Citation Nr: 18148443 Decision Date: 11/07/18 Archive Date: 11/07/18 DOCKET NO. 14-24 549A DATE: November 7, 2018 ORDER Entitlement to service connection for a bilateral big toe disability is denied. Entitlement to service connection for a right upper extremity radiculopathy (claim as a right shoulder disability) secondary to service-connected neck disability is granted. For the rating period prior to January 6, 2014, an initial 10 percent disability rating, but not higher, for a left (minor) shoulder disability is granted. For the entire rating period on appeal, a disability rating in excess of 10 percent for a left (minor) shoulder disability is denied. From the beginning of the claim, a 30 percent disability rating for a migraine headache disability is granted. For the entire rating period on appeal, a disability rating in excess of 30 percent for a migraine headache disability is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, including depression and anxiety, is remanded. Entitlement to a total rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. The Veteran does not have a current bilateral big toe disability that is separate from her already service-connected bilateral hallux valgus and bilateral hammertoes. 2. Resolving all doubt in the Veteran’s favor, the lay and medical evidence is at least in equipoise as to whether she has a current diagnosis of right upper extremity radiculopathy that is related to her service-connected neck disability. 3. For the entire initial rating period on appeal, the Veteran’s left shoulder disability has not resulted in limitation of motion of the right arm to midway between side and shoulder level, malunion of the humerus with moderate or marked deformity, or recurrent dislocation of a scapulohumeral joint with frequent episodes of guarding, fibrous union, nonunion, or loss of head of the humerus. 4. For the entire initial rating period on appeal, the Veteran has had characteristic prostrating attacks of migraine headaches occurring on an average once a month over last several months, but the headache attacks are not shown to be completely prostrating and prolonged and productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria to establish service connection for a bilateral big toe disability aside from already service-connected toe/foot disabilities, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303 (2017); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). 2. The criteria to establish service connection for cervical radiculopathy of the right upper extremity (claimed as right shoulder disability) have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012), 38 C.F.R. §§ 3.102, 3.310 (2017). 3. For the period on appeal prior to January 6, 2014, the criteria for a rating of 10 percent, but not higher, for a left shoulder disability have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5201 (2017). 4. For the entire rating period on appeal, the criteria for a rating in excess of 10 percent for a left shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5201 (2017). 5. From the beginning of the claim, the criteria for a rating of 30 percent for migraine headache disability have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.21, 4.124a, Diagnostic Code 8100 (2017). 6. For the entire rating period on appeal, the criteria for a rating in excess of 30 percent, for migraine headache disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.21, 4.124a, Diagnostic Code 8100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1987 to July 1987, from April 3, 1998 to April 30, 1998, and from October 1998 to August 2004. In February 2017, the Board remanded the case for further development, to include obtaining outstanding VA treatment records, and providing the Veteran with new VA examinations. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may alternatively be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a) (2017). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.310(b) (2017); Allen v. Brown, 8 Vet. App. 374 (1995). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012). A Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Id. at 1287 (quoting 38 U.S.C. § 5107 (b)). Bilateral Big Toe The Veteran asserts that she has a bilateral big toe disorder that is related to her military service. Specifically, she states that the disorder developed as a result of wearing combat boots during service. The record, however, does not reveal that the Veteran meets the threshold element of any service connection claim, namely a current disability. The current record fails to show a diagnosis of a bilateral toe disability that is separate from her already service-connected bilateral hallux valgus and bilateral hammertoes. Subsequent to the Board’s February 2017 remand, the Veteran underwent a VA “foot conditions” examination in July 2017, during which the examiner confirmed diagnoses of the already service-connected bilateral hallux valgus and hammertoes, and found no other foot or toe disorder. Specifically, the examiner stated that there is no big toe disorder separate from the bilateral hallux valgus or bilateral hammertoes, and explained that there is no secondary disability as a result of her hallux valgus. The examiner further explained that the Veteran’s hammertoes were surgically repaired and do not cause any secondary disability. The examiner added that the only disability is bilateral enlargement of the 1st metatarsal phalangeal joint, namely, hallux valgus, and no other deformity. Range of motion of the 1st MTP joint was within normal limits, bilaterally, there was no pain to palpation of either left or right 1st MTP joint, and the Veteran did not have abnormal gait or difficulty walking. The laws authorizing Veterans’ benefits provide benefits only where there is competent evidence of a current disability. In the absence of proof of a current disability, there is no valid claim of service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board concludes that the Veteran has not presented competent evidence showing that she has a current bilateral big toe disability that is not already compensated for. See 38 U.S.C. § 5107 (a) (“[A] claimant has the responsibility to present and support a claim for benefits.”); Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009) (holding that it is the claimant’s general evidentiary burden to establish all elements of the claim). In analyzing this claim, the Board recognizes that the Veteran is competent to report her observable symptoms and signs of a bilateral big toe condition; however, her lay statements are not competent to establish a medical diagnosis, as she is not shown to possess the requisite medical training. Moreover, the record reflects that her complaints of big toe pain and any other toe symptoms are attributed to her already service-connected bilateral hallux valgus and bilateral hammertoes. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). For the reasons and bases discussed above, the preponderance of the evidence is against the Veteran’s claim, and it therefore must be denied. See 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017). Right Shoulder Neurological Complaints The Veteran asserts that she has a right shoulder disability that is related to service. Alternatively, the record raises the question of whether it is related to her service-connected neck disability. In the February 2017 remand, the Board requested a new examination to determine whether the Veteran has a current right shoulder disability because there was conflicting medial evidence. After a careful review of the evidence, both lay and medical, the Board finds that the evidence is at least in equipoise as to whether the Veteran has a current diagnosis of upper right extremity radiculopathy secondary to her service-connected neck disability. Turning to the evidence, a VA general medical examination dated in September 2004 shows complaints of cervical spine pain with radiation to the right upper trapezius. VA treatment records dated in May 2005 show complaints of right-sided neck pain radiating down into the upper arm without numbness or tingling. Additional VA treatment records dated in July 2007 indicate that the Veteran reported neck pain radiating down her right hand without weakness, and indicated that she had a history of cervical stenosis. An April 2010 VA examination report indicates that the Veteran reported bilateral shoulder pain, which she attributed to her neck disability. During the examination, it was noted that there was guarding of movement of the right shoulder, and upon physical examination, range of motion of the right shoulder was normal. Reflex examination was normal with no signs of pathologic reflexes, and x-rays of the right shoulder were within normal limits. The examiner concluded that there was no diagnosis because there was no pathology to render a diagnosis. Subsequent VA treatment records dated in January 2011 indicate that the Veteran reported neck and right shoulder pain. The medical professional noted “positive spasm right trapezius muscle.” Thereafter, treatment notes dated in June 2011 indicate that the Veteran continued to have neck pain with radiation along the right trapezius. Private treatment records dated in January 2011 show a diagnosis of degenerative cervical multi-disc disease with right upper extremity radiculopathy. Additional private treatment records dated in February 2011 contain a MRI of the cervical spine and not a history of radiculopathy for eleven-years. Additional VA treatment records dated in June 2013 show complains of neck pain with bilateral shoulder numbness. During a January 2014 VA examination for her neck and shoulders, no diagnosis was rendered for a right shoulder disability, and there was no indication of radiculopathy stemming from her neck disability. Though, VA treatment records during the same time contain an orthopedic surgery spine note showing reports of right-sided neck pain radiating to the right shoulder with numbness in the right middle finger. Additional VA treatment records dated in November 2015 show reports of neck pain and spasms in the right shoulder. Thereafter, treatment notes dated in June 2016 indicate some tenderness to palpation of the right shoulder. Subsequent to the Board’s remand, a November 2017 VA examiner concluded that the shoulder was found to be clinically normal, and x-rays were ordered but were not done. The examiner concluded that the shoulder was declared to be normal, and the examiner did not explore medically unexplained chronic multi-symptom illnesses. In a subsequent March 2018 addendum, the examiner stated that myofascial shoulder pain is a disease with a clear and specific etiology and diagnosis and was less likely related to a specific exposure the Veteran had during her service in Southwest Asia. It was again noted that x-rays were not done, but x-rays in 2010 and 2014 were normal. Here, the Board assigns little probative weight to the November 2017 and March 2018 opinions and therefore finds them inadequate to decide the claim. First, the examiner failed to discuss the competent lay reports and history of radiating pain from the neck to the right shoulder. Second, despite acknowledging a diagnosis of myofascial shoulder pain, the examiner concluded that the shoulder was completely normal. Nonetheless, after a careful review of the evidence, the Board finds that the evidence is at least in equipoise as to whether the Veteran competent lay reports of right shoulder pain are related to the radiating pain from her service-connected neck to her right shoulder. Notably, private treatment records and a 2011 MRI confirm a diagnosis of bilateral upper extremity radiculopathy. Moreover, the Board finds that the Veteran continuously reported functional limitation of her bilateral shoulder, such as the inability to wash her hair. In this regard, the Board recognizes that a recent Court decision in Saunders v. Wilkie, No. 2017-1466, 2018 U.S. App. LEXIS 8467 (Fed. Cir. Apr. 3, 2018) held that pain which causes functional limitation is appropriately considered a disability. Specifically, the Court indicated that pain resulting in functional impairment constitutes a disability as contemplated in 38 U.S.C. § 1110, even in the absence of a presently-diagnosed condition. Here, even if it is concluded that there is no objective evidence of radiculopathy per diagnostic study, the Veteran’s competent reports, as well as the evidence of functional limitation, is sufficient to establish the existence of a current disability. In addition, the Veteran’s already service-connected shoulder disability was granted as secondary to her neck disability, and the evidence here suggests that the only reason the right shoulder was not service-connected was due to the examiners’ opinions that there was no current disability. Therefore, resolving all doubt in the Veteran’s favor, service connection for right upper extremity radiculopathy, as secondary to service-connected neck disability, is granted. Increased Rating Disability evaluations are determined by comparing a veteran’s present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran’s condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Where the veteran is appealing the rating for an already established service-connected condition, her present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Left Shoulder – Rating Criteria The Veteran’s left (minor) shoulder disability is rated pursuant to DC 5010. However, the Board considers additional DCs that are relevant in rating the Veteran’s disability. Under DC 5003, degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5003. DC 5010 provides that traumatic arthritis is rated as for degenerative arthritis. 38 C.F.R. § 4.71a, DC 5010. DC 5024 provides that tenosynovitis is to be rated based on limitation of motion of the affected parts, as degenerative arthritis (except in cases involving gout). 38 C.F.R. § 4.71, DC 5024. Under DC 5201, limitation of motion of the major or minor extremity at the shoulder level warrants a 20 percent rating. Limitation of motion midway between the side and shoulder level warrants a 30 percent rating for the major extremity and 20 percent rating for the minor extremity. Where motion is limited to 25 degrees from the side warrants a 40 percent rating for the major extremity and 30 percent rating for the minor extremity. 38 C.F.R. § 4.71a, DC 5201. Normal range of motion of the shoulder is flexion from 0 to 180 degrees, abduction from 0 to 180 degrees, and internal and external rotation from 0 to 90 degrees. 38 C.F.R. § 4.71a, Plate I. When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. 38 C.F.R. § 4.45. Left Shoulder – Rating Analysis Prior to January 6, 2014 During this initial period on appeal, beginning on February 4, 2010, the Veteran’s left (minor) shoulder disability is assigned a noncompensable rating. Turning to the evidence, in April 2010, the Veteran underwent a VA examination for her shoulders. She reported that her condition started in 1999, which she attributed to her neck disability. The examiner noted that she reported symptoms of weakness; stiffness; swelling; lack of endurance; locking; fatigability; tenderness; and, pain. She denied any flare-ups; heat; redness; giving way; deformity; drainage; effusion; subluxation; or, dislocation. She further noted that in the previous 12-months her condition did not result in any incapacitation. In terms of functional impairment, the Veteran reported that she was unable to lift her arms, could not wash her hair, and could not sit in the same position for a long time. Upon physical examination, there was guarding of movement, but without signs of edema; instability; abnormal movement; effusion; weakness; tenderness; redness; heat; deformity; or, malalignment and drainage. There was also no evidence of subluxation or ankylosis. Range of motion of the left shoulder was within normal limits for flexion, abduction, external and internal rotation (to 180 and 90 degrees, respectively). The Veteran was able to do repetitive use resting, which resulted in no additional loss of range of motion. X-rays of the left shoulder revealed evidence of degenerative arthritic changes. The examiner rendered a diagnosis of degenerative arthritis of the left shoulder joints showed by objective x-ray findings and subjective factors including pain. Subsequent private and VA treatment records show continuous complaints of chronic shoulder pain. Based on the foregoing, after review of the lay and medical evidence of record, the Board finds that an initial rating of 10 percent rating, but no higher, for the left shoulder disability have been met for the entire period on appeal. Throughout the period on appeal, the Veteran has reported experiencing pain on left shoulder motion and the objective evidence confirmed findings of arthritis. Therefore, the minimum compensable rating, 10 percent, is warranted for the entire period on appeal based on evidence of arthritis and painful motion. Nevertheless, a rating in excess of 10 percent for the left shoulder disability is not warranted. Throughout the entire period on appeal, the range of motion of the left shoulder was normal, and she denied any flare-ups. Even taking into consideration her reports of painful motion, such does not rise to the level of limitation of motion of the major extremity at the shoulder level. There are no other severe symptoms reported to suggest that the Veteran’s left shoulder warrant a rating in excess of 10 percent. In considering these rating criteria, the Board has considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, here, even when considering the Veteran’s reports of flare-ups, the Veteran had normal flexion and abduction to 180 degrees, and her reports of pain, to include flare-ups, does not more nearly approximate limitation of motion of the major extremity at the shoulder level. As such, a rating of 10 percent, but no higher, for left shoulder disability is warranted. From January 6, 2014, Forward During this period on appeal, the Veteran’s left shoulder disability is rated as 10 percent disabling due to painful motion with x-rays showing arthritis. In January 2014, the Veteran underwent a VA examination to determine the current severity of her left shoulder disability. The examiner confirmed a diagnosis of degenerative arthritis. The Veteran reported flare-ups, and their impact on functionality of the shoulder was described as “numbness and weakness.” Upon physical examination, range of motion of the left shoulder revealed flexion and abduction to 110 degrees with objective evidence of pain at end point. After repetitive-use testing of three repetitions, there was no additional limitation in range of motion. The examiner noted that the Veteran had functional loss/functional impairment of the left shoulder identified by less movement than normal and pain on movement. There was no evidence of localized tenderness or pain on palpation of the joint, and no guarding. Muscle strength testing was normal and there was no evidence of ankylosis. There was no evidence of mechanical symptoms or recurrent dislocation. The examiner further noted that both the Veteran’s left shoulder external and internal rotation ended at 65 degrees with objective evidence of pain at 65 degrees. There were contributing factors of pain, weakness, fatigability and/or incoordination and there was additional limitation of functional ability of the shoulder joint during flare-ups or repeated use over time. The examiner estimated that the degree of range of motion loss during pain on use or flare-ups was approximately 10 degrees on flexion, abduction, internal and external rotation. The same was noted regarding repeated use over time. Subsequent VA treatment records continue to show complaints of left shoulder pain and spasms. In September 2016, it was noted that bilateral upper extremity range of motion revealed flexion to 100 degrees, abduction to 90 degrees, extension to 20 degrees, and external and internal rotation within functional/normal limits. The Veteran underwent an additional VA examination in July 2017, at which time the examiner indicated that she had a normal bilateral shoulder examination. The Veteran denied flare-ups or functional loss/impairment. Upon physical examination, range of motion of the left shoulder was all normal with no objective evidence of pain. There was no additional functional loss or range of motion after repetitive use-testing with three repetitions. There was no evidence of pain with weight bearing, no objective evidence of localized tenderness or pain to palpation, and no evidence of crepitus. The examiner noted that the Veteran was not examined immediately after repetitive use over time, but stated that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. Muscle strength testing was normal throughout, with no muscle reduction or muscle atrophy. There was no ankylosis, instability, or dislocation of the shoulder. The examiner further noted that there was no evidence of pain on passive motion testing or on use of the joint in non-weight bearing. It was additionally noted that the left shoulder examination was normal, and the pain at the top of the shoulder and between the shoulder blades was pain from her neck. Lastly, the examiner noted that x-rays were ordered, but were not done. Subsequent VA treatment records show that she continued to complain of left shoulder pain, which at times was described as 10 out of 10 in intensity. After review of the lay and medical evidence of record, the Board finds that a rating in excess of 10 percent is also not warranted from January 6, 2014, forward. As discussed above, the competent medical evidence does not support finding that the Veteran’s limitation of motion of the left shoulder approximate limitation of motion of the minor extremity at the shoulder level (90 degrees) which warrants a 20 percent rating. Furthermore, subsequent records, to include the Veteran’s July 2017 examination show that the Veteran denied flare-ups, and range of motion was normal. Although an isolated treatment note dated in September 2016 indicated that abduction was to 90 degrees, this note was not specific to the left shoulder, but rather noted the bilateral upper extremities. Furthermore, the subsequent July 2017 VA examination specifically noted normal range of motion, which is more consistent with the evidence throughout the pendency of the appeal. Accordingly, a rating in excess of 10 percent is not warranted during any period of the appeal. In considering these rating criteria, the Board has considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, here, even when considering the Veteran’s reports of flare-ups in 2014, the examiner specifically indicated that such would result in an additional 10 degrees loss, namely, flexion and abduction to 100 degrees, which still excess 90 degrees, and does not more nearly approximate limitation of motion of the minor extremity at the shoulder level. As such, an increased rating for the Veteran’s service-connected left shoulder disability is not warranted on the basis of functional loss due to pain or weakness. Migraine Headaches – Rating Criteria The Veteran’s migraine headache disability is rated pursuant to DC 8100. Under such code, migraine headaches with less frequent attacks than the criteria for a 10 percent rating are rated as non-compensable. Migraine headaches with characteristic prostrating attacks averaging one in two months over the last several months are rated 10 percent disabling. Migraine headaches with characteristic prostrating attacks occurring on an average once a month over last several months are rated 30 percent disabling. Migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability are rated 50 percent disabling. The term “prostrating attack” is not defined in regulation or case law, but can be defined as extreme exhaustion or powerlessness. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999) (quoting Diagnostic Code 8100 verbatim but not specifically addressing the definition of a prostrating attack); DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1531 (32d ed. 2012). Further, “severe economic inadaptability” is also not defined in VA law. See Pierce v. Principi, 18 Vet. App. 440, 446 (2004). In addition, the Court has held that nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating. Id. It was explained by the Court that if “economic inadaptability” were read to import unemployability, the appellant, should he or she meet the economic-inadaptability criterion, would then be eligible for a TDIU rather than just a 50 percent rating. Id. citing 38 C.F.R. § 4.16. The Court discussed the notion that consideration must also be given as to whether the disability was capable of producing severe economic inadaptability, regardless of whether the condition was actually causing such inadaptability. See Pierce, 18 Vet. App. at 446. In this regard, VA conceded that the words “productive of” could be read to mean either “producing” or “capable of producing.” Id. at 446-447. The Board may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). Prior to March 2, 2011, the RO rated the Veteran’s migraine headache disability as 10 percent disabling. From March 2, 2011, forward, the RO rated the Veteran’s migraine headache disability as 30 percent disabling. The Veteran asserts that her headaches are worse than what is contemplated by the assigned ratings. Turning to the evidence, VA treatment records dated in September 2007 show that the Veteran reported nearly daily headaches at the center of her head, throbbing with associated nausea and photophobia. It further noted that she was taking Zomig, Excedrin, and Gabapentin (the medical professional noted that Gabapentin did not help her and she was taking Excedrin daily). In correspondence received by VA in October 2007, the Veteran indicated that the pain increased in frequency and severity, indicating that she had headaches almost every day, and some days she could not get out of bed. She further noted that she went to her doctor twice during her migraine episode and “gotten the shot,” because the VA was too far for her. In support of her claim, the Veteran also submitted a “buddy statement” from her friend, who indicated, “I have been present on numerous occasions (too many too count) when [the Veteran] had migraine headaches and was unable to get out of bed or function, sometimes she can’t get up for a couple of days at a time.” Subsequent VA treatment records dated in November 2008 indicate that the Veteran reported headaches that began two days earlier and have been intermittent since that time. She indicated that her headaches were alleviated by sleeping in a dark room and taking Excedrin provided minimal relief. Her pain was described as 9 out of 10 in severity. A few weeks later, the Veteran complained of one-month history of increased frequency of migraine headaches. She denied increased intensity of headaches. She further reported that prior to this month, she had a migraine headache once per month. The headaches were increased by activity, and were described as throbbing pain location behind the eyes and associated with photophobia and phonophobia. She indicated that at the time of this appointment her headaches were daily. After she was prescribed Topamax, in December 2008, the Veteran reported that she went three weeks without a headache as opposed to weekly migraines prior. Additional VA treatment notes dated in February 2010 show that the Veteran called to report a severe headache she experienced overnight with no relief by medication. VA treatment records dated in December 2010 indicate that the Veteran reported to the emergency room due to severe headaches and nausea that lasted all day. She continued to report headaches two days later. In January 2011, the Veteran underwent a VA compensation examination to determine the current severity of her headaches. She described her headaches as pain in the forehead and eyes. She was not sure what triggered her headaches, and indicated that when they occur, she had to stay in bed and was unable to do anything. The level of severity was described as 7 out of 10, and she noted that she experienced headaches on an average of once a day, which lasted for about one hour. Additional symptoms associated with the headaches were nausea and weakness. The examiner noted that her reported overall functional impairment was “unable to function at all.” The examiner concluded that there was no change in the diagnosis of migraine headache, and at the time the Veteran’s disability was quiescent. The examiner further noted that subjective factors included headache pain, and objective factors revealed normal examination, which did not require the use of migraine medication. The Veteran submitted a private medical evaluation on March 2, 2011, authored by an internal medicine specialist who is also a senior disability analyst and diplomate who is certified by the American Board of Disability Analysts. The disability analyst indicated that he was contacted by the Veteran’s attorney at the time, and after an extensive and objective review of the claims file, confirmed a diagnosis of headaches, probably migraine in type. It was noted that the headaches were associated with her neck pain and were described as throbbing, mostly on the left side, and associated with nausea, phobophobia, and phonophobia. She claimed constant pain described as 6 out of 10 in severity in the morning, 8 out of 10 in severity in the evening, and flare-ups described as 10 out of 10 in severity that occurred recently for two ot three months every couple of nights, and were incapacitating. The disability analyst disagreed with the assigned rating for the Veteran’s headaches, indicating that despite the Veteran’s use of medication, she continued to have headaches and should be rated as 30 percent disabling (at the time of the report her headaches were still rated as 10 percent disabling). Subsequent VA treatment records show that the Veteran continued to complain of daily moderate to severe migraine headaches, for which she was prescribed numerous medications. In February 2012, she reported headaches that lasted for three-days and were not relieved by medication, and in March 2012, she reported to the emergency room again and received an injection, which was noted to help with the migraines. In January 2014, the Veteran underwent an additional VA compensation examination to determine the current severity of her headaches, where a diagnosis of migraine headaches, including migraine variants, was confirmed. The Veteran indicated that her current symptoms at the time were “intermittent migraine.” The examiner noted that treatment included taking medication, and listed “Advil” as the form of treatment. Her headache pain was described as pulsating or throbbing on both sides of the head. Additional symptoms associated with the headaches included nausea, sensitivity to light and sound, and changes in vision. The duration of a typical head pain was one to two days. The examiner noted that the Veteran had characteristic prostrating attacks more frequently than once per month that were very frequent prostrating and prolonged attacks of migraine headache pain. The examiner concluded that the Veteran’s headache condition did not impact her ability to work. Thereafter, in December 2015, the Veteran underwent an additional VA examination to determine the current severity of her headaches. The examiner indicated that treatment included taking medication, to include “QHS” and Flexeril 10 QHS. Her pain was noted to be on both sides of the head and associated symptoms included nausea and sensitivity to light and sound. The duration of a typical headache was less than one-day. The examiner noted that the headaches had characteristic prostrating attacks more frequently than once per month and very frequent prostrating and prolonged attacks of migraine headache pain. The examiner concluded that the Veteran’s headaches impacted her ability to work, which was described as “migraine headaches, poor concentration, sensitivity to bright light and loud noise.” Subsequent VA treatment records continue to show complaints of migraine headaches, which were treated with medication. On review, the Board resolves any reasonable doubt in the Veteran’s favor, and finds that the criteria for a 30 percent rating have been met since the beginning of the claim based on evidence of her headaches producing characteristic prostrating attacks occurring on average once a month over last several months. However, a higher rating of 50 percent is not warranted at any time during the appeal period. Although the Veteran’s headaches are reported to be completely prostrating at times, the evidence does not show that the completely prostrating attacks are very frequent in nature. Moreover, while the evidence shows that headache pain and sensitivity to light and sound impacts the Veteran’s work in that she has poor concentration, it does not result in her being severely incapable of working. Indeed, the Veteran does not report, and the medical evidence does not show, that she has missed a severe amount of time at work because of her migraine headache pain. In fact, at no point has she referenced any work problems due to headache pain that rise to the level of severe economic incapability. Additionally, even the private disability analyst concluded that her headaches more nearly approximate the criteria for a 30 percent disability rating with no indication of any criteria meeting the next-higher rating. For these reasons, the Board concludes that the 30 percent rating is warranted from the beginning of the claim, but a higher rating is not warranted. Finally, the Board notes that neither the Veteran nor her attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND A remand is necessary to provide the Veteran with an adequate VA examination regarding her claim for service connection for an acquired psychiatric disorder. In the February 2017 remand, the Board asked that the examiner (a) identify any currently diagnosed psychiatric disorder other than the already service-connected insomnia (b) opine whether any bereavement disorder or adjustment disorder that the Veteran has or has had since she filed her claim in March 2011 was related to service, and (c) opine whether any currently diagnosed psychiatric disorder since March 2011 was caused or aggravated by her service-connected disabilities. The Veteran underwent a VA mental health examination in July 2017, at which time the examiner rendered diagnoses of persistent depressive disorder with anxious distress with intermittent major depressive episodes and insomnia disorder. The examiner opined that her depressive disorder was less likely than not related to her military service, indicating that her service treatment records were silent for any evidence of mental health related concerns, complaints, evaluations, disorders, or treatment. Instead, the examiner indicated that the evidence indicates that her son died in 2012, and the previously diagnosed bereavement disorder was deemed to be less likely than not related to service, but rather to this tragic event. The examiner explained that she no longer has a diagnosis of bereavement because such symptoms do not persist for longer than twelve-months, but noted that perhaps the fact that the Veteran did not mention her son during the examination was an indication of a more complex bereavement process. The examiner then stated that the current diagnosis was separate and distinct from bereavement. The examiner next opined that the chronic adjustment disorder was not related to service for the same reasons indicated above. Regarding secondary service connection, the examiner opined that the depressive disorder was not caused or aggravated by any of her service-connected disabilities because she did not express any distress related to these conditions, nor do clinical records reflect such association. Lastly, the Board notes that the examiner indicated insomnia is usually a symptom of depression, but in this Veteran’s case, her insomnia is severe enough to warrant a separate rating. Nevertheless, a careful review of the record suggests that the examiner’s review of the record was cursory at best. For example, an initial mental health evaluation dated in September 2012 show that the Veteran stated that “getting out of the military was a significant source of stress,” and noted “I was so used to being in the military.” The mental health professional diagnosed anxiety disorder, NOS, depressive disorder, NOS, and under Axis III noted “see medical history.” Additional treatment records at the same time show that the Veteran reported “feeling depressed occasionally because of chronic pain in her neck,” and that “anxiety in closed spaces started after she had an MRI following her accident” (which led to her service-connected neck and bilateral shoulder disabilities). In addition, the record is replete with evidence showing reports of depressed mood due to lack of sleep. Lastly, treatment records show reports of nightmares and panic attacks, and specifically in July 2016 indicate that the Veteran reported waking up from nightmares of going over a cliff in a speeding car (which could be related to her accident in service, but this possible relationship was not explored by the examiner). This evidence is limited to a few examples; however, the record is replete with additional evidence of potential relationship between the Veteran’s diagnosed psychiatric disabilities and service and or service-connected disabilities. Accordingly, an adequate VA mental health examination is necessary prior to making a decision on the merits. In addition, in light of the above, the issue of a TDIU is inextricably intertwined with the issue being remanded, and the Board’s decision herein, and adjudication of TDIU must be deferred pending the proposed development. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). The matters are REMANDED for the following action: 1. Ensure that all outstanding VA treatment records since August 2018 SSOC are associated with the claims file. 2. Then, provide the Veteran with a VA mental health examination to determine the nature and etiology of any currently diagnosed mental health disorder aside from her already service-connected insomnia disorder. Any necessary tests or studies must be conducted and all clinical findings should be reported in detail and correlated to a specific diagnosis. The claims file and a copy of this remand will be made available to the examiner. The examiner is asked to: (a) Elicit from the Veteran the history and onset of her psychiatric symptoms. (b) Identify all currently diagnosed psychiatric disorders since March 2011, to include depression and anxiety. Specifically, the examiner’s attention is called to previous diagnoses of depressive disorder, NOS, and anxiety disorder, NOS. If any of the previously diagnosed psychiatric disorders since March 2011 have been resolved, the examiner is asked to explain any discrepancies, and or explain why they no longer show any pathology. (c) Provide an opinion as to whether it is more likely than not (50 percent or more) that any current psychiatric disorder is related to the Veteran’s active duty service. In doing so, please address her nightmares of going over a cliff in a speeding car, and or any other lay assertions provided during the examination. (d) Provide an opinion as to whether it is more likely than not (50 percent or more) that any current psychiatric disorder was caused or aggravated by any of her service-connected disabilities. In doing so, please address her competent lay reports of feeling depressed because of chronic pain in her neck, having anxiety in closed spaces started after she had an MRI following her accident, and reports of depressed mood due to lack of sleep. The examiner should provide a complete rationale for all opinions on direct, causation, AND aggravation bases. (Continued on the next page)   3. Then, readjudicate the remanded claim on appeal, to include entitlement to a TDIU. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Yaffe, Associate Counsel