Citation Nr: 1805015 Decision Date: 01/25/18 Archive Date: 02/05/18 DOCKET NO. 14-20 513 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a cervical spine disability, to include cervical radiculopathy. 2. Entitlement to service connection for chronic fatigue syndrome. 3. Entitlement to service connection for fibromyalgia (also claimed as myalgia and myositis). 4. Entitlement to service connection for sinusitis. 5. Entitlement to service connection for ulcers. 6. Entitlement to a compensable evaluation prior to November 25, 2015, and in excess of 30 percent since November 25, 2015, for migraine headaches. 7. Entitlement to an initial evaluation in excess of 10 percent prior to January 5, 2016, and in excess of 20 percent since January 5, 2016 for degenerative arthritis of the right shoulder. 8. Entitlement to an initial compensable evaluation prior to January 5, 2016, and in excess of 10 percent since January 5, 2016, for Achilles tendonitis of the right ankle with degenerative changes status post stress fracture of the right tibia. 9. Entitlement to an initial compensable evaluation prior to January 6, 2016, and in excess of 10 percent since January 5, 2016, for Achilles tendonitis of the left ankle. 10. Entitlement to an initial compensable evaluation prior to April 26, 2016, and in excess of 10% since April 26, 2016, for plantar fasciitis status post bilateral metatarsal fractures with postoperative open reduction, internal fixation of the right foot, and bilateral degenerative changes of the first metatarsophalangeal joints. 11. Entitlement to an initial compensable evaluation for Arnold Chiari malformation type I with syringomyelia. REPRESENTATION Appellant represented by: Stacey Penn Clark, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD P. Olson, Counsel INTRODUCTION The Veteran served on active duty from July 1991 to July 2011. This matter is before the Board of Veterans' Appeals (Board) following a Board Remand in September 2015. This matter was originally on appeal from a rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in St. Petersburg, Florida. In February 2015, the Veteran testified at a Travel Board hearing. A transcript of that hearing is of record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C. § 7107(a)(2) (West 2012). The issues of entitlement to service connection for a cervical spine disability, to include cervical radiculopathy, and entitlement to an initial compensable evaluation for Arnold Chiari malformation type I with syringomyelia are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The competent medical evidence shows that the Veteran is not currently diagnosed as having chronic fatigue syndrome; the Veteran's chronic fatigue is not part of an undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, or a diagnosable chronic multi-symptoms illness with a partially explained etiology attributable to environmental exposures arising from his service in Southwest Asia during the Gulf War; it is part and parcel of a service-connected disability with a clear and specific etiology and diagnosis. 2. The competent medical evidence shows that the Veteran is not currently diagnosed as having fibromyalgia; the Veteran's musculoskeletal pain is not part of an undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, or a diagnosable chronic multi-symptoms illness with a partially explained etiology attributable to environmental exposures arising from his service in Southwest Asia during the Gulf War; it is part and parcel of a service-connected disability with a clear and specific etiology and diagnosis. 3. The competent medical evidence shows that the Veteran is not currently diagnosed as having chronic sinusitis; the Veteran's sinus complaints are not part of an undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, or a diagnosable chronic multi-symptoms illness with a partially explained etiology attributable to environmental exposures arising from his service in Southwest Asia during the Gulf War; they are part and parcel of a service-connected disability with a clear and specific etiology and diagnosis. 4. The competent medical evidence shows that the Veteran is not currently diagnosed as having ulcers; the Veteran's stomach complaints are not part of an undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, or a diagnosable chronic multi-symptoms illness with a partially explained etiology attributable to environmental exposures arising from his service in Southwest Asia during the Gulf War; they are part and parcel of a service-connected disability with a clear and specific etiology and diagnosis. 5. Prior to February 6, 2013, the Veteran's migraine headaches were not manifested by characteristic prostrating attacks averaging one every other month in a twelve-month period. 6. From February 6, 2013, to June 11, 2014, the Veteran's migraine headaches were manifested by prostrating attacks occurring on an average once a month but not by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 7. From June 12, 2014, the Veteran's migraine headaches were manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 8. Prior to January 5, 2016, the Veteran's right shoulder degenerative arthritis was manifested by x-ray evidence of arthritis and painful motion but not by right arm motion limited to midway between the side and shoulder level or lower (45 degrees or less). 9. Since January 5, 2015, the Veteran's right shoulder degenerative arthritis has not been manifested by right arm motion limited to midway between the side and shoulder level or lower (45 degrees or less). 10. Prior to April 23, 2013, the Veteran's service-connected right ankle Achilles tendonitis was manifested by normal motion with no objective evidence of painful motion and no x-ray evidence of arthritis. 11. Since April 23, 2013, at its worst, the Veteran's service-connected right ankle Achilles tendonitis with degenerative changes was manifested by dorsiflexion limited to 5 degrees and 10 degrees with knee flexed; it has not been manifested by marked limitation of motion. 12. Prior to April 23, 2013, the Veteran's service-connected left ankle Achilles tendonitis was manifested by normal motion with no objective evidence of painful motion and no x-ray evidence of arthritis. 13. Since April 23, 2013, at its worst, the Veteran's service-connected left ankle Achilles tendonitis with degenerative changes was manifested by dorsiflexion limited to 5 degrees with knee extended and 10 degrees with knee flexed; it has not been manifested by marked limitation of motion. 14. Prior to April 23, 2013, the Veteran's service-connected bilateral foot disability was manifested mild symptoms including objective evidence of plantar fasciitis with slight tenderness on palpation of the plantar surface of both feet and x-ray evidence of mild degenerative changes in the proximal left fifth metatarsophalangeal joint. There was no evidence of weak foot, metatarsalgia, hallux valgus or hallux rigidus, hammer toe, or malunion or nonunion of tarsal or metatarsal bones. The Veteran did not demonstrate limitation with standing or walking and did not require any assistive device for ambulation or any type of support for his shoes. 15. From April 23, 2013, to February 9, 2014, the Veteran's service-connected bilateral foot disability was manifested by moderate symptoms including objective evidence of tenderness on palpation of the right fifth metatarsal base and at the junction of the arch and heel bilaterally, x-ray evidence of right foot fifth metatarsal base fracture and healed metatarsal four shaft stress fracture, and x-ray evidence of left foot healed fifth metatarsal stress fracture. There was no evidence of swelling, characteristic callosities, moderately severe malunion or nonunion of tarsal or metatarsal bones, or moderately severe foot injury. 16. From February 10, 2014, to May 25, 2016, the Veteran's service-connected bilateral foot disability was manifested moderately severe symptoms including objective evidence of painful feet elicited by motion, swelling, decreased medial longitudinal arch, excessive pronation, x-ray evidence of inferior calcaneal spurs bilaterally, diffuse degenerative joint disease, increased cortical thickening throughout the lesser metatarsals, structural changes consistent with previous stress fractures of the metatarsals, and structural changes consistent with previous open reduction internal fixation of a fifth metatarsal fracture of the right foot. There was no evidence of marked inward displacement and severe placement of the tendo-Achilles on manipulation not improved by orthopedic shoes or appliances, severe malunion or nonunion of tarsal or metatarsal bones, or severe foot injury. 17. Since May 26, 2016, the Veteran's service-connected bilateral foot disability has been manifested by severe symptoms including bilateral foot disabilities included objective evidence of bilateral plantar fasciitis, degenerative joint disease of the right and left midfeet, pain on use and pain on manipulation of feet, extreme tenderness of the plantar surface of both feet not improved by arch supports or orthotics, decreased longitudinal arch height on weight bearing, marked deformity, and marked pronation not improved by orthopedic shoes or appliances chronically compromising weight bearing and requiring constant use of orthotics. There have been no swelling or characteristic callosities, no "inward" bowing or marked inward displacement, and no severe spasm on manipulation of the Achilles tendon. CONCLUSIONS OF LAW 1. The Veteran does not have chronic fatigue syndrome that was incurred in or aggravated by active service, to include environmental exposures arising from his service in Southwest Asia during the Gulf War. 38 U.S.C. §§ 1110, 1117 (2012); 38 C.F.R. §§ 3.303, 3.317 (2017). 2. The Veteran does not have fibromyalgia that was incurred in or aggravated by active service, to include environmental exposures arising from his service in Southwest Asia during the Gulf War. 38 U.S.C. §§ 1110, 1117; 38 C.F.R. §§ 3.303, 3.317. 3. The Veteran does not have chronic sinusitis that was incurred in or aggravated by active service, to include environmental exposures arising from his service in Southwest Asia during the Gulf War. 38 U.S.C. §§ 1110, 1117; 38 C.F.R. §§ 3.303, 3.317. 4. The Veteran does not have ulcers that were incurred in or aggravated by active service, to include environmental exposures arising from his service in Southwest Asia during the Gulf War. 38 U.S.C. §§ 1110, 1117; 38 C.F.R. §§ 3.303, 3.317. 5. Prior to February 6, 2013, the criteria for an initial compensable evaluation for the Veteran's migraine headaches were not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.124a, Diagnostic Code 8100 (2017). 6. From February 6, 2013, to June 11, 2014, the criteria for an evaluation of 30 percent, but no higher, for the Veteran's migraine headaches were met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.124a, Diagnostic Code 8100. 7. Since June 12, 2014, the criteria for the maximum evaluation of 50 percent for the Veteran's migraine headaches have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.124a, Diagnostic Code 8100. 8. Prior to January 5, 2015, the criteria for an initial evaluation of 20 percent, but no higher, for the Veteran's right shoulder degenerative arthritis were met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Codes Diagnostic Codes 5010-5201. 9. Since January 5, 2015, the criteria for an evaluation in excess of 20 percent for the Veteran's right shoulder degenerative arthritis have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Codes Diagnostic Codes 5010-5201. 10. Prior to April 23, 2013, the criteria for a compensable evaluation for right ankle Achilles tendonitis were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5271. 11. Since April 23, 2013, the criteria for an evaluation of 10 percent, but no higher, for right ankle Achilles tendonitis and degenerative changes have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5271. 12. Prior to April 23, 2013, the criteria for a compensable evaluation for left ankle Achilles tendonitis were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5271. 13. Since April 23, 2013, the criteria for an evaluation of 10 percent, but no higher, for left ankle Achilles tendonitis have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5271. 14. Prior to April 23, 2013, the criteria for a compensable evaluation for plantar fasciitis status post bilateral metatarsal fractures with postoperative right foot surgery and bilateral degenerative changes of the first metatarsophalangeal joints, were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5284. 15. From April 23, 2013, to February 9, 2014, the criteria for an evaluation of 10 percent, but no higher, for plantar fasciitis status post bilateral metatarsal fractures with postoperative right foot surgery and bilateral degenerative changes of the first metatarsophalangeal joints, were met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5284. 16. From February 10, 2014, to May 25, 2016, the criteria for an evaluation of 20 percent, but no higher, for plantar fasciitis status post bilateral metatarsal fractures with postoperative right foot surgery and bilateral degenerative changes of the first metatarsophalangeal joints, were met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5284. 17. Since May 26, 2016, the criteria for an evaluation of 30 percent, but no higher, for plantar fasciitis status post bilateral metatarsal fractures with postoperative right foot surgery and bilateral degenerative changes of the first metatarsophalangeal joints, have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5284. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters Pursuant to the Board's September 2015 Remand, the Appeals Management Center (AMC) obtained all available outstanding treatment records, scheduled VA examinations to determine etiology of any current chronic fatigue syndrome, fibromyalgia, sinusitis, and ulcers and to determine the severity of service-connected ankle, shoulder, and foot disabilities, readjudicated the claim, and issued a Supplemental Statement of the Case. Based on the foregoing actions, the Board finds that there has been compliance with the Board's September 2015 Remand. Stegall v. West, 11 Vet. App. 268 (1998). As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). The requirements of 38 U.S.C. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. In June 2011, the Veteran acknowledged such information. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. Moreover, during the February 2015 Board hearing, the undersigned explained the issues on appeal and asked questions designed to elicit evidence that may have been overlooked with regard to the claim. These actions provided an opportunity for the Veteran and his representative to introduce material evidence and pertinent arguments, in compliance with 38 C.F.R. § 3.103(c)(2) and consistent with the duty to assist. There is no evidence that additional records have yet to be requested, or that additional examinations are in order. Service Connection The Veteran seeks service connection for chronic fatigue syndrome, fibromyalgia (also claimed as myalgia and myositis), sinusitis, and ulcers. Service connection means that the facts establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service treatment records indicate that in June 2006, the Veteran reported fatigue in addition to difficulty sleeping since his motor vehicle accident in 2002; past medical history included sinus headaches. In July 2006, the Veteran completed a sleep questionnaire in which he complained of daytime fatigue but no significant daytime sleepiness. In August 2007, the Veteran reported developing upper respiratory symptoms one week prior along with neck stiffness, myalgias/arthralgias and nausea. The Veteran also reported feeling tired. In April 2008, the Veteran reported productive cough for one week with fatigue. In August 2008, the Veteran noted feeling tired (fatigue); the provider noted a sleep study in December 2006 that revealed obstructive sleep apnea with loud snoring, sore throat in the morning, daytime fatigue, and sleepiness. Blood tests were conducted to rule out anemia as a cause of fatigue. In September 2008, the Veteran noted some fatigue in his lower extremities over the prior couple of weeks during a period of poor sleep. Service treatment records indicate that the Veteran had diagnoses of myalgia and myositis NOS following motor vehicle accident in March 2002 and received trigger point injections for right posterior scapulothoracic pain. An adult preventative and chronic care flowsheet indicates chronic illnesses including myalgia and myositis. Service treatment records indicate diagnoses of deviated nasal septum with previous history of nasal fracture, other disease of nasal cavity and sinuses, and hypertrophy of nasal turbinates in December 2005. The Veteran underwent septoplasty/turbinate reduction. In December 2007 and February 2008, the Veteran was diagnosed as having acute sinusitis; however, the provider in February 2008 noted that sinusitis diagnosis was not fully supported by documented history and examination. On the Report of Medical History completed by the Veteran in conjunction with his retirement physical in April 2011, he reported long term chronic sinus issues resulting in two septoplasties. An adult preventative and chronic care flowsheet indicates chronic illnesses including acute sinusitis. On his Dental Health Questionnaire completed by the Veteran in January 2011, he reported sinus problems. On the Report of Medical History completed by the Veteran in conjunction with his retirement physical in April 2011, he reported long term chronic sinus issues resulting in two septoplasties. Despite complaints of fatigue, musculoskeletal pain, and sinusitis and diagnosis of acute sinusitis during service, the Board cannot conclude that chronic fatigue syndrome, fibromyalgia, or chronic sinusitis was incurred during service. That an injury or illness occurred in service alone is not enough; there must be chronic disability resulting from that injury or illness. For a showing of chronic disability in service there is required a combination of manifestations sufficient to identify the disorder, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." On his Dental Health Questionnaire completed by the Veteran in January 2011, he denied ever having painful joints. On the clinical examination for retirement from service in April 2011, the Veteran's sinuses, upper and lower extremities, and neurologic health were evaluated as normal. In addition, the service treatment records are absent complaints, findings or diagnoses of ulcers during service. On his Dental Health Questionnaire completed by the Veteran in January 2011, he denied ever having ulcers. On the Report of Medical History completed by the Veteran in conjunction with his retirement physical, he reported chronic acid reflux and symptoms similar to irritable bowel syndrome but no ulcers. (Service connection has been granted for gastoesophageal reflux disease, with hiatal hernia and irritable bowel syndrome, and this matter is not otherwise at issue in this appeal.) Thus, there is no medical evidence that shows that the Veteran suffered from chronic fatigue syndrome, fibromyalgia, chronic sinusitis, and ulcers during service. As for statutory presumptions, service connection may also be established for a current disability on the basis of a presumption under the law that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.303, 3.304, 3.307 and 3.309(a). Peptic ulcers can be service-connected on such a basis. However, there is no evidence of an ulcer within the first year after the Veteran's retirement from service. Alternatively, when a chronic disease is not present during service, service connection may be established under 38 C.F.R. § 3.303(b) by evidence of continuity of symptomatology. Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); 38 C.F.R. § 3.303(b). Such evidence is lacking here. An ulcer was not "noted" during service. When a disease is first diagnosed after service, service connection can still be granted for that condition if the evidence shows it was incurred in service. 38 C.F.R. § 3.303(d). To prevail on the issue of service connection there must be medical evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v. West, 12 Vet App. 341, 346 (1999). In this case, the medical evidence indicates that the Veteran is not currently diagnosed with chronic fatigue syndrome, fibromyalgia, chronic sinusitis, or ulcers. With respect to symptoms of fatigue, the Veteran underwent VA examination in July 2011 at which time the Veteran reported having constant symptoms of unexplained fatigue. On physical examination, there were no findings of palpable or tender lymph nodes or of non-exudative pharyngitis. The examiner noted that there was no reduction in the Veteran's routine activities after a diagnosis of chronic fatigue syndrome. The examiner stated that the Veteran did not meet the criteria for the diagnosis of chronic fatigue syndrome because he either does not have both of the primary criteria or at least six of the ten secondary criteria. The examiner noted with regard to the secondary criteria, the Veteran had fatigue lasting 24 hours or longer after exercise, migratory joint pains, generalized muscle aches or weakness headaches (and the severity or pattern of the headaches is different from the premorbid state), and sleep disturbance. The Veteran also underwent VA examination in January 2016. After physical examination and a review of the file, the examiner stated that there was no objective evidence of chronic fatigue syndrome and opined that the Veteran's service-connected mental health condition and obstructive sleep apnea were the most likely causes for his symptoms of fatigue. The Veteran underwent VA examination in June 2017 at which time the Veteran reported that if he did not take his Adderall, he was too tired and could not function. The Veteran reported that he has felt tired and run down since 2003. After review of the file, the examiner, a VA physician, noted that the objective evidence is absence a diagnosis of chronic fatigue syndrome, that the Veteran had many service-connected diagnosable non-multi-system illnesses that were the likely cause of his fatigue, and that being unable to exercise also likely contributed. The examiner noted that a diagnosis of chronic fatigue syndrome was not made on a one-time visit at a disability examination as this would be medically inappropriate. With respect to symptoms of musculoskeletal pain, at the July 2011 VA examination, the Veteran reported that his condition come about gradually over time and that in 2001 he was diagnosed as having fibromyalgia. He reported having constant symptoms of unexplained fatigue; headaches; sleep disturbance; anxiety; depression; Raynaud's-like symptoms; paresthesia; stiffness of the back, knees, and ankles; and musculoskeletal weakness of the legs. The Veteran indicated that there was widespread musculoskeletal pain located in the legs and widespread joint pain located in the knees and ankles. The Veteran also reported gastrointestinal disturbances, primarily alternating diarrhea and constipation, abdominal cramps and abdominal bloating. Symptoms were reportedly exacerbated by environmental stress of a drastic change in temperature, extreme cold, and extreme heat as well as by emotional stress and overexertion. The symptoms are alleviated by rest. The examiner noted that there was no pathology to render a diagnosis of myalgia or fibromyalgia. At the January 2016 VA examination, physical examination demonstrated no tender points characteristic of fibromyalgia. The examiner stated that there was no objective evidence of fibromyalgia and that the Veteran described and the record substantiated multiple previously service-connected structural musculoskeletal etiologies for his pain symptoms. At the June 2017 VA examination, the Veteran reported that after he got back from Iraq, he had a lot of problems with pain in his back, shoulder, and all over; and still has constant pain in right should shoulder and feet. Physical examination demonstrated that trigger point palpation was negative for pain. The examiner, a VA physician noted that the objective evidence is absence a diagnosis of fibromyalgia, that the Veteran had many service-connected diagnosable non-multi-system illnesses that were the likely cause of his pain, and that being unable to exercise also likely contributed. The examiner noted that a diagnosis of fibromyalgia was not made on a one-time visit at a disability examination as this would be medically inappropriate. With respect to sinus symptoms, at the July 2011 VA examination, the Veteran reported sinus problems that had existed for 10 years. The Veteran reported that during sinus episodes, he was incapacitated as often as twice per year and that each incident lasted for seven days. He also reported experiencing headaches with his sinus episodes. The Veteran reported that antibiotic treatment was needed for his sinus problem but that the treatment did not last four to six weeks. The Veteran reported symptoms of interference with breathing through his nose, purulent discharge from the nose, hoarseness of the voice, and pain. He denied crusting. Physical examination of the nose revealed no nasal obstruction, no deviated septum, no partial loss of the nose, no partial loss of the ala, no nasal polyps, no scar, and no disfigurement. There was no rhinitis noted and no sinusitis detected. The sinus x-ray was within normal limits. The examiner noted that there was no pathology to render a diagnosis of sinusitis. At the January 2016 VA examination, the Veteran reported that he had had two septoplasties but still could not breathe out of the right side and that he had a lot of infections for which he took antibiotics. The Veteran reported that the last time he was prescribed antibiotics for a sinus infection was around the time he retired. Physical examination of the nose indicated that the Veteran had a traumatic deviated nasal septum. After examination of the Veteran and a review of the file, the Veteran was diagnosed as having a history of acute sinusitis resolved without residuals. The examiner noted that the Veteran did not meet the criteria for a diagnosis of chronic sinusitis or rhinosinusitis. The June 2017 VA examiner noted that there was no evidence on examination or of record of chronic sinusitis. (The Veteran is service connected for septoplasty residuals and that issue is not otherwise before the Board.) With respect to stomach pain, at the July 2011 VA examination, the Veteran reported being diagnosed with ulcers and noted that the condition has existed for seven years. The Veteran reported that his stomach hurt to the point where he could not eat. The Veteran reported that over the prior 20 years, he had gained 46 pounds. He reported abdominal pain located in the stomach occurring frequently precipitated by eating and alleviated by antacids. The Veteran also reported nausea and vomiting as often as three times per week but that he had never vomited blood or passed any black, tarry stools. The treatment was Zantac. The upper GI report showed GERD with hiatal hernia. The examiner noted that there was no pathology to render a diagnosis of ulcers. The January 2016 VA examiner noted that a July 2015 EGD documented the absence of an ulcer condition and the presence of gastroesophageal reflux disease. The examiner opined that the Veteran GERD was most likely causing his claimed "ulcer" symptoms. . The June 2017 VA examiner noted that there was no evidence on examination or of record of ulcers. In the absence of competent medical evidence that the Veteran has chronic fatigue syndrome, fibromyalgia, chronic sinusitis, or ulcers, the requirements for establishing service connection for chronic fatigue syndrome, fibromyalgia, chronic sinusitis, or ulcers have not been met. 38 U.S.C. §§ 1110; 38 C.F.R. §§ 3.303, 3.310(a). For veterans who served in the Southwest Asia theater of operations during the Persian Gulf War, service connection may also be established for chronic disability that cannot be attributed to a known clinical diagnosis (undiagnosed illness) or for a medically unexplained multi-symptom illness (e.g., chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome). See 38 U.S.C. § 1117 (2012); 38 C.F.R. § 3.317 (2017). Because the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, consideration of 38 C.F.R. § 3.317 is warranted in this case. Section 3.317 explicitly acknowledges that a claimant's "signs or symptoms" need not be shown by medical evidence; however, the regulation does specifically require some "objective indications" of disability. See 38 C.F.R. § 3.317 (a). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317 (b). In June 2017, A VA physician provided her opinion that there was no objective evidence of chronic fatigue syndrome, fibromyalgia, chronic sinusitis, or ulcers; that there was no undiagnosed illness, no diagnosable but medically unexplained chronic multisystem illness of unknown etiology, and no diagnosable chronic multisymptom illness with a partially explained etiology; and that the conditions had clear and specific etiologies and diagnoses. The physician noted that the Veteran had many service connected diagnosable non-multi-system illness that were the likely cause of his fatigue and pain. The Board must also consider the Veteran's own opinion that he has chronic fatigue syndrome, fibromyalgia, chronic sinusitis, or ulcers that are related to active service. In this case, the Board does not find him competent to provide an opinion regarding the diagnosis of his symptoms as this question is of the type that the courts have found to be beyond the competence of lay witnesses. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Some medical issues, however, require specialized training for a determination as to diagnosis and causation, and such issues are, therefore, not susceptible of lay opinions on etiology, and the statements of the Veteran therein cannot be accepted as competent medical evidence. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection for chronic fatigue syndrome, fibromyalgia, chronic sinusitis, and ulcers; and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran is appealing the original assignments of disability evaluations following awards of service connection for migraines, right shoulder degenerative arthritis, Achilles tendonitis of both ankles and degenerative changes in the right ankle, plantar fasciitis status post bilateral metatarsal fractures with postoperative open reduction, internal fixation surgery of the right foot, and bilateral degenerative changes of the first metatarsophalangeal joints. As such, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In every instance where the schedule does not provide a zero percent rating for a diagnostic code, a zero percent rating shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. With respect to the right shoulder and ankles, disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant on motion. Disability of the musculoskeletal system is the inability to perform normal working movement with normal excursion, strength, speed, coordination, and endurance, and that weakness is as important as limitation of motion, and that a part that becomes disabled on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, through atrophy, for example. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. §§ 4.45 and 4.59 also contemplate inquiry into whether there is limitation of motion, weakness, excess fatigability, incoordination, and impaired ability to execute skilled movements smoothly, and pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing, and weight-bearing are also related considerations. The Court has held that diagnostic codes predicated on limitation of motion require consideration of a higher rating based on functional loss due to pain on use or due to flare-ups. 38 C.F.R. §§ 4.40, 4.45, 4.59; Johnson v. Brown, 9 Vet. App. 7 (1997); and DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Migraines The Veteran's service-connected migraine headaches have been rated as noncompensably disabling prior to November 25, 2015, and 30 percent disabling since November 25, 2015, pursuant to 38 C.F.R. § 4.124a , Diagnostic Code 8100, for migraines. Diagnostic Code 8100 provides for a 10 percent disability rating for migraine with characteristic prostrating attacks averaging one in 2 months over the last several months; a 30 percent disability rating for migraine with characteristic prostrating attacks occurring on an average once a month over the last several months; and a 50 percent disability rating for migraine with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The rating formulation provided in Diagnostic Code 8100 is based entirely on the frequency of the headaches and the extent to which such headaches are prostrating. The rating criteria do not define "prostrating." The Board additionally observes that the Court has not undertaken to define "prostrating." 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 Stedman's Medical Dictionary, "prostration" is defined as "a marked loss of strength, as in exhaustion." Stedman's Medical Dictionary (27th Ed. 2000) at 1461. At the July 2011 VA examination, the Veteran reported that when headaches occurred, which he described as sharp pain, he was able to go to work but required medication. The Veteran indicated that the level of severity for the headaches was at a pain level of 5/10. He reported experiencing headaches on the average of once a day lasting for six hours. Medical records from Jacksonville Naval Air Station indicate that the Veteran presented on February 6, 2013, with complaints of 2/10 headache almost every day and exacerbations up to 10/10 pain approximately three times per month. The Veteran reported that the pain always began in the right occipital region and moved to behind the right eye. The Veteran reported associated tearing with particularly bad headaches, but no flushing or diaphoresis. The Veteran reported that his headaches lasted several hours and occasionally lasted all day and were associated with photophobia, phono phobia, and nausea/vomiting. The Veteran reported that sometimes, there was a visual aura described as a "worm" floating in his vision. The Veteran could not think of any triggers. The provider noted that the Veteran's constant low grade daily headache could be attributed to medication overuse while insomnia and poor sleep quality could also be contributing factors. The Veteran presented in February 2014 with complaints of chronic headaches with new symptoms of vertigo lasting 10 and 15 seconds provoked by head movement and occurring once in association with a migraine and subsequent episodes not associated with headache. The Veteran reported that at times, the vertigo could go on for 15 to 20 minutes and seemed to be associated with headaches suggesting the possibility of migraine associated vertigo. The Veteran presented on June 12, 2014, with complaints of a daily headache for prior few months and that multiple times per week he experienced a severe 10/10 stabbing, throbbing headache occurring behind the right eye associated with light and sound sensitivity, nausea, and occasional vomiting. He described visual changes occurring during the headache. He characterized the visual change as a "crystalized worm." The headache typically lasts for hours in duration; and he used Maxalt for rescue therapy. The Veteran preventative regimen was noted to be Botox every three to four months but had not noticed any significant improvement in the frequency of his headaches while on Botox therapy. The Veteran testified in February 2015 that he kept a low-grade headache all the time. He explained it as having a dull pain in his head all the time. He stated that it went to a migraine two to three times a week and he had to go bed, cover his eyes, and be in a cold place. The Veteran reported that he was taking Topamax but stopped taking it because it was causing problems with his fingers and feet. The Veteran testified that he was in school, and that several times a month, he had to miss class or work because he just could not bear the light or the noise. The Veteran testified that maybe once or twice a week, but that generally he would miss a class at least four to five times a quarter even if it was just half the class. On May 26, 2015, the Veteran submitted a Disability Benefits Questionnaire for headaches completed by his treating neurologist. The neurologist indicated that the Veteran experienced constant, pulsating or throbbing head pain localized to one side of the head which worsened with physical activity; that he experienced nausea, vomiting, sensitivity to light and sound, changes in his vision and sensory changes with duration of between one to two days located on the right side of head. The neurologist noted prostrating attacks more frequently than once per month and that the Veteran had very frequent prostrating and prolonged attacks of migraine headache pain. On November 25, 2015, the Veteran presented for follow up at outpatient neurology clinic for migraine headaches and Arnold Chiari malformation. The Veteran complained of a daily dull headache dating back to 2006. The provider, the Veteran's treating neurologist, noted that the Veteran was experiencing one to two migraine headaches per week which he described as severe throbbing headaches that begin the right occipital region and radiate to the right retro-orbital region associated with light and sound sensitivity, nausea and vomiting. The Veteran was diagnosed as having migraine with aura, not intractable, without status migrainosus. It was noted that the Veteran had been on multiple different preventative and rescue therapies over the prior 10 year period and had found Maxalt MLT to be moderately effective as rescue therapy. Restarting Botox therapy for preventative measures was discussed. Taking such evidence into account, the Board finds that from February 6, 2013, a 30 percent evaluation is warranted for characteristic prostrating attacks occurring on an average once a month. In addition, from June 12, 2014, a 50 percent evaluation is warranted for migraine with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Although the February 2013 and June 2014 provider, the Veteran's treating neurologist, did not mention prostrating attacks, the Board to find that the Veteran's headaches of 10/10 severity lasting several hours to all day and associated with photophobia, phono phobia, nausea/vomiting, or visual changes are prostrating. In addition, the Veteran testified in February 2015 that several times a month, he had to miss class or work because he just could not bear the light or the noise. The Board finds that it is not unreasonable to consider missing school or work several times a month as severe economic inadaptability. Prior to February 6, 2013, however, the Veteran's migraine headaches did not approach the severity contemplated for a compensable disability rating as the record prior to February 6, 2013, as the record is absent evidence of severe headaches and absent evidence of prostrating attacks. At the July 2011 VA examination, the Veteran reported that the level of severity of his daily headaches was 5/10 and that he was able to go to work but required medication. In addition, the record from February 6, 2013, to June 12, 2014, is absent evidence of severe economic inadaptability. As such, the Board finds that the evidence of record warrants a 30 percent evaluation from February 6, 2013 and a 50 percent evaluation from June 12, 2014. The preponderance of the evidence of record is against a grant of an initial compensable evaluation for the Veteran's service connected migraine headaches prior to February 6, 2013, and against a grant of a 50 percent evaluation prior to June 12, 2014. Right Shoulder Disabilities of the shoulder are generally contemplated by Diagnostic Codes 5200 to 5203. Initially, the Board notes that as the Veteran's right shoulder is not productive of ankylosis of scapulohumeral articulation or impairment of the humerus, clavicle or scapula, Diagnostic Codes 5200, 5202, and 5203 are not for application. The Veteran's service-connected right shoulder degenerative arthritis has been rated as 10 percent disabling prior to January 5, 2016, and 20 percent disabling since January 5, 2016, pursuant to 38 C.F.R. § 4.71a , Diagnostic Codes 5010-5201. The hyphenated diagnostic codes in this case indicate that traumatic arthritis (Diagnostic Code 5010) is the service-connected disorder and that limitation of motion of the arm (Diagnostic Code 5201) is a residual condition. Traumatic arthritis is to be rated on the basis of limitation of motion. When however, the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71, Diagnostic Code 5010. The rating criteria for evaluating disabilities of the shoulder, including Diagnostic Code 5201, distinguish between the major (dominant) extremity and the minor (non-dominant) extremity. See 38 C.F.R. 4.69. Because the record on appeal establishes that the appellant is right-handed, the criteria for rating disabilities of the major extremity are for application. Diagnostic Code 5201 provides that a 20 percent rating is warranted when motion of the major arm is limited to shoulder level (90 degrees), a 30 percent rating is warranted when motion is limited to midway between the side and shoulder level (45 degrees), and a 40 percent rating when motion is limited to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2017). Normal range of motion of the shoulder is abduction from 0 to 180 degrees. 38 C.F.R. § 4.71, Plate I (2017). At the July 2011 VA examination, the Veteran reported experiencing weakness, stiffness, swelling, giving way, lack of endurance, fatigability, tenderness, and pain. He indicated that he did not experience heat, redness, locking, deformity, drainage, effusion, subluxation, and dislocation. The Veteran reported experiencing flare-ups as often as once per day and lasting for 6 hours with a severity level of 5/10. The Veteran reported that flare-ups were precipitated by physical activity, they occurred spontaneously, and they were alleviated by rest and by NSAIDs. The Veteran reported that during flare-ups, he was unable to lift items and had limitation of motion of the joint. Treatment included injections. On physical examination, there was tenderness but no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, drainage, or subluxation. Flexion was to 180 degrees, abduction was to 100 degrees with pain, and external and internal rotation was to 90 degrees. The joint function was not additionally limited after repetitive use by pain, fatigue, weakness, lack of endurance, or incoordination. There was no ankylosis. The right shoulder x-ray showed degenerative arthritic changes. At the January 5, 2016 VA examination, the Veteran reported that it was difficult to move his shoulder. On physical examination, flexion and abduction were from zero to 170 degrees, and external and internal rotation were both full, from zero to 90 degrees. Although pain was noted on flexion and abduction, the examiner reported that it did not result in or cause functional loss. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue or crepitus. After repetitive use, there was no additional functional loss or loss of motion. The examiner noted that the Veteran was not having a flare up that day, and opined that it would be speculative to report additional range of motion loss or determine whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare up or when the joint was used repeatedly over a period of time. Muscle strength testing was normal; and there was no muscle atrophy and no ankylosis. All shoulder impingement testing and instability testing were negative. X-rays of the right shoulder revealed arthritis. At the June 2017 VA examination, the Veteran reported a constant aching pain in his right shoulder. The Veteran did not report flare ups but noted functional impairment of the right shoulder which limited him from performing typical overhead welding procedures or grinding for more than five minutes. On physical examination, flexion and abduction were from zero to 170 degrees, and external and internal rotation were both full, from zero to 90 degrees. Pain was noted on passive motion, on active motion and with weight bearing on the right but not on the left. Pain on flexion and abduction was noted to cause functional loss but the examiner opined that it would be speculative to report additional range of motion loss when the joint was used repeatedly over a period of time as the Veteran was not being evaluated after repetitive use testing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue or crepitus. Muscle strength testing was normal; and there was no muscle atrophy and no ankylosis. All shoulder impingement testing and instability testing were negative. Initially, the Board notes that as the Veteran's right shoulder is not productive of ankylosis of scapulohumeral articulation or impairment of the humerus, clavicle or scapula, Diagnostic Codes 5200, 5202, and 5203 are not for application. VA regulation provides that joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. A veteran experiencing an actually painful joint is entitled to at least the minimum compensable rating for the joint. The minimum compensable rating under the limitation of motion code pertaining to the affected right shoulder joint is 20 percent. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. The recorded findings at this time are similar to those which later resulted in an increased rating, so resolving reasonable doubt the Board concludes the 20 percent is warranted for the earlier period. Taking such evidence into account, the Board finds that prior to January 5, 2016, the Veteran's service-connected right shoulder disability warranted a 20 percent disability evaluation for degenerative arthritis of the right shoulder joint, painful motion, and limitation of abduction. A higher evaluation, however, is not warranted at any time during the appeal period as the Veteran's right shoulder disability has not approached the severity contemplated for a 30 percent evaluation. The record is absent motion limited to half way to the shoulder level. The Board also finds that even when considering the Veteran's reported right shoulder symptomatology, the reported symptomatology does not, when viewed in conjunction with the medical evidence, tend to establish additional limitations of motion to the degree that would warrant an initial rating in excess of 20 percent at any time during the appeal period under 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. As such, the Board finds that the evidence of record warrants a 20 percent evaluation during the entire appeal period. The Board, however, finds that the preponderance of the evidence is against an evaluation in excess of 20 percent for the Veteran's service connected right shoulder disability at any time during the appeal period. Ankles Disabilities of the ankle are generally contemplated by Diagnostic Codes 5270 through 5274. The Veteran's service-connected right and left ankle disabilities, right ankle Achilles tendonitis and degenerative changes status post stress fracture of the right tibia and left ankle Achilles tendonitis, have been each rated as noncompensably disabling prior to January 5, 2016, and 10 percent disabling since January 5, 2016, pursuant to 38 C.F.R. § 4.124a , Diagnostic Code 5271. Under this diagnostic code, a moderate limitation of ankle motion warrants a 10 percent rating and a marked limitation warrants a 20 percent rating. The normal range of motion of the ankle is 20 degrees of dorsiflexion and 45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II. At the July 2011 VA examination, the Veteran reported being diagnosed with tendonitis, that the condition had existed for 15 years, and that the condition happened from prolonged marching. The Veteran reported weakness, stiffness, swelling, lack of endurance, tenderness, and pain. He indicated that he did not experience heat, redness, giving way, locking, fatigability, deformity, drainage, effusion, subluxation, and dislocation. The Veteran reported experiencing flare-ups as often as 2 times per month and each time lasting for four days with a severity level of 4/10. The flare-ups were noted to be precipitated by physical activity, occurring spontaneously, and alleviated by rest and Motrin. The Veteran reported that during flare-ups, he had difficulty with standing and walking. On physical examination, there were no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, guarding of movement, malalignment, drainage, subluxation, or ankylosis of either ankle. Dorsiflexion was from zero to 20 degrees and plantar flexion was from zero to 45 degrees. The joint function was not additionally limited after repetitive use by pain, fatigue, weakness, lack of endurance, or incoordination. There was no ankylosis. X-rays of the right tibia and fibula as well as x-rays of both ankles were within normal limits; there was no indication of a malunion of the os calcis or astragalus on either the right or the left. Medical records from Jacksonville Naval Air Station indicate that on April 23, 2013, the Veteran presented for evaluation of his feet at which time ankle dorsiflexion was 5 degrees with his knee extended and 10 degrees with knee flexed. In February 2014 and June 2014, the Veteran was seen by podiatry clinic for painful feet. Muscle strength was grated at 5/5 all muscle groups crossing the ankles. There was no ankle weakness observed. Dorsiflexion strength, plantar flexion strength, inversion strength, and eversion strength of the ankles were normal. At the January 5, 2016 VA examination, the Veteran reported constant pain in the medial aspect of the ankles/feet. He reported receiving no treatment for his ankles since service, no assistive devices, and no surgical interventions. The Veteran did not report flare-ups of the ankles or any functional loss or functional impairment. Range of motion of the ankles was normal with dorsiflexion from zero to 20 degrees and plantar flexion from zero to 45 degrees. No pain was noted on examination. There was no evidence of pain with weight bearing, no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, and no crepitus. After repetitive use, there was no additional functional loss or loss of motion. The examiner noted that the Veteran was not having a flare up that day, and opined that it would be speculative to report additional range of motion loss or determine whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare up or when the joint was used repeatedly over a period of time. Muscle strength testing was normal; and there was no muscle atrophy and no ankylosis. All ankle stability testing was negative. The examiner noted, "The veteran is obese. There is no swelling, erythema or ecchymosis of the lower legs. No tenderness upon palpation of the lower leg and Achilles tendon bilat[erally], no tendon thickening, no nodules, no crepitus, no palpable defects. Strength 5/5, complete active range of motion of the ankles without evidence of pain." At the June 2017 VA examination, the Veteran reported a constant, aching sensation with pain level of 4/10. The Veteran did not report flare-ups of the ankle pain but noted that he was unable to walk for more than five minutes, run, or lift. Range of motion of the ankles was normal with dorsiflexion from zero to 20 degrees and plantar flexion from zero to 45 degrees with pain. There was also evidence of pain with weight bearing and objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no objective evidence of pain on passive motion, pain with non-weight bearing, or crepitus. After repetitive use, there was no additional functional loss or loss of motion. The examiner noted that it was impossible to state, without undue speculation, whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare up or when the joint was used repeatedly over a period of time. The examiner noted that additional factor contributing to disability was disturbance of locomotion. Muscle strength testing was normal, there was no muscle atrophy, there was no ankylosis, and there was no suspected ankle instability. Initially, the Board notes that as the Veteran's ankles are not productive of ankylosis or impairment of the os calcis or astragalus, Diagnostic Codes 5270, 5272, 5273, and 5274 are not for application. VA regulation provides that joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. A veteran experiencing an actually painful joint is entitled to at least the minimum compensable rating for the joint. The minimum compensable rating under the limitation of motion code pertaining to the affected ankle joints is 10 percent. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. Taking such evidence into account, the Board finds that as of April 23, 2013, the Veteran's service-connected right and left ankle disabilities were productive of symptoms contemplated for a 10 percent evaluation. At that time, ankle joint dorsiflexion was 5 degree with knee extended and 10 degree with knee flexed. The record prior to April 23, 2013, however, is absent objective evidence of loss of ankle motion or painful ankle motion. The Board also finds that since April 23, 2013, the Veteran's service-connected right and left ankle disabilities did not approach the severity contemplated for a 20 percent rating. The record during the appeal period is absent marked limited ankle motion. On VA examinations, range of motion of the ankles has been consistently normal with dorsiflexion from zero to 20 degrees and plantar flexion from zero to 45 degrees. The Board also finds that even when considering the Veteran's reported right and left ankle symptomatology, the reported symptomatology does not, when viewed in conjunction with the medical evidence, tend to establish additional limitations of motion to the degree that would warrant compensable evaluations prior to April 23, 2013, in excess of 10 percent from April 23, 2013 under 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. As such, the Board finds that the evidence of record warrants 10 percent evaluations from April 23, 2013 for service-connected right and left ankle disabilities. The preponderance of the evidence of record is against a grant of an initial compensable evaluation for the Veteran's service connected right and left ankle disabilities prior to April 23, 2013, and against grants above 10 percent evaluations at any time during the appeal period. Feet Disabilities of the feet are contemplated by Diagnostic Codes 5276 through 5284, which in some instances, provide for disability ratings for unilateral or bilateral disabilities. 38 C.F.R. § 4.71a. The Veteran's service-connected foot disabilities, plantar fasciitis status post bilateral metatarsal fractures with postoperative open reduction internal fixation of the right foot and bilateral degenerative changes of the first metatarsophalangeal joints, have been rated as noncompensably disabling prior to April 26, 2016, and 10 percent disabling since April 26, 2016, pursuant to 38 C.F.R. § 4.124a , Diagnostic Code 5284. Initially, the Board notes that as the Veteran's service-connected bilateral foot disability is not manifested by weak foot, claw foot (pes cavus), hallux valgus, hallux rigidus, hammer toe, Diagnostic Codes 5277, 5278, 5280, 5281, and 5282 are not for application. In addition, service connection has specifically been denied for pes cavus; as such, Diagnostic Code 5278 is not for application. Under Diagnostic Code 5276, for acquired flatfoot, a noncompensable evaluation is assigned for mild symptoms relieved by guilt-up shoe or arch support. A10 percent evaluation is assigned for unilateral or bilateral moderate disabilities of the feet with the weight-bearing line over or medial to the great toe, inward bowing of the tendo-Achilles, and pain on manipulation and use of the feet. A 30 percent evaluation is assigned for bilateral (20 percent for unilateral) severe acquired disabilities of the feet with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated indication of swelling on use, and characteristic callosities. A 50 percent evaluation is assigned for bilateral (30 percent for unilateral) pronounced acquired disabilities of the feet with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo-Achilles on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276 (2017). Under Diagnostic Code 5284, for other foot injuries, a 10 percent evaluation is assigned for moderate injury, a 20 percent evaluation is assigned for moderately severe injury, and a 30 percent evaluation is assigned for severe injury. With actual loss of use of the foot, a 40 percent evaluation is assigned. At the July 2011 VA examination, the Veteran reported being diagnosed with plantar fasciitis which had existed for 15 years due to injury while performing training. The Veteran reported constant pain, described as squeezing, burning, aching, sharp, sticking, and cramping pain in both feet with a severity level of 7/10. The Veteran reported that the pain could be exacerbated by physical activity and relieved by rest. At the time of pain, the Veteran reported that he could function without medication. At rest, the Veteran had stiffness but no pain, weakness, swelling, and fatigue but that while standing or walking he did have pain, weakness stiffness, swelling, and fatigue. The Veteran walked with a normal gait and what with respect to tandem gait, his walk was normal. Examination of the feet did not reveal any signs of abnormal weight bearing or breakdown, callosities, or any unusual shoe wear pattern. Physical examination of the feet revealed bilateral planter fasciitis. Both feet revealed no tenderness, painful motion, weakness, edema, heat, redness, instability, atrophy, or disturbed circulation; and there was active motion in the metatarsophalangeal joint of the great toes. Palpation of the plantar surface of both feet revealed slight tenderness. Achilles tendons were normal in both weight bearing and non-weight bearing. There was no evidence of pes planus, pes cavus, hammer toes, Morton's metatarsalgia, hallux valgus, or hallux rigidus. The Veteran did not have any limitation with standing and walking, did not require any assistive device for ambulation, and did not require any type of support with his shoes. X-rays of the right foot, both weight bearing and non-weight bearing, were within normal limits. X-rays of the left foot, both weight bearing and non-weight bearing, showed mild degenerative changes, healing incomplete fracture of the proximal fifth metatarsophalangeal joint. VA treatment records indicate that in June 2012, the Veteran was seen by podiatrist and reported pain in both ankles, feet, and heels made worse with walking and standing. X-rays were ordered and a consultation was authorized for double depth shoes. X-rays in August 2012 showed stress fracture of the right fifth metatarsal. The Veteran reported that he was prone to spontaneous fractures and that he had been suffering with them for years. He declined a referral to podiatry. In October 2012, the Veteran was seen at VA for follow up visit and noted that he was waiting to be seen by a private podiatrist as he wanted a second opinion outside the VA. Medical records from Jacksonville Naval Air Station indicate that on April 23, 2013, the Veteran was seen by podiatry clinic for bilateral foot pain. He had been diagnosed six months prior by VA for a left foot stress fracture and immobilized in a cast for six weeks with return to a normal shoe thereafter. The Veteran had a history of left fourth and fifth metatarsal fracture. He stated that his feet were constantly in pain and admitted having other medical conditions that contributed to his daily pain. Previous treatment included two pair of orthotics, a corticosteroid heel injection, a night splint, NSAIDs, and new balance sneakers authorized by VA. Physical examination demonstrated that dorsalis pedis and posterior tibial pulses were 2/4 bilaterally. Capillary fill test was less than three seconds to digits one to five bilaterally. There was no edema, ecchymosis, or erythema. There were no lower extremity sensory deficits. There was tenderness to palpation to the right fifth metatarsal base. He was tender to palpation also at the junction of the arch and heel bilaterally. Muscle strength was 5/5 in all lower extremity quadrants. There was no crepitus with range of motion. Range of motion was 20 degrees inversion and 10 degrees eversion. Ankle joint dorsiflexion was 5 degrees with knee extended and 10 degrees with knee flexion. Pes cavus foot structure was noted. X-rays of the right foot revealed previous fifth metatarsal base fracture and healed metatarsal four shaft stress fracture and mild to moderate first metatarsophalangeal joint degenerative change; the left foot x-rays revealed a healed fifth metatarsal stress fracture and mild to moderate first metatarsophalangeal joint degenerative change. In November 2013, the Veteran followed up with his VA primary care physician who noted that the Veteran preferred to do things through the Navy. The provider noted that the Veteran had a foot fracture the prior year and wore a cam boot but again felt that he had broken the foot due to increased pain with walking over the prior view weeks. On February 10, 2014, the Veteran was seen by podiatry clinic for painful feet. The Veteran reported that he continued to wear supportive shoes and indicated that his symptoms persisted and that he was barely able to walk on his feet. The Veteran indicated that his pain had progressed from not only involving the dorsum but was also in the lateral aspect of the feet along the fifth metatarsals bilaterally, right greater than left. He also reported discomfort pain on the plantar and posterior aspect of both heels. Physical examination demonstrated that neurovascular status was intact with dorsalis pedis and posterior tibial pulses grated at 2/4 bilaterally. Temperature gradient was found to be within normal limits bilaterally. Capillary return was found to be instantaneous to all digits on both feet. There were no signs of ecchymosis or atrophy of the skin, no clinical signs of any ascending cellulitis/lymphangitis, and no clinical signs of hyperpigmentation or hypopigmentation. Muscle strength was grated at 5/5 all muscle groups crossing the ankles. There was no ankle weakness observed. Dorsiflexion strength, plantar flexion strength, inversion strength, and eversion strength of the ankles were normal. No subtalar weakness was observed. No peripheral neuropathy was noted. Pain of both feet was elicited by motion. There was no deformity of the feet. Both feet showed swelling, medial longitudinal arch was decreased, and there was excessive pronation; however, there was no erythema, and no abnormal warmth. X-rays on weight bearing of both feet demonstrated mild degenerative change to the left metatarsophalangeal joint, mild to moderate degenerative change to the right metatarsophalangeal joint, mild varus of right hind food, mild deformity of the right proximal fourth and fifth metatarsals, and tiny left plantar calcaneal spur. X-rays obtained on June 11, 2014 revealed inferior calcaneal spurs bilaterally, diffuse degenerative joint disease, increased cortical thickening through the lesser metatarsals, structural changes consistent with previous stress fractures of the metatarsals, structural changes consistent with previous open reduction internal fixation of a fifth metatarsal fracture of the right foot. Impression was no significant change since previous examination in April 2013. The podiatrist noted radiographic evidence on both sets of x-rays (in April 2013 and February 2014) indicate chronic and progressive degenerative joint disease involving the midfoot, the anterior and posterior aspects of the heel, the base of the fifth metatarsal on the right foot, and the cuboid bone on the left foot as well as possible signs of chronic seronegative arthropathy. The Veteran was diagnosed as having plantar fasciitis, osteoarthritis localized secondary foot left and right midfoot. The Veteran was informed that the diagnoses associated with his feet were chronic and appeared to be progressed and that future surgical intervention should be considered. A June 2014 application for disabled person parking permit noted that the Veteran had severe limitation in his ability to walk (200 feet without stopping to rest) due to arthritis, neurological, or orthopedic condition. On May 26, 2015, the Veteran submitted a Disability Benefits Questionnaire for foot conditions completed by his podiatrist at which time diagnoses included bilateral plantar fasciitis and degenerative joint disease of the right and left midfeet. The podiatrist noted that the Veteran had pain on use and accentuated on manipulation of both feet, no swelling, and no characteristic calluses. There was extreme tenderness of the plantar surface of both feet not improved by arch supports or orthotics. Both feet demonstrated decreased longitudinal arch height on weight bearing, objective evidence of marked deformity, and marked pronation not improved by orthopedic shows or appliances. Weight bearing line fell over or medial to the great toe on both feet. There was no deformity other than pes planus causing alteration of weight-bearing line, no "inward" bowing or marked inward displacement and severe spasm on manipulation of the Achilles tendon. The podiatrist indicted that the Veteran's foot condition chronically compromised weight bearing and required constant use of orthoses. The examiner noted that functional loss included less movement than normal; excess fatigability; incoordination; pain on movement, weight-bearing, and non-weight-bearing; disturbance of locomotion; and interference with standing. The podiatrist noted that the Veteran's bilateral foot condition caused an inability to walk or run for more than 10 minutes without severe pain. The podiatrist also noted imaging studies demonstrated degenerative arthritis of both feet. The Veteran presented to podiatry clinic in November 2015 with complaints that he felt as if something was broken especially in the right mid-foot. Physical examination demonstrated neurovascular status was intact with dorsalis pedis and posterior tibial pulses graded at 2/4 bilaterally. Temperature gradient was found to be within normal limits bilaterally. Capillary return was found to be instantaneous to all digits on both feet. There were no signs of ecchymosis or atrophy of the skin and no clinical signs of any ascending cellulitis/lymphangitis, and no clinical signs of hyperpigmentation or hypopigmentation. Muscle strength testing was 4/5 in all muscle groups crossing the ankles. Pain in both feel was elicited by motion. There was no deformity of the feet. There was swelling, decreased medial longitudinal arch, excessive pronation in both feet but no erythema or abnormal warmth. X-rays taken revealed inferior calcaneal spurs bilaterally, diffuse degenerative joint disease, increased cortical thickening throughout the lesser metatarsals, structural changes consistent with previous stress fractures of the metatarsals, structural changes consistent with previous open reduction, internal fixation of a fifth metatarsal fracture of the right foot. Examination of the Veteran's shoes was consistent with pes cavus deformity via the demonstration of excessive lateral wear. Assessment was secondary osteoarthritis bilateral ankles and feet, plantar fascial fibromatosis, and pes cavus deformity noted bilaterally. The Veteran presented for a VA podiatry consultation on February 8, 2016 at which time physical examination revealed that the skin was free of edema, rash and ulceration; nails were thickened hallux; hair growth was sparse, and temperature was warm to cool. Pulses were palpable, and capillary fill test was less than three seconds. Deep tendon reflexes were intact and somatosensory sensations were normal. Palpation of all bones, joints and ligaments were consistent with pes cavus. There was pain around the plantar fascia bilaterally. Muscle strength and muscle tone was within normal limits. Impression included pes cavus, multiple stress fractures, rule out osteoporosis. The Veteran underwent VA examination on April 26, 2016 at which time he was diagnosed as having acquired pes cavus (claw foot) of both the right and left feet and plantar fasciitis, resolved with no residuals of both the right and left feet. The Veteran reported daily foot pain more so with prolonged standing and no flare-ups. The Veteran noted that by the end of the day, his pain was more of a throbbing pain and, depending on the level of activity, he just elevated his feet at night. The Veteran reported that he continued to take pain pills for all of his generalized pain which also helped his foot pain. With respect to acquired pes cavus, there was very subtle hind foot significant improvement with use of orthotics, right more than left. The examiner noted that the examination was after regular use of orthotics for over a few weeks to more than a month. There was no pain/tenderness at the insertion of the plantar fascia, no irregularity/nodularity along the plantar surface of the fleet, and no residuals of plantar fasciitis on examination. The Veteran did have pain on physical examination consistent with degenerative joint disease which did not contribute to functional loss; and there was no functional loss during flare-ups or after repetitive use. The examiner also noted a surgical scar on the lateral aspect of the distal right foot that measured 6 centimeters by 0.2 centimeters which was not painful or unstable. The Veteran underwent VA examination on June 27, 2017 at which time he reported constant aching pain on the soles of both feet with severity level of 5 to 6/10. The Veteran did not report flare-ups but reported that due to the pain in the bottoms of his feet, he could not walk for more than five minutes, lift more than 10 pounds, and run or stand for more than five to 10 minutes. The Veteran was noted to have metatarsalgia with pain on palpation of the 5th metatarsals bilaterally. In addition, there was pain on touching the soles especially near the heels bilaterally. The examiner noted pes cavus of hind foot bilaterally, mild, of unknown cause but no pain or tenderness due to pes cavus. The examiner noted a history of malunion of the left 5th metatarsal fracture and nonunion metatarsal of the right foot. The examiner noted that the Veteran had moderate severity of his foot conditions, that the conditions compromised weight bearing, and that the conditions required orthotics. There was a surgical scar of the lateral aspect of the right foot which measured 8 centimeters by 0.2 centimeters and which was not painful or unstable. After repetitive use, there was no additional functional loss or loss of motion. The examiner noted that it was impossible to state, without undue speculation, whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare up or when the joint was used repeatedly over a period of time. There was objective evidence of pain on active but not passive motion as well as pain with weight bearing but not with non-weight bearing. The Veteran was diagnosed as having bilateral pes cavus and bilateral plantar fasciitis, status post metatarsal fractures with postoperative open reduction, internal fixation surgery of the right foot and bilateral degenerative changes, first metatarsophalangeal joints. In July 2017 Addendum, the examiner who conducted the June 2017 VA foot examination clarified that the Veteran had no diagnosis of pes planus, no swelling or pain on use or on manipulation of feet, no characteristic callouses, no extreme tenderness of plantar surfaces, no decreased longitudinal arch height on weight bearing, no marked deformity or pronation, and no marked inward displacement and severe spasm of Achilles tendon on manipulation. The examiner noted that the weight bearing line did not fall over or was not medial to great toe. The examiner noted that there was pes cavus bilaterally, that the use of orthotics had helped, but that the Veteran's feet were still painful. Taking such evidence into account, the Board finds that prior to April 23, 2013, the Veteran's service-connected foot disability did not approach the severity contemplated for a compensable disability rating. The Board notes that prior to April 23, 2013, there was evidence of plantar fasciitis with slight tenderness on palpation of the plantar surface of both feet and x-ray evidence of mild degenerative changes in the proximal left fifth metatarsophalangeal joint. At that time, however, the Veteran did not have any limitation with standing and walking, did not require any assistive device for ambulation, and did not require any type of support with his shoes. There was also no evidence at that time of metatarsalgia. Thus, prior to April 23, 2013, the Veteran's mild symptoms warranted a noncompensable evaluation under Diagnostic Code 5284 for other foot injuries and Diagnostic Code 5276 for acquired flatfoot. For the purpose of rating disability from arthritis, the interphalangeal, metatarsal, and tarsal joints are considered groups of minor joints. See 38 C.F.R. § 4.45. In the absence of limitation of motion, x-ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5010, Note 1. In this case, prior to April 23, 2013, the x-ray evidence shows that only one group of joints on the left foot involved arthritic changes. Thus, a compensable rating under the diagnostic codes pertaining to arthritis is not warranted because the degenerative joint disease only affects one minor joint group. The Board also finds that from April 23, 2013, the evidence indicates that a 10 percent evaluation is warranted for moderate foot injury. At that time, the evidence showed tenderness to palpation to the right fifth metatarsal base and also at the junction of the arch and heel bilaterally. X-rays of the right foot revealed previous fifth metatarsal base fracture and healed metatarsal four shaft stress fracture; the left foot x-rays revealed a healed fifth metatarsal stress fracture. The Board further finds that from February 10, 2014, the evidence indicates that a 20 percent evaluation is warranted for moderately severe foot injury. At that time, the evidence showed pain on both feet was elicited by motion, swelling, decreased medial longitudinal arch, and excessive pronation. X-rays revealed inferior calcaneal spurs bilaterally, diffuse degenerative joint disease, increased cortical thickening throughout the lesser metatarsals, structural changes consistent with previous stress fractures of the metatarsals, structural changes consistent with previous open reduction internal fixation of a fifth metatarsal fracture of the right foot. The June 2014 podiatrist noted radiographic evidence on both sets of x-rays (in April 2013 and February 2014) indicate chronic and progressive degenerative joint disease involving the midfoot, the anterior and posterior aspects of the heel, the base of the fifth metatarsal on the right foot, and the cuboid bone on the left foot as well as possible signs of chronic seronegative arthropathy. The Board finally finds that from May 26, 2015, the evidence indicates that a 30 percent evaluation is warranted for severe foot injury. At that time, the Veteran's treating podiatrist completed a VA Disability Benefits Questionnaire regarding pes planus and noted that his bilateral foot disabilities included bilateral plantar fasciitis and degenerative joint disease of the right and left midfeet. The podiatrist noted that the Veteran's bilateral foot disability was manifested by pain on use and pain on manipulation of feet but no swelling on use or characteristic calluses. The podiatrist noted extreme tenderness of the plantar surface of both feet not improved by arch supports or orthotics, decreased longitudinal arch height on weight bearing, objective evidence of marked deformity, and marked pronation not improved by orthopedic shows or appliances. Weight bearing line fell over or medial to the great toe on both feet. There was no deformity other than pes planus causing alteration of weight-bearing line, no "inward" bowing or marked inward displacement and severe spasm on manipulation of the Achilles tendon. The podiatrist indicted that the Veteran's foot condition chronically compromised weight bearing and required constant use of orthoses. The podiatrist noted that the Veteran's bilateral foot condition caused an inability to walk or run for more than 10 minutes without severe pain. The Board notes that in order to warrant an evaluation in excess of 30 percent for service-connected foot disability, the evidence must show actual loss of the foot or pronounced acquired flat foot with marked inward displacement and severe spasm of the tendo Achilles on manipulation of both feet. These symptoms have clearly not been demonstrated at any time during the appeal period. These symptoms were not found by the Veteran's treating psychiatrist on the VA DBQ submitted in May 2015 or by VA examiners in either April 2016 or June 2017. As such, the Board finds that the evidence of record warrants a 10 percent evaluation from April 23, 2013, a 20 percent evaluation from February 10, 2014, and a 30 percent evaluation from May 26, 2015, for service-connected bilateral foot disability. The preponderance of the evidence of record is against a grant of an initial compensable evaluation for the Veteran's service connected bilateral foot disability prior to April 23, 2013, and against a grant above a 10 percent evaluation prior to February 10, 2010, against a grant above a 20 percent evaluation prior to May 25, 2015, and against a grant above a 30 percent evaluation at any time during the appeal period. Additionally, the Board has not overlooked the Veteran's statements with regard to the severity of his disabilities on appeal. The Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing pain; and the Board finds that the Veteran's reports have been credible. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Board has considered the Veteran's reports along with findings from VA examinations and additional medical records. The Board notes, with respect to the Rating Schedule, where the criteria set forth therein require medical expertise which the Veteran has not been shown to have, the objective medical findings and opinions provided by the Veteran's VA examination reports in particular, have been accorded greater probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). ORDER Entitlement to service connection for chronic fatigue syndrome is denied. Entitlement to service connection for fibromyalgia, also claimed as myalgia and myositis, is denied. Entitlement to service connection for sinusitis is denied. Entitlement to service connection for ulcers is denied. Entitlement to an initial compensable evaluation prior to February 6, 2013, for migraine headaches is denied. Entitlement to a 30 percent evaluation, but no higher, from February 6, 2013 to June 11, 2014, for migraine headaches is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to a maximum 50 percent evaluation since June 12, 2014, for migraine headaches is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to an initial evaluation of 20 percent, but no higher, prior to January 5, 2016, for degenerative arthritis of the right shoulder is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to an evaluation in excess of 20 percent since January 5, 2016, for degenerative arthritis of the right shoulder is denied. Entitlement to an initial compensable evaluation prior to April 23, 2013, for Achilles tendonitis of the right ankle with degenerative changes status post stress fracture of the right tibia is denied. Entitlement to an evaluation of 10 percent, but no higher, since April 23, 2013, for Achilles tendonitis of the right ankle with degenerative changes status post stress fracture of the right tibia is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to an initial compensable evaluation prior to April 23, 2013, for Achilles tendonitis of the left ankle is denied. Entitlement to an evaluation of 10 percent, but no higher, since April 23, 2013, for Achilles tendonitis of the left ankle is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to an initial compensable evaluation prior to April 23, 2013, for plantar fasciitis status post bilateral metatarsal fractures with postoperative open reduction, internal fixation of the right foot, and bilateral degenerative changes of the first metatarsophalangeal joints is denied. Entitlement to an evaluation of 10 percent, but no higher, from April 23, 2013 to February 9, 2014, for plantar fasciitis status post bilateral metatarsal fractures with postoperative open reduction, internal fixation of the right foot, and bilateral degenerative changes of the first metatarsophalangeal joints is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to an evaluation of 20 percent, but no higher, from February 10, 2014, to May 25, 2016 for plantar fasciitis status post bilateral metatarsal fractures with postoperative open reduction, internal fixation of the right foot, and bilateral degenerative changes of the first metatarsophalangeal joints is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to an evaluation of 30 percent, but no higher, since May 25, 2016, for plantar fasciitis status post bilateral metatarsal fractures with postoperative open reduction, internal fixation of the right foot, and bilateral degenerative changes of the first metatarsophalangeal joints is granted subject to the law and regulations governing the payment of monetary benefits. REMAND The Veteran seeks service connection for a cervical spine disability. Service treatment records indicate that the Veteran complained of acute slight stiffness and discomfort in the neck and upper back with slight headache in January 2003. Treatment consisting of electric stimulation, cryotherapy, chiropractic manipulation, ultrasound therapy, and/or hot or cold packs therapy for cervical pain occurred from May 1999 to June 2003. Diagnoses of cervicocranial syndrome, cervicalgia, and sprain of neck were rendered from June 2002 to June 2003. In September 2004, the Veteran complained of posterior head and neck pain when coughing, right interscapular pain and intermittent parasthesias in right arm since MVA; assessment included cervical radiculopathy with normal examination and no reflex, motor, or sensory deficits. The provider noted that MRI and EMG should be considered if symptoms persisted. A February 2007 EMG Report noted that there was no evidence of peripheral entrapment neuropathy, cervical radiculopathy, thoracic outlet syndrome, or any other peripheral neuromuscular disorder. A March 2007 Office Note indicates that the Veteran returned for follow up for his ongoing neck and upper extremity pain syndrome, that he had had a careful and full work up including EMG which showed normal nerve conduction velocities and normal electrode examination of the muscles sampled. The MRI scan of the cervical spine showed Chari malformation with a tonsil descended approximately 1 centimeter below the foramen magnum but which did not reach the level of C1 and also an underlying syringomyelia that was stable. There was some mild disc bulging but no significant nerve root compromise or central canal compression. Later in March 2007, the Veteran returned for follow up for neurosurgery evaluation. He stated that the continued to experience intermittent radicular symptoms from his right cervical lumbar region into his back and right upper extremity extending into his right and small finger. After normal examination, the physician's assistant diagnosed the Veteran as having cervical radiculopathy. An adult preventative and chronic care flowsheet indicates chronic illnesses including cervicalgia and cervical radiculopathy. At the July 2011 VA examination, the Veteran reported constant neck pain which began in 2001 and travels to the spine. The Veteran reported that his pain level was moderate and that the pain could be exacerbated by physical activity and relieved by rest. The Veteran reported that he can function without medication during pain. Physical examination demonstrated flexion from zero to 45 degrees, extension from zero to 45 degrees, right and left lateral flexion from zero to 45 degrees, and right and left rotation from zero to 80 degrees. There was also normal range of motion after repetitive use with no additional degree of limitation. There was no evidence of radiating pain on movement muscle spasm, tenderness, guarding, weakness, loss of tone, or atrophy of the limbs. There was no ankylosis. The examiner noted that the joint function of the cervical spine was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The examination of the cervical spine also revealed no sensory deficits from C3 to C8. The examination of the cervical/thoracic spine revealed no motor weakness. Bilateral upper extremity reflexes revealed biceps jerk 2+ and triceps jerk 2+. The upper extremities showed no signs of pathologic reflexes, and the examination revealed normal cutaneous reflexes. There were no signs of cervical intervertebral disc syndrome with chronic and permanent nerve root involvement. The cervical spine x-ray findings were within normal limits. The examiner noted that there was no pathology of the cervical spine to render a diagnosis. The Veteran was seen for, inter alia, neck and right shoulder pain from February 2014 to December 2014 in Coastal Spine and Pain Center. In February 2014, the Veteran described the pain as 7/10, constant, sharp, dull, achy, burning located in the right shoulder and neck. In April 2014, the Veteran was seen for follow up for neck pain with associated spasm and neuropathic pain exacerbated by static positions, external rotation head/neck, use of bilateral upper extremities. On examination of the cervical spine, there was pain with extension, external rotation, flexion and reversal flexion with resultant decreased active range of motion. There was also significant para-vertebral tenderness noted. The Veteran was assessed as having Chiari malformation by patient history, cervical spondyloarthritis/facet joint disease by history and examination, cervicalgia/neck pain. In September 2014, the Veteran was seen for pain located in the neck and right shoulder. In October 2014, the Veteran was seen with complaints of aching neck pain. On physical examination, there were muscle spasms in the neck. Assessment included cervical spondyloarthritis/facet joint disease by history and examination and cervicalgia/ neck pain. In September 2015, the Board remanded the case for an etiology opinion of any cervical spine disability. The Veteran underwent VA examination in January 2016 by a physician's assistant who determined after physical examination and a review of the file, "There is no objective evidence of a current cervical spine pathology - OPINION is therefore not indicated." On November 25, 2015, the Veteran's neurologist stated that the Veteran's chronic posterior based headaches and neck stiffness "may be related to his known congenital malformation." The Veteran underwent VA examination in June 2017 at which time he reported that he has significant pain in the back of the neck which has worsened gradually over the years since his motor vehicle accident in 2002. The Veteran also reported constant numbness with tingling of the lateral three digits of the right hand and the thumb of the left hand since 2016. After physical examination of the Veteran and review of the file, he was diagnosed as having Arnold-Chiari malformation with syringomyelia and cervical spine strain. The examiner opined that the diagnosis of cervical spine strain was less likely as not incurred in, caused by or a result of active military service and less likely as not aggravated by his service connected Arnold Chiari malformation with syringomyelia. The examiner noted that the objective evidence was absent a diagnosis of cervical spine strain being incurred in or caused by active military service or aggravated by service-connected Arnold Chiari malformation with syringomyelia. The examiner noted that the Veteran did not have intervertebral disc syndrome of the cervical spine, that the presence of disc disease on imaging of the spine does not necessarily have to be associated with intervertebral disc syndrome, and that that radiologic findings do not necessarily have clinical manifestations. Unfortunately, the June 2017 examiner did not provide a complete rationale for the opinion. As such, the issue must be remanded for an additional opinion. The Veteran also seeks a compensable evaluation for his service-connected Arnold Chiari I Malformation with Syringomyelia which has been rated pursuant to 38 C.F.R. § 4.124a, Diagnostic Codes 8099-8024. Arnold Chiari malformation does not have a specific diagnostic code. When a Veteran is diagnosed with an unlisted condition, it must be rated under an analogous diagnostic code. 38 C.F.R. §§ 4.20, 4.27. The diagnostic code is "built-up" by assigning the first two digits from that part of the schedule most closely identifying the part of the body involved and then assigning "99" for the last two digits for all unlisted conditions. Then, the disease is rated by analogy under a diagnostic code for a closely related disease that affects the same anatomical functions and has closely analogous symptomatology. Therefore, the Veteran's service-connected Arnold Chiari malformation with syringomyelia is rated according to the analogous condition of syringomyelia under Diagnostic Code 8024, which provides for a minimum rating is 30 percent. Higher ratings are assigned by analogy to other Diagnostic Codes. The Note under this Diagnostic Code states the following: It is required for the minimum ratings for residuals under diagnostic codes 8000-8025, that there be ascertainable residuals. Determinations as to the presence of residuals not capable of objective verification, i.e., headaches, dizziness, fatigability, must be approached on the basis of the diagnosis recorded; subjective residuals will be accepted when consistent with the disease and not more likely attributable to other disease or no disease. It is of exceptional importance that when ratings in excess of the prescribed minimum ratings are assigned, the diagnostic codes utilized as bases of evaluation be cited, in addition to the codes identifying the diagnoses. 38 C.F.R. § 4.124 (a) further directs that: [With the exceptions noted, disability from the following diseases and their residuals may be rated from 10 percent to 100 percent in proportion to the motor, sensory, or mental function. Consider especially psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, and etc., referring to the appropriate bodily system of the schedule. With partial loss of one or more extremities from neurological lesions, rate by comparison with mild moderate, severe, or complete paralysis of peripheral nerves]. In this case, a noncompensable evaluation has been assigned for the Veteran's Arnold Chiari malformation with syringomyelia on the basis that he had a diagnosis but no current ascertainable residuals that would warrant a 30 percent evaluation. Initially, the Board notes that according to the Mayo Clinic, Chiari malformation is a condition in which brain tissue extends into the spinal canal. It occurs when part of the skull is abnormally small or misshapen pressing on the brain and forcing it downward. Chiari malformation is categorized into three types depending on the anatomy of the brain tissue that is displaced into the spinal canal and whether developmental abnormalities of the brain or spine are present. Chiari malformation type I develops as the skull and brain are growing. As a result, signs and symptoms may not occur until late childhood or adulthood. Many people with Chiari malformation have no signs or symptom. Headaches, often severe, are the classic symptoms of Chiari malformation which generally occur after sudden coughing, sneezing, or straining. People with Chiari malformation type I can also experience neck pain, unsteady gait (problems with balance), poor hand coordination (fine motor skills), numbness and tingling of the hands and feet, dizziness, difficulty swallowing, sometimes accompanies by gagging, choking and vomiting, vision problems (blurred or double vision), and speech problems such as hoarseness. Less often, people with Chiari malformation may experience tinnitus, weakness, slow heart rhythm, curvature of the spine (scoliosis) related to spinal cord impairment, and abnormal breathing, such as central sleep apnea characterized by periods of breathing cessation during sleep. https://www.mayoclinic.org/diseases-conditions/chiari-malformation/symptoms-causes/syc-20354010. At the July 2011 VA examination, the Veteran described headaches, numbness of the arm and elbow, tingling of the neck, burning sensation in the feet, mood swings, confusion, slowness of thought, problems with attention/concentration, problems with reading, feeling dyslectic, problems with anxiety (he cannot relax), moderate short term memory problem, fatigue (he is always tired), hearing problems, ringing, smell and taste problems, hypersensitivity to light during migraines, intolerance to heat (abnormal sweating/sweating profusely), restlessness, problems sleeping, a general feeling of discomfort of his entire body (pain in neck, shoulder, upper back caused by slipped disc), dizziness once per week and vertigo twice per week, difficulty finding the right words to express himself, difficulty pronouncing words, difficulty swallowing solid foods, having a urinary urgency problem, erectile dysfunction, occasional constipation. Objective findings revealed that the Veteran's autonomic nervous system was within normal limits with no evidence of hyperhidrosis, heat intolerance, or orthostatic hypotension; normal motor and sensory functions; normal deep tendon reflexes. The Veteran's skull and cervical spine x-ray findings were normal. The Veteran was diagnosed as having Type I Arnold Chiari malformation with syrinx. At the August 2011 VA examination, the Veteran reported being diagnosed with peripheral vestibular disorder which had existed for eight years due to multiple concussive blast injuries to both ears in Iraq in 2003 and 2005. The Veteran also reported constant hearing loss bilaterally and a history of ear infections. The Veteran indicated that he had intermittent vertigo occurring twice per month and lasting for 30 minutes each time. The Veteran reported intermittent problems with balance occurring 15 times per month and lasting for two minutes each time. The Veteran denied ear discharge, ear pain, dizziness, a staggering gait, and a cerebellar gait. After physical examination, the examiner diagnosed the Veteran as having positional vertigo but indicated that no objective factors were evident on examination and that there was no hearing loss. At the February 2014 neurology clinic visit, the neurologist noted that the Veteran had a remote history of being diagnosed with a Chiari one malformation with benign-appearing cervical spine syrinx. At the June 2014 neurology clinic visit at which time the neurologist noted a "benign-appearing Chiari one malformation" unlikely related to headache syndrome and noted that he found no abnormalities on neurological examination referable to the Chiari malformation (no cranial nerve deficits, no downbeat nystagmus, no signs of myelopathy). The November 25, 2015 outpatient neurology medical record noted that the Veteran had a known small Chiari malformation with associated small cervical syrinx. He had no focal cranial nerve deficits or other neurological deficits referable to the cranial cervical junction. In January 2017, the Veteran underwent VA examination for residuals of traumatic brain injury (TBI) at which time the examiner noted that there was no evidence of TBI residuals. The examiner noted that MRI Brain was normal except for Chiari I malformation with syrinx, a separate condition, not related to TBI events. It not clear from the record whether the Veteran is suffering from symptoms of Arnold Chiari malformation, excluding those symptoms for which he is receiving a separate evaluation, that would warrant a compensable rating. 38 C.F.R. § 4.124 (a), Diagnostic Code 8024. Although the evidence is clear that the Veteran suffers with numerous symptoms, service connection is currently in effect for PTSD with symptoms such as depression, primary insomnia, attention deficit disorder, and short term memory loss), obstructive sleep apnea, migraine headaches, tinnitus, varicose veins bilateral lower extremities, gastroesophageal reflux disease with hiatal hernia and irritable bowel syndrome, temporomandibular joint dysfunction, Achilles tendonitis bilateral ankles, plantar fasciitis with postoperative open reduction and internal fixation surgery of the right foot with degenerative changes of the first metatarsophalangeal joint, degenerative arthritis of right shoulder, thoracic spine, lumbar spine, and bilateral knees, peripheral vestibular disorder, septoplasty with turbinate reduction, residuals of inguinal hernia surgical repair including scar, erectile disorder, carpal tunnel syndrome and cubital tunnel syndrome of the right upper extremity. Unfortunately, the issue must be remanded for a medical opinion to identify all manifestations of the Veteran's Arnold-Chiari malformation and to determine the nature and severity of all manifestations. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. The Veteran should be afforded a VA neurologic examination to determine the current manifestations and severity of such manifestations. The examiner, a physician with expertise in diagnosing and treating Chiari malformation, preferably a neurologist/neurosurgeon, is to be provided access to Virtual VA and VBMS and must specify in the report that these records have been reviewed. All pertinent symptomatology and findings should be reported in detail. Any indicated diagnostic tests and studies should be accomplished. (a) The physician should identify all manifestations of the Veteran's Arnold Chiari I malformation which are part and parcel of a service-connected disability. Service connection has been established for PTSD with symptoms such as depression, primary insomnia, attention deficit disorder, and short term memory loss), obstructive sleep apnea, migraine headaches, tinnitus, varicose veins bilateral lower extremities, gastroesophageal reflux disease with hiatal hernia and irritable bowel syndrome, temporomandibular joint dysfunction, Achilles tendonitis bilateral ankles, plantar fasciitis with postoperative open reduction and internal fixation surgery of the right foot with degenerative changes of the first metatarsophalangeal joint, degenerative arthritis of right shoulder, thoracic spine, lumbar spine, and bilateral knees, peripheral vestibular disorder, septoplasty with turbinate reduction, residuals of inguinal hernia surgical repair including scar, erectile disorder, carpal tunnel syndrome and cubital tunnel syndrome of the right upper extremity. (b) The physician should identify all manifestations of the Veteran's Arnold Chiari I malformation which are NOT part and parcel of a service-connected disability. For each such manifestation NOT considered part and parcel of a service-connected disability, in accordance with the latest rating worksheets, the physician should provide a detailed review of the Veteran's complaints as well as the nature and severity of each manifestation. (c) If the Veteran's complaints of cervical pain and stiffness are NOT considered to be attributed to Arnold Chiari I malformation, the physician should identify all current chronic cervical spine disorders and provide an opinion as to a. whether it is at least as likely as not that any such disorder had its onset in service or is otherwise related in any way to the Veteran's active duty service to include symptoms documented during such service; or b. whether it is at least as likely as not that any such disorder is caused by or aggravated by a service-connected disability. c. If aggravation is found, the physician should also state, to the extent possible, the baseline level of disability prior to aggravation. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. It would be helpful if the examiner would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner should provide a complete rationale for any opinion provided. 2. The Veteran is hereby notified that it is his responsibility to report for the examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. In the event that the Veteran does not report for the aforementioned examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 3. After the development requested above has been completed, the examination report should be reviewed to ensure that it is in complete compliance with the directives of this REMAND. If the report is deficient in any manner, corrective procedures should be implemented at once. 4. The case should be reviewed on the basis of the additional evidence. If the benefit sought is not granted in full, the Veteran and his attorney should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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. §§ 5109B, 7112 (West 2012). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs