Citation Nr: 1339330 Decision Date: 11/29/13 Archive Date: 12/13/13 DOCKET NO. 02-10 465 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a testicular disorder (claimed as testicular pain). 2. Entitlement to an increased evaluation for left shoulder strain, rated 10 percent disabling until August 6, 2004, and 20 percent disabling thereafter. 3. Entitlement to an increased evaluation for right shoulder strain, rated 10 percent disabling until August 6, 2004, and 20 percent disabling thereafter. 4. Entitlement to an evaluation in excess of 10 percent for bilateral plantar fasciitis and pes planus with right foot tibial sesamoid fracture. 5. Entitlement to an initial compensable evaluation for tension headaches. 6. Entitlement to an initial compensable evaluation for insomnia (symptom associated with both service-connected psychiatric disorder and service-connected sleep apnea). 7. Entitlement to an initial compensable evaluation for right (major) fifth metacarpal fracture residuals. 8. Entitlement to total disability based on individual unemployability (TDIU) prior to July 16, 2012. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M.H. Stubbs, Counsel INTRODUCTION The Veteran served on active duty from July 1979 to February 2000, including in the Southwest Asia theatre of operations during the Persian Gulf War. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 2000 and November 2001 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In April 2009 and July 2012 the Board remanded some of the claims for additional development. The case has now been returned to the Board for appellate disposition. The Board denied the claim of entitlement to an initial compensable rating for tension headaches. The Veteran appealed the July 2012 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a May 2013 joint motion the claim was remanded to the Board for compliance with Jones v. Shinseki, 26 Vet. App. 56 (2012). The Board notes that the RO was directed in the Board's April 2009 remand to provide appropriate notice and assistance in regard to the spine rating in the event that the RO saw fit to reduce the rating for a given period of time. No such rating reduction was initiated by the RO and the Board decision to granted entitlement to an initial 40 percent evaluation for lumbosacral strain, dating from October 10, 2000 to April 26, 2001, and a deny an evaluation in excess of 10 prior to October 10, 2000, is final since it was not been appealed. As such, the Board finds that there remains to current controversy on the lumbosacral strain issue for the Board to consider. The Board notes that, in addition to the paper claims file, there are electronic records pertaining to the Veteran's claims. These records have also been reviewed in conjunction with the following decisions and remands. The issues of entitlement to service connection for a testicular disorder and entitlement to TDIU prior to July 16, 2012 are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's right shoulder strain manifested by no more than limitation of motion of the major shoulder to shoulder level throughout the entire periods on appeal; symptoms consistent with loss of humeral head, nonunion of the humerus, fibrous union of the humerus, ankylosis or dislocation of the clavicle or scapula are not shown. 2. The Veteran's left shoulder strain manifested by no more than limitation of motion of the minor shoulder to shoulder level throughout the entire periods on appeal; symptoms consistent with loss of humeral head, nonunion of the humerus, fibrous union of the humerus, ankylosis or dislocation of the clavicle or scapula are not shown. 3. The Veteran's bilateral pes planus with tibial sesamoid fracture and plantar fasciitis manifested in pain (both with and without weight-bearing), a right 4th toe deformity, and bilateral arthritis; these symptoms represent no more than overall moderately severe foot disabilities. 4. The credible evidence of record does not support a finding that the Veteran's tension headaches result in characteristic prostrating attacks. 5. The Veteran was service connected for an acquired psychiatric disorder and insomnia, both effective February 22, 2000, and both including the symptom of limited sleep. The Veteran's insomnia was also noted to require the use of a CPAP machine and to cause hypersomnia. His insomnia was rated analogous to sleep apnea. He was subsequently service connected for sleep apnea, with a 50 percent rating effective July 18, 2006. Affording the Veteran the greatest benefit, his increased rating claim for insomnia will be addressed under the analogous rating for sleep apnea which affords him the greatest benefit. He was initially diagnosed with sleep apnea and provided a CPAP machine prior to discharge from service. 6. To avoid compensating the Veteran for the same symptoms under different disabilities, the Veteran's insomnia symptoms will be absorbed into his sleep apnea and adjustment disorder disabilities, from July 18, 2006 (the grant of service connection for sleep apnea). 7. The Veteran is currently in receipt of the maximum schedular disability rating for his service-connected right (major) fifth metacarpal fracture residuals. The competent evidence of record does not establish that the service-connected right (major) fifth metacarpal fracture residuals has been additionally manifested by symptoms, such as ankylosis, warranting an amputation disability rating. 8. The competent evidence of record does not establish that the service-connected right (major) fifth metacarpal fracture residuals has resulted in any limitation of motion of other digits of the hand or interference with the overall function of the right hand, such that a separate disability rating is warranted. CONCLUSIONS OF LAW 1. For the period prior to August 6, 2004, the criteria for a disability rating of 20 percent, and no higher, for right shoulder strain are met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.69, 4.71a, Diagnostic Codes (DC) 5201, 5202, 5203 (2013). 2. For the period from August 6, 2004, the criteria for a disability in excess of 20 percent for right shoulder strain have not been met. 38 U.S.C.A. § 115; 38 C.F.R. §§ 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.69, 4.71a, Diagnostic Codes (DC) 5201, 5202, 5203. 3. For the period prior to August 6, 2004, the criteria for a disability rating of 20 percent, and no higher, for left shoulder strain are met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.69, 4.71a, Diagnostic Codes (DC) 5201, 5202, 5203. 4. For the period from August 6, 2004, the criteria for a disability in excess of 20 percent for left shoulder strain have not been met. 38 U.S.C.A. § 115; 38 C.F.R. §§ 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.69, 4.71a, Diagnostic Codes (DC) 5201, 5202, 5203. 5. The criteria for an initial rating of 20 percent for bilateral plantar fasciitis and pes planus with right foot tibial sesamoid fracture have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 4.2, 4.3, 4.6, 4.10, 4.40, 4.45, 4.71a, DCs 5279, 5283, 5284. 6. The criteria for an initial compensable rating for tension headaches have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8100; Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). 7. For the period from February 22, 2000 to July 17, 2006, the criteria for an initial 50 percent rating for insomnia (including features of sleep apnea) have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 4.2, 4.3, 4.6, 4.10, 4.40, 4.45, 4.100 DC 6847. 8. From July 18, 2006, the Veteran's service-connected insomnia will be absorbed into his service-connected sleep apnea and adjustment disorders to prevent pyramiding. See 38 C.F.R. § 4.14. 9. The criteria for an initial compensable disability rating for the right (major) fifth metacarpal fracture residuals are not met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.321, 3.326(a), 4.1, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5227-5299, 5230. REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159, provide that VA will 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. They also require VA to notify the 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. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. The Board also notes the Court has held that the plain language of 38 U.S.C.A. § 5103(a), requires that notice to a claimant pursuant to the VCAA be provided "at the time" that or "immediately after" VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment and earning capacity, as well as general notice regarding how ratings and effective dates are assigned. Vazquez- Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The VCAA notice requirements may be satisfied notwithstanding errors in the timing or content of the notice if such errors are not prejudicial to the claimant. Pelegrini at 121. Further, a defect in the timing of the notice may be cured by sending proper notice prior to a re-adjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333-1334 (Fed. Cir. 2006). In this case, the RO sent to the Veteran a VCAA letter in March 2001. Therein, VA notified the Veteran of the evidence obtained, the evidence VA was responsible for obtaining, and the evidence necessary to establish entitlement to the benefits sought including the types of evidence that would assist in this matter. The RO supplemented the initial notice letter with letters dated in August 2003, September 2003, and July 2004. VA notified the Veteran in a May 2008 letter of how VA assigns disability ratings. Additionally, following the Board's remand decision in April 2009, VA provided the Veteran with a comprehensive notice letter dated in June 2009 on those issues now before the Board that fully complied with the VCAA requirements. Following the June 2009 VCAA notice letter, VA readjudicated the claims in an August 2010 SSOC. The claims were last readjudicated in August 2013. In view of the above, the Board finds that VA has satisfied its duty to notify and notes that, in the instant case, neither the Veteran nor his representative has demonstrated any prejudicial or harmful error in the VCAA notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (an error in VCAA notice should not be presumed prejudicial;, the burden of showing harmful error rests with the party raising the issue, and must be decided on a case-by-case basis). VA further has a duty to assist. 38 U.S.C.A. § 5103A ; 38 C.F.R. § 3.159. That is, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). Here, the Board also finds the Veteran has been afforded adequate assistance in regard to the claims. All relevant medical records have been obtained and associated with the record to include service treatment records, VA treatment records, Tricare records, and written statements by the Veteran. The Veteran has been afforded VA medical examinations in response to the claims herein decided. The Board previously reviewed the record, determined that VA examinations were necessary on the claims herein decided, and remanded the case for the purpose of obtaining such. Thereafter, VA obtained appropriate VA examinations and medical opinions where needed. The Board has reviewed the examination reports and finds substantial compliance with the requirements articulated in the Board's prior remand and provides adequate information upon which to decide the following claims. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). For the reasons set forth above, the Board finds that VA satisfied its obligations pursuant to the VCAA in this case. The Board has reviewed all 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). Laws and Regulations-Increased Ratings Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. 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. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14. The Court has held that a veteran may not be compensated twice for the same symptomatology as "such a result would over compensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Court has acknowledged, however, that when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different Diagnostic Codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40 and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more of less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The "amputation rule" that provides in pertinent part that "[t]he combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed." 38 C.F.R. § 4.68. Shoulders The Veteran's bilateral shoulder strains were initially rated analogous to DC for impairment of the clavicle or scapula. DC 5203 provides a 10 percent evaluation for both the major and minor shoulders for malunion or nonunion without loose movement. DC 5203 provides a 20 percent rating for both major and minor shoulders for nonunion with loose movement and dislocation of the clavicle or scapula. DC 5203 does not provide criteria for a rating higher than 20 percent. 38 C.F.R. § 4.71a. When a disability not specifically provided for in the rating schedule is encountered, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. 38 C.F.R. § 4.20. The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." Butts v Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Subsequently, the Veteran's bilateral shoulder strains were rated analogous to DC 5201 for limitation of motion of the arm. DC 5201 provides a 20 percent rating for major and minor shoulders with limitation of motion to shoulder level. 30 percent and 20 percent ratings are assigned for the major and minor shoulder limitation of motion midway between side and shoulder level, respectively. 40 and 30 percent ratings are assigned for major and minor shoulder limitations of motion to 25 degrees from the side, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 degrees to 180 degrees, abduction from 0 degrees to 180 degrees, external rotation from 0 degrees to 90 degrees, and internal rotation from 0 degrees to 90 degrees. 38 C.F.R. § 4.71, Plate I. Other potentially applicable DCs that provide for separate evaluations include DC 5200 and DC 5202, which address limitation of motion and other impairment of the humerus. DC 5200 applies to ankylosis of the scrapulohumeral articulation DC 5202addresses other impairment of the humerus and provides ratings for recurrent dislocation, fibrous union, and loss of humerus head. As noted above, the Veteran is currently assigned 10 percent ratings for his bilateral shoulder strains prior to August 5, 2004, and 20 percent ratings thereafter. In service, the Veteran suffered from bilateral shoulder pain. In September 1995, he "over did it" with weight training and complained of shoulder and neck pain. He did not have tendonitis on evaluation. He did have active spasm of the trapezius. He was assessed with bilateral shoulder strain. Subsequently, the Veteran was involved in two motor vehicle accidents in service. The second accident occurred in March 1998. Within ten days of the accident he complained of aching arms and "sharper" pain in his shoulders. At the time he had a full range of motion of his bilateral shoulders, without edema or erythema. Later, he described pain on each side of his neck and upper back pain from the top of his shoulders to his should blades. He reported both that his shoulder pain occurred when he stated in one position for too long and that it was constant pain. In April 1999, the Veteran reported a history of painful or "trick" shoulder or elbow, which he elaborated as "sharp pain shoulder, elbow." A corresponding August 1999 Medical Evaluation Board report noted "multiple musculoskeletal discomforts." Following an examination he was diagnosed with several musculoskeletal disorders, but his shoulders were not addressed. In May 1999, the Veteran was afforded a VA general medical evaluation. At the time of the examination, he complained of neck and thoracic spine symptoms. A physical evaluation of his shoulders noted a normal active range of motion both shoulders, but with crepitus throughout and pain at endpoints of motion. The examination did not include repetitive testing or information about additional limitations due to pain, fatigue, weakness or lack of endurance. In April 2001, the Veteran was again afforded a VA general medical examination. He was noted to be "a poor history [who was] unable to give details regarding his overall symptoms." Essentially, "limited information" was obtained due to the Veteran's vague complaints. His musculoskeletal complaints did not include complaints regarding his bilateral shoulders although he complained of neck, wrist, knee, back, and feet pain. He reported polyarthralgia. Chronic pain syndrome was diagnosed by a rheumatologist and orthopedic evaluation within the last six to eight months due to an overall unremarkable work up. During the examination he refused to fully participate in range of motion testing. He reported he could not move his knee farther than 50 degrees on testing, but was able to sit in a chair with his knee to 90 degrees. He similarly refused to complete spine range of motion testing. He was not assessed with a shoulder disability in the examination report. The claims file and virtual VA contain limited treatment records and statements pertaining to the Veteran's bilateral shoulder disorder. In December 2004, the Veteran was afforded a VA shoulder examination. He complained of pain along the upper back and medial and inferior aspect of the scapula bilaterally. He reported the pain began following a 1997 motor vehicle accident and continued to the present. His symptoms included constant dull pain with increased pain of the upper back and peri-scapular area with movement of the shoulders and lifting of the arms. He did not report any episodes of dislocation or recurrent subluxation. The examiner noted that the shoulder disabilities did not significantly adversely affect the Veteran's occupational activities. The Veteran was noted to be right hand dominant. Upon physical examination, he complained of pain with elevation of the arms. He had forward flexion of 90 degrees and abduction of the arms to 90 degrees. The limitation of range of motion to 90 degrees was due to a complaint of pain of the trapezius area of the upper back. The examiner noted the Veteran did not have a complaint of shoulder joint pain. The Veteran did not suffer any additional loss of motion due to pain, fatigue, weakness, or lack of endurance following repetitive movement. There was a palpable mild spasm of the trapezius areas with probable rhomboid and scapulae levator involvement. There was no evidence of ankylosis. X-rays revealed a normal left shoulder and minor degenerative irregularity of the right inferior glenoid rim. He was assessed with myofascial pain syndrome of the upper back, peri-scapular musculature. A private treatment record from January 2006, noted the Veteran sought treatment for chronic pain in multiple areas. The physician noted that the Veteran's physical examination was "totally inconsistent" with his complaints. His complaints included his entire spine, knees and questionably his hips. He was also referred to as a "suboptimal historian." Despite this, the physician continued to believe that the Veteran did indeed have pain. A treatment record from October 2006 noted complaints of joint pain with reach above shoulder with decreased range of motion. The physician indicated the Veteran would be unable to lift more than 15 lbs. Upon evaluation, the physician indicated the Veteran was "unable to elevate arm above shoulder." Again, there are limited treatment records for the bilateral shoulders between 2006 and 2013. In July 2012, the Board remanded the claim so that an additional VA examination could be completed. In June 2013, the Veteran was afforded another VA shoulders examination. He complained of bilateral shoulder pain since his in-service injury in 1997. He reported dull chronic pain which increased with repetitive movement of the shoulders or with overhead lifting. He denied a history of dislocation or subluxation. He had no surgical history. On physical examination, the Veteran had right shoulder flexion to 150 degrees, with objective evidence of pain at 150 degrees. Right shoulder abduction was to 160 degrees with objective painful motion at 160 degrees. Left shoulder flexion and abduction were to 160 degrees with objective painful motion at 160 degrees. After repetitive testing, his right and left flexion and abduction remained the same. The examiner found that he did not have additional limitation of range of motion of the shoulders with repetitive testing. He did not have ankylosis of either shoulder, he had a negative impingement test, a negative intraspinous strength test, and a negative subscapularis tendinopathy test. He was noted to have mechanical symptoms such as clicking or catching, but no history of recurrent subluxation. He was noted to have traumatic arthritis of the right shoulder only, via x-ray. In adjudicating a claim, the Board must assess the competence and credibility of the Veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board acknowledges that the Veteran is competent to give evidence about what he experienced. See Layno v. Brown, 6 Vet. App. 465 (1994). Competency of evidence, however, must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Here, ultimately the Board finds the Veteran's complaints of shoulder pain and flare-ups to be credible. More than one treatment care provider has indicated that the Veteran is a poor historian, and he was not fully cooperative during a VA examination. Additionally, his pain complaints were felt to be out of proportion to diagnostic findings. However, ultimately the care providers have noted that he has objective pain and trapezius muscle spasm. In service, the Veteran complained of shoulder pain, but his range of motion was not impaired. During a 1999 VA examination he was noted to have a full range of active motion of his shoulders; however, the examination did not conform to Deluca standards as potential flare-ups were not considered. His next evaluation, in 2004, found that his shoulder was limited to motion to shoulder height. In 2006, this was confirmed during an evaluation regarding work limitations. Notably, in 2013 the Veteran's bilateral range of motion had increased significantly, including upon repetitive testing. As there were no adequate evaluations of the Veteran's bilateral shoulder disability prior to 2004, and he has complained of similar levels of pain throughout his appeal process, the Board finds that entitlement to a 20 percent rating for bilateral shoulders is warranted prior to August 6, 2004. As noted in the April 2009 Board remand, the claims of entitlement to staged increased ratings for bilateral shoulder strains were not properly perfected for appellate review; however, given the ROs addressed the claims as though they were on appeal and the Veteran responded with arguments to continue the appeals, the Board took jurisdiction over the claims in 2009. Thus, this increased rating for the period prior to August 6, 2004 is quite generous. The Board finds that the competent and credible evidence does not support ratings in excess of 20 percent for bilateral shoulder strains from August 6, 2004. The most recent VA examination revealed repetitive range of motion to significantly more than shoulder height. For the entire period on appeal, the Veteran's shoulder range of motion has not been limited to midway between his side and shoulder. He has not suffered from malunion, recurrent dislocation, nonunion, loss of humeral head or ankylosis at any time during the appeal period, and thus additional higher ratings are not warranted. The Board notes that the date of August 6, 2004 appears to be arbitrary. The RO indicated the Veteran submitted a claim for increased rating on that date; however, the Board was unable to find this document in the claims file. By providing a 20 percent rating for the entire period on appeal, the arbitrary date of increase is no longer a confusing addition to the Veteran's shoulder ratings. Feet The Veteran is currently service connected for bilateral plantar fasciitis and pes planus with right foot tibial sesamoid fracture. His initial 10 percent rating was provided analogous to DC 5276. Diagnostic Code 5276 provides ratings for acquired flatfoot. Moderate flatfoot (unilateral or bilateral), with weight-bearing line over or medial to great toe, inward bowing of the tendo Achilles, pain on manipulation and use of the feet warrants a 10 percent rating. Severe flatfoot with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities warrants a 20 percent rating unilaterally, and a 30 percent rating bilaterally. Diagnostic Code 5277 (weak foot), Diagnostic Code 5278 (claw foot), and Diagnostic Code 5283 (malunion or nonunion of tarsal or metatarsal bones) are not applicable in this case as the medical evidence does not reveal atrophy of the musculature, disturbed circulation, weakness, contracture of the plantar fascia, dorsiflexion with limited motion of any toes, or malunion or nonunion of tarsal or metatarsal bones. Diagnostic Codes 5280, 5281, and 5282 do not provide ratings in excess of 10 percent. Diagnostic Code 5284 provides criteria for rating other foot injuries. A moderate foot injury warrants a 10 percent disability evaluation. A moderately severe foot injury warrants a 20 percent disability evaluation and a severe foot injury is assigned a 30 percent disability evaluation. A note to Diagnostic Code 5284 provides that a 40 percent disability evaluation will be assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5284. The terms "slight," "moderate" and "severe" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The Veteran's service treatment records reveal that he began complaining of bilateral foot pain shortly after his 1998 motor vehicle accident. In the August 1999 Medical Evaluation Board report, the Veteran complained of bilateral foot pain after long periods of standing, walk or other aggressive use. He reported pain daily, and the physician noted extensive conservative treatment for a diagnosis of plantar fasciitis. On examination, his feet were diffusely tender over the dorsal medial aspect over the mid tarsal and tarsometatarsal areas. His sensation was intact and his ankle and subtalar range of motion was full and normal. His foot appeared normal to observation. He had no instability to the ankle and toe alignment was normal. Foot x-rays revealed mild degenerative joint disease of the mid tarsal and tarsometatrasal joints diffusely with formation of marginal osteophytes, subcondral sclerosis and joint space narrowing. He had a normal gait. During a May 1999 VA general medical examination, the Veteran complained of bilateral heel pain. He reported a diagnosis of plantar fasciitis with conservative treatment. He reported pain with walking, standing, and running. Flare-ups of severe pain occurred daily, which he reported limited his daily activities "60 to 70 percent." Upon physical examination, the Veteran deltoid ligament was tender bilaterally. He had some pain with ankle range of motion testing. He was assessed with bilateral plantar fasciitis. A May 2000 VA treatment record noted the Veteran wore arch supports in both shoes, and that walking and weight bearing caused increased pain to his feet. He was noted to be a poor historian by the treating physician. He had tenderness of the ankles and feet on the plantar aspect. Inversion and eversion were unremarkable. In April 2001, the Veteran reported his bilateral plantar fasciitis caused severe pain, and that he could not stand longer than 10 minutes due to pain and "circulation complaints." X-rays from October 2000 revealed bilateral flat foot deformities. In April 2001, the Veteran was afforded a VA general medical examination. He had a normal gait, without limp when reporting to the examination. He reported having memory problems and was noted to be a poor historian, who was unable to give details regarding his overall symptoms. He complained of feet pain on the plantar aspect. He was noted to have a "known right hallux chip" and bilateral fasciitis. The Veteran did not fully cooperate with the examination; however, he reported plantar tenderness on the medial edge bilaterally even with light touch. A September 2002 VA treatment records showed the Veteran complained of bilateral foot pain with and without weight bearing. He was noted to possibly have weak instability of inversion/eversion of the ankle due to observed ambulation. Even light palpation of the foot caused increased pain, especially on the plantar surface of the calcaneus. In June 2003, a VA podiatrist noted the Veteran had "severe bow legs and pain and numbness descend from knee to feet." He was assessed with pes planus secondary to genu varum and he was prescribed orthotics. During an August 2004 VA mental health examination, the examiner noted the Veteran reported exaggerated pain of an 8 or 9 out of 10 although he had a normal gait, normal respirations, and a relaxed posture. The examiner also noted inconsistencies in what the Veteran reported to care providers regarding the effectiveness of his treatment and what he reported to the VA examiner. In May 2006, the Veteran was afforded a VA feet examination where he complained of pain, numbness, and "pins and needles" with walking more than 1/4 mile or standing more than 1/2 hour. He reported his symptoms have progressively worsened. He stated the bottom of his feet "sting" at night. The Veteran used shoe inserts. The Veteran did not fully cooperate with the examination. He "pull[ed] his foot back with wincing with the slightest touch to ankles and feet." He was noted to have a callus on his left great toe. He did not have an unusual shoe wear pattern. He was unable to squat, rise on his toes or heels. He was noted to have a right 4th hammer toe and bilateral pes planus. There was no degree of valgus or malalignment of the forefoot or midfoot. He did not have hallux valgus. Or clawfoot. He was diagnosed with bilateral pes planus and plantar fasciitis. There are limited treatment records for the period between 2006 and 2013, to include review of virtual records. In June 2013, the Veteran was afforded another VA feet examination. The Veteran reported bilateral flat feet since childhood with pain beginning with service and prolonged standing, walking and running. He reported pain in both feet with waking which improves to some degree with 30 minutes of activity. He complained of increased pain with standing and walking. He used inserts, rest, activity modification, and Tylenol to relieve some symptoms. The Veteran did not have pain with manipulation of the feet, but reported increased pain with use of foot. He had no swelling, calluses, alignment problems or deformities (other than flat foot). He used inserts, but they did not alleviate his symptoms He did not have extreme tenderness of plantar surface of the feet. The Veteran reported he used a cane and arch supports due to his pes planus. In the 2006 examination it was noted he used a cane due to his knee and low back disabilities. He was assessed with degenerative arthritis of both feet. As noted above, the Veteran is a poor historian. VA examiner and treatment care providers have indicated the possibility of exaggeration of symptoms. The Board notes that the Veteran reported his cane was necessary for his flat feet in 2013, but noted it was for his knees and low back in 2006. As such, the Board considers the Veteran's statements regarding the severity of his symptoms was less than fully credible. While the Veteran's feet are currently rated 10 percent under DC 5276 for pes planus, DC 5284 is more applicable in this case. Under the flat foot criteria, the Veteran does not meet the next higher rating of 30 percent for bilateral severe flat foot with marked deformity, indication of swelling on use and characteristic callosities. The 2013 VA examination report specifically noted that the Veteran did not have characteristic callosities or swelling. The Veteran described his bilateral plantar fasciitis with calcaneal spurs affecting his activities of daily living and ability to work due to pain. While the Veteran is less than fully credible, and he would not allow a full examination in 2006, he has consistently reported intense pain with standing and walking. X-rays have revealed calcaneal spurs and VA treatment records have included notations that the Veteran suffered pain during palpation. Lastly, VA treatment records reveal that the Veteran was treated with inserts and he has reported treatment with "injections." The Board will resolve reasonable doubt in his favor by assigning a 20 percent rating for a moderately severe foot injury. The Board finds that the evidence does not support a finding of severe foot injury due to the information regarding the Veteran's exaggeration of his symptoms and notations in the record that he had a normal gait, and that there was no pain with manipulation of the foot (2013 VA examination). Headaches The Veteran is currently noncompensably rated for service-connected tension headaches, which are rated analogous to migraine headaches under DC 8100. Diagnostic Code 8100 provides as follows: A 50 percent rating for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability; a 30 percent evaluation for characteristic prostrating attacks occurring on an average once a month over the last several months; 10 percent for characteristic prostrating attacks averaging one in 2 months over the last several months; and a noncompensable rating with less frequent attacks. 38 C.F.R. § 4.124a. Service treatment records show complaints of headaches. Post-service treatment records also show treatment for headaches. The Veteran has reported that sometimes he gets blurred vision for a few minutes and has to pull over if he is driving. Report of VA examination dated in May 1999 reflects a history of daily headaches resulting from neck pain, relieved with medication. There was no change in the frequency or severity of the headaches over the last two years. The Veteran denied nausea, vomiting, or visual disturbances associated with the headaches. Neurologic examination showed that the Veteran was fully oriented. Tension headaches were diagnosed. In an April 2001 statement, the Veteran reported that he had neck pain and severe daily headaches, which were not relieved by medication and which were constant and persistent. Report of VA examination dated in April 2001 reflects complaints of chronic daily headaches. He described them as moderate to severe in service. He described pain as tightness around the eyes, back of the neck, and head. The Veteran reported frequent headaches without any associated symptoms. Report of VA examination dated in August 2004 reflects complaints of headache occurring 4 to 5 times a week, lasting 10 to 20 minutes, triggered by stress or high blood pressure. The Veteran described pressure that begins at the insertion of the nape of the neck muscles and occipital area. It may be felt over the forehead. If the headaches occur when he is outdoors, he has to wear sunglasses to keep the light out of his eyes. The Veteran denied taking any medication for relief because "of the briefness of the headache." It was noted that "he just relaxes with resolution." By history, "the headaches are moderate." The Veteran reported that he feels tired when he gets a headache. Physical examination was normal. A past MRI of the brain was normal. The diagnosis was tension headaches. In an undated statement, the Veteran reported that he had severe tension headaches. He reported that, during one episode, he could not see and had to pull over while driving. He reported that his headaches are constant and persistent and that they are not relieved with medication. Report of VA examination dated in July 2010 reflects complaints of headache occurring about every day, treated with Tylenol twice a day, and usually lasting hours. The Veteran reported that he often awakens with a headache but it may occur later in the day; that sometimes his eyes tear up with a headache; and that he sometimes missed work due to headaches. The examiner characterized the headaches as not prostrating, noting that the Veteran could maintain ordinary activity, and that they were not treated with continuous medication. In July 2012, the Board denied the Veteran's claim for an initial compensable rating for tension headaches. The Veteran appealed this decision to the Court, and in a joint motion, the claim was remanded to the Board. The parties agreed that the claim had to be remanded so that the Board could comply with the Court's decision in Jones v. Shinseki, 26 Vet. App. 56 (2012). In Jones, the appellant sought a higher rating for his irritable bowel syndrome (IBS). The Board denied the claim in part because medication provided some relief from the symptoms. The Court vacated the Board's decision, holding that "the Board committed legal error by considering the effects of medication on the appellant's IBS when those effects were not explicitly contemplated by the rating criteria," and that "the Board may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria") (emphasis added). Id. at 61, 63. The Court reasoned that had VA wanted to include the effect of medication as a factor to be considered when rating a particular disability, it would have done so, as it had done in other diagnostic codes. Id. at 62 (citing 38 C.F.R. § 4.71a, DC 5025 (2012) (10 percent rating for fibromyalgia requires symptoms "[t]hat require continuous medication for control"); 38 C.F.R. § 4.97 , DC 6602 (2012) (rating criteria for bronchial asthma)). Symptoms the same when first occurred and with medication). The Joint Motion noted that the Board, in this case, had reasoned that the Veteran's headaches did not warrant a compensable rating because they only lasted a short time and that the resolved with over-the-counter medication. The Court noted that the Board erred in this reasoning because the effect of medication on his headaches is not a factor included within the rating criteria for migraine headaches. The claim was remanded to the Board to "consider the impact, if any, of the Court's decision in Jones in evaluating the Appellant's claim." Subsequently, in June 2013, the Veteran was afforded another VA headaches examination. He complained of headaches consisting of intense dull pain, which start suddenly or begin gradually and build rapidly. He endorsed accompanying symptoms of phonophobia and photophobia, as well as occasional nausea. He reported headaches occur once every two months and last one to two hours, resolving gradually. He did not have a history of incapacitating headaches. He used Tylenol daily as needed for pain, which provided some relief. The duration of the typical headache was noted to be less than one day. The examiner found that the Veteran did not have characteristic prostrating attacks of migraine or tension headache pain. There are limited treatment records regarding the Veteran's headaches, to include in virtual VA. Here, the Board notes that the Veteran is not credible. In the analysis for the Veteran's claims for shoulder strain and feet disabilities the Board noted the VA and private treatment care providers and VA examiner's observations that the Veteran may be exaggerating his symptoms, that he is a poor historian, and that he did not fully cooperate during examinations. With regard to his claim for headaches, the Board notes the internal inconsistencies the Veteran has reported throughout the claims process. He denied nausea and visual/audial disturbances in 1999 and 2001. He indicated a need to wear sunglasses if he developed a headache while outside, but not that he needed to avoid light. Again, he did not report photo or phonophobia in 2010. Yet, in 2013 he reported both and nausea associated with his headaches. He has reported daily severe headaches (2001), short headaches 4 to 5 times a week (2004), severe constant headaches (undated statement), daily headaches lastly hours (2010), and headaches every two months lasting two hours (2013). Additionally, he has reported that he has relief with medication and he does not have relief with medication, although he has reported the same use of Tylenol throughout the record. Notably, he has reported the use of Tylenol to control his musculoskeletal pain as well. Due to the inconsistent descriptions of symptoms throughout the time period, the Board finds the Veteran's statements regarding his headaches to be less than credible. For a compensable rating under DC 8100, the evidence would have to show characteristic prostrating attacks averaging one in two months over the last several months. Here, there is no evidence of characteristic prostrating attacks. The 2010 and 2013 VA examiners have noted that the Veteran's tension headaches do not include characteristic prostrating attacks, and the 2013 VA examination is a fully developed and adequate examination. Treatment records do not include evidence of characteristic prostrating attacks. Additionally, even though the Board has found the Veteran to be than credible due to inconsistencies, even his inconsistencies to not include a description of prostrating attacks. He has described headaches which resolve quickly without the need for immediate rest. When he described a headache in the sun, he stated he merely put on sunglasses to combat the effects of the light. Without medical evidence, or credible subjective evidence, of characteristic prostrating attacks, the Board finds that an initial compensable rating for tension headaches is not warranted. Insomnia The Veteran was initially granted entitlement to service connection for insomnia in a November 2001 rating decision. The RO noted in an April 2001 VA examination reports that he slept only three to four hours a night, and an in-service diagnosis of refractory psychophysiologic insomnia from February 2000, and the delivery of a CPAP machine in 2000 as the basis for the grant of service connection. The Veteran was provided a noncompensable rating effective February 22, 2000. His noncompensable rating was provided as analogous to DC 6847, for sleep apnea. Under DC 6847, a noncompensable rating is assigned for asymptomatic sleep apnea with documented sleep disorder breathing. A 30 percent is provided for persistent day-time hypersomnolence. A 50 percent rating is provided when sleep apnea requires use of breathing assistance device such as continuous airway pressure (CPAP) machine. A total, 100 percent, rating is provided for chronic respiratory failure with carbon dioxide retention or cor pulmonale or requires a tracheostomy. Notably, in a March 2000 rating decision, the Veteran was granted service connection for an adjustment disorder with anxiety and depression. He was provided a 10 percent rating effective February 22, 2000. The RO cited the Veteran's reports of only sleeping two to three hours a day as part of his symptoms which warranted a 10 percent rating. In a February 2007 rating decision, the RO granted entitlement to sleep apnea effective July 18, 2006, with a 50 percent rating. The RO noted that the Veteran underwent a polysomnography in December 1998 which diagnosed mild positional obstructive sleep apnea. The RO noted the Veteran requested a CPAP machine, which was finally issued in July 18, 2006 (thus providing the effective date of the 50 percent rating). In a July 2013 rating decision, the RO increased the Veteran's rating for adjustment disorder with mixed anxiety and depression to 30 percent, effective July 16, 2012. The RO changed the description of the Veteran's service connected psychiatric disability to indicate that it was "also claimed as insomnia/sleep disturbance." The rating decision noted "your claim for insomnia (sleep disturbances/problems) is a symptom of your already service-connected mental issue of adjustment disorder with mixed anxiety and depression." A review of the Veteran's service treatment records reveals that he was diagnosed with primary insomnia, psychophysiologic insomnia, and mild positional obstructive sleep apnea during service. He additionally complained of loss of sleep due to musculoskeletal pains. In July 2013, the claims file was returned to a July 2010 VA examiner for an addendum opinion regarding whether the Veteran has any symptoms of insomnia that are separate and distinct from the symptoms of his sleep apnea and psychiatric disorder. The examiner noted "insomnia is the difficulty getting to sleep or waking up in the night and being unable to get back to sleep. It can be related to PTSD, however, many individuals without PTSD also have insomnia." The examiner noted that a mental health profession would have to determine "how much of his insomnia is related to his psychiatric issues," and suggested reviewing a 2004 examination. The examiner noted that sleep apnea is an anatomical abnormality where the upper airway collapses upon itself during sleep causing obstruction of the movement of air to the lungs. While sleep apnea can cause people to wake in the night, they usually can go back to sleep, but they can feel very tired the next day. The examiner noted that sleep apnea is not caused by insomnia and has its own symptoms and etiology. The Board notes that the examiner has indicated that both insomnia and sleep apnea can cause people to feel tired during the day and to have sleep disturbance at night. In August 2004, during a VA mental health examination, the Veteran reported poor sleep. He stated his wife reported he walked and hit out in his sleep. He reported common nightmares due to noises, and difficulty sleeping when guns were fired at a nearby military fort. Essentially, in 2001 the Veteran was granted service connection for insomnia and the factual background upon which the grant was made related both to the Veteran's psychiatric disorder (difficulty falling asleep and staying asleep) and his obstructive sleep apnea (difficulty staying asleep and hypersomnolence). As noted above, the Court has held that a veteran may not be compensated twice for the same symptomatology as "such a result would over compensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The RO has chosen, via the July 2013 rating decision to absorb the symptom of insomnia into the psychiatric rating, at least effective July 16, 2012. The problem, however, is that the Veteran's grant of service connection for insomnia was at least partially based on his treatment for sleep apnea, and he was provided a noncompensable rating based on an analogous rating to sleep apnea. He was then subsequently service connected for sleep apnea and provided a 50 percent rating, but with an effective date of only July 18, 2006. In order to provide the Veteran the greatest benefit, the Board will grant a 50 percent rating for insomnia (to include features of sleep apnea) from February 22, 2000 to July 17, 2006. This rating is based on the in-service diagnosis of mild positional sleep apnea, and the RO's indication in the rating decision that he received a CPAP machine in January 2000, prior to discharge from service. Notably, an increased total rating (100 percent) is not warranted because there is no evidence in the claims file that the Veteran suffers from chronic respiratory failure. By changing the issue to insomnia (to include features of sleep apnea), the Veteran receives consideration for his use of a CPAP and his hypersomnolence. Any part of his insomnia which is due to his psychiatric disorder (nightmares, difficulty falling asleep) was already addressed with the initial grant of service connection for his psychiatric disorder as was evidenced by the ROs description of his psychiatric symptoms including limited sleep. By linking the Veteran's current claim for an increased rating to his service connection for sleep apnea he receives a greater benefit than linking his insomnia to his psychiatric disorder as his sleep apnea is afforded a higher rating. The Board notes that the 50 percent rating for insomnia (with features of sleep apnea) must be limited to the period from February 20, 2000 to July 17, 2006 because his 50 percent rating for sleep apnea begins July 18, 2006. As both his insomnia and sleep apnea consider the same symptoms (and are rated under the same diagnostic code) to provide both ratings would be pyramiding. Thus, for the period from February 20, 2000 to July 17, 2006, the Board will provide a 50 percent rating for insomnia (with features of sleep apnea). From July 18, 2006 the Veteran's service-connected insomnia will be absorbed into his service-connected sleep apnea and adjustment disorders to prevent pyramiding. See 38 C.F.R. § 4.14 Right 5th Finger The Veteran is in receipt of a non-compensable (0 percent) disability rating, by analogy, under 38 C.F.R. § 4.71a, DC 5227 for his right fifth metacarpal fracture residuals. The Veteran is right-hand dominant and he is currently service-connected for a disability to the little finger (i.e., fifth) of his right hand. Under DC 5227, a maximum 0 percent rating is assigned for favorable or unfavorable ankylosis of the ring or little finger (whether on the major (dominant) or minor (non-dominant) hand). 38 C.F.R. § 4.71a, DC 5227. A Note to DC 5227 provides that evaluation as amputation should be considered, and whether an additional evaluation is warranted for any resulting limitation of motion of other digits or interference with the overall function of the hand. Id. Since the Veteran is in receipt of the maximum disability rating available under DC 5257, the Board also will consider other potentially applicable DC's in the Rating Schedule. A maximum 0 percent rating is assigned under DC 5230 for any limitation of motion of the ring or little finger (whether on the major (dominant) or minor (non-dominant) hand). 38 C.F.R. § 4.71a, DC 5230. Thus, the Veteran is also in receipt of the maximum disability rating under DC 5230. Additionally, the Veteran is only service-connected for one disability of a digit (finger), and so DCs 5216-5223 are not applicable. The Board notes that the intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. However, the regulations do not provide a minimum compensable rating for the fifth finger. A September 2002 x-ray of the right hand revealed degenerative joint disease of the right little finger. DC 5003 for degenerative arthritis noted that arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code. DC 5003 also provides a 10 percent rating for "each major joint" where the limitation of motion is noncompensable under the appropriate diagnostic code. Here, however, the fifth finger is not a "major joint." Although the Board recognizes that the Veteran currently is in receipt of the maximum 0 percent disability rating, the Note to DC 5227 states that an amputation evaluation should also be considered, particularly where ankylosis is present. Ankylosis is defined as immobility and consolidation of a joint due to disease, injury, surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992) (memorandum decision); see Nix v. Brown, 4 Vet. App. 462, 465 (1993); see also Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). Here, there is no competent evidence suggesting that the Veteran experiences ankylosis in his right little finger. 38 C.F.R. § 4.71a , DC 5227. In the May 1999 general medical examination the Veteran complained of pain and swelling with repetitive use (bending and gripping) of his right little finger. During the April 2001 examination, he had limited motion from zero to 50 degrees. He was able to touch his thumb and little finger, and his palm and little finger, although with pain. During an August 2004 VA examination, the Veteran had a normal range of motion of the right metacarpophalangeal. He had flexion from zero to 55 degrees of the distal interphalangeal. He had no pain with motion of the finger unless he forces flexion to the maximum. He was able to reach his 5th finger to the transverse flap of the palm, had a normal range of motion of the other fingers of the right hand, and had a normal grip strength. In June 2013, the Veteran had full range of motion of his right 5th finger, including after repetitive use. He did not have loss of motion of other fingers, and he had a normal grip strength of his right hand. Thus, the Board concludes that an increased rating is not warranted via the amputation codes because although the Veteran complains of pain and swelling, he has motion of his 5th finger and normal grip strength, which leads the Board to conclude that his right little finger disability is not analogous to amputation. Id. The Note to DC 5227 also states that an additional evaluation is warranted for any resulting limitation of motion of other digits or interference with the overall function of the hand due to the service-connected right little finger. Here, however, there is no competent evidence in the VA examinations or the treatment records to suggest that the Veteran's right little finger has resulted in any limitation of motion of other digits of the hand or interference with the overall function of the right hand such that a separate evaluation is warranted under the Note to DC 5227. 38 C.F.R. § 4.71a, DC 5227. The Veteran is also service-connected for bilateral carpal tunnel syndrome. The Board finds that the evidence of record does not establish that the Veteran's right little finger has resulted in any limitation of motion of other digits of the hand or interference with the overall function of the right hand, such that a separate evaluation is warranted under the Note to DC 5227. 38 C.F.R. § 4.71a, DC 5227. In summary, the Veteran is not entitled to an increased (compensable) rating for his service-connected right (major) fifth metacarpal fracture residuals. Id. The Board is cognizant of, and has carefully considered, the Veteran's subjective reports in support of his claim (pain, swelling, decreased use due to pain). However, none of the criteria required for a higher disability rating were diagnosed or noted. The treatment notes of record similarly do not provide medical support for a higher rating. Extraschedular considerations In Thun v. Peake, 22 Vet. App. 111 (2008), the Court addressed at length the extra-schedular provisions of 38 C.F.R. § 3.321(b). The Court held that the determination of whether a claimant is entitled to an extra-schedular rating is a three-step inquiry. Id. at 115. In Anderson v. Shinseki, 22 Vet. App. 423, 427 (2008), the Court clarified that the Thun steps are, in fact, "elements." The first element is a finding of whether the evidence before the VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun, 22 Vet. App. at 115. Therefore, initially, the Board must make be a comparison between the level of severity and symptomatology of the Veteran's bilateral shoulder strains, feet disorders, insomnia (with features of sleep apnea), and headaches with their corresponding diagnostic codes. In this case, the Board finds that the first element is not met and the evidence before the VA does not present such an exceptional disability picture that the available schedular evaluations under Diagnostic Codes pertaining to the issues above are inadequate. The Veteran's shoulder strains were rated based on range of motion findings, and DC 5201 provided for increased ratings for increased symptoms. However, the Veteran did not exhibit the decreased range of motion required for the next higher level, even taking into account his subjective symptoms. The Board also addressed additional diagnostic codes associated with the shoulder, but the Veteran did not meet the criteria for higher ratings under these either. The Veteran's feet disorders were addressed under both the DC for flat feet (under which the Veteran was initially rated), and his symptoms did not meet the criteria for the next higher rating. The Board then sought an increased rating under other potentially applicable diagnostic codes and an increased evaluation was provided under DC 5284. The Board noted the Veteran's inconsistencies in the record regarding his subjective complaints. He simply did not meet the criteria for the next higher ratings available. The Veteran's headaches do not include prostrating attacks. He was also found to be less than credible and inconsistent in his reporting of his headache symptoms. DC 8100 provides criteria for increased ratings, however, without symptoms of prostrating attacks, he does not meet the criteria. Without a consistent description of the length and frequency of his headaches, and with complaints of severe pain without accompanying behavioral corrections (severe headache but remains outside in the sun, just with sunglasses on), the schedular evaluation is adequate. The Veteran's insomnia had a unique procedural history, and the Board has afforded the Veteran the greatest benefit based upon his symptoms. Insomnia was rated analogous to sleep apnea, and the next higher rating included criteria of chronic respiratory failure or a tracheostomy. The Veteran is separately service-connected for a psychiatric disorder which including sleep disruption. Because his insomnia and adjustment disorder both had sleep disturbance symptoms, his symptoms are covered under two diagnostic codes. There is no evidence to suggest he has additional symptoms which are not covered by his current ratings. The Veteran's right 5th finger rating is the highest schedular rating under the applicable diagnostic codes and is also a noncompensable rating. DC 5227 provided additional consideration for loss of use (amputation) and the effect of the digit on the use of the hand/other digits. The Veteran did not meet these other standards, and he has use of his right finger, although with pain at the end points of motion. Overall, higher ratings were available under the applicable DCs or under alternative DCs, but the criteria are simply more severe than the symptoms described by the Veteran, and shown in his medical treatment records. As the Board has found that the first element for an extraschedular inquiry was not met in this case, as the rating formulas adequately address the Veteran's disabilities, the Board does not have to address the second element in the inquiry. The Board does; however, note that the Veteran has reported his is not employable due to his service-connected disorders. The Veteran is 100 percent schedular rating effective July 16, 2012. The Board will address a claim of TDIU in the remand section of this claim. In conclusion, the rating criteria reasonably describe the Veteran's disability levels and symptomatologies and provide for higher ratings for additional or more severe symptoms than currently shown by the evidence. Thus, his disability pictures are contemplated by the rating schedule, and the assigned schedular evaluations are, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). ORDER Entitlement to an initial 20 percent rating for left shoulder strain prior to August 6, 2004 is granted. Entitlement to a rating in excess of 20 percent for left shoulder strain from August 6, 2004, is denied. Entitlement to an initial 20 percent rating for right shoulder strain prior to August 6, 2004, is granted. Entitlement to a rating in excess of 20 percent for right shoulder strain from August 6, 2004, is denied. Entitlement to an evaluation 20 percent for bilateral plantar fasciitis and pes planus with right foot tibial sesamoid fracture is granted. Entitlement to an initial compensable evaluation for tension headaches is denied. Entitlement to an initial 50 percent rating for insomnia (with features of sleep apnea) is warranted from February 20, 2000, to July 18, 2006. Entitlement to an initial compensable evaluation for right (major) fifth metacarpal fracture residuals is denied. REMAND Testicular pain In July 2010, the Veteran was afforded a VA examination concerning his claim of entitlement to service connection for a testicular disorder. He reported bilateral testicular pain since an accident in service in 1997. He reported blood in his urine following the accident. In June 2010 he had an ultrasound which revealed bilateral hydroceles. He reported testicular pain with erections. He also reported night voiding, three times per night. He was noted to likely have erectile dysfunction as a result of the 1997 trauma. His testicle examination was normal. He was diagnosed with remote ochitis. The medical opinion provided addressed whether the Veteran's testicular pain was a result of unexplained illness (Gulf war syndrome) and did not address direct service connection. In July 2013 an addendum opinion was provided (located in Virtual VA). After a review of the records, the evaluator opined that the Veteran's testicular disorder was less likely than not due to his service. The evaluator noted that hydroceles can result from trauma but will usually occur within a relatively short period of time, and not years later. The examiner noted that hydroceles generally do not cause pain, but the underlying cause of the hydrocele may cause pain. The examiner noted he was unable to find diagnosis or treatment for testicular pain from the veteran's in-service complaint to the present. The Board notes that in service the Veteran was diagnosed with prostatitis. In May 2010 the Veteran was diagnosed with epididymitis of the right testicle. The July 2010 VA examiner diagnosed otitis. He complained of testicular pain in May 2001 and September 2002. As such, the record contains diagnoses that were not addressed by the 2013 evaluator, and should be addressed with a new VA examination on remand. Additionally, the Veteran's subjective complaints of pain, and pain with erection, since his in-service injury though noted were not taken into account by the examiner. Specifically, the examiner noted that the underlying cause of a hydrocele could be painful, but did not explain what the underlying cause was or if, in this case, the underlying cause was related to service. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that an examination must consider lay evidence of in-service incurrence or continuity of symptomatology since service). TDIU The Board notes that effective July 16, 2012 the Veteran has a combined 100 percent schedular rating. Prior to July 16, 2012 the Veteran is service connected for numerous disabilities, with a combined rating of 90 percent. In June 2013, the Veteran was afforded several VA examination, and the examiner was asked to provide an opinion regarding the Veteran's employability. The examiner noted that "he is not likely a viable candidate for future employability, particularly given his skill set, age and the current job market." Total disability will be considered to exist where there is impairment of mind or body sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned where the schedular rating is less than total when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, the disability shall be ratable at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16. If the schedular rating is less than 100 percent, the issue of unemployability must be determined without regard to the advancing age of the Veteran. 38 C.F.R. §§ 3.341(a), 4.19 (emphasis added). Factors to be considered are the Veteran's education, employment history, and vocational attainment. Ferraro v. Derwinski, 1 Vet. App. 326 (1991). As such, the opinion is not adequate as it specifically takes into account the Veteran's age and the state of the "job market." On remand, an additional opinion should be sought. In Bradley v. Peake, 22 Vet. App. 280, 294 (2008)the Court determined that a separate total disability evaluation based on individual unemployability due to service connected disorders rating predicated on one disability (although perhaps not ratable at the schedular 100 percent level) when considered together with another disability separately rated at 60 percent or more could warrant special monthly compensation under 38 U.S.C.A. § 1114(s). Thus, the Court reasoned, it might benefit the Veteran to retain a rating based on individual unemployability, even where a 100 percent schedular rating has also been granted. Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, Bradley recognizes that a separate award of a total disability evaluation based on individual unemployability due to service connected disorders predicated on a single disability may form the basis for an award of special monthly compensation (SMC ), which is contrary to the holdings in VAOGCPREC 6-99. Currently, the Veteran does not have a 60 percent or higher rating for any one service-connected disorder. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to address his claim of entitlement to service connection for a testicular disorder. The examiner should be given access to the claims file and virtual records. After review of the records, interview, and examination of the Veteran, the examiner should provide the following opinion: Is it at least as likely as not (50/50 probability or greater) the Veteran suffers from a testicular disorder that is due to or the result of his active service, to include his in-service motor vehicle accident and in-service diagnosis of prostatitis? The examiner should address the diagnoses of ochitis, hydroceles, prostatitis and epididymitis that are contained in the claims file, as well as any additionally identified testicular diagnoses. The requirement that a current disability be present is satisfied when a claimant has a disability at the time of a claim for VA disability compensation is filed or during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319 (2009). The examiner should also address the statement that the "underlying cause" of a hydrocele may cause pain in relation to this case (i.e., what is the Veteran's underlying cause of hydroceles, and is the underlying cause related to service). The examiner should take into account the Veteran's statements of ongoing testicular pain since service, to include pain in his testes during erections. A rationale must be provided for all opinions expressed. 2. Schedule the Veteran for an examination to ascertain the impact of all of his service-connected disabilities on his unemployability. A review of the claims folder should be reviewed and electronic records should be indicated in the examination report. The examiner should opine as to whether it is as likely as not (50/ 50 probability or greater) that the Veteran's service-connected disabilities (without consideration of his non-service-connected disabilities and age) render him unable to secure or follow a substantially gainful occupation. A rationale must be provided for all opinions expressed. 3. After the development requested above, and any additional development deemed necessary has been completed to the extent possible, the record should be reviewed and the claims readjudicated. If the benefits sought on appeal are denied, then the Veteran and his representative should be furnished with a supplemental statement of the case that includes the regulations governing TDIU claims and be given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. The appellant 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). ______________________________________________ N. L. RIPPEL Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs