veteran. The evidence, particularly from the January 2013 VA examination, does not indicate that the Veteran would be in need of regular aid and attendance for his solely service-connected disabilities as noted by the severity of those disabilities on that examination. Moreover, the evidence-including Drs. T.L.S. and F.P.G's examinations, when viewed with the January 2013 examiner's findings-allows the Board to adequately assess the Veteran's need for aid and attendance in this case, and find that the aid and attendance necessity is associated with his nonservice-connected lumbar spine disorder and pancreatic cancer, rather than his relatively minor headache, left foot and knee disabilities. Therefore, the Board finds that the evidence of record therefore adequately addresses the need for aid and attendance based on his service-connected disabilities, and a remand for further examination is not required at this time. See Geib v. Shinseki, No.2012-7164, 2013 WL XXXXXXX, at *Y (Fed. Cir. Oct. 29, 2013) (In a TDIU determination, "VA's duty to assist does not require obtaining a single medical opinion regarding the combined impact of all service-connected disabilities."); see also Smith v. Shinseki, 647 F.3d 1380, 1385-86 (Fed. Cir. 2011) (VA is not required to obtain an industrial survey from a vocational expert before making a TDIU determination but may choose to do so in an appropriate case). Accordingly, the Board finds that entitlement to SMC for aid and attendance must be denied at this time, because while the Veteran does certainly have a need for aid and attendance in this case, such a need to does not stem from his service-connected disabilities, but rather from his nonservice-connected lumbar spine disorder and terminal pancreatic cancer. See 38 C.F.R. §§ 3.350, 3.352. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Service connection for a left hip disorder is denied. Service connection for a left tibia disorder is denied. An initial evaluation in excess of 30 percent for tension headaches is denied. An initial evaluation in excess of 10 percent for a left foot tendonitis is denied. An initial evaluation in excess of 10 percent for a left knee patellofemoral syndrome is denied. Entitlement to SMC based on need for aid and attendance is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs