Citation Nr: 1612185 Decision Date: 03/25/16 Archive Date: 03/29/16 DOCKET NO. 09-37 921 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a low back disorder, including early degenerative joint disease (DJD) changes consistent with arthritis and mild dextroscoliosis of the lumbar spine. 2. Entitlement to service connection for residuals of a right ankle fracture or injury. 3. Entitlement to service connection for an acquired psychiatric disorder, to include depression, and to include as secondary to service-connected migraines. 4. Entitlement to a rating in excess of 10 percent for residuals of a left ankle fracture or injury. 5. Entitlement to a compensable rating for migraines prior to December 23, 2009, and in excess of 50 percent thereafter. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD A. Hodzic, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active military service from September 1975 to October 1987 in the United States Army. These matters come before the Board of Veterans' Appeals (Board) on appeal from April 2008, August 2009, and May 2011 rating decisions of the Department of Veteran's Affairs (VA) Regional Offices (ROs) in St. Petersburg, Florida and Montgomery, Alabama. The Agency of Original Jurisdiction (AOJ) for the Veteran's case is the RO in Montgomery. The April 2008 rating decision denied service connection for a low back disorder and right ankle disorder, but granted service connection for a left ankle disability and assigned a rating of 10 percent effective July 31, 2006. The August 2009 rating decision granted service connection for migraines and assigned a noncomensable (zero) rating for this disability, effective August 2, 1996. Although the Veteran requested a reconsideration and a claim for an earlier effective date for the assignment of a higher rating for this disability by his September 2009 and December 2009 statements, the substance of his statements shows that he was in disagreement with the assigned rating and that he wanted a higher initial rating assigned for his migraines. Thus, the Board has re-characterized the issue as it appears above. The May 2011 rating decision denied entitlement to service connection for depression but increased the Veteran's rating for this migraines to 50 percent effective December 23, 2009 and denied a compensable rating for his migraines prior to this date. The Veteran appealed these denials and the assigned ratings in these decisions and the matters are now before the Board. The low back, right ankle, and left ankle claims were previously before the Board in April 2014, at which time the Board remanded them for additional evidentiary and procedural development. The Board finds that there has been substantial compliance with its remand orders regarding the low back and left ankle claims, and that it may, therefore, proceed with a determination of these issues on appeal. See Stegall v. West, 11 Vet. App. 268 (1998). The issue of entitlement to an earlier effective date for residuals of a left ankle fracture or injury has been raised by the record in a February 2014 statement by the Veteran's representative but has not been adjudicated by the AOJ. Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). The issue of entitlement to service connection for residuals of a right ankle fracture or injury is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's low back arthritis did not manifest during service or within one year of separation from service, and his current low back disorder is not etiologically related to his active military service. 2. After resolving all doubt in the Veteran's favor, his current depression symptoms are caused by his service-connected disabilities, including migraines. 3. For the entire time period on appeal, the Veteran's left ankle disability has manifested with less movement than normal, weakened movement, excess fatigability, incoordination, and pain resulting in a marked limitation of motion of this joint. 4. Resolving all doubt in the Veteran's favor, his migraines have manifested with characteristic prostrating attacks occurring approximately two to four times per month prior to December 23, 2009, but they have not been very frequent and completely prostrating with prolonged attacks that were productive of severe economic inadaptability prior to December 23, 2009. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disorder have not been met. 38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2015). 2. The criteria for service connection for depression have been met. 38 U.S.C.A. §§ 1101, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310, 4.125 (2015). 3. The criteria for a rating of 20 percent, but not higher, for residuals of a left ankle fracture or injury have been met for the entire time on appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5299-5271 (2015). 4. The criteria for a rating of 30 percent, but not higher, for migraine headaches prior to December 23, 2005 have been met, but the criteria for a rating in excess of 50 percent since December 23, 2005 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.124a, DC 8100 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection, Generally Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). "To establish a right to compensation for a present disability, a Veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service'-the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may also be established under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, and subsequent manifestations of the same chronic disease or injury at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331, 1340 (Fed. Cir. 2013). The record indicates that the Veteran's low back disorder has DJD changes that are consistent with arthritis, which is a chronic condition listed under 38 C.F.R. § 3.303(b); as such, 38 C.F.R. § 3.303(b) is applicable. Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. However, where the evidence does not warrant presumptive service connection, a veteran is not precluded from establishing service connection with proof of direct causation. See Combee, 34 F.3d at 1043. When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3 (2015). In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2014). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Low Back Disorder The Veteran contends that his low back disorder was caused by his active military service. Initially, the Board notes that the Veteran has a current low back disorder. Specifically, a May 2014 VA examination report, as well as additional VA treatment records, show that he was diagnosed with lumbosacral strain and lumbar spondylosis. Moreover, diagnostic testing showed that he had dextroscoliosis and changes of spondylosis and degenerative disc disease narrowing between the L4 and L5 spinal vertebra. Thus, the first element of service connection is met. Regarding the second element, the Veteran's service treatment records show complaints of symptomatology related to his back in service. Specifically, a June 1980 chronological record of medical care showed that he complained of lower back pain, which was due to a pulled lower back muscle six days before. Likewise, a July 1981 chronological record of medical care showed that he complained of tightness in his chest with lower back pain. The note showed that it was hard for him to swallow and he had soreness around his neck. The medical professional assessed him as having an upper respiratory infection. Two days later, another service treatment record showed that he still complained of back and side pains, as well as a scratchy throat and arthralgias in his wrists and ankles. The medical professional noted that he probably had viral syndrome, but it could remotely be Reiter's or some other cardiothoracic disease. In another service treatment record two days later, the Veteran's joints were noted to be much less sore, but his back was still somewhat stiff. The assessment was probable viral syndrome that was resolving. Additionally, in a March 1982 service treatment record, he reported lower back pain that was present for one and a half weeks. The medical professional noted that he did not have a previous injury or a recent injury but just started having gradual lower back pain, which was aggravated by sexual activity. His range of motion testing showed good results and he did not have scoliosis, swelling, or a deformity. The medical professional assessed him with a probable muscle strain. These service treatment records show that he had an in-service incurrence a disease or injury to his lower back; thus, the second element of service connection is met. The Board notes, however, that the claims file is silent as to a manifestation of arthritis in his back during military service or within one year of separation from service. Thus, the presumptive provisions relating to chronic diseases are not for application in the Veteran's case. Since service, the first instance of complaints of symptoms related to his back comes from a December 2004 VA progress note, in which he complained of back pain and was assessed as having back pain that was normal after x-ray studies. He was advised not to perform squats for approximately six weeks to resolve his back pain. Pain symptoms were also noted in subsequent VA treatment records, including in June 2005, July 2005, April 2006, and March 2007. Additionally, he had a VA examination in July 2007, which showed mild dextroscoliosis involving the lumbar spine, muscle spasms, and early DJD changes that were consistent with arthritis but without compression fractures. The claims file also includes records received from the Social Security Administration (SSA) regarding his various medical disorders. A January 2012 disability determination and transmittal form showed that the Veteran's disorders included osteoarthritis and allied disorders, as well as migraines. While the abovementioned medical records show complaints and treatment for back disorder symptoms, they do not discuss the overall etiology of these symptoms or their relationship to the Veteran's military service. However, a May 2014 VA examination report specifically addresses the etiology of the Veteran's back disorder. Following an in-person examination, review of the Veteran's records, and notation of his self-reported symptoms and history, the VA examiner diagnosed him with a lumbar strain and lumbar spondylosis. The Veteran reported that he was on active duty when he hurt his back in 1984 while lifting heavy objects. He continued with pain and with further injury by lifting heavy objects as he worked in a military warehouse. After noting his current symptoms and history, the examiner concluded that his current back disorder was less likely than not (less than 50 percent probability) incurred in or caused by his claimed in-service injury, event, or illness. The examiner explained that the Veteran has changes of lumbar and thoracic spondylosis that are age related. The examiner noted that there were not significant back problems while on active duty and that the Veteran was separated from the Army in 1987 but did not have back problems documented for many years after that until he sought care from VA in 2007. In addition to the medical evidence above, the claims file includes statements from the Veteran and his representative regarding the etiology of his current low back disorder. He filed a claim for service connection for this disorder in September 2005. In a December 2005 statement, he contended that his back disorder had existed since his military service and the symptoms had increased in severity and frequency. He made very similar contentions in his May 2008 notice of disagreement. In his October 2009 substantive appeal (VA Form 9), he again reiterated that his back disorder has existed since service and that it has gotten worse. He noted that he has early signs of DJD and that the back pain in service was the onset of his current pain. He stated that he did not have any other injury to his back since service. Similarly, the Veteran's representative contended in a February 2014 statement that the Veteran should be granted service connection for his back disorder because the record shows incurrences in service, continuity of symptoms, and a current chronic diagnosis. In a February 2016 statement, the Veteran's representative contended that the Veteran's back disorder was due to his antalgic or altered gait, which he associates with the Veteran's flat feet. The Board notes that the Veteran is not service connected for a flat foot disorder. In light of the aforementioned evidence, the Board finds that the Veteran's current back disorder is not etiologically related to his active military service. While he currently has a diagnosis of early DJD changes consistent with arthritis and mild dextroscoliosis of the lumbar spine, his low back arthritis did not manifest during service or within one year after separation form service. In fact, the claims file does not show treatment for any back symptoms until December 2004, approximately 17 years after separation from service. Furthermore, the May 2014 VA examiner concluded that his current back disorder was less likely than not due to his active military service. Instead, the examiner concluded, his current back disorder was caused by age-related changes. The Board finds this examiner's opinions to be the most probative evidence on the issue of etiology of the current back disorder because of the VA examiner's expertise, training, education, proper support and rationale, and thorough review of the Veteran's records. After considering the many years from separation from service until he sought treatment for back pain and the May 2014 VA examiner's opinions, the Board concludes that his current back disorder is not etiologically related to his military service. Although another plausible explanation is what the Veteran and his representative have contended during the appeal, i.e., that his back pain has been present since service and that it has increased in severity and frequency since service, the Board has determined that its conclusion is more in keeping with the record as a whole. Accordingly, as the preponderance of the evidence is against service connection for a low back disorder, including early DJD changes consistent with arthritis and mild dextroscoliosis of the lumbar spine, the benefit of the doubt doctrine does not apply, and the Veteran's claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Acquired Psychiatric Disorder Next, the Veteran contends that his depression is caused by his service-connected disabilities, namely, his migraine headaches and a left ankle disability. A claim for service connection for a mental disability may encompass claims for service connection of any mental disability that may reasonably be encompassed by several factors, including the claimant's description of the claim, the symptoms the claimant describes and the information the claimant submits or that the Secretary obtains in support of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Accordingly, the Board has taken an expansive view of the Veteran's claim pursuant to Clemons. While the Veteran's service treatment records document complaints of mental disorder symptoms, including an inability to cope with personal and military problems and anxiety related to a medical condition, he does not contend that his current acquired psychiatric symptoms are caused by his military service. Rather, he claims that his depression is caused by the chronic pain and financial difficulty he experiences as a result of his service-connected migraines. As will be discussed in more detail below, the Board finds that it can adjudicate his depression claim through consideration of secondary service connection, and thus, it does not need to address direct service connection. Except as provided in 38 C.F.R. § 3.300(c), a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). This includes any increase in disability (aggravation) that is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310(b). Establishing service connection on a secondary basis requires (1) medical evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). When aggravation of a veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). The claims file includes many VA treatment records, including an August 2010 VA examination report, which note a diagnosis of depression. Thus, presence of a current disability is not in question. Likewise, the Veteran's claims file includes ample evidence showing that he has been service connected for migraine headaches since August 1996 and residuals of a fracture of the left ankle disability since July 2006. Thus, the second element of secondary service connection is not in question either. Regarding the third element, i.e., medical nexus evidence establishing a connection between the service-connected disability and the current disability, the Board notes that the claims file contains conflicting medical evidence regarding the cause of the Veteran's depression. Specifically, one VA doctor attributes his depression to a Hepatitis C disorder, which is not service connected, while a VA examiner and a different VA doctor attribute his depression to financial and unemployability problems, which stem from his service-connected migraines. In August 2010, the Veteran was afforded a VA examination for his psychiatric symptoms, during which the examiner reviewed his claims file, performed an in-person examination, and took down his self-reported symptoms and history. The examiner diagnosed him with an adjustment disorder with depressed mood and assigned a Global Assessment of Functioning (GAF) score of 60. The examiner explained that the Veteran's depression was due to and caused by financial strain, which in turn was caused by him not having full-time employment. The Veteran indicated that the reason that he could not work full-time was because his migraine headaches interfered with his work performance, which previously resulted in termination. The examiner also noted that his depression, taken solely, was not of such severity that it would interfere with his ability to maintain gainful employment. The Board notes that the Veteran was granted a total disability rating based upon individual unemployability (TDIU) due to his service-connected migraines since March 22, 2011. Contrasted against this VA examiner's opinion, which shows that his depression is due to his inability to maintain a full-time job due to his service-connected migraines, is an October 2011 letter from a VA psychiatrist that indicates that the Veteran's major depression was due to his Hepatitis C infection. While this doctor stated the Veteran's psychiatric symptoms and the fact that he was unemployable, he did not expound on the conclusion that the Veteran's depression was due to his Hepatitis C infection. Contrarily, in a November 2011 letter, another VA doctor indicated that the Veteran's headaches have had a profound impact on his life and caused him to not be able to work as a truck driver. This doctor stated that the migraines have also severely disrupted his sleep cycle and have likely caused worsening of his depression and anxiety. Furthermore, the claims file includes several VA treatment records from 2002 that noted poly-substance abuse and diagnoses of depression in VA psychiatry and mental health notes from May 2004, December 2004, July 2005, and November 2009. However, these records do not discuss the etiology of his depression symptoms. A December 2009 VA gastroenterology outpatient note indicated that he had some depression symptoms that were due to decreased weight and strength. An October 2011 VA psychiatry clinic note indicated that his depression was due to his general medical condition and financial stressors. Similar causes were noted in March 2010 and January 2011 VA psychiatry notes. In addition to the medical evidence noted above, the Veteran and his representative have consistently contended that his depression is caused by his service-connected migraines. For example, in a December 2009 statement, the Veteran stated that his migraines were causing him employment problems and that his social life suffered due to migraine symptoms. He stated that he was severely depressed because he could not get any relief from his migraines, which manifested two times a week and lasted for days at a time. Similarly, in a March 2010 statement, he indicated that his migraines caused problems in his family and social life and work because he could not take medication for migraines and continue to work as a truck driver. In his June 2011 notice of disagreement, the Veteran stated that it was always his contention that his depression resulted from his inability to maintain a job due to his migraine headache symptoms. In a February 2014 statement, the Veteran's representative indicated that the Veteran had an in-service incurrence, continuity of symptoms, and chronicity related to his stress and psychiatric symptoms. Additionally, the representative contended in a February 2016 statement that signs of the Veteran's depression were present in service. The examiner noted that it is impossible for the Veteran's Hepatitis C infection to be a causal factor in his development of depression because his depression symptoms go back as early as 2002 but his Hepatitis C was not discovered until 2004. The Board notes that the record as a whole corroborates this contention. In light of the aforementioned evidence, and after resolving all reasonable doubt in the Veteran's favor, the evidence is at least in equipoise in showing that his current depression symptoms are etiologically related to his service-connected migraines. Specifically, while the claims file contains several VA records indicating that this disability is due to his Hepatitis C infection, it also contains a medical opinion from a VA examiner that indicates that his depression is caused by financial duress stemming from a lack of full-time work due to service-connected migraines. Moreover, the claims file includes a medical opinion from a VA doctor who concluded that his migraine headaches have likely caused worsening of his depression and anxiety. While the Board acknowledges that several VA treatment records indicate that his depression is due to his Hepatitis C infection, the claims file shows that his depression symptoms predated his knowledge of a Hepatitis C infection. The Board also finds it significant that the claims file does not include a medical opinion concluding that the Veteran's depression is not etiologically related to his service-connected migraines. After weighting the probative value of the October 2011 letter from a VA doctor against the conclusions of the August 2010 VA examiner and the November 2011 letter from a VA doctor, as well as the credible statements from the Veteran and his representative, the Board finds that his current depression symptoms are caused by his service-connected disabilities, including migraines. Accordingly, after applying the benefit of the doubt doctrine, the evidence is at least in equipoise in showing that service connection for depression is warranted. Thus, the Veteran's claim is granted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Increased Ratings, Generally The Veteran is also seeking increased ratings for his left ankle and migraine disabilities. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture if it more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Where, as here, entitlement to service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The following discussion addresses the Veteran's level of disability from July 31, 2006 for his left ankle disability and from August 2, 1996 for his migraines, i.e., the dates that he was granted service connection for these disabilities. See Francisco, 7 Vet. App. 55; see also Hart, 21 Vet. App. 505. Left Ankle Disability The Veteran is seeking a rating in excess of 10 percent for his left ankle disability for the entire time on appeal. The present appeal involves a disability of the musculoskeletal system. The Veteran's left ankle disability is rated under DC 5299-5271. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2015). The use of the "99" series and a hyphenated diagnostic code reflects that there is no specific diagnostic code applicable to the left ankle disability, and it must be rated by analogy. 38 C.F.R. § 4.20 (2015). Under DC 5271, a 10 percent rating is assigned for moderate limited motion of the ankle. A 20 percent rating is assigned for marked limitation of the ankle. 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, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In determining the appropriate rating for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant 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. The factors involved in evaluating and rating disabilities of the joints include increased or limited motion, weakness, fatigability, incoordination, painful movement, swelling, deformity, or disuse atrophy. 38 C.F.R. § 4.45. Painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 must be considered. Deluca v. Brown, 8 Vet. App. 202, 207-08 (1995). The Court of Appeals for Veterans Claims (Court) has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The Board notes, however, that 38 C.F.R. § 4.40 does not require a separate rating for pain but rather provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). The Veteran filed a claim for service connection for a left ankle disability in July 2006. In an October 2006 VA primary care outpatient note, he complained of left ankle pain that had been occurring for approximately eight months and that was exacerbated by physical activity. The VA medical professional noted that there was no swelling, erythema, or warmth. The Veteran had full range of motion of his ankle, including during extension and flexion, but there was some pain at the extremes of inversion and eversion. He was noted to have early osteoarthritis in his ankle. A March 2007 VA primary care note showed that his ankle condition was stable with no changes in symptoms or medication for this disability. A January 2008 VA podiatry clinic note showed that he had left ankle pain. He was afforded a VA examination in July 2007 for his left ankle disability, which noted that he intermittently but frequently uses a brace, a cane, and a walker to assist with walking. He did not have incapacitating episodes of arthritis and he was able to stand for 15 to 30 minutes. He was able to walk more than a quarter of a mile, but less than one mile. He complained of pain, weakness, and giving way in his ankles. Range of motion testing of his left ankle revealed dorsiflexion of zero to 20 degrees with pain beginning at 20 degrees and ending at zero degrees. Plantar flexion was zero to 45 degrees with pain at 45 degrees and pain ending at zero degrees. There was no additional limitation of motion on repetitive use. An x-ray examination showed that there was no significant intrinsic ankle abnormality. The examiner noted that his bilateral ankles had a significant effect on his occupational activities due to pain and increased absenteeism. He was afforded another VA examination in August 2013 during which he was diagnosed with a left ankle strain. He complained of constant feelings of weak ankles and moderate pain. The examiner noted that he used ibuprofen to alleviate his symptoms and that he used a brace and a cane due to feeling that his ankle gives way. He reported flare-ups and that his ankle was worse with prolonged walking. Range of motion testing revealed plantar flexion from zero to 30 degrees with objective evidence of painful motion beginning at zero degrees and plantar dorsiflexion from zero to 10 degrees with objective evidence of painful motion beginning at zero degrees. After three repetitions, his plantar flexion was 30 degrees and his dorsiflexion was 10 degrees. The examiner noted that he did not have additional limitation in range of motion after repetitive-use testing, but that he did have functional loss and/or functional impairment of the ankle, including less movement than normal and pain on movement. The examination further revealed no pain on palpation, normal muscle strength testing, and negative anterior drawer and talar tilt tests. The Veteran did not have ankylosis of the ankle, subtalar and/or tarsal joints and he did not have shin splints, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), an astragalectomy, or any ankle surgery. The examiner noted that he used a brace and a cane on a regular basis to help with ambulation. The examiner further noted that his left ankle disability impacted his ability to work by preventing heavy physical labor, but did not preclude light physical or sedentary work. During a May 2014 VA examination, the Veteran stated that he did not have flare-ups. Range of motion testing revealed plantar flexion from zero to 40 degrees with objective evidence of pain beginning at 20 degrees and plantar dorsiflexion from zero to 15 degrees with objective evidence of pain beginning at five degrees. Following repetitive-use testing, his plantar flexion was at 40 degrees and his dorsiflexion was at 15 degrees. He did not have additional limitation in range of motion after repetitive-use testing but he did have functional loss and/impairment in this ankle, including less movement than normal, weakened movement, excess fatigability, pain on movement, incoordination such as an impaired ability to execute skilled movements smoothly, and interference with sitting, standing, and weight-bearing. The examiner noted that he had pain on palpation and that his muscle strength testing showed normal results. The anterior drawer test and talar tilt test were negative and he did not have ankylosis of the ankle. He also did not have shin splints, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), an astragalectomy, or any previous ankle surgery. The examiner noted that he constantly used a brace and a cane to help with ambulation. Diagnostic testing showed degenerative or traumatic arthritis in his ankle and the examiner noted that he also had bilateral pes planus and large plantar calcaneal spurs. The x-ray showed talar beaks from degenerative changes of intertarsal joints. The examiner further noted that his left ankle disability impacted his ability to work because he has to use a cane for support and he cannot lift heavy objects. The examiner specifically addressed the Mitchell criteria in stating that he does not have flare-ups. He has functional limitation from pain and fatigue and weakness due to repeated use needing to rest but no impact on range of motion and no functional impact of incoordination. VA treatment records also show left ankle symptoms. Specifically, an October 2007 VA podiatry consultation note showed that he complained of left ankle pain and that he was issued bilateral leg braces. Similarly, the Veteran again complained of left ankle pain in April 2011 and the evaluation showed mild tenderness to manipulation but no edema or erythema. An x-ray of his left ankle showed no acute abnormalities. In addition to the medical evidence noted above, the Veteran has endorsed symptoms of pain and limited motion in his left ankle during the pendency of this appeal. For example, in a May 2008 notice of disagreement, he stated that his left ankle was very unstable and that it interfered with his ability to make a living. Similarly, in his October 2009 VA Form 9, he again endorsed symptoms of pain and instability in this ankle. He also noted that he uses a cane and brace for stability, and that his left ankle gives way. In light of the aforementioned evidence, the Board finds that for the entire time period on appeal, the Veteran's left ankle disability has manifested with less movement than normal, weakened movement, excess fatigability, incoordination, and pain resulting in a marked limitation of motion of this joint. While several VA treatment records, including x-rays, showed that his left ankle does not show any abnormalities, the VA examinations reports from July 2007, March 2013, and May 2014 show marked limitation in motion of his ankle. Specifically, the range of motion testing results from the July 2007 and March 2013 VA examinations showed that the Veteran had objective evidence of pain starting at zero degrees for plantar flexion and dorsiflexion. Moreover, while the May 2014 VA examiner noted 40 degrees of flexion and 15 degrees of dorsiflexion after repetitive use, the Veteran was noted to have less movement than normal, weakened movement, excess fatigability, pain on movement, incoordination such as an impaired ability to execute skilled movements smoothly, and interference with sitting, standing, and weight-bearing. Additionally, the record shows that the Veteran is required to wear a brace and use a cane to ambulate. Thus, the record demonstrates that his disability picture approximates a 20 percent rating for his left ankle disability for the entire appeal period. The Board has also considered the other diagnostic codes located in 38 C.F.R. § 4.71a relating to the ankle but it concludes that these diagnostic codes are not applicable for the Veteran's left ankle disability. Specifically, the record shows that he did not have shin splints, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), an astragalectomy, or any previous ankle surgery during the appeal period. A 20 percent rating for limitation of motion of the ankle is the highest schedular rating available under the current diagnostic code, and while the Board has considered other potentially applicable DCs, the Board finds that a rating of greater than 20 percent is not warranted for the Veteran's symptoms. Accordingly, after resolving all doubt in the Veteran's favor, the Board concludes that his residuals of a left ankle fracture or injury have been 20 percent disabling, but not higher, for the entire period on appeal. Thus, his increased rating claim must be granted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. Migraines The Veteran also seeks an increased rating for his migraine headaches. Currently, this disability is rated as noncompensable (zero) from August 2, 1996 to December 22, 2009, and as 50 percent disabling since December 23, 2009. The Veteran's headaches are rated under 38 C.F.R. § 4.124a, DC 8100, which provides for a zero percent rating for migraines with less frequent attacks, a 10 percent rating for migraines with characteristic prostrating attacks averaging one in two months over the last several months, a 30 percent rating on evidence of characteristic prostrating attacks occurring on average once a month over the last several months. A maximum schedular rating of 50 percent is warranted for very frequent completely prostrating attacks productive of severe economic inadaptability. 38 C.F.R. §4.124a, DC 8100. The rating criteria do not define "prostrating," nor has the Court. See Fenderson v. West, 12 Vet. App. 119 (1999) (quoting DC 8100 verbatim, but without specifically addressing the matter of what a prostrating attack is). According to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, p. 1080 (3rd Ed. 1986), "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY, p. 1531 (32th Ed. 2012), in which "prostration" is defined as "extreme exhaustion or powerlessness." The Veteran filed a claim for service connection for headaches in August 1996. In a February 2002 VA addition severity index, he was noted to have chronic headaches, which interfered with his life. In an April 2004 VA mental health clinic note, he was noted as using cocaine to cope with his headache pain. The doctor noted that he has a history of headaches, which had never been fully worked up by a medical professional. In a December 2004 VA progress note, he again complained of headache pain and he stated that he has had these headaches since service. The doctor stated that he has headaches one to two times per month that required six Tylenol to knock out. His headaches were described as an abrupt pounding in the left jaw, which then spread to the temple, and the headaches were sometimes preceded by flashing lights. The Veteran's medication of Zomig did not help. In a March 2005 VA neurology consultation note, the doctor noted that he has had ongoing migraine symptoms for the last 20 years and that he has only been treated with abortive therapy, such as Zomig. The doctor also noted that he used aspirin and cocaine to treat his symptoms, and the doctor prescribed new medication for this disability. The onset of a migraine forced the Veteran to lie down in a dark room. In an April 2005 follow-up neurology note, the doctor noted that he had a decrease in the frequency of his headaches since he began using Topamax; however, he was still having headaches once every three to four days. In a June 2005 VA clinic note, the Veteran stated that he can abort his migraines if he takes a lot of medication early, otherwise, he has to sleep off his migraine attacks. A December 2005 primary care physician's note showed that the Veteran had run out of medication for his migraines and that his migraines were stable when he took his medication. His prescriptions medication was renewed. The Veteran again ran out of his medication in April 2006, and the doctor again renewed his prescriptions. He was afforded a VA examination in August 2007 in regard to his claim for service connection for headaches, at which time he was diagnosed with migraine headaches. The Veteran reported that he functions normally without a headache, but when he has a headache, he cannot do any work for about five to seven hours. He stated that his headache occurred once a week. In a January 2010 VA neurology consultation, the doctor noted that he has had 17 out of 30 days when he was headache free. He was noted to be incapacitated by his headaches a few times per month. He was a truck driver, but lost his job due to poor control of his headaches. He was assessed as having a longstanding history of poorly controlled migraine headaches and being currently only on abortive therapy. The doctor noted that he was also suffering from medication overuse for his headaches. He underwent another VA examination in April 2010, during which he reported problems with headaches at least two to three times per week. They usually lasted 24 hours but could last up to 72 hours. He reported that the headaches cause him to have to lie down and sleep in a dark room. The examiner stated that he basically reported that he is prostrate for several hours. The examiner noted that the Veteran was employed as a long-route truck driver. In a May 2011 VA examination report, the Veteran's headaches were noted to have progressed to two to three per week, and lasting up to two days. His doctor had increased his medication in order to alleviate his symptoms. The examiner noted that most of his attacks were prostrating, that they occurred weekly, and that they lasted one to two days. The Veteran reported that he lost his job as a commercial truck driver about a year and a half prior due to the severity and frequency of his headaches. A November 2011 letter from a VA doctor notes that the Veteran had more than 15 headaches per month. The doctor stated that these headaches had a profound impact on the Veteran's life and that they had made it impossible for him to continue working as a truck driver and that he would not be able to hold any employed position. In an August 2013 VA examination report, the Veteran was reported to have pulsing, severe headaches of two to three per week that lasted one to three days. The examiner noted that they are usually prostrating migraines, which prevented physical and sedentary work. He noted that he could not drive due to the effects of the medication. In addition to the medical evidence noted above, the claims file includes statements from the Veteran and his representative regarding his migraine symptoms. For example, in a December 2005 statement, the Veteran indicated that his migraine symptoms had grown worse in severity and frequency since service. Similarly, in a September 2009 statement, he stated that his headaches had increased in severity and that they occurred several times per week. He also indicated that his headaches have taken a toll on his ability to work and to deal with the severity of his symptoms. He stated that the headaches can last for several days and that he often has to leave work due to these symptoms. Immediately when he feels a headache coming on, he has to retreat to a darkened room to lie down. In his December 2009 notice of disagreement, the Veteran stated that he has had these headaches occurring on average two to three times per month and that they lasted for several days at a time. He indicated that he was unable to function during these times and that the sensitivity to light and sound was so severe that he had to confine himself to a dark, quiet place. He stated that Topamax only provided him with short-lived relief, and that he was taken off of this medication. He contended that his headaches greatly reduced the quality of his life and they caused him to miss too many days of work. He made similar contentions in a March 2010 statement, where he also indicated that his migraines lasted two to three days at a time and that he had them for several times per month. In a December 2010 statement, the Veteran contended that he should be rated at 30 percent for his migraines since August 2, 1996, as that is the time that he filed for a service-connection claim, and because his migraines were more frequent and severe than those for a rating of zero percent since that time. In a May 2011 statement, he reported that his headaches occurred at least once per week and that he had to be in a quiet, dark place. He stated that he was a truck driver, but that he was fired and had to stop working because he could not always drive due to his migraines and his medication, which in turn deteriorated his performance at work. In a February 2016 statement, the Veteran's representative contended that the VA medical evidence indicated that he had one to two prostrating migraines per month for many years in December 2004, and that this notation represented an improvement. The representative stated that the Veteran should be rated at least at 30 percent disabling from the original date of claim. After reviewing the entire claims file, and after resolving all doubt in the Veteran's favor, the Board finds that his migraine headaches have more nearly approximated the criteria for a 30 percent rating from August 2, 1996 to December 23,2009. The Veteran's prostrating migraine headaches occurred at least two to four times per month and lasted for hours to several days at a time during this time period. However, the migraines have not been very frequent and completely prostrating with prolonged attacks that were productive of severe economic inadaptability prior to December 23, 2009. During the entire period on appeal, the Veteran's symptoms have been prostrating. Specifically, he has routinely showed that when a migraine headache begins, he has to sleep it off or go to a dark and quiet room to alleviate his symptoms. Additionally, all of the evidence of record indicates that his migraines occurred at least once a month during the entire appeal period. Thus, his disability picture approximates a 30 percent rating prior to December 23, 2009. However, his disability picture does not warrant a rating in excess of 30 percent disabling prior to December 23, 2009 because the record shows that the Veteran was employed, including as a truck driver, during this time period. Several VA treatment records show that his prostrating headaches were stable. However, beginning in December 2009, his migraine symptoms increased in severity and frequency, including more frequent migraine attacks and longer-lasting symptoms, to the point that these headaches caused him to be fired from his trucking job. Thus, beginning on December 23, 2009, the date that the Veteran informed VA of the increased severity and frequency of these symptoms, his migraines have been very frequent and completely prostrating with prolonged attacks that were productive of severe economic inadaptability. Thus, his symptoms warrant a rating of 50 percent since December 23, 2009 pursuant to 38 C.F.R. § 4.124a, DC 8100. A 50 percent rating for migraine headaches is the highest schedular rating available under DC 8100, and while the Board has considered other potentially applicable diagnostic codes, the Board finds that a rating of greater than 50 percent is not warranted for the Veteran's symptoms at any period on appeal. Accordingly, after resolving all doubt in the Veteran's favor, the Board concludes that the Veteran's migraine disability has been 30 percent disabling, but not higher, prior to December 23, 2009, but that it does not warrant a rating in excess of 50 percent since December 23, 2009. Thus, his increased rating claim must be granted in part. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. Extraschedular Considerations The Board has also considered whether referral for one or more "extraschedular" ratings is warranted. An extraschedular rating is a rating outside of the regular rating criteria and is permitted if certain factors are present. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the Veteran's disability level and symptomatology, then his disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Id. at 115. If the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." If the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, a veteran's disability picture requires the assignment of an extraschedular rating. Here, the schedular rating criteria used to rate his service-connected disabilities above reasonably describe and assess his disability level and symptomatology. The criteria rate his left ankle disability on the basis of pain, range of motion, and diminished utility; thus, the demonstrated manifestations - namely pain, limited range of motion, instability, and lowered use due to pain - are contemplated by the provisions of the rating schedule, the Deluca and Mitchell factors, and the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.150. Additionally, the schedular rating criteria used to rate his migraines reasonably describe and assess his disability level and symptomatology. The criteria rate his headache disability on the basis of frequency of occurrence, level of severity, length of occurrence, and the effect on economic adaptability; thus, the demonstrated manifestations - namely more than one prostrating headache per month, effect on employment, and headaches lasting between 24 to 72 hours or more - are contemplated by the provisions of the rating schedule. Thus, as the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluations are adequate. For these reasons, the Board finds that the schedular rating criteria are adequate to rate his left ankle and migraine disabilities, and referral for consideration of an extra-schedular evaluation is not warranted. Furthermore, the Board notes that it granted service connection for depression above. However, the record as a whole has not indicated that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. See Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Nonetheless, the Board has fully considered the migraine, left ankle, and depression disabilities in concluding that referral for consideration on an extraschedular rating is not warranted. The Board has also considered whether an inferred claim for a total disability rating based upon individual unemployability (TDIU) has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009) prior to March 22, 2011. An April 2013 rating decision granted a TDIU effective March 22, 2011. Basically, a TDIU award permits for the assignment of a total rating even when an individual service-connected disability or disabilities are rated as less than total. While the Veteran's representative contended in a February 2016 statement that his migraines prevented him from working no later than January 14, 2010, the record shows that he was employed until March 2011. Specifically, a May 2012 reply to a request for employment information in connection with a claim for disability benefits (VA Form 21-4192) by the Veteran's former employer showed that he worked from June 29, 2010 to March 21, 2011 and that his salary was $5,384.51 in the previous 12-month period. The Veteran's May 2012 application for a TDIU noted that he worked from September 2010 to January 2011 and that he earned $1,900.00 per month. The Veteran's representative indicated in the February 2016 statement that the Veteran's employment to March 2011 consisted of intermittent and temporary assignments that should not be considered substantially gainful employment. Marginal employment shall not be considered substantially gainful employment, and generally shall be deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a) (2015). The Board concludes that the Veteran was not marginally employed prior to March 22, 2011. Specifically, the Veteran's income of $1,900.00 per month exceeded the poverty threshold for one person in 2010 of $10,830, which was the last full year of employment for the Veteran. The overall record has not indicated that he was prevented from security or maintaining gainful employment due to his service-connected disabilities prior to March 22, 2011. Thus, Rice is inapplicable in the present case for that time period. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. Notice letters were sent to the Veteran in December 2005, July 2007, July 2008, and February 2010, prior to the initial adjudication of the claims on appeal. Notices sent to the Veteran included descriptions of what information and evidence must be submitted to substantiate the claims, including a description of what information and evidence must be provided by the Veteran and what information and evidence would be obtained by VA. The Veteran was also advised to inform VA of any additional information or evidence that VA should have, and to submit evidence in support of the claims to the RO. The content of the letters complied with the requirements of 38 U.S.C.A. § 5103(a) (West 2014) and 38 C.F.R. § 3.159(b) (2015). VA also has a duty to assist a veteran in the development of a claim. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating a claim. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159; see Golz v. Shinseki, 590 F.3d 1317, 1320-21 (2010) (stating that the "duty to assist is not boundless in its scope" and "not all medical records . . . must be sought - only those that are relevant to the veteran's claim"). The Board finds that VA has satisfied its duty to assist by acquiring service treatment records, SSA records, and VA treatment records. The duty to assist was further satisfied by VA examinations in July 2007, August 2007, April 2010, August 2010, May 2011, March 2013, and May 2014, during which examiners conducted physical examinations of the Veteran, took down the Veteran's history, laid factual foundations for the conclusions reached, and reached conclusions and offered opinions and findings based on the Veteran's history and examinations that are consistent with the record. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations has been met. 38 C.F.R. § 3.159(c)(4); Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of their opinion). Finally, the Board remanded the lumbar spine and left ankle matters on appeal in April 2014 for additional development, including scheduling the Veteran for VA examinations for these medical conditions, and issuing a supplemental statement of the case (SSOC) if any benefit was denied by the RO. Accordingly, VA scheduled him for VA examinations in May 2014 and issued an SSOC in August 2014. Therefore, the Board finds that there has been substantial compliance with its April 2014 remand directives regarding the service connection claim for a low back disorder and an increased rating claim for the left ankle disability, and the Board has properly proceeded with the foregoing decision. See Stegall, 11 Vet. App. at 271 (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders). Based on the foregoing, VA has fully met its duties to notify and assist the claimant with the development of the claims above and no further notice or assistance is required. ORDER Entitlement to service connection for a low back disorder, including early DJD changes consistent with arthritis and mild dextroscoliosis of the lumbar spine, is denied. Entitlement to service connection for depression is granted. Entitlement to a rating of 20 percent, but not higher, for residuals of a left ankle fracture or injury is granted, subject to the rules and regulations governing VA compensation benefits. Entitlement to a rating of 30 percent, but not higher, for migraines prior to December 23, 2009 is granted, subject to the rules and regulations governing VA compensation benefits, but a rating in excess of 50 percent since December 23, 2009 is denied. REMAND Unfortunately, the Veteran's claim of entitlement to service connection for residuals of a right ankle fracture or injury must be remanded due to noncompliance with remand directives articulated by the Board. Specifically, the Board must remand this matter for an addendum VA medical opinion regarding the etiology of the Veteran's right ankle disorder. The record shows that the Veteran's right ankle fracture was incurred in the early 1970s, and thus, it preexisted his military service. The Board's April 2014 remand directives asked a VA examiner to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's preexisting right ankle condition was permanently worsened beyond normal progression during his active duty service. In a May 2014 VA examination report, an examiner concluded that the Veteran's right ankle disorder, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury, or illness. In providing a rationale for this conclusion, the examiner stated that the Veteran had a fracture of the right ankle prior to joining military in 1973. He had DJD of both ankles while in the military service. He had prominent talar beaks in previous X rays that are seen again. He has calcaneal spur likely from an old injury. He has some limitation of range of motion of both ankles. He had a gunshot wound to the left foot in 2000. In the examiner's opinion, the Veteran's right ankle DJD has not progressed beyond normal course over the years. The Board finds this examiner's opinion regarding the relationship between the Veteran's current right ankle disorder and his military service to be inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (noting that when VA undertakes to provide an examination or obtain an opinion, it must ensure that the examination or opinion is adequate). Specifically, while the examiner indicated that his current right ankle disorder was not aggravated beyond its natural progression by service, the examiner did not indicate a rationale for this conclusion. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (a medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions); Miller v. West, 11 Vet. App. 345, 348 (1998) (a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record); Bloom v. West, 12 Vet. App. 185, 187 (1999) (the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). The Board also notes that the examiner did not appear to consider, mention, or discuss several service treatment records relating to the Veteran's right ankle in formulating this opinion. These records include an August 1978 service treatment record in which the Veteran complained of a painful right ankle, several December 1982 records which showed that his right ankle was swollen and that he had a resolving soft tissue injury to his left foot, and a December 1982 consultation sheet that showed that he had occasional pain in his ankles, mild decreased right ankle motion, and was subject to an occasional misstep due to his ankles. Thus, the Veteran's right ankle claim must be remanded for a VA addendum medical opinion. Accordingly, the case is REMANDED for the following action: 1. Arrange for an addendum medical opinion to be obtained from the May 2014 VA examiner, or if unavailable, from another qualified examiner, with respect to the Veteran's claim of entitlement to service connection for a right ankle disorder. The entire claims file, including this Remand, should be made available to the examiner, and the examiner should indicate review of such records, including the Veteran's service treatment records and the lay contentions of record. The examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's preexisting right ankle condition was permanently worsened beyond normal progression during his active duty service. In rendering this opinion, the examiner should provide a detailed rationale for all opinions and conclusions expressed. Furthermore, the examiner should specifically address the Veteran's service treatment records from August 1978 and December 1982 that discuss in-service occurrences related to his right ankle in formulating an opinion. The term "aggravated by" means a lasting increase in severity of the underlying disability that is not due to the natural progress of the disease. 2. After completing all indicated developments above, readjudicate the claim of entitlement to service connection for residuals of a right ankle fracture or injury in light of all the evidence of record. If any benefit sought on appeal remains denied, an SSOC should be furnished to the Veteran and his representative, and they should be afforded a reasonable opportunity to respond 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 2014). ______________________________________________ M. TENNER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs