Citation Nr: 1419237 Decision Date: 04/30/14 Archive Date: 05/06/14 DOCKET NO. 05-33 030 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to a disability rating in excess of 20 percent for chronic muscular neck pain, status post cervical strain. 2. Entitlement to a disability rating in excess of 10 percent for chronic right foot pain, status post Chilblain's Syndrome. 3. Entitlement to a disability rating in excess of 10 percent for chronic left foot pain, status post Chilblain's Syndrome. 4. Entitlement to a compensable disability rating, prior to March 30, 2010, for chronic headaches. 5. Entitlement to a disability rating in excess of 10 percent from March 30, 2010, for chronic headaches. 6. Entitlement to an initial compensable disability rating, prior to September 20, 2007, for pseudofolliculitis barbae. 7. Entitlement to an initial disability rating in excess of 10 percent from September 20, 2007, for pseudofolliculitis barbae. 8. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). 9. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to service-connected disabilities. 10. Entitlement to service connection for insomnia, to include as secondary to service-connected disabilities. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. Spector, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1991 to November 1999. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which granted service connection for pseudofolliculitis barbae and assigned a noncompensable disability rating, effective July 31, 2003; and denied increased rating claims for (1) chronic muscular neck pain, status post cervical strain (rated 10 percent), (2) chronic right foot pain, status post Chilblain's Syndrome (rated 10 percent), (3) chronic left foot pain, status post Chilblain's Syndrome (rated 10 percent), and (4) chronic headaches (rated zero percent). During the course of the appeal, the RO increased the ratings for pseudofolliculitis barbae disability to 10 percent, effective September 20, 2007; chronic muscular neck pain, status post cervical strain to 20 percent, effective July 31, 2003 (date of claim); and chronic headaches to 10 percent, effective March 30, 2010. Since these increases did not constitute a full grant of the benefits sought, these increased rating issues remain in appellate status. See AB v. Brown, 6 Vet. App. 35, 39 (1993). The Veteran testified before the undersigned Acting Veterans Law Judge during a February 2011 Board video-conference hearing. A transcript of that proceeding has been prepared and incorporated into the evidence of record. The issue of entitlement to TDIU has not been certified for appeal. However, when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Veteran testified in February 2011 that he was medically discharged from his job working for the U.S. Postal Service due to service-connected disabilities. As the evidence suggests that the Veteran may be unemployed due to symptoms of his service-connected disabilities, the issue of entitlement to a TDIU has been raised. Therefore, as the Board has jurisdiction over this issue. Additionally, the Veteran submitted additional medical evidence following his February 2011 Board hearing, and specifically waived agency of original jurisdiction consideration. See 38 C.F.R. § 20.1304 (2013). Furthermore, in a May 2013 rating decision, the RO denied the Veteran's claims of service connection for ED and insomnia. The Veteran filed a notice of disagreement with these denials in June 2013. In an October 2013 statement, the Veteran stated that he wished to file a reopened claim for sleep apnea. The Board interprets the Veteran's statement as an implicit new and material evidence claim of service connection for sleep apnea. See 38 U.S.C.A. § 7104 (West 2002), 38 C.F.R. § 20.1105 (2013). As that claim has not been developed for appellate review, the Board refers it to the RO for appropriate action. As a final introductory matter, the Board notes that, in addition to the paper claims file, there are electronic claims files (Virtual VA and the Veterans Benefits Management System) associated with the aforementioned claims. A review of these electronic documents reveals additional VA treatment records related to the Veteran's claims on appeal. These records have been reviewed and considered by the Board. The issues of service connection for ED and insomnia, and an increased disability rating for pseudofolliculitis barbae are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Chronic muscular neck pain, status post cervical strain, is not productive of severe limitation of motion, or severe intervertebral disc syndrome, with recurring attacks with intermittent relief; it does not involve ankylosis; and it does not result in forward cervical spine flexion limited to 15 degrees or less, incapacitating episodes, or associated objective neurologic abnormalities. 2. Chronic right foot pain, status post Chilblain's Syndrome, is manifested by arthralgia and numbness; it is not manifested by locally impaired sensation, or by any tissue loss, nail abnormalities, color changes, hyperhidrosis, or X-ray abnormalities. 3. Chronic left foot pain, status post Chilblain's Syndrome, is manifested by arthralgia, numbness, cold sensitivity; it is not manifested by locally impaired sensation, or by any tissue loss, nail abnormalities, color changes, hyperhidrosis, or X-ray abnormalities. 4. Throughout the appeal period, the Veteran's chronic headaches have been manifested by pain, blurred vision, nausea, and characteristic prostrating attacks occurring approximately several times each month; the chronic headaches do not result in very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 5. The competent and probative medical evidence of record does not show that the Veteran's service-connected chronic muscular neck pain, status post cervical strain; chronic right foot pain, status post Chilblain's Syndrome; chronic left foot pain, status post Chilblain's Syndrome; or chronic headaches are so exceptional or unusual that referrals for extraschedular consideration by designated authority are required. 6. The Veteran is unable to secure or follow a substantially gainful occupation due to the functional impairment caused by his service-connected disabilities. CONCLUSIONS OF LAW 1. The schedular criteria for a disability rating in excess of 20 percent for chronic muscular neck pain, status post cervical strain, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, Diagnostic Codes 5003, 5287, 5290, 5293 (effective prior to September 26, 2003), and Diagnostic Codes 5003, 5237-5243 (2013). 2. The criteria for an evaluation in excess of 10 percent for chronic right foot pain, status post Chilblain's Syndrome, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.10, 4.104, Diagnostic Code 7122 (2013). 3. The criteria for an evaluation in excess of 10 percent for chronic left foot pain, status post Chilblain's Syndrome, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.10, 4.104, Diagnostic Code 7122 (2013). 4. The criteria for an evaluation of 30 percent, but no nigher, for chronic headaches have been met throughout the appeal period. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.124a, Diagnostic Code 8100 (2013). 5. Application of the extraschedular rating provisions is not warranted for the Veteran's service-connected chronic muscular neck pain, status post cervical strain; chronic right foot pain, status post Chilblain's Syndrome; chronic left foot pain, status post Chilblain's Syndrome; or chronic headaches. 38 C.F.R. § 3.321(b) (2013). 6. Resolving all reasonable doubt in the Veteran's favor, the criteria for a total disability rating based on unemployability due to the service-connected disabilities are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented at 38 C.F.R. § 3.159, amended VA's duties to notify and assist a claimant in developing the information and evidence necessary to substantiate a claim. Under 38 U.S.C.A. § 5103, VA must notify the claimant of any information or evidence not of record that is necessary to substantiate the claim and that information or evidence VA will seek to provide, and what parts VA expects the claimant to provide. 38 C.F.R. § 3.159(b). VA must provide such notice to a claimant prior to an initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction, even if the adjudication occurred prior to the enactment of the VCAA. See Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004). VCAA requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all elements of a claim for service connection, so that VA must provide notice that a disability rating and an effective date will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Though notification to the Veteran may not have met all of the requirements of the VCAA and related case law, the matter decided below may be addressed at this time, without further remand, because no errors in notice are prejudicial, and the Veteran has been provided all information needed for a reasonable person to prove these claims. In any event, the United States Court of Appeals for the Federal Circuit (Federal Circuit) recently vacated the previous decision of the United States Court of Appeals for Veterans Claims (Court) in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), concluding that generic notice in response to a claim for an increased rating is all that is required. See Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (2009). VA notified the Veteran of the information and evidence needed to substantiate and complete a claim by way of a number of letters provided between August 2008 and October 2009. These documents in combination provided notice of what part of that evidence is to be provided by the claimant, and notice of what part VA will attempt to obtain. The RO informed the Veteran of the specific criteria to substantiate his claims for higher disability ratings. The RO has provided adequate notice of how effective dates are assigned and the claims were readjudicated most recently in a July 2010 supplemental statement of the case; and with respect to the headaches rating claim, in a July 2010 rating decision that increased the assigned rating to 10 percent effective March 30, 2010. To the extent the Veteran did not receive full notice prior to the initial decision, after pertinent notice was provided he was afforded a meaningful opportunity to participate in the adjudication of the claims on appeal. The claimant was provided the opportunity to present pertinent evidence. The record contains service treatment, VA and private medical treatment records, and Social Security records. The duty to assist includes the duty to provide a medical examination or obtain a medical opinion when such is necessary to make a decision on the claim, as defined by law. VA examined the medical history of the Veteran's service-connected disabilities for compensation purposes addressing the rating claims. Findings from the examination reports are adequate for the purposes of deciding the claims on appeal. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Significantly, regarding the claims decided below, the Board observes that although the Veteran has reported that disabilities worsened over time, he has not reported that they have worsened since the most recent VA examinations in connection with the appeal. As such, a remand is not required solely due to the passage of time since the July 2007 VA examination. See Palczewski v. Nicholson, 21 Vet. App. 174, 182-83 (2007); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). In sum, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. VA has fulfilled its duty to assist the claimant by obtaining identified and available evidence needed to substantiate the claim, and, as warranted by law. Significantly, the Veteran has not identified, and the record does not otherwise indicate, that any additional evidence exists that has not been obtained and would be necessary for a fair adjudication of the claim. Hence, no further notice or assistance is required to fulfill VA's duty to assist the Veteran 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). Finally, in Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010), the Court held that there are two duties imposed by 38 C.F.R. 3.103(c)(2), (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked are not impacted by the Veteran's receipt of letter that complies with VA's duty to notify. During the hearing in this case, the undersigned discussed the elements that were lacking to substantiate the Veteran's claim and the Veteran's representative demonstrated actually knowledge of this information. The questions posed by the undersigned and the Veteran's representative specifically elicited responses designed to establish that the Veteran understood the criteria necessary to substantiate his claims. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (explaining that actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim.) Accordingly, the Veteran is not shown to be prejudiced on this basis. Further, the undersigned sought to identify any pertinent, outstanding evidence that might have been overlooked. Accordingly, the Veteran is not shown to be prejudiced on this basis. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the undersigned has complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Lastly, the Veteran was given an opportunity to request another hearing. Alternatively, he requested that the previous September 2011 Board decision be vacated and a new decision issued, without requiring an additional hearing. II. Increased Rating Claims The Veteran contends that his service-connected disabilities are more severe than currently contemplated by his assigned disability ratings. The Board disagrees. Governing Law and Regulations Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002). Evaluations of a service-connected disability require review of the entire medical history regarding the disability. 38 C.F.R. §§ 4.1, 4.2. If there is a question that arises as to which evaluation to apply, the higher evaluation is for application if the disability more closely approximates the criteria for that rating; otherwise, the lower rating is for assignment. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Under VA regulations, separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). However, the evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14; Fanning v. Brown, 4 Vet. App. 225 (1993). When a disability is not specifically listed in the Rating Schedule, it may be rated under a closely related injury in which the functions affected and the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2013). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In appeals of the initial assignment of a disability rating, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). VA regulations require that disability evaluations be based upon the most complete evaluation of the condition that can be feasibly constructed with interpretation of examination reports, in light of the whole history, so as to reflect all elements of the disability. Medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10 (2013). The Veteran's statements and testimony describing the symptoms of his service-connected disabilities are deemed competent evidence. 38 C.F.R. § 3.159(a)(2) (2013). However, these statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria. On evaluating the condition of service-connected disability, if it is not possible to separate the effects of a service-connected condition from that of a nonservice-connected condition, then 38 C.F.R. § 3.102 requires that reasonable doubt be resolved in the Veteran's favor; that is, any such ambiguity as to the origin of such signs and symptoms shall be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Thus, in this case, if any symptoms cannot be distinguished as between service-connected and nonservice-connected symptomatology, the Board must consider both as service-connected disability. Id. The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." See 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. Any change in a Diagnostic Code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). A. Chronic Muscular Neck Pain, Status Post Cervical Strain The Veteran claims he is entitled to a disability rating in excess of the currently assigned 20 percent for his chronic muscular neck pain, status post cervical strain. When evaluating joint disabilities rated on the basis of limitation of motion-as in this section and with the bilateral foot disability rating section below-VA may consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, functional loss due to pain is rated at the same level as functional loss where motion is impeded. See Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). The Veteran submitted his claim in July 2003. Prior to and during the pendency of the Veteran's claim, the regulations pertaining to evaluation of disabilities of the spine were amended twice. See 67 Fed. Reg. 54345- 54349 (Aug. 22, 2002) (effective September 23, 2002); See 68 Fed. Reg. 51454- 51456 (Aug. 27, 2003) (effective September 26, 2003). The changes made effective September 23, 2002, involve only changes to the rating of intervertebral disc syndrome (IVDS), rating this disability based on the occurrence of incapacitating episodes. The second change, effective September 26, 2003, renumbered all of the spine diagnostic codes, and provides for the evaluation of all spine disabilities under a new General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. Because both criteria were effective during the period of consideration for this case, the Board must determine whether the revised version is more favorable to the Veteran. See VAOPGCPREC 7-2003. However, even if the revised version is more favorable, the reach of the new criteria can be no earlier than the effective date of that change. See VAOPGCPREC 3-2000. Diagnostic Code 5287, in effect prior to September 26, 2003, provided ratings based on ankylosis of the cervical spine. Favorable ankylosis of the cervical spine is to be rated 30 percent disabling . Unfavorable ankylosis of the cervical spine is to be rated 40 percent disabling, which is the maximum rating under that code. 38 C.F.R. § 4.71a., Diagnostic Code 5287 (2003). Diagnostic Code 5290, in effect prior to September 26, 2003, provided ratings based on limitation of motion of the cervical spine. Moderate limitation of motion of the cervical spine is to be rated 20 percent disabling. Severe limitation of motion of the cervical spine is to be rated 30 percent disabling, which is the maximum rating under that code. 38 C.F.R. § 4.71a, Diagnostic Code 5290 (2003). Under Diagnostic Code 5293, in effect prior to September 23, 2002, for intervertebral disc syndrome, a 60 percent rating was assigned for pronounced, persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc with little intermittent relief. A 40 percent rating was assigned for severe, recurring attacks with intermittent relief. A 20 percent rating was assigned for moderate, recurring attacks. 38 C.F.R. § 4.71a, Diagnostic Code 5293 (2003). Under the revised criteria, effective from September 23, 2002, intervertebral disc syndrome is evaluated either on the total duration of incapacitating episodes over the past 12 months or by combining under 38 C.F.R. § 4.25, separate evaluations of its chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities, whichever method results in the higher evaluation. See 38 C.F.R. § 4.71a, Diagnostic Code 5393, as amended by 67 Fed. Reg. 54345-54349 (Aug. 22, 2002). Under the revised criteria of VA's Rating Schedule, the applicable criteria for evaluating disability of the spine provide a single set of criteria for rating conditions of the spine, the General Rating Formula for Disease and Injuries of the Spine (General Rating Formula). See 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243. Under VA's Rating Schedule, disabilities of the spine, are to be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. 38 C.F.R. § 4.71a, The Spine, General Rating Formula for Diseases and Injuries of the Spine, Note (6) (2013). Under the General Rating Formula, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, The Spine, General Rating Formula for Diseases and Injuries of the Spine, Diagnostic Codes 5235 to 5243 (2013). A 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. Id. A 40 percent evaluation is warranted for range of motion of forward flexion of the thoracolumbar spine limited to 30 degrees or less, or if the disability exhibits favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the entire thoracolumbar spine warrants a 50 percent rating. Finally, unfavorable ankylosis of the entire spine warrants a 100 percent evaluation. Id. The following notes pertain to the General Rating Formula for Diseases and Injuries of the Spine: Note (1) Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2): For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. (See also 38 C.F.R. § 4.71a, Plate V). Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (0 degrees) always represents favorable ankylosis. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 20 percent evaluation is assigned for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent evaluation is assigned for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent evaluation is assigned for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, The Spine, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Diagnostic Codes 5235 to 5243 (2013). For purposes of evaluations under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4,71a, The Spine, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1) (2013). If intervertebral disc syndrome is presented in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes, or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4,71a, The Spine, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (2). The report of a December 2003 VA examination shows that the Veteran reported complaints of cervical spine problems since a motor vehicle accident resulting in a whiplash injury in service. He reported having continuous pain in the cervical spine, which he rated as 4 to 5 in severity out of 10. He reported having popping in the neck and some radiation of symptoms to the left elbow. He had flares of pain that increased to 8 at least two times per week, lasting one to two hours. On examination the neck was supple, and range of motion demonstrated flexion of 30 degrees with slight pain; and extension of 25 degrees. Lateral flexion was to 40 degrees bilaterally and rotation was 45 degrees bilaterally. He had no particular tenderness on examination of the cervical spine. The assessment was cervical strain with mild to moderate impairment related to pain. During a September 2007 VA examination the Veteran reported he had severe cervical pain on a daily basis that worsened with range of motion and hyperextension. He reported having pain and popping in the neck with pain and numbness that radiated to the bilateral arms. He reported having severe functional impairment that was progressively worsening since onset. The Veteran treated the condition with Tylenol and Robaxin with no history of hospitalization or surgery. Examination of the cervical spine revealed that there was no spasm, atrophy, guarding, pain with motion, tenderness, or weakness. The Veteran's posture and head position were both normal. There was no abnormal spinal curvatures. Motor examination showed normal findings including muscle tone and there was no muscle atrophy. Sensory and reflex examination were normal. Range of motion of the cervical spine showed flexion from zero to 20 degrees with pain beginning at 18 degrees and ending at 15 degrees, both active and passive. Extension was from zero to 30 degrees with pain beginning at 20 degrees and ending at 15 degrees, active and passive. Left lateral flexion was from zero to 30 degrees, with pain beginning at 25 degrees and ending at 20 degrees. Right lateral flexion was from zero to 25 degrees, with pain beginning at 20 degrees and ending at 15 degrees. Left lateral rotation was from zero to 20 degrees, with pain beginning at zero degrees. Right lateral rotation was from zero to 30 degrees, with pain beginning at zero degrees. Diagnostic testing included CT examination at C1-T1, which showed mild spondylotic changes of the spine. The examination contains an impression and diagnosis of mild spondylotic changes. The report noted that the Veteran was currently employed as a full-time mail carrier. The report contains a summary noting there were significant effects of the cervical spine disability on the Veteran's usual occupation. Effects of the disability on his usual daily activities were listed, which ranged predominantly from no effect to moderate effects. During a March 2010 VA examination, the Veteran reported that he had moderate spasmodic neck pain, with stiffness and tiredness. He had flare-ups about five times per month, and was being treated. The Veteran reported he had a history of fatigue, decreased motion, stiffness, weakness, and spasm, with severe flare-ups weekly lasting hours. On examination the Veteran had normal posture, head position, and symmetry, and no abnormal curvatures. The Veteran had no spasm, atrophy or weakness. He exhibited guarding, tenderness, and pain on motion to the left. Motor examination of the upper extremities was normal with active movement against full resistance; and sensory and reflex examination of the upper extremities were normal. Active range of motion included flexion and extension both from zero to 20 degrees; left lateral flexion and rotation, and right lateral rotation, were all to 30 degrees; and right lateral flexion was from zero to 20 degrees. There was objective evidence of pain on active range of motion. Repetitive motion did not result in pain, and there was no additional limitation in range of motion after three repetitions. The report concludes with an impression of no disc herniation; minimal suspicious neural foraminal encroachment on the left at C2-4 and bilateral at C3-4; and a diagnosis of cervical strain and cervical spasm. The examiner opined that the disability resulted in significant effects on the Veteran's usual occupation due to pain; and in effects on his daily activities ranging predominantly from none to moderate, except that it prevents participation in sports. The Board has reviewed the remainder of the pertinent competent evidence of record and finds nothing inconsistent with the comprehensive findings from the three VA examinations of the cervical spine discussed above. In light of the rating criteria in effect prior to September 26, 2003, on review of the competent evidence on file the Board finds that the evidence does not demonstrate that the cervical spine symptoms are productive of favorable ankylosis of the cervical spine, or of severe limitation of motion of the cervical spine, or of severe, recurring attacks of intervertebral disc syndrome with intermittent relief, so as to warrant a disability rating in excess of 20 percent under relevant rating criteria, even after consideration of pain, weakness and other symptoms described in DeLuca. 38 C.F.R. § 4.71a, Diagnostic Code 5287, 5290, 5293 (2003). In light of the rating criteria in effect from September 26, 2003, on review of the competent evidence on file the Board finds that the evidence does not demonstrate that the cervical spine symptoms are productive of forward flexion of the cervical spine limited to 15 degrees or less, or of favorable ankylosis of the entire cervical spine, so as to warrant assigning the disability a 30 percent disability rating, even after consideration of pain, weakness and other symptoms described in DeLuca. See also 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Although at one examination there was some pain at 15 degrees on flexion range of motion, at all three VA examinations, the range of motion of flexion was at least to 20 degrees. Although the Veteran reported pain and numbness that radiated to the bilateral arms during the September 2007 VA examination, the Veteran was not diagnosed with any neurological disability of as a result of his neck disability at that time. Additionally, the competent evidence of record does not show any associated objective neurologic abnormalities so as to warrant a separate evaluation on that account. See Note (1), General Rating Formula for Diseases and Injuries of the Spine. The evidence also does not show symptoms productive of incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. Thus, a rating in excess of 20 percent for intervertebral disc syndrome based on incapacitating episodes is not warranted. 38 C.F.R. § 4.71a, The Spine, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Diagnostic Codes 5235 to 5243. B. Chronic Bilateral Foot Pain, Status Post Chilblain's Syndrome The Veteran's service-connected bilateral foot disabilities (Chronic Left and Right Foot Pain, Status Post Chilblain's Syndrome) are each evaluated as cold injuries pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7122, and each are assigned a 10 percent disability rating. These disabilities are appropriately evaluated under criteria for cold injuries because, according to Dorland's, Chilblain is a recurrent localized erythema and doughy subcutaneous swelling caused by exposure to cold associated with dampness, and accompanied by pruritus and a burning sensation. See Dorland's Illustrated Medical Dictionary 348 (31st ed. 2007). Under Diagnostic Code 7122, a 10 percent rating is provided for arthralgia or other pain, numbness, or cold sensitivity. A 20 percent rating is assigned for arthralgia or other pain, numbness, or cold sensitivity plus tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or X-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis). A maximum rating of 30 percent rating is assigned for arthralgia or other pain, numbness, or cold sensitivity plus two or more of the following: tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or X-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis). During VA examination in December 2003 the Veteran reported that he had continuous problems with his feet including a throbbing and stinging sensation, since he was diagnosed with Chilblain's in service. He reported complaints of stinging and throbbing sensations, pain that was continuous, and associated weakness, redness, and fatigability. On examination, the Achilles' tendon reflexes were 2/2 bilaterally with toes down-going. The Veteran had diminished sensation to the lower extremities. No rash or open sores were noted. Radial pulses were 2/2, bilaterally, and dorsalis pedis pulses were 3/3, bilaterally. Posterior tibial pulses were 2/2, bilaterally. The assessment was history of Chilblain's syndrome with mild to moderate impairment related to pain and numbness. During a September 2007 VA examination, the Veteran reported that he had severe functional impairment due to the pain in the bilateral feet, with flare-ups daily lasting for hours. He reported he received partial relief from medication and had not had surgery. He had prescribed shoe inserts. He reported symptoms involving both feet, including pain, redness, stiffness, fatigability, weakness, and lack of endurance, but no swelling or heat. He reported that he was able to stand for one hour and unable to walk more than a few yards. On examination, the examiner found no objective evidence of painful motion, swelling, tenderness, instability, weakness, abnormal weight bearing, or other abnormal conditions, bilaterally, and gait was appropriate. The diagnosis was bilateral hallux valgus deformity and bilateral pes planus deformity. The examiner opined that the bilateral foot disabilities resulted in significant occupational effects with decreased mobility and pain; and resulted in daily activities effects predominantly ranging from none to moderate effects, except that it prevented sports. During a March 2010 VA examination the Veteran reported having a throbbing pain to both feet at the ball of the feet that radiated to the heel, and redness, and occasional swelling. Prolonged standing aggravated the symptoms. The Veteran had pain daily. He was presently employed as a postal carrier on light duty at work because of the feet. He was using Capsaicin and Carbidopa/Levodopa with partial relief. On examination, bilaterally, there was no evidence of painful motion, swelling, instability, weakness, abnormal weight bearing or other symptoms, but did have tenderness of the ball of the foot. There was no atrophy and the gait was appropriate. The impression was bilateral hallux valgus deformity. The examiner opined that the bilateral foot disabilities resulted in significant occupational effects with decreased mobility and pain; and resulted in daily activities effects predominantly ranging from none to moderate effects, except that it prevented sports. On careful review of the record, the Board finds that the Veteran's chronic right foot pain, status post Chilblain's Syndrome, and chronic left foot pain, status post Chilblain's Syndrome, each do not warrant a 20 percent evaluation bilaterally. Here, most recently, regarding both feet, VA examination showed no evidence of painful motion, swelling, instability, weakness, abnormal weight bearing or other symptoms. There was tenderness of the ball of the foot, but there was no atrophy and the Veteran's gait was appropriate. A disability rating in excess of 10 percent would require evidence of arthralgia or other pain, numbness, or cold sensitivity, plus tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or X-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis). In this case, there is evidence of foot pain, and diminished sensation or numbness, but there is no evidence of symptoms productive of tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis (excessive sweating), or X-ray abnormalities. There is also no specific evidence of cold sensitivity. The Board acknowledges that the Veteran's lower extremities symptoms include tenderness, and there are diagnoses including bilateral hallux valgus deformity and bilateral pes planus deformity. These latter conditions, however, have not been etiologically linked to the service-connected bilateral chronic foot pain, status post Chilblain's Syndrome. As such, these unrelated conditions cannot serve as the basis for a higher evaluation under the criteria for any service-connected cold injury of the same affected part. C. Chronic Headaches The RO has assigned the Veteran's chronic headaches a noncompensable disability rating prior to March 30, 2010, and a 10 percent disability rating thereafter. The RO has assigned these ratings pursuant to 38 C.F.R. § 4.124(a), Diagnostic Code 8100 (2013). Under that Diagnostic Code, migraine headaches are rated as 50 percent disabling with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. They will be rated as 30 percent disabling with characteristic prostrating attacks occurring on an average once a month over last several months. They will be rated as 10 percent disabling with characteristic prostrating attacks averaging one in two months over last several months. A noncompensable rating will be assigned for less frequent attacks. 38 C.F.R. § 4.124(a), Diagnostic Code 8100 (2013). The rating criteria do not define "prostrating," nor has the Court. Cf. Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack.). According to Dorland's Illustrated Medical Dictionary 1554 (31st ed. 2007), "prostration" is defined as "extreme exhaustion or powerlessness." In December 2003, the Veteran underwent a VA examination. At this time, the Veteran indicated a worsening of his headaches. He provided an account of experiencing a sharp pain to his head that was right periorbital and right frontal. He had some blurring of vision. The headaches occurred at least once per week and lasted for up to 45 minutes. He reported that he would continue working at his job at the post office during the headaches. He denied any slurred speech or seizures. The examiner concluded the report with an assessment of chronic headaches (post motor vehicle accident) with mild impairment. During a September 2007 VA neurological disorders examination, the Veteran current symptoms as a throbbing pain to the bilateral temporal area that occurred every day and would last more than four hours. He reported having associated blurred vision during the headaches. He denied having nausea or vomiting. Aggravating factors were light or sunlight, and alleviating factors were silence and a dark room. He currently was on medication including Butalbital and Tylenol. He reported that the headaches course had been to become progressively worse since onset. The examination contains notation summarizing the Veteran's report that there was a weekly frequency of headaches in the past 12 months, and the condition was treated with continuous medication. Most of the attacks were prostrating and would last hours. After examination, the examiner diagnosed migraine headaches, and opined that the headaches had significant effects on the Veteran's occupation due to decreased concentration and pain. During a March 2010 VA neurologic examination, the Veteran reported that he had an increase in the frequency of his migraine headaches, which he described as severe stabbing type pain to the bilateral temporal area that was intense and lasting for two to three days. He reported that he occasionally saw floaters. He reported that he also had nausea but no vomiting, and was sensitive to light and noise. He presently treated the symptoms with Hydrocodone and Tylenol, and reported he had tried several medications but none had been efficacious. The Veteran reported that the course of the symptoms had become progressively worse since onset. He had a weekly frequency of headaches during the past 12 months. The headaches attacks were mostly prostrating and would last longer than two days. Numerous other treatment records and statements, both lay and professional, have been associated with the claims folder, in connection with the Veteran's claim. To some extent, these records are consistent with the findings noted above and corroborate the Veteran's account of headache severity and frequency. The Veteran has provided competent and credible evidence that his service-connected chronic headaches are manifested by severe pain, some blurring of vision, and to some extent nausea. Although he has reported varying frequencies of headaches, these headaches may fairly be characterized as occurring quite often, from daily to weekly, although not always prostrating. Affording the Veteran the benefit of the doubt, the Board finds that the competent evidence of record warrants a 30 percent disability rating for the chronic headaches. The Board finds that the disability picture is productive of headaches with characteristic prostrating attacks occurring on average once a month over the last several months. Though the chronic headache symptoms have varied to some extent over time, the Board finds that this criteria has generally been met throughout the appeal period, and therefore warrants a 30 percent disability rating for the entire period of the appeal. 38 C.F.R. § 4.124(a), Diagnostic Code 8100; See Hart supra. The preponderance of the evidence is against finding, however, that a disability rating in excess of 30 percent is warranted at any time during the appeal period. The record shows that as of the time of the March 2010 VA examination, the Veteran was still employed as a postal carrier, although on light duty work because of his feet-as reflected in the VA foot examination report dated in March 2010. Consequently, the Board finds that the Veteran's service-connected chronic headaches are not manifested by symptoms productive of characteristic prostrating attacks that result in severe economic inadaptability. Thus, a 50 percent evaluation is not warranted. The symptoms associated with the Veteran's service-connected chronic headaches more nearly approximate the criteria for a 30 percent evaluation. 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Code 8100 (2013). As such, the Board finds that a 30 percent evaluation, but not more, is warranted for the Veteran's service-connected chronic headaches throughout the pendency of this appeal. D. Conclusions In light of the holding in Hart v. Mansfield, with respect to each of the decisions above, the Board has considered whether a staged rating is appropriate at any time during the entire period under consideration. However, because the symptoms of Veteran's disabilities on appeal remained relatively constant throughout the course of the period of appeal and at no point were more disabling than reflected by the evaluations in effect or granted here above. The Board has not assigned staged ratings as the factual findings do not show distinct time periods that the Veteran's disability warranted different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The preponderance of the evidence establishes that the Veteran's service-connected neck disability and bilateral foot disabilities do not meet the criteria for a rating greater than that already in effect, and the reasonable doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Further, the preponderance of the evidence establishes that the Veteran's service-connected chronic headaches do not meet the criteria for a rating greater than that granted above. Id. In conclusion, the Board finds that a 30 percent disability rating is warranted for the Veteran's chronic headaches. The preponderance of the evidence is against finding that the Veteran's chronic headaches warrants a higher disability rating; or that service-connected neck disability or bilateral foot disabilities warrant a higher rating evaluation than currently in effect. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b) regarding benefit of the doubt. Further, based on the evidence discussed above and the applicable law, the Board finds that at no time during the pendency of the appeal has the Veteran been entitled to a rating higher than 30 percent for chronic headaches. See 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Hart v. Mansfield, 21 Vet. App. 505 (2007). In addition, in exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Based on the above discussions, the symptoms associated with the Veteran's chronic muscular neck pain, status post cervical strain, to include pain, limitation of motion, popping, fatigue, decreased motion, stiffness, weakness, spasms, severe flare-ups weekly lasting hours, guarding, and tenderness, are not shown to cause any impairment that is not already contemplated by the rating criteria (DCs 5003, 5287, 5290, 5293 (effective prior to September 26, 2003), and DCs 5003, 5237-5243 (2013)), and the Board finds that the rating criteria reasonably describe his disability. Additionally, the symptoms associated with the Veteran's chronic right and left foot pain, status post Chilblain's Syndrome, to include throbbing and stinging sensation, pain, weakness, redness, and fatigability are not shown to cause any impairment that is not already contemplated by the rating criteria (DC 7122), and the Board finds that the rating criteria reasonably describe his disability. Further, the symptoms associated with the Veteran's chronic headaches, to include sharp pain and sensitivity to light and sound, nausea, and blurring of vision, are not shown to cause any impairment that is not already contemplated by the rating criteria (DC 8100), and the Board finds that the rating criteria reasonably describe his disability. For these above stated reasons, referral for consideration of extraschedular ratings are not warranted for these increased rating claims. III. TDIU Consideration Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total if it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of 1) a single service-connected disability ratable at 60 percent or more, or 2) as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 3.340, 3.34l, 4.16(a). In this regard, the Board highlights that disabilities resulting from a common etiology or a single accident, and disabilities affecting a single body system (i.e., the orthopedic, digestive, respiratory, cardiovascular-renal, or neuropsychiatric system), are considered to be one disability. 38 C.F.R. § 4.16(a). Where these percentage requirements are not met, entitlement to the benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. § 4.16(b). Entitlement to a TDIU requires the presence of an impairment so severe that it is impossible for the average person to secure and follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or the impairment caused by non-service- connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. In making this determination, the Board must assess the credibility and probative value of evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wood v. Derwinski, 1 Vet. App. 190 (1991). While the Board is not free to ignore the opinion of a treating physician, it is free to discount the credibility of that physician's statement. See Guerrieri v. Brown, 4 Vet. App. 467, 471-73 (1993); Sanden v. Derwinski, 2 Vet. App. 97, 101 (1992). The Board notes that the fact that a Veteran is unemployed or has difficulty obtaining employment is insufficient, in and of itself, to establish unemployability. The relevant question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. §§ 4.1, 4.15). The Veteran contends that he is entitled to a TDIU. Specifically, he reported that his service-connected disabilities hindered him from performing his duties as a letter carrier, rendering him unemployable. In this case, service connection is in effect for multi-level thoracolumbar spondylosis, rated as 40 percent disabling; chronic headaches, rated as 30 percent disabling; posttraumatic stress disorder (PTSD), rated as 30 percent disabling; chronic muscular neck pain, rated as 20 percent disabling; chronic right and left foot pain, status post Chilblain's Syndrome, separately rated as 10 percent disabling; pseudofolliculitis barbae, rated as 10 percent disabling; radiculopathy of the left and right lower extremities, separately rated as 10 percent disabling; and sinusitis, rated as noncompensable. The Veteran's combined disability rating is 90 percent. Accordingly, the Veteran meets the percentage requirements of 38 C.F.R. § 4.16 because at least one disability is ratable at 40 percent or more, thoracolumbar spondylosis, and his additional service-connected disabilities bring his combined disability rating to 90 percent, which is above the required 70 percent rating. Turning to the evidence of record, the September 2007 VA examination report contained a summary noting that there were significant effects of the cervical spine disability on the Veteran's usual occupation. Additionally, the Veteran reported that he had severe functional impairment due to the pain in the bilateral feet, with flare-ups daily lasting for hours. The examiner opined that the Veteran's bilateral foot disabilities resulted in significant occupational effects with decreased mobility and pain. Further, the examiner diagnosed the Veteran with migraine headaches, and opined that the headaches had significant effects on the Veteran's occupation due to decreased concentration and pain. Additionally, the Veteran submitted a July 2010 letter, written by his VA primary care physician. The physician noted the Veteran's medical conditions and treatment. She concluded that his current medication regime had the potential of causing inattention and drowsiness. Because of his joint problems with his spine, knee, and feet, he was unable to lift more than 20 pounds consecutively, climb/ descend stairs, twist torso, squat, kneel, bend at the waist, or prolonged sitting or standing for more than 20 minutes at a time. The Veteran's condition started during his military career and was getting progressively worse. The physician did not anticipate any improvement in his condition other than joint replacement surgery at a certain age. At the November 2012 VA examination, the VA examiner noted that the Veteran's PTSD caused difficulty in establishing and maintaining effective work and social relationships. The Veteran also submitted a December 2010 letter from the Office of Personnel Management (OPM) that stated that the Veteran claimed he was disabled due to bipolar II disorder, bilateral peripheral neuropathies, equines, and flatfoot. In reviewing the Veteran's medical records, OPM found that the Veteran was disabled for his position as a letter carrier. Lastly, the evidence of record contains a September 2013 letter from a VA Vocational Rehabilitation Counselor. He stated that according to the record, the Veteran had a service-connected disability rating of 90 percent for degenerative arthritis of the spine, PTSD, migraines, cervical spine condition, residuals of cold injury, and eczema. He received Social Security Disability benefits. He was found entitled to benefits under Chapter 31 program in 2008 and participated in an employment training program; however, his conditions had worsened to the point that it was infeasible for him to achieve and maintain employment. He would not be provided with further employment-related services under Chapter 31 at that time. After a careful review of the evidence, the Board finds that the Veteran's pertinent lay evidence and the positive nexus opinion provided by the VA Vocational Rehabilitation Counselor, demonstrate that his service-connected medical and psychiatric disabilities cause functional impairment that render him unemployable. Specifically, the Vocational Rehabilitation Counselor concluded that the Veteran's conditions had worsened to the point that it was infeasible for him to achieve and maintain employment. Therefore, the Board finds that reasonable doubt exists as to whether the Veteran is able to secure and follow substantially gainful employment as a result of his service-connected disabilities. Accordingly, applying the doctrine of the benefit of the doubt, the Board grants the Veteran's claim of entitlement to a TDIU. 38 U.S.C.A. § 5107(b). ORDER A disability rating in excess of 20 percent for chronic muscular neck pain, status post cervical strain, is denied. A disability rating in excess of 10 percent for chronic right foot pain, status post Chilblain's Syndrome, is denied. A disability rating in excess of 10 percent for chronic left foot pain, status post Chilblain's Syndrome, is denied. A disability rating of 30 percent for chronic headaches, throughout the appeal period, is granted, subject to the applicable criteria governing the payment of monetary benefits. Subject to the laws and regulations governing monetary awards, entitlement to a total disability rating based on individual unemployability due to the service connected disabilities is granted. REMAND The Board notes that the issues of entitlement to an initial compensable disability rating prior to September 20, 2007, for pseudofolliculitis barbae, and to an initial disability rating in excess of 10 percent from September 20, 2007, for pseudofolliculitis barbae were remanded in a September 2011 Board decision. However, it does not appear that the AMC addressed the remand directives requesting a VA examination to address the current level of severity of the Veteran's service-connected pseudofolliculitis barbae. There, the issues are again remanded for that development to be completed. Additionally, a review of the record reflects that the Veteran filed a timely June 2013 notice of disagreement with respect to the RO's May 2013 rating decision denying service connection for ED and insomnia, to include as secondary to a service-connected disability. However, no subsequent action was taken. Where a notice of disagreement has been timely filed with regard to an issue, and a statement of the case has not been issued, the appropriate Board action is to remand the issue for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). Therefore, the Board finds that a remand is necessary for the issuance of a statement of the case for the issues of entitlement to service connection for ED and insomnia. Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran identify any outstanding VA or private treatment records pertaining to his service-connected pseudofolliculitis barbae. After securing any necessary authorization from him, obtain copies of any records the Veteran identifies, to include any outstanding VA treatment records not on file. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. The RO should issue the Veteran a statement of the case pertaining to the issues of entitlement to service connection for erectile dysfunction and insomnia, to include as secondary to a service-connected disability. The Veteran should be notified that he must file a timely and adequate substantive appeal in order to perfect an appeal of these issues to the Board. 38 C.F.R. §§ 20.200, 20.202, and 20.302(b). If a timely substantive appeal is not filed, the claims should not be certified to the Board. If so, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. 3. After associating all available outstanding VA and private treatment records and lay statements, the RO should schedule the Veteran for an appropriate VA examination to determine the nature, extent, location, frequency and severity of any dermatological impairment related to his pseudofolliculitis barbae. The claims file should be made available to and reviewed by the examiner. This should be noted in the examination report. The examiner should conduct all indicated tests and studies. The examiner should identify all pseudofolliculitis barbae pathology found to be present, and describe the nature, extent, location, surface area affected, frequency, and severity of such pathology. The examiner should identify whether the predominant disability is productive of (1) disfigurement of the head face, or neck; or (2) scars; or (3) dermatitis; or manifestations analogous to one of these three. The examiner should specifically include, to the extent possible, findings regarding the percentage of the entire body affected; the percentage of the exposed areas affected; and indicate the frequency with which any systemic therapy has been required in relation to a previous 12 month period during the appeal period. The examiner should comment on the effects of the pseudofolliculitis barbae on the Veteran's ability to work. All findings and conclusions should be set forth in a legible report. 4. Thereafter, readjudicate the Veteran's pseudofolliculitis barbae disability rating claim. If a benefit sought remains denied, the Veteran and his representative must be furnished a supplemental statement of the case and be given an opportunity to submit written or other argument in response before the claims file is returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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. 2013). ______________________________________________ K. A. KENNERLY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs