Citation Nr: 18145487 Decision Date: 10/30/18 Archive Date: 10/29/18 DOCKET NO. 15-12 149A DATE: October 30, 2018 ORDER Entitlement to service connection for a left arm disability is granted. Entitlement to service connection for a right arm disability is granted. Entitlement to an initial 10 percent rating for residuals of a right heel disability is granted. Entitlement to an initial compensable rating for residuals of a head injury is denied. Entitlement to an initial compensable rating for posttraumatic headaches is denied. FINDINGS OF FACT 1. A left arm disability is as likely as not attributable to service. 2. A right arm disability is as likely as not attributable to service. 3. Residuals of a right heel injury are manifested by painful motion. 4. Residuals of a head injury are not manifested by any cognitive, emotional/behavioral, or physical symptomatology. 5. Posttraumatic headaches are not manifested by characteristic prostrating attacks that average one every two months lasting over several months. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left arm disability have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2017). 2. The criteria for entitlement to service connection for a right arm disability have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2017). 3. The criteria for an initial 10 percent rating, but no higher, for residuals of a right heel injury have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.59, 4.7, 4.71a, Diagnostic Code 5284 (2017). 4. The criteria for an initial compensable rating for residuals of a head injury have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2017). 5. The criteria for an initial compensable rating for posttraumatic headaches have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.124a, Diagnostic Code 8100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service in the U.S. Air Force from September 1973 to September 1977. Initially, the Board notes that the Veteran perfected an appeal to the denial of a compensable evaluation for multiple noncompensable service-connected disabilities. In an April 2017 rating decision, however, the benefit sought on appeal was granted. As the benefit sought on appeal has been granted, this issue is no longer before the Board. Entitlement to service connection for left and right arm disabilities The Veteran appeals the denial of service connection for left and right arm disabilities. He reports having shoulder pain during service and claims that since his discharge from service he has had problems with his shoulders. During his October 2017 hearing, the Veteran testified and submitted evidence showing that he sought treatment for his left shoulder in 1979. Service connection may be established for disability resulting from personal injury sustained or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, such as arthritis, may be presumed to be service connected if manifested to a degree of 10 percent or more within one year after separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. The continuity and chronicity provisions of 38 C.F.R. § 3.303(b) only apply to the chronic diseases enumerated in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), overruling Savage v. Gober, 10 Vet. App. 488, 495-96 (1997) (applying 38 C.F.R. § 3.303(b) to a chronic disease not listed in 38 C.F.R. § 3.309(a) as “a substitute way of showing in-service incurrence and medical nexus.”) Service treatment records show complaints of left shoulder pain in April 1977. At that time, tendonitis was assessed. In July 1977, the Veteran reported infrequent left shoulder pain. The Veteran was noted to have a shoulder problem in July 1977. Myositis was diagnosed. He complained of left shoulder pain in August 1977. During his April 1977 separation examination, he reported a history of painful or “trick” shoulder or elbow. During the January 2013 VA examination, bilateral shoulder strain was diagnosed. Based upon a review of the record and examination, the VA examiner opined that the Veteran’s bilateral mild shoulder strain was not caused by or a result of service. The VA examiner noted that the Veteran had a few complaints of shoulder pain in 1970, and that he was diagnosed with tendinitis in April 1976, myositis in June 1977 and mild tendinitis of the left shoulder in August 1977. The VA examiner further noted that on the separation examination in April 1977 the Veteran was found to have good range of motion and strength of the left and right shoulders. In contrast, however, in October 2017 Dr. A found that there was a high probability that the Veteran’s osteoarthritis of the bilateral shoulders resulted from injuries he suffered from while in the Air Force since he started having symptoms about year after separation. Dr. A noted that the Veteran served in the Air Force from 1973 to 1977 and that he started complaining of shoulder pain in July 1978. The Board has weighed the positive and negative evidence of record, and in resolving reasonable doubt, the Board finds in favor of the claim. In making this determination, the Board finds that positive evidence has been submitted showing a link between the Veteran’s service and his current left and right shoulder disability. To that end, the Veteran reports having shoulder pain during service and continued shoulder problems since his discharge from service. The Veteran is competent to report shoulder problems and the circumstances surrounding such. Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds the Veteran has presented credible statements regarding the onset and continuity of his disability. The credible lay statements of record in conjunction with the medical opinion from Dr. A place the evidence at least in equipoise. Because there is an approximate balance of positive and negative evidence, the benefit of the doubt must be applied in favor of the Veteran. 38 U.S.C. § 5107(b); see Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also 38 C.F.R. § 3.102. Accordingly, resolving reasonable doubt in his favor, service connection for a left and right shoulder disability is granted. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. Evaluation of a service-connected disorder requires a review of a veteran’s entire medical history regarding that disorder. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In Fenderson v. West, 12 Vet. App. 119 (1999), the United States Court of Appeals for Veterans Claims (Court) held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the ‘staging’ of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126-127; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The basis of disability evaluation is the ability of the body, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40 and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Entitlement to an initial compensable evaluation for residuals of a right heel disability The Veteran appeals the denial of an initial compensable rating for his residuals of a right heel disability. The Veteran’s right heel disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5284 which evaluates foot injuries. Under this Code, a 10 percent rating is assigned for moderate foot injuries, a 20 percent rating is assigned for moderately severe foot injuries and a 30 percent rating is assigned for severe foot injuries. During the March 2013 VA examination, the Veteran reported that he sustained injury over his right heel while playing basketball in August 1977. Since that time, he reported experiencing right heel pain and that his symptoms increase after prolonged standing, walking and climbing. The pain varied in nature, intensity and duration. At that time, he had no pain. Chronic residual mild heel pain syndrome secondary to the injury was diagnosed. The February 2017 VA examination disclosed that the Veteran had right heel pain from standing for more than 30 minutes, walking 6-8 blocks and climbing 2-3 flight of stairs, or on uneven surfaces. It was determined that the Veteran’s disability was mild in severity. There was pain on examination which resulted in functional loss. The VA examiner noted that the Veteran was a retired mail handler but that he would have difficulty doing work that required repeated heavy lifting or walking. The VA examiner noted that the heel examination was normal. During the July 2017 VA examination, the Veteran reported right heel pain from walking for more than 30 minutes or on uneven surfaces and climbing 2-3 flights of stairs. He reported limitations in prolonged walking and standing due to foot pain. He denied having flare-ups that impacted the function of the foot. There was pain on examination which resulted in functional loss. The VA examiner stated there was no evidence of pain on passive range of motion testing and there was no evidence of pain when the joint was used in weight bearing, and that there were no abnormalities in the opposing joint. The Veteran reiterated, during his October 2017 hearing, that his feet hurt when walking long distances, walking fast, running and climbing stairs. After review of the record, the Board finds that an initial rating of 10 percent, but no higher, is warranted for the Veteran’s residuals of a right heel injury. To that end, VA examinations, outpatient treatment records and lay statements of record throughout this appeal show continued complaints of heel pain and objective evidence of heel pain. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Based upon the credible evidence of right heel pain and the provisions of 38 C.F.R. § 4.59, the Board finds that a 10 percent evaluation is warranted for residuals of a right heel injury. The Board finds, however, that a rating higher than 10 percent for the service connected residuals of a right heel injury is not warranted as a moderately severe foot injury is not shown. To that end, while the Veteran reports right heel pain and there is a notation of functional loss with pain, examinations disclose essentially normal findings for the right foot. The Board also notes that the Veteran reported heel after prolonged standing, walking and climbing. He is, however, able to walk for at least 30 minutes without pain and he denies flare-ups that impact the function of the foot. At most, the Board finds that the evidence shows a moderate disability. In reaching this conclusion, the Board has considered the requirements of 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The Board finds, however, that the more probative evidence is devoid of a showing of a moderately severe foot disability as to warrant the next higher evaluation. The Board acknowledges the Veteran’s assertions to include his reports of pain. The Veteran is competent to report his symptoms and has presented credible testimony. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board has also considered the lay statements of record which discuss the Veteran’s functional limitations. The Board finds, however, that neither the lay or medical evidence demonstrates that the criteria for a 20 percent evaluation have been met. The most probative evidence is that prepared by neutral skilled professionals, and such evidence demonstrates that no more than a 10 percent evaluation is warranted. Accordingly, a rating of 10 percent, but no higher, for residuals of a right heel injury is granted. Entitlement to an initial compensable evaluation for residuals of a head injury The Veteran appeals the denial of an initial compensable rating for residuals of a head injury. The Veteran’s head injury is rated under Diagnostic Code 8045. Under this criteria, there are three main areas of dysfunction listed that may result from a traumatic brain injury and have profound effects on functioning: cognitive (which is common in varying degrees after a traumatic brain injury), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Evaluate cognitive impairment under the table titled “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified.” (Hereinafter “table.”) Subjective symptoms may be the only residual of a traumatic brain injury or may be associated with cognitive impairment or other areas of dysfunction. The rater is instructed to evaluate subjective symptoms that are residuals of a traumatic brain injury, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table. However, the rater is to separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere’s disease, even if that diagnosis is based on subjective symptoms, rather than under the table. Further, the rater is to evaluate emotional/behavioral dysfunction under 38 C.F.R. § 4.130 (Schedule of ratings--mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, emotional/behavioral symptoms should be evaluated under the criteria in the table titled “Evaluation of Cognitive Impairment and Other Residuals of a traumatic brain injury Not Otherwise Classified.” Physical (including neurological) dysfunction is to be evaluated based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of a traumatic brain injury. For residuals not listed here that are reported on an examination, such should be evaluated under the most appropriate diagnostic code. Each condition should be evaluated separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under 38 C.F.R. § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. Additionally, the rater is to consider the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. The table contains 10 important facets of a traumatic brain injury related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled “total.” However, not every facet has every level of severity. The consciousness facet, for example, does not provide for an impairment level other than “total,” since any level of impaired consciousness would be totally disabling. Assign a 100-percent evaluation if “total” is the level of evaluation for one or more facets. If no facet is evaluated as “total,” assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. Note (1): There may be an overlap of manifestations of conditions evaluated under the table with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): “Instrumental activities of daily living” refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one’s own medications, and using a telephone. These activities are distinguished from “Activities of daily living,” which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4): The terms “mild,” “moderate,” and “severe” traumatic brain injury, which may appear in medical records, refer to an injury classification made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. As a preliminary matter, the Board notes that the Veteran is currently service connected for posttraumatic headaches. In order to avoid impermissible pyramiding, the Board will not consider the symptoms associated with this disability when evaluating the severity of his TBI. 38 C.F.R. § 4.14. The evidence shows that during the April 2013 VA examination, the Veteran had no complaints of impairment of memory, attention, concentration or executive functions. His judgment, consciousness, motor activity, social interaction, visual spatial orientation and orientation were normal. He was able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language, and he had no neurobehavioral effects. His only subjective symptom was headaches which did not interfere with instrumental activities of daily living, work, family or other close relationships. He scored 26 out of 30 on his Montreal Cognitive Assessment (MOCA) which is within the normal range. The VA examiner noted that there was no functional impact on his ability to do any type of physical or sedentary work because of his condition, and that he retired three years ago as a mail handler at the post office because of age and length of service not because of this injury. Neurological examination in November 2016 was noted to be normal. The February 2017 VA examination disclosed there was objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment. The Veteran scored 2 out of 5 on the memory portion of the MOCA. His judgment, consciousness, motor activity, social interaction, visual spatial orientation and orientation were normal. He was able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language, and he had no neurobehavioral effects. It was noted that the Veteran did not have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere’s disease). His MOCA score was also normal. The VA examiner found that Veteran was less likely than not to have a TBI from a fall while in the Air Force, and that his poor performance in delayed recall is at least as likely as not from age and/or years of substance misuse. During the July 2017 VA examination, there was objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment. The Veteran’s judgment, consciousness, social interaction, visual spatial orientation and orientation were normal. He was able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language, and he had no neurobehavioral effects. It was noted that the Veteran did not have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere's disease). His MOCA score was also normal. The VA examiner noted that the Veteran is essentially unchanged from his last TBI evaluation and that there is no obvious evidence of residuals from a TBI. The examiner stated that his low score on the delayed recall section of the MOCA is likely due to other factors [age, substance misuse]. He further noted that the Veteran was able to successfully work 32 years at the post office after the fall while in the Air Force. At his hearing in October 2017, the Veteran voiced his belief that behavioral changes such as being short-tempered and aggressively arguing with his spouse were residuals of his TBI. After review of the record, the Board finds against the claim for a compensable rating for residuals of a TBI under DC 8045. To that end, the first facet for consideration is memory, attention, concentration and executive functions. A level of severity of “0” has been assigned for the memory, attention, concentration, and executive functions facet. Although the February 2017 and July 2017 VA examiners found there was objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment, such were noted to be at least as likely as not due to the Veteran’s age and/or years of substance misuse not his TBI. As such, impairment in memory, attention, concentration and executive functions due to TBI is not shown by the record. A higher level of severity of “1” is not warranted unless there is evidence of mild impairment of memory, attention, concentration, or executive functions due to the service connected TBI which is not the case here. A level of severity of “0” has been assigned for the judgment facet, indicating that the examiner found evidence of normal judgment. A higher level of severity of “1” is not warranted unless there is evidence of mildly impaired judgment, including symptoms such as impairment for complex or unfamiliar decisions, occasional inability to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision. The Veteran’s judgment was evaluated as intact during the pendency of the appeal. A level of severity of “0” has been assigned for the social interaction facet, indicating that the examiner found evidence of appropriate social interaction. A higher level of severity of “1” is not warranted unless social interaction is occasionally inappropriate. As the Veteran’s behavior has been considered appropriate during the pendency of the appeal, a higher level of severity of “1” for social interaction is not warranted. A level of severity of “0” has been assigned for the orientation facet, indicating that the examiner found evidence that the Veteran was oriented to person, time, place, and situation. He was evaluated as alerted and oriented during clinical evaluations. A higher level of severity of “1” is not warranted unless there is evidence such as occasional disorientation to one of the four aspects (person, time, place, situation) of orientation. There is no finding of impairment of orientation during the pendency of the appeal. A level of severity of “0” has been assigned for the motor activity (with intact motor and sensory system) facet, indicating normal motor activity. A higher level of severity of “1” is not warranted unless there is evidence that motor activity is normal most of the time, but mildly slowed at times due to apraxia (in ability to perform previously learned motor activities. There is no finding of motor impairment during the pendency of the appeal. A level of severity of “0” has been assigned for the visual spatial orientation facet, indicating that the examiners found such orientation is normal. A higher level of severity of “1” is not warranted unless there is evidence of mild impairment, including occasionally getting lost in unfamiliar surroundings, having difficulty reading maps or following directions, and being unable to use assistive devices such as GPS. There is no finding of visual spatial orientation impairment during the pendency of the appeal. A level of severity of “0” is assigned for subjective symptoms facet that do not interfere with work, instrumental activities of daily living, or work, family, or other close relationships. The Veteran has not asserted that he has subjective complaints associated with his residuals of TBI that interfere with his activities of daily living as well as his work and familial relationships. Rather, at most, in April 2013 his only subjective symptom was headaches which did not interfere with instrumental activities of daily living, work, family or other close relationships. The Board also notes that the Veteran is separately rated for his headaches. A higher level of severity of “1” is not warranted unless there is evidence of three or more subjective symptoms that mildly interfere with work, instrumental activities of daily living, or work, family, or other close relationships. There is no showing of three or more subjective symptoms during the pendency of the appeal. A level of severity of “0” has been assigned for the neurobehavioral effects facet, indicating that the examiners found no neurobehavioral impairment. Although the Veteran reports he aggressively argues with his wife at times, he has not asserted nor is it shown that he has neurobehavioral effects that interfere with his workplace or social interaction. A higher level of severity of “1” is not warranted unless there is a showing of one or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction or both but do not preclude them. There is no showing of such neurobehavioral effects during the pendency of the appeal. A level of severity of “0” has been assigned for the communication facet, indicating that the examiner found evidence that the Veteran is able to communicate by spoken and written language (expressive communication), and comprehend spoken and written language. A higher level of severity of “1” is not warranted unless there is comprehension or expression, or both, of either spoken language or written language that is only occasionally impaired, and that the veteran can communicate complex ideas. There is no finding of communication issues during the pendency of the appeal. Finally, for the entire period on appeal, the evidence does not indicate that the Veteran experienced a persistently altered state of consciousness, such as a vegetative state, minimally responsive state, or coma. Therefore, he does not meet a total disability rating due to his state of consciousness. The evidence does not show that a compensable rating for the Veteran’s TBI is warranted under Diagnostic Code 8045. Using the table to evaluate cognitive impairment, the Veteran’s residuals have not been rated as any more than at a level “0” impairment at any point during the appeal. Using the table to evaluate subjective symptoms, the Veteran’s TBI residuals have not been characterized as any more severe than a level “0.” An assigned value of “0” yields a noncompensable evaluation, and only one evaluation may be assigned for all of the applicable facets under 38 C.F.R. § 4.124a, Diagnostic Code 8045. Therefore, a compensable rating is not warranted, and the noncompensable evaluation currently assigned for the Veteran’s TBI is most appropriate. In so holding, the Board acknowledges the Veteran’s lay perceptions of TBI residuals including behavioral changes. However, the VA examiners have specialized knowledge of TBI residuals and have determined with their expertise that the Veteran does not manifest any significant TBI symptoms. The Board finds that the expert opinions hold more probative value than the Veteran’s lay perceptions. Entitlement to an initial compensable evaluation for posttraumatic headaches The Veteran appeals the denial of an initial compensable rating for his posttraumatic headaches. The Veteran’s disability has been evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8100. Under Diagnostic Code 8100, a 10 percent rating is in order where there is evidence of characteristic prostrating attacks due to migraines that average one every two months lasting over several months. A 30 percent rating is warranted for migraine headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months. A maximum 50 percent rating is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The term “productive of severe economic inadaptability” is not defined by VA regulations. The Court, however, has stated that this term is not synonymous with being completely unable to work and that the phrase “productive of” could be read to mean either “producing” or “capable of producing” economic inadaptability. See Pierce v. Principi, 18 Vet. App. 440, 446-47 (2004). During the April 2013 VA examination, the Veteran reported headaches in the forehead without warning which were throbbing and lasted from 4 to 5 hours to up to 3 to 4 days. He reported the headaches were intermittent and without a particular pattern. He reported severe headaches about every 5 to 7 months, and that he only had seven severe headaches since his fall. He reported that his headaches were infrequent, non-prostrating and did not interfere with his regular activities. He was found, however, to have prostrating attacks of non-migraine headache pain which occurred much less than once every 2 months. It was found that the Veteran’s headache condition did not affect his ability to work. It was noted that when he was working, the infrequent headaches he had did not impair his ability to work. The November 2016 VA examination disclosed an assessment of posttraumatic headaches. During this examination, the Veteran reported having two non-prostrating headaches which were 6/10 twice a week in 2016. He reported pain on both sides of the head, and pulsating or throbbing head pain. He denied non-headache symptoms associated with his headaches (including symptoms associated with an aura prior to headache pain). It was noted that he did not have any characteristic prostrating attacks of migraine/non-migraine headache pain. Neurological examination was normal. The Veteran’s headache condition was noted to impact his ability to work. During his October 2017 hearing, the Veteran described having headaches three to four time weekly which require him to lay in the bed for a while. He stated that the headaches last for an hour or two, and that they just come and go. While the Veteran has provided evidence regarding the frequency and duration of his headaches during this time, the next higher evaluation under Diagnostic Code 8100, however, requires characteristic prostrating attacks due to migraines that average one every two months lasting over several months. Neither the rating criteria nor the Court has defined the term “prostrating.” According to Webster’s New World Dictionary of American English, Third College Edition 1080 (1986), “prostration” is defined as “utter physical exhaustion or helplessness.” A very similar definition is found in Dorland’s Illustrated Medical Dictionary 1367 (28th ed. 1994), in which “prostration” is defined as “extreme exhaustion or powerlessness.” At most, the Veteran reported during his hearing that he has headaches occurring 3 to 4 times per week when he wakes up which requires him to stay in bed for an additional hour or so. He did not, however, describe “utter physical exhaustion or helplessness” or “extreme exhaustion or powerlessness” at this hearing and/or during any examination. Additionally, the VA medical examiners who interviewed the Veteran found that he did not describe prostrating attacks of headaches. Although the evidence shows that the Veteran has frequent headaches, the more probative evidence is against a showing of characteristic migraine like prostrating attacks. The Veteran has presented competent and credible evidence regarding the frequency and severity of his headaches. See Layno, 6 Vet. App. at 469. The evidence, however, does not show that his headaches are prostrating in nature as required for a compensable rating under Diagnostic Code 8100. Accordingly, a compensable initial rating for posttraumatic headaches is not warranted. REMAND Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. REASONS FOR REMAND The Veteran appeals the denial of service connection for a left knee and right knee disability. He claims that he developed problems with his left knee during service and that he injured his right knee in Thailand when he slipped and fell down a muddy hill during monsoon season. He also reported injury to his right knee from running. Service treatment records show that the Veteran complained of a sore left knee in July 1974. An impression was given of chondromalacia patella at that time. He reported right knee pain in May 1976. Old injury, giving way once was noted in the evaluation. In August 1977, the Veteran was treated for right knee pain following a basketball injury. During his April 1977 separation examination, he reported a history of “trick” or locked knee. During the January 2013 VA examination, the Veteran reported that he “blewout” his left knee playing basketball in 1987 and that he underwent reconstructive surgery. He reported pain in both knees on an intermittent basis. Left knee mild strain and right knee normal examination on diagnosis was diagnosed. Despite the subjective complaints, the VA examiner stated that there was no evidence to support a right knee diagnosis. Based upon a review of the record and examination, the VA examiner opined that the Veteran’s left knee condition was not caused by or a result of service. Before reaching this conclusion, he noted that by the Veteran’s statements, his left knee injury occurred 10 years after his discharge from service. The examiner further noted that the Veteran had an episode of knee pain in service for which chondromalacia patella of the left knee was shown in July 1974, and that on his separation examination in April 1977 he had no knee complaints and examination of the knee was normal. The Board notes, however, that the VA opinion is inadequate as it is based upon an inaccurate factual history. In this regard, the VA examiner noted that the Veteran had an episode of knee pain in service in July 1974. The record shows that he had more than a single complaint of knee pain in service. Furthermore, while the VA examiner also noted that the Veteran had no knee complaints at separation, during his separation examination the Veteran reported a history of “trick” or locked knee which is contrary to the VA examiner’s findings that the Veteran had no complaints at separation. In light of the inadequate VA opinion, the Board finds that another examination and opinion is warranted. With regard to the claim for service connection for a cervical spine disability, the Board also finds that further development is warranted. To that end, service treatment records show treatment for a head injury after a fall in September 1973. The Veteran complained of neck pain in April 1994 since an injury three to four months prior. In May 1994, it was noted that the Veteran was a social worker who had injured himself lifting a heavy bag of mail in February 1993. At that time, Dr. J stated that the Veteran had a history of a work-related neck injury and that his symptoms are most consistent with cervical sprain and myofascial pain. In April 1996, the Veteran complained of headaches which started at the parietal region and radiated to the neck. It was noted that his symptoms started in March 1996 after he tried to pick up a heavy object from a conveyor belt. During the March 2013 VA examination, the VA examiner noted that the Veteran’s had a history of head injury that occurred in service, and that he never had neck pain or shoulder pain. The VA examiner also noted that the Veteran had a history working in the post office, and that he was injured in the post office in 1992 and received Workman’s Compensation, time off and light duty. He stated that the Veteran also has a history of a car accident. In view of all these circumstances, he opined that the Veteran’s neck condition was not caused by or the result of the head injury which occurred during service. In an April 2013 VA examination, it was opined that the cervical disks did not appear to be due to the head injury as the Veteran did not complain of neck pain at the time and based on his history the herniated disk occurred in 1993 while working in the private sector. The Board notes, however, that during his October 2017 hearing the Veteran reported that his neck problems started in service. The Board also notes that the Veteran is service connected for headaches and the record shows a report of headaches which started at the parietal region and radiated to the neck. An opinion has not been obtained addressing the Veteran’s lay statements of an in-service onset and continuity of symptoms, and/or whether his cervical spine disability is related to his service connected headaches and/or shoulder disability. On remand, such an opinion should be obtained. The matters are REMANDED for the following action: 1. Associate with the claims folder updated private and VA treatment records. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of right and left knee disability. The examiner must opine whether any left and/or right knee disability that is diagnosed upon examination or in the record is at least as likely as not related to an in-service injury, event, or disease. In doing so, the examiner must consider: (1) service treatment records which show complaints of a sore left knee in July 1974 and finding of chondromalacia patella at that time, report of right knee pain in May 1976, the August 1977 treatment for right knee pain following a basketball injury and the April 1977 separation examination report of “trick” or locked knee, (2) the report of a left knee injury while playing basketball in 1987 and the resulting reconstructive surgery and (3) the Veteran’s report that he developed problems with his knees during service and that he has had continued problems since service. A complete rationale for any opinion should be provided. The examiner must not rely solely on the absence of a diagnosis or symptom in service as the basis for a negative opinion. It is also noted that the mere passage of time without treatment is not a sufficient basis for finding that no relationship between a current disability and service exists. Any opinion should be reconciled with the service treatment and personnel records, any post-service diagnoses, lay statements and testimony of the Veteran. If the lay evidence is rejected, an explanation must be provided. If an opinion cannot be made without resort to speculation, please state so and include an explanation for that conclusion. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his cervical spine disability. After examination and review of the record, the examiner must opine whether it is at least as likely as not, i.e., is there a 50/50 chance that the Veteran’s cervical spine disability had its onset in service or was caused by service; or whether it is at least as likely as not, i.e., is there a 50/50 chance that the Veteran’s cervical spine disability was caused and/or aggravated beyond the normal progress of the disorder by the service-connected headaches and/or shoulder disability. In doing so, the examiner must consider: (1) service treatment records which show a head injury after a fall in September 1973, (2) the Veteran’s post service work related injuries beginning in 1993, (3) the April 1996 complaint of headaches which started at the parietal region and radiated to the neck, and (4) the Veteran’s belief that his neck pain began at the same time as his shoulder pain documented in the service treatment records. A complete rationale for any opinion should be provided. The examiner must not rely solely on the absence of a diagnosis or symptom in service as the basis for a negative opinion. It is also noted that the mere passage of time without treatment is not a sufficient basis for finding that no relationship between a current disability and service exists. Any opinion should be reconciled with the service treatment and personnel records, any post-service diagnoses, lay statements and testimony of the Veteran. If the lay evidence is rejected, an explanation must be provided as to whether there is any medical reason to accept or reject the Veteran’s belief that a chronic neck disability started in service. If an opinion cannot be made without resort to speculation, please state so and include an explanation for that conclusion. 4. Upon completion of the above requested development and any additional development deemed appropriate, the AOJ should readjudicate the remanded issues. If any benefit sought on appeal remains denied, the appellant and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T.S. Willie