Citation Nr: 18153415 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 16-42 103 DATE: November 27, 2018 ORDER Entitlement to service connection for a left ankle condition is denied. Entitlement to a rating in excess of 20 percent for a low back disorder is denied. Entitlement to an effective date prior to August 13, 2014 for the grant of service connection for tinnitus is denied. Entitlement to an effective date prior to June 4, 2013 for the grant of service connection for an acquired psychiatric disorder, to include depression and an insomnia disorder, is denied. Entitlement to an effective date prior to August 13, 2014 for the grant of service connection for a headache condition is denied. REMANDED Entitlement to service connection for a cervical spine condition is remanded. Entitlement to service connection for residuals of a traumatic brain injury is remanded. Entitlement to a rating in excess of 70 percent for an acquired psychiatric disorder is remanded. Entitlement to a rating in excess of 50 percent for a headache condition is denied. Entitlement to an effective date prior to August 13, 2014 for the grant of service connection for a low back disorder is remanded. Entitlement to a total disability rating on the basis of individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the competent medical evidence is against a finding that the Veteran’s diagnosed left ankle condition is a chronic condition that was incurred in service or is otherwise attributable to the Veteran’s active service or any incident of service, to include an in-service left ankle sprain. 2. For the entire period of the appeal, the Veteran’s low back disorder was productive of forward flexion of the thoracolumbar spine of 40 degrees and a combined range of motion of the thoracolumbar spine of 115 degrees; the condition did not require doctor-prescribed bed rest, and forward flexion did not decrease to 30 degrees or below after repetitive use. 3. The Veteran’s first communication indicating that he was seeking service connection for tinnitus was received on August 13, 2014; there is nothing in the record received prior to that date which could be construed as an informal claim seeking this benefit. 4. The Veteran’s first communication indicating that he was seeking service connection for an acquired psychiatric disorder was received on June 4, 2013; there is nothing in the record received prior to that date which could be construed as an informal claim seeking this benefit. 5. The Veteran’s first communication indicating that he was seeking service connection for a headache condition was received on August 13, 2014; there is nothing in the record received prior to that date which could be construed as an informal claim seeking this benefit. CONCLUSIONS OF LAW 1. The criteria for service connection for a left ankle condition have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 2. The criteria for entitlement to an initial rating in excess of 20 percent for a low back disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5242. 3. The criteria for an effective date earlier than August 13, 2014 for the grant of service connection for tinnitus have not been met. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.155(a), 3.303, 3.400. 4. The criteria for an effective date earlier than June 4, 2013 for the grant of service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.155(a), 3.303, 3.400. 5. The criteria for an effective date earlier than August 13, 2014 for the grant of service connection for a headache condition have not been met. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.155(a), 3.303, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1983 to May 1987. In view of the facts found, and to provide broader consideration on appeal, the Board has recharacterized the claim of service connection for an unspecified depressive disorder (claimed as a psychiatric condition manifested by impaired sleep) as one for an acquired psychiatric disorder, to include depression and an insomnia disorder. The Board notes also that neither the Veteran nor his representative has raised any other issues, nor have any issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Entitlement to service connection for a left ankle condition The Veteran contends that his currently diagnosed left ankle condition is attributable to a left ankle sprain he suffered in service. The question before the Board is whether there is a nexus between the Veteran’s currently diagnosed left ankle condition and an in-service injury, event, or disease. The Board concludes that, while the Veteran has a diagnosed left ankle lateral collateral ligament sprain, the preponderance of the evidence weighs against finding that the condition began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). A review of the Veteran’s service medical records shows that he twisted his left ankle in March 1984 and sought treatment for swelling and pain. The impression was a light ankle sprain, and the only recorded treatment was wrapping the ankle in an ace bandage. No subsequent records show any further treatment for a left ankle sprain. The Veteran was not evaluated as having any lower extremity abnormalities on his January 1987 discharge examination, and did not report experiencing left ankle pain on the corresponding January 1987 Report of Medical History. The Veteran was afforded a VA examination in January 2015 to evaluate the nature and etiology of his left ankle condition. According to him, his left ankle regularly collapsed, causing him to trip and fall about once or twice a month. He reported that he injured his left ankle in service in 1984, and that the only treatment he received while in service was to have the ankle wrapped the day that he sought treatment and to take pain medication. After an in-person examination, the diagnosis was a left ankle lateral collateral ligament strain, with a date of onset on January 15, 2015. The examiner then opined that it was less likely than not that the left ankle condition was attributable to the documented in-service left ankle sprain and/or any other in-service injury or event. In support thereof, the examiner noted that there was no evidence of further treatment for a left ankle condition after the initial treatment in March 1984. Moreover, no left ankle condition was recorded on the discharge examination, and the Veteran did not report experiencing symptoms of a left ankle condition on the corresponding Report of Medical History. Available VA medical records do not reflect that the Veteran has specifically sought treatment for any symptoms of a left ankle sprain, although he has been treated for left lower extremity neurological issues as well as pain throughout his body attributed to fibromyalgia. A left ankle condition is not recognized as one of the Veteran’s current medical issues in the VA medical system records. While the Veteran is competent to report having experienced symptoms of a left ankle condition and when they began, he is not competent to provide a diagnosis in this case or determine that any such symptoms were manifestations of a left ankle condition that has persisted since service or is otherwise attributable to service, in the absence of medical training and credentials. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Ultimately, although there is evidence that the Veteran has a left ankle condition, it was first diagnosed in January 2015, over 30 years after the isolated complaint of a left ankle sprain in service. He has not submitted any objective medical evidence in support of his claim, and the available VA medical records do not reflect that he even currently receives treatment for a left ankle condition. The January 2015 VA opinion, by comparison, is highly probative of the issue at hand, as the examiner reviewed the entire record and referred to the Veteran’s documented medical history in support of their determination that it was less likely than not that the left ankle condition was incurred in service or was otherwise attributable to service. Sklar v. Brown, 5 Vet. App. 140 (1993). The preponderance of the evidence therefore is against a determination that the left ankle condition was incurred in service or is otherwise attributable to service. Accordingly, the Board finds that no medical nexus exists between the Veteran’s left ankle condition and an in-service injury, event or disease. 38 U.S.C. § 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). As the preponderance of the evidence is against the Veteran’s claim of service connection for a left ankle condition, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b). Entitlement to an increased initial rating for a low back disorder. The Veteran is service connected for a low back disorder, characterized as a lumbosacral strain with intervertebral disc syndrome (IVDS). The condition is rated as 20 percent disabling, and he seeks an increased rating for the entire period of the appeal. Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, multiple (“staged”) ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In determining the appropriate rating for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Factors of joint disability include increased or limited motion, weakened movement, excess fatigability, incoordination, and painful movement, including during flare-ups and after repeated use. DeLuca v. Brown, 8 Vet. App. 202, 206-08 (1995); 38 C.F.R. § 4.45. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. Where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. However, subjective pain in and of itself will not establish a current disability. Consideration should be given to the impact, or lack thereof, from pain, focusing on evidence of functional limitation caused by pain. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). Pain in a particular joint may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40. Spinal conditions are evaluated under either the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (Formula for Rating IVDS), whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. The General Rating Formula provides for a 20 percent rating for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5242). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, Plate V. According to the Formula for Rating IVDS, under Diagnostic Code 5243, a 20 percent rating requires evidence of incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past twelve months; a 40 percent rating requires evidence of incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent rating requires evidence of incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An “incapacitating episode” is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). If IVDS is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment will be evaluated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. Id. at Note (2). Upon consideration of the record, the Board finds that the preponderance of the evidence is against a determination that an initial rating in excess of 20 percent is warranted for the Veteran’s low back disorder. The Veteran was afforded a VA examination in January 2015 that did not reveal symptomatology that warranted a rating in excess of 20 percent. Specifically, forward flexion was not 30 degrees or less, and there was no evidence of disability resulting from localized tenderness or guarding of the thoracolumbar spine, although the examiner did note muscle spasms resulting in abnormal spinal contour. Moreover, the Veteran did not report experiencing incapacitating episodes requiring doctor-prescribed bed rest in the 12 months preceding the examination, nor was any ankylosis documented. The Board does acknowledge that the Veteran exhibited less movement than normal during the examination as due to the pain he experienced when moving, and as a result he experienced an additional five-degree loss of range of motion throughout his lumbosacral spine. Furthermore, it is also noted that the Veteran had difficulty sitting, and could not perform the straight leg raising test, which was attributed to his back pain. However, there is no indication that he experienced such a degree of increased impairment from this specific symptomatology that would be commensurate with the loss of forward flexion or incomplete ankylosis sufficient to warrant a higher rating. In fact, the additional loss of range of motion following repetitive usage noted on the examination did not increase his functional impairment to the levels needed to warrant a higher rating. The Board has reviewed the Veteran’s lay testimony and both the VA and private medical records in the claims file, but this evidence does not tend to show that the symptoms of his low back disorder warrant a rating in excess of 20 percent. The VA medical records show that the Veteran has continued to receive treatment for his low back pain, but there is no indication that he has experienced any additional loss of range of motion of his lumbosacral spine or experiences any ankylosis throughout his lumbosacral spine, nor has the Veteran required any doctor-prescribed bed rest. The 20 percent rating was granted with consideration of the functional loss stemming from the Veteran’s symptoms of pain and weakness. As stated, for the additional functional loss to warrant a higher rating, that loss must rise to the level of the more restricted forward flexion necessary for entitlement to the next degree of disability, which has not been shown. Therefore, the Board finds that the assigned 20 percent initial rating adequately contemplates the functional impairment resulting from the Veteran’s low back disorder. See 38 C.F.R. §§ 4.40, 4.45. The evidence of record does not show objective neurologic abnormalities associated with the Veteran’s low back disorder. There is accordingly no basis for separate evaluations for any such disorders. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). Earlier Effective Date In general, the effective date of an award based on an original claim shall be fixed in accordance with the facts found, but shall not be earlier than the date of the receipt of the application. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. However, if the claim is received within one year after separation from service, the effective date of an award of disability compensation shall be the day following separation from active service. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i). Additionally, 38 U.S.C. § 5101(a) provides that “[a] specific claim in the form prescribed by the Secretary... must be filed in order for benefits to be paid or furnished to any individual.” For VA compensation purposes, a “claim” is defined as “a written communication requesting a determination of entitlement or evidencing a belief in entitlement, to a specific benefit under the laws administered by the Department of Veterans Affairs submitted on an application form prescribed by the Secretary.” 38 C.F.R. § 3.1(p). An informal claim is “[a]ny communication or action indicating an intent to apply for one or more benefits.” 38 C.F.R. § 3.155(a). It must “identify the benefit sought.” Id. Thus, the essential elements for any claim, whether formal or informal, are “(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing.” Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). VA must look to all communications from a claimant that may be interpreted as an application or claim, both formal and informal, for benefits and is required to identify and act on informal claims for benefits. See Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). In addition, an application that had been previously denied cannot preserve an effective date for a later grant of benefits based on a new application. 38 C.F.R. § 3.400(q). Thus, the effective date of an award of service connection is not based on the earliest medical evidence showing a causal connection, but on the date that the application upon which service connection was eventually awarded was filed with VA. Lalonde v. West, 12 Vet. App. 377, 382 (1999). 1. Entitlement to an earlier effective date for the grant of service connection for tinnitus. The Veteran contends generally that he is entitled to an earlier effective date for the grant of service connection for tinnitus. He is currently in receipt of service connection for tinnitus with an effective date of August 13, 2014, the date of his claim seeking entitlement to this benefit. There is no evidence of any claim for this benefit, as defined in the aforementioned VA laws and regulations, prior to this date, and specifically not in the one year following separation from service in May 1987. VA laws and regulations are clear that the effective date of a grant of service connection will not otherwise be earlier than the date of claim. Accordingly, the August 13, 2014 date is the correct effective date, and the claim is denied. 2. Entitlement to an earlier effective date for the grant of service connection for an acquired psychiatric disorder. The Veteran contends generally that he is entitled to an earlier effective date for the grant of service connection for an acquired psychiatric disorder. He is currently in receipt of service connection for an acquired psychiatric disorder with an effective date of June 4, 2013, the date of his informal claim seeking entitlement to this benefit. Again, there is no evidence of any claim for this benefit, as defined in the aforementioned VA laws and regulations, prior to this date, and specifically not in the one year following separation from service in May 1987. VA laws and regulations are clear that the effective date of a grant of service connection will not otherwise be earlier than the date of claim. Accordingly, the June 4, 2013 date is the correct effective date, and the claim is denied. 3. Entitlement to an earlier effective date for the grant of service connection for a headache condition. The Veteran contends generally that he is entitled to an earlier effective date for the grant of service connection for a headache condition. He is currently in receipt of service connection for a headache condition with an effective date of August 13, 2014, the date of his claim seeking entitlement to this benefit. Once again, there is no evidence of any claim for this benefit, as defined in the aforementioned VA laws and regulations, prior to this date, and specifically not in the one year following separation from service in May 1987. VA laws and regulations are clear that the effective date of a grant of service connection will not otherwise be earlier than the date of claim. Accordingly, the August 13, 2014 date is the correct effective date, and the claim is denied. REASONS FOR REMAND 1. Entitlement to service connection for a cervical spine condition is remanded. In support of its denial of entitlement to service connection for a cervical spine condition, the Regional Office in an August 2016 statement of the case referred specifically to the lack of any current formal diagnosis of a cervical spine condition. Subsequently, more contemporary VA medical records reflect that the Veteran was diagnosed with degenerative joint disease throughout his cervical spine. As he has never been afforded a VA examination in support of his cervical spine condition claim, on remand, the Veteran must be scheduled for such an examination in order to properly diagnose the cervical spine condition and elicit an opinion as to the likely etiology of any such cervical spine condition. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for residuals of a traumatic brain injury is remanded. The Veteran was afforded an examination in support of his claim of entitlement to service connection for residuals of a traumatic brain injury in January 2015. After confirming a history of traumatic brain injury due to a skull fracture that reportedly occurred prior to the Veteran entering service in 1983, the examiner found that the Veteran did not experience any residual symptomatology that was attributable to a traumatic brain injury. The examiner then opined that the Veteran’s preexisting skull laceration injury was not aggravated by any in-service injury or event. The January 2015 examiner’s opinion is deficient because they did not utilize the proper standard in determining whether the Veteran’s traumatic brain injury residuals pre-existed service and, if so, whether any preexisting residual condition was worsened beyond natural progression during service. Moreover, it is not entirely clear from the examination report whether the examiner diagnosed any current residual conditions attributable to a prior traumatic brain injury; in the diagnosis section of the report, residual conditions are acknowledged, but when going into specifics as to the diagnostic criteria for residual conditions, the examiner found no evidence of any of the 10 available criteria. On remand, the Veteran must be afforded a new examination to properly determine whether he currently experiences any residual conditions of a prior traumatic brain injury, and, if so, the likely etiology of any diagnosed residual conditions. 3. Entitlement to a rating in excess of 70 percent for an acquired psychiatric disorder is remanded. During the most recent VA examination provided to the Veteran addressing the severity of his acquired psychiatric disorder, dated in July 2016, the examiner noted that there was no evidence of traumatic brain injury residuals, and thus did not distinguish between the acquired psychiatric disorder symptomatology and any mental health symptomatology attributable to a prior traumatic brain injury. As discussed above, it is not clear whether the Veteran currently experiences any residual conditions of a prior traumatic brain injury, and thus the Board is unable to determine whether there is any symptomatology that may be attributable to a traumatic brain injury residual condition that would also be considered in the assignment of a rating for the acquired psychiatric disorder. Accordingly, the claim for an increased rating of the acquired psychiatric disorder must be remanded pending the resolution of the traumatic brain injury claim as such claims are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180 (1991). 4. Entitlement to an increased initial rating in excess of 50 percent for a headache condition is remanded. The Board notes that a 50 percent rating, which is awarded for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability, is the highest possible rating available for a headache condition. 38 C.F.R. § 4.124a, Diagnostic Code 8100. However, the Veteran has submitted an evaluation dated in June 2016 from a Dr. H.S. in which he found that the headache condition would prevent the Veteran from maintaining substantially gainful employment. Specifically, Dr. H.S. found that the Veteran would miss three or more days of work a month due to headaches, would need to leave work early three or more days a month, and would not be able to stay focused for at least seven hours of an eight-hour workday on three or more workdays per month. This evaluation raises the suggestion that the Veteran’s headache condition alone results in his inability to obtain or maintain substantially gainful employment; as such, a claim for an increased rating of the headache condition on an extraschedular basis has been raised in this instance. See Thun v. Peake, 22 Vet. App. 111 (2008). The Board is precluded by regulation from assigning extraschedular ratings under 38 C.F.R. § 3.321(b)(1) in the first instance, and, as such, the Board finds that referral for extraschedular consideration of the headache condition to the Director of VA’s Compensation and Pension Service is warranted under 38 C.F.R. § 3.321(b)(1). 5. Entitlement to an earlier effective date for the grant of service connection for a low back condition is remanded. The Regional Office in a January 2015 rating decision granted service connection for a low back condition, with a 20 percent rating effective August 13, 2014. In an April 2015 notice of disagreement, the Veteran requested both a rating in excess of 20 percent and an earlier effective date of the grant of service connection. The Regional Office did address the issue of entitlement to an increased rating of the low back condition in a subsequent statement of the case (SOC) dated in August 2016, but to date the Regional Office has not addressed the issue of an earlier effective date of the grant of service connection for a low back condition. The Board accordingly must remand the issue to the agency of original jurisdiction for issuance of a SOC. Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). 6. Entitlement to TDIU is remanded. A decision on the issue of entitlement to TDIU is deferred pending resolution of the other claims being remanded, as such claims are inextricably intertwined. Harris, supra. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA spine examination to address the nature and etiology of any diagnosable cervical spine condition. The entire claims file, to include a complete copy of this REMAND, must be made available to the individual designated to examine the Veteran, and the examination report should include discussion of the Veteran’s documented medical history and assertions relating to any symptoms of a cervical spine condition. All necessary special studies or tests must be accomplished. The examiner must first provide a diagnosis to account for the Veteran’s documented cervical spine symptomatology. Then, if a cervical spine condition is diagnosed, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that any diagnosed cervical spine condition is related to the Veteran’s active service. The examiner must provide any and all opinions as to etiology in the form of a probability, and must provide a complete rationale for any opinion expressed. 2. Schedule the Veteran for a VA neurological examination to address the nature and etiology of any residual conditions attributable to a prior traumatic brain injury. The entire claims file, to include a complete copy of this REMAND, must be made available to the individual designated to examine the Veteran, and the examination report should include discussion of the Veteran’s documented medical history and assertions relating to any residual symptoms of a traumatic brain injury. All necessary special studies or tests must be accomplished. The examiner must first determine whether the Veteran experiences any residual symptomatology attributable to a prior traumatic brain injury. If traumatic brain injury residuals are identified, the examiner must distinguish between that symptomatology attributable to the residual condition or conditions and any symptomatology attributable to other service-connected disabilities, to specifically include an acquired psychiatric disorder and/or a headache condition. Then, based upon the claims file review, the history presented by the Veteran, and the examination results, the examiner is requested to provide an opinion as to whether any diagnosed residual condition clearly and unmistakably preexisted service, and clearly and unmistakably did NOT worsen beyond natural progression during service. Regardless of whether the examiner determines that a residual condition clearly and unmistakably preexisted service or not, an opinion must also be rendered as to whether any diagnosable residual condition is at least as likely as not (a 50 percent or greater probability) etiologically related to service. In rendering said opinions, the examiner must consider, and discuss as necessary, lay testimony regarding the Veteran’s development of residual conditions during service, as well as his assertion that he suffered a traumatic brain injury in January 1987. The examiner must provide a complete rationale for all opinions expressed. 3. Refer the Veteran’s claim for entitlement to an initial rating in excess of 50 percent for a service-connected headache condition to the Under Secretary for Benefits or the Director of Compensation and Pension Service, for extraschedular consideration under 38 C.F.R. § 3.321(b)(1). All documentation resulting from this request must be added to the claims file. 4. Issue a Statement of the Case to the Veteran which addresses the issue of entitlement to an effective date prior to August 13, 2014 for the grant of service connection for a low back condition. The Veteran should be given the appropriate opportunity to respond to the SOC. If, and only if, he perfects the appeal should the case be returned to the Board. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Christopher M. Collins, Associate Counsel