Citation Nr: 18154244 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 17-10 670A DATE: November 29, 2018 ORDER Service connection for an eye disability manifested by light sensitivity, to include as secondary to service-connected traumatic brain injury (TBI), is denied. Service connection for status post hemorrhoidectomy is denied. Service connection for scar, status post hemorrhoidectomy, is denied. Service connection for sinusitis is denied. An initial compensable rating for TBI is denied. An initial rating of 10 percent, and no higher, for posttraumatic headaches is granted. REMANDED Entitlement to service connection for a cervical spine disorder is remanded. Entitlement to service connection for bilateral neurological disorder of the upper extremities characterized by tingling and numbness is remanded. Entitlement to service connection for bilateral shoulder disorders is remanded. Entitlement to service connection for bilateral wrist disorders is remanded. Entitlement to service connection for bilateral elbow disorders is remanded. Entitlement to service connection for a right hand, fourth digit, disorder is remanded. Entitlement to service connection for bilateral hip disorders is remanded. Entitlement to service connection for bilateral knee disorders, to include bursitis and patellofemoral syndrome, is remanded. Entitlement to service connection for bilateral shin splints is remanded. Entitlement to service connection for a left ankle disorder is remanded. Entitlement to service connection for bilateral foot disorders is remanded. Entitlement to service connection for a left hamstring disorder is remanded. FINDINGS OF FACT 1. The most probative evidence establishes that the Veteran does not have an eye disability manifested by light sensitivity which was incurred in or is otherwise causally related to service, or is causally related to his service-connected TBI. The most probative evidence establishes that his subjective light sensitivity is a symptom of his service-connected headaches. 2. The most probative evidence establishes that the Veteran does not have current residuals of a hemorrhoidectomy. 3. The most probative evidence establishes that the Veteran does not have a scar, status post hemorrhoidectomy. 4. The most probative evidence establishes that the Veteran does not have a sinus disability, to include sinusitis, which was incurred in or is otherwise causally related to his active service. 5. For the entire period on appeal, the Veteran’s TBI is not manifested by any residuals of cognitive, emotional/behavioral, or physical impairment which is not already contemplated in separate ratings assigned for tinnitus and posttraumatic headaches. 6. For the entire period on appeal, the Veteran’s posttraumatic headaches have been manifested by pain, sensitivity to light and sound, and vision changes. He did not experience prostrating attacks occurring on average once a month. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for an eye disability manifested by light sensitivity, to include as secondary to service-connected TBI, have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.309, 3.310. 2. The criteria for entitlement to service connection for status post hemorrhoidectomy have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.303, 3.304. 3. The criteria for entitlement to service connection for scar, status post hemorrhoidectomy, have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.303, 3.304. 4. The criteria for entitlement to service connection for sinusitis have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.303, 3.304. 5. Entitlement to an initial compensable rating for TBI is denied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, 4.124a, DC 8045. 6. The criteria for entitlement to an initial rating of 10 percent, and no higher, for posttraumatic headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.124a, DC 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Marine Corps from November 1998 to August 2015. He is the recipient of the Navy and Marine Corps Commendation Medal with Combat “V”, the Navy and Marine Corps Commendation Medal, the Navy and Marine Corps Achievement Medal on two occasions, the Combat Action Ribbon for service in Afghanistan, the Combat Action Ribbon for service in Kuwait/Iraq, the Marine Corps Good Conduct Medal on five occasions, and the Meritorious Mast. This matter comes before the Board of Veterans’ Appeals (Board) from a January 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The grant of service connection for lumbar spine degenerative arthritis with intervertebral disc syndrome, left lower extremity radiculopathy, and right lower extremity radiculopathy, in a July 2017 rating decision, constitutes a full award of the benefit sought on appeal with respect to that claim. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of “downstream” elements such as the disability rating or effective date assigned). A Supplemental Statement of the Case (SSOC) was issued in August 2017. This SSOC also discussed the issues of entitlement to service connection for bilateral lower extremity cold weather injuries. However, while these issues had been denied in the January 2016 rating decision, the Veteran did not file a timely NOD with respect to such. It appears that such were included in the SSOC erroneously. As the Board does not have jurisdiction over those issues, they will no longer be discussed in this decision. See 38 C.F.R. § 20.200. The Board regrets any confusion. Additionally, while the Veteran did not explicitly appeal the issue of entitlement to service connection for residuals of hemorrhoidectomy, the Board observes that the RO construed his disagreement with the denial of service connection for hemorrhoidectomy scar broadly and treated hemorrhoidectomy residuals and hemorrhoidectomy scar as two separate issues in the SOC and SSOC. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. “To establish a right to compensation for a present disability, a Veteran must show: ‘(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service’—the so-called ‘nexus’ requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including arthritis and other organic diseases of the nervous system, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). Light sensitivity, hemorrhoids, and sinusitis are not qualifying chronic disabilities for the purposes of these provisions. To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). Eye disability manifested by light sensitivity, secondary to TBI The Board finds that service connection is not warranted for an eye disability manifested by light sensitivity, to include as secondary to TBI. During his April 2015 separation health assessment, the Veteran denied eye symptoms or complaints. Examination of the eyes was normal. The Veteran was afforded a compensation and pension examination for his eyes in April 2015. The Veteran reported that he began to experience photophobia and headaches in 2010. No eye disability was diagnosed following examination because there was no pathology upon which to render a diagnosis. The Board has considered the Veteran’s lay history of symptomatology related to his claimed disorder throughout the appeal period. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through an individual’s senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Veteran in this case is not competent to determine the cause of his symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. The Board finds the separation examination and compensation and pension examination reports to be of greater probative weight than the Veteran’s lay assertions as to whether he has an eye disability. As the Veteran served in the Southwest Asia theater of operations, the Board has considered whether his subjective light sensitivity is an undiagnosed illness or a medically unexplained chronic multisymptom illness. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a). However, there is no competent evidence, nor is it contended, that light sensitivity is an undiagnosed illness or a medically unexplained chronic multisymptom illness. Indeed, during the Veteran’s April 2015 separation health assessment, the Veteran denied symptoms or complaints related to Persian Gulf and Afghanistan infectious diseases or undiagnosed illness and unexplained chronic multisymptom illness. His eyes were examined and found to be normal. The June 2015 examiner who conducted the headaches examination attributed the Veteran’s reports of light sensitivity to his service-connected posttraumatic headaches. The Veteran’s reports of light sensitivity with headaches are competent and credible. The Board notes that the June 2015 headaches disability benefits questionnaire states that the Veteran reported that headaches were manifested by constant pain on both sides of the head, nausea, sensitivity to light, sensitivity to sound, and changes in vision. As there is no competent evidence of a separate and distinct eye disability manifested by light sensitivity, and the Veteran himself complained of light sensitivity in conjunction with his service-connected headaches, the Board finds that the Veteran’s subjective light sensitivity is a symptom of his service-connected headaches. Thus, although the Board finds that there is no competent evidence of a current eye disability manifested by light sensitivity, the Veteran’s competently- and credibly-reported light sensitivity in conjunction with headaches is a symptom which has been taken into account in the assignment of the initial rating for headaches discussed below. See Mittleider v. West, 11 Vet. App. 181 (1998). Such symptomatology is discussed further below with respect to the rating for his headache disability. In short, the evidence of record does not demonstrate that the Veteran has a current separate and distinct eye disability manifested by light sensitivity, but rather that such subjective symptomatology experienced by the Veteran is due to his service-connected headache disability. Accordingly, service connection for an eye disability manifested by light sensitivity must be denied at this time based on the evidence of record. See 38 C.F.R. §§ 3.102, 3.303; McClain v. Nicholson, 21 Vet. App. 319 (2007) (the requirement that a current disability be present is satisfied “when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim . . . even though the disability resolves prior to the Secretary's adjudication of the claim.”); Brammer v. Derwinski, 3 Vet. App. 223 (1995) (Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability). Status post hemorrhoidectomy and scar, status post hemorrhoidectomy The Board finds that service connection is not warranted for status post hemorrhoidectomy or for scar, status post hemorrhoidectomy. The Veteran underwent hemorrhoidectomy in June 2002. On a February 2005 Report of Medical History, the Veteran endorsed a past history of hemorrhoids. The Physician’s Assistant who examined the Veteran at such time indicated that the Veteran had indeed experienced hemorrhoids in or about 2002, but had no sequelae from such. In a March 2011 Report of Medical History, the Veteran denied rectal disease, hemorrhoids, or blood from the rectum. During his April 2015 separation health assessment, the Veteran endorsed hemorrhoids with respect to complaints regarding anus and rectum. However, anus and rectum were not examined. The Veteran was afforded a VA examination for the rectum and anus in April 2015. The Veteran reported that he experienced hemorrhoids in 2001 and that there were no current symptoms. There were no findings, signs, or symptoms; and no diagnosis was rendered. The Veteran declined rectal examination. The examiner noted that there was no pathology upon which to render a diagnosis. An April 2016 clinical note indicates that the Veteran’s past medical history was remarkable for hemorrhoid surgery around 2000. There is no competent evidence of a current disability of hemorrhoids or residuals of hemorrhoidectomy, to include scar. The Veteran was afforded an examination in conjunction with his claim in April 2015. However, he declined rectal examination. He also indicated that he had no current symptoms. Where entitlement to a VA benefit cannot be established or confirmed without a current VA examination and a claimant, without good cause, fails to report for such examination scheduled in conjunction with an original compensation claim, the claim shall be rated on the evidence of record. 38 C.F.R. § 3.655. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. 38 C.F.R. § 3.655(a). When a claimant fails to participate in a scheduled VA examination, the Board must consider (1) whether the examination was necessary to establish entitlement to the benefit sought and (2) whether the claimant lacked good cause to miss the scheduled examination. Turk v. Peake, 21 Vet. App. 565, 568 (2008). The Veteran was scheduled for examination to determine the nature and etiology of any and all residuals of hemorrhoidectomy, to include scar, but failed to permit rectal examination to occur. He has offered no argument or evidence regarding good cause for this. Under these circumstances, the Board finds that the Veteran’s failure to cooperate in the examination process is analogous to failure to report for an examination as it frustrated VA’s attempt to fulfill its duty to assist. Thus, the claim must be adjudicated based upon the evidence of record. 38 C.F.R. § 3.655(b); Turk, supra. The Board further notes that it is the Veteran’s obligation to actively participate in the retrieving of any information pertinent to his claim, to include attending scheduled VA examinations and identifying relevant records. He is expected to cooperate in the efforts to adjudicate the claim, and his failure to do so subjects him to the risk of an adverse adjudication based on an incomplete and underdeveloped record. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991); Kowalski v. Nicholson, 19 Vet. App. 171, 178 (2005). “If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence.” Wood, 1 Vet. App. at 195. Again, there is no competent evidence that the Veteran has a current disability of hemorrhoids or residuals of hemorrhoidectomy, to include scar. Indeed, the Veteran himself reported during his April 2015 examination that he was asymptomatic. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1131. Thus, where the collective lay and medical evidence indicates that, fundamentally, the Veteran does not have a current disability for which service connection is sought, there can be no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Gilpin v. West, 155 F.3d 1353, 1356 (Fed. Cir. 1998). Accordingly, service connection for hemorrhoids or residuals of hemorrhoidectomy, to include scar, must be denied at this time based on the evidence of record. See 38 C.F.R. §§ 3.102, 3.303; McClain, supra; Brammer, supra.   Sinusitis Upon weighing the evidence, the Board finds that service connection for sinusitis is not warranted. Service treatment records indicate that the Veteran was prescribed a nasal spray, cromolyn sodium, in December 2014. During his April 2015 separation health assessment, the Veteran denied symptoms or complaints regarding the sinuses. Examination of the sinuses was essentially normal. The Veteran was afforded a VA examination in April 2015. A sinus disability, including sinusitis or rhinitis, was not diagnosed. Paranasal radiographs performed in April 2015 were normal. While the Veteran reported that he began to experienced sinus problems in 2015, the examiner stated that there was no pathology upon which to render a diagnosis. In February 2016, the Veteran stated that he was treated for sinus problems while on active duty. He indicated that his problems began in Afghanistan. The Board has considered the Veteran’s lay history of symptomatology related to his claimed disorder throughout the appeal period. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through an individual’s senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Veteran in this case is not competent to determine the cause of his symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis); see also Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). The Veteran has not produced competent medical evidence to contradict the conclusions set forth in the April 2015 examination report, although he has been afforded ample opportunity to present competent medical evidence in support of his claim. It is the claimant’s responsibility to support a claim for VA benefits. See 38 U.S.C. § 5107(a). Thus, the April 2015 examination report stands unchallenged as competent evidence on this crucial question of whether the Veteran has a current sinus disability. As the Veteran served in the Southwest Asia theater of operations, the Board has considered whether his sinus complaints are manifestations of an undiagnosed illness or a medically unexplained chronic multisymptom illness. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a). However, there is no competent evidence, nor is it contended, that the Veteran’s sinus complaints indicate the presence of an undiagnosed illness or a medically unexplained chronic multisymptom illness. Indeed, during the Veteran’s April 2015 separation health assessment, the Veteran denied symptoms or complaints related to Persian Gulf and Afghanistan infectious diseases or undiagnosed illness and unexplained chronic multisymptom illness. His sinuses were examined and found to be normal. The April 2015 examiner indicated that there was no pathology upon which to render a diagnosis. Paranasal radiographs were normal. Although he had sinus problems in service, such appear to have resolved. Indeed, the Veteran himself denied sinus problems during his April 2015 separation health assessment, although he endorsed sinus problems during his April 2015 VA examination. To the extent that the Veteran may be claiming service connection for sinusitis because he had sinus problems while on active duty, rather than because he has had sinus problems during the period on appeal, the Board observes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1131. Thus, where the collective lay and medical evidence indicates that, fundamentally, the Veteran does not have a current disability for which service connection is sought, there can be no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Gilpin v. West, 155 F.3d 1353, 1356 (Fed. Cir. 1998). Accordingly, service connection for sinusitis must be denied at this time based on the evidence of record. See 38 C.F.R. §§ 3.102, 3.303; McClain, supra; Brammer, supra. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Rating Claims Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, 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 severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staging the ratings.” See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). TBI The Veteran’s service-connected TBI has been evaluated under Diagnostic Code (DC) 8045 for residuals of TBI. DC 8045 provides for three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive, emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. See 38 C.F.R. § 4.124a, DC 8045. 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. In a given individual, symptoms may fluctuate in severity from day to day. VA is to evaluate cognitive impairment under the table titled “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified.” 38 C.F.R. § 4.124a, DC 8045. Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” However, 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 “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table. Id. Evaluate emotional/behavioral dysfunction under § 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, evaluate emotional/behavioral symptoms under the criteria in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” Id. VA is to evaluate physical (including neurological) dysfunctions under an appropriate diagnostic code for that disability. Evaluate each condition 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 “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified” table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. 38 C.F.R. § 4.124a, DC 8045. The table titled “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified” 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 fifth level, the highest level of impairment, and labeled “total.” The evaluator is to 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. 38 C.F.R. § 4.124a, DC 8045. There may be an overlap of manifestations of conditions evaluated under the TBI Table with manifestations of a comorbid mental or neurologic disorder or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, no more than one evaluation is to be assigned based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, a single evaluation is assigned 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, a separate evaluation is assigned for each condition. Id. at Note 1. Applying the criteria set forth above to the facts in this case, the Board finds that the preponderance of the evidence is against assignment of an initial compensable rating for TBI at any time during the period on appeal. The Veteran was afforded a VA examination in May 2015. The claims file was reviewed. He incurred a TBI while serving in Iraq in 2006 from improvised explosive devices (IED). The Veteran reported hitting his head in 2010 on a ship. Later that year, a branch fell on his head in the same place and he received seven staples at the emergency room. With respect to residuals, the Veteran complained of tinnitus and headaches twice weekly. He does not take any medicine other than resting for an hour and taking a Motrin if he is able. He was exposed to more than three blasts, one of which was severe enough to knock him down or cause injury. The current treatment plan did not include taking continuous medication. There were no complaints of impairment of memory, attention, concentration, or executive functions. Judgment was normal. Social interaction was routinely appropriate. The Veteran was always oriented to all spheres. Motor activity was normal. Visual spatial orientation was normal. Subjective symptoms were headaches and tinnitus, but such did not interfere with work, instrumental activities of daily living, or work, family, or other close relationships. There were no neurobehavioral effects. The Veteran was able to communicate by and comprehend spoken and written language. Consciousness was normal. Residuals included headaches. There was a scar. However, such was not painful or unstable; and the total area was not greater than 39 square cm (six square inches). Rather, the length and width of the scar was 5 cm on the top of the head; such was not noted to result in any characteristics of disfigurement at that time. There was no impact on the Veteran’s ability to work. The May 2015 VA psychiatric examiner opined that the Veteran’s headaches and tinnitus were attributable to his TBI, while his poor sleep, nightmares, anxiety, irritability, startle, hypervigilance, intrusive memories, avoidance, isolation, depression, and poor concentration were the result of his PTSD. Of record is a statement from the Veteran received in February 2016. In such statement, the Veteran stated that he believed his TBI rating should be “higher due to the difficulties the TBI causes in my life.” The Board has considered the 10 facets discussed above. The Veteran’s disability has been manifested by no greater than level 0 impairment for any of the facets under the Cognitive Table. For memory impairments, the Veteran had no complaints during the May 2015 examination. There was no objective evidence during testing of any impairment of memory, attention, concentration, or executive functions. With respect to judgment, the objective evidence indicates that the Veteran’s judgment was normal, indicative of level 0 impairment. Social interaction was routinely appropriate. He was always oriented to person, time, place, and situation. Motor activity was normal. Visual spatial orientation was normal. Thus, the Board finds that the Veteran experienced level 0 impairment with respect to social interaction, orientation, motor activity, and visual spatial orientation. Moreover, the Veteran did not experience any neurobehavioral effects. He was able to communicate by spoken and written language and comprehend spoken and written language. His consciousness was normal. The Board finds that the Veteran experienced level 0 impairment with respect to such. With regard to subjective symptoms, the Board observes that the Veteran experienced headaches and tinnitus. The May 2015 examiner indicated that such did not interfere with work, instrumental activities of daily living, or work, family, or other close relationships. Here, the Board notes that the rating criteria direct that any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere’s disease, should be rated separately, even if that diagnosis is based on subjective symptoms, rather than under the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table. Service connection is in effect for tinnitus and posttraumatic headaches. Tinnitus is rated at 10 percent, the maximum schedular rating under DC 6260. Also, service connection for scar on scalp is in effect. Such is rated as noncompensable. The Veteran did not appeal the initial rating assigned. The issue of entitlement to an initial compensable rating for posttraumatic headaches is discussed infra. The Board observes that the Veteran has also contended that light sensitivity is a residual of his TBI. However, as discussed infra with respect to entitlement to an initial compensable rating for headaches, the Board finds that the Veteran’s subjective light sensitivity is a manifestation of his service-connected headaches. In any event, the May 2015 examiner noted that the Veteran’s subjective symptoms did not interfere with work. Thus, the Board finds that the Veteran’s subjective symptoms more nearly approximate level 0 impairment, particularly as his headaches and tinnitus are rated separately. In any event, it would not benefit the Veteran to have his tinnitus, headaches, and light sensitivity each considered a separate subjective symptom, even if such mildly interfered with work. That would only warrant a single 10 percent rating under DC 8045; which is less beneficial than two 10 percent ratings, one for tinnitus and one for headaches, discussed infra. Additionally, to increase his compensation under DC 8045 for these symptoms concurrently would be unlawful pyramiding. See also 38 C.F.R. § 4.14. Thus, the Veteran more nearly approximated no greater than level 0 impairment for each facet. An initial compensable rating for TBI is not warranted. The Board has also considered DC 8045’s instruction to consider entitlement to special monthly compensation. The record does not show, nor does the Veteran contend, that his TBI, in and of itself, results in sensory impairments or the need for aid and attendance. The Veteran is already in receipt of special monthly compensation for loss of use of a creative organ. The Board has also considered whether any other diagnostic codes would be appropriate to evaluate the Veteran’s TBI. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Board observes that the Veteran’s TBI symptoms include tinnitus and headaches. DC 8045 provides that VA separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headaches, even if that diagnosis is based on subjective symptoms, rather than under the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified. Here, headaches and tinnitus have been diagnosed, and service connection is in effect for such. Likewise, service connection is in effect for scar on scalp. With respect to the Veteran’s complaints of light sensitivity, the Board has considered entitlement to service connection for an eye disability supra. Further, such is discussed as a symptom of service-connected posttraumatic headaches infra. In summary, the Board has considered the 10 facets in the table of “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified”. After so doing, the Board concludes that the initial noncompensable rating assigned for the Veteran’s TBI is appropriate and that the preponderance of the evidence is against the assignment of an initial compensable rating. The Board has considered the Veteran’s February 2016 statement to the extent that he believed that an initial noncompensable rating for TBI did not take into account difficulties the Veteran experienced as a result of his TBI. However, the Board notes that the Veteran did not address particular symptoms in this statement. Rather, he just stated that there were unspecific “difficulties the TBI causes in [his] life.” While an initial compensable rating for TBI under DC 8045 is not warranted, the Board emphasizes that the Veteran’s headaches and tinnitus, both residuals of his TBI, are rated separately under different diagnostic codes as directed by the rating criteria. Tinnitus is rated as 10 percent disabling, which is the maximum schedular rating. Entitlement to an initial compensable rating for headaches is discussed infra. To the extent that the Veteran may consider that his poor sleep, nightmares, anxiety, irritability, startle, hypervigilance, intrusive memories, avoidance, isolation, depression, and poor concentration are attributable to his TBI, rather than his service-connected PTSD, the Board notes that the Veteran is certainly competent to report his symptoms, but has not been shown to be competent to determine the cause of such. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board affords greater probative weight to the May 2015 VA psychiatric examiner’s opinion that such symptoms are attributable to PTSD. There is no competent opinion to the contrary. Indeed, such symptoms were taken into account in the current 50 percent rating in effect for service-connected PTSD; and a claimant may not be compensated twice for the same symptomatology. 38 C.F.R. § 4.14; Brady, supra. The Board emphasizes that, although an initial compensable rating for TBI under DC 8045 is not warranted, the Veteran’s TBI-related symptoms, including headaches and tinnitus, are compensated under other diagnostic codes. To the extent that the Veteran considers any and all psychiatric symptomatology to be the result of his TBI rather than his PTSD, all of his psychiatric symptomatology was attributed to his PTSD by the May 2015 VA examiner. Thus, the disability rating for PTSD, currently 50 percent, takes all such symptoms into account. If the Veteran disagrees with such rating, he is invited to file a claim for an increased evaluation for PTSD. Accordingly, an initial compensable evaluation under Diagnostic Code 8045 for the Veteran’s residuals of a TBI is not warranted based on the evidence of record at this time for the foregoing reasons. The Board must therefore deny that claim at this time. See 38 C.F.R. §§ 4.7, § 4.124a, DC 8045. Headaches The Board finds that an initial 10 percent rating, and no higher, is warranted for the Veteran’s posttraumatic headaches. The Veteran’s service-connected posttraumatic headaches have been rated by analogy to migraine headaches. 38 C.F.R. § 4.20. Under DC 8100, pertaining to migraine headaches, a 10 percent rating is assigned for migraines with characteristic prostrating attacks averaging one in two months over the last several months; a 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months; and a maximum 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks, productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. The Veteran was afforded a VA examination in June 2015. Posttraumatic headaches were diagnosed. He endorsed constant pain on both sides of the head, nausea, sensitivity to light, sensitivity to sound, and changes in vision. Head pain typically lasted for less than one day. He did not experience prostrating attacks. There was no impact on his ability to work. In February 2016, the Veteran argued that an initial compensable rating for headaches was warranted because of the frequency of his headaches and expressed displeasure with the examinations rendered. The Board finds that the Veteran’s posttraumatic headache symptoms more nearly approximate the severity contemplated by the rating criteria for an initial 10 percent rating for the entire period on appeal. Although the Veteran does not experience prostrating attacks, and has not contended otherwise, his headaches are manifested by pain, sensitivity to light and sound, and changes in vision. Indeed, his headaches are rated by analogy to migraine headaches under DC 8100. The Board finds that the preponderance of the evidence is against the award of an initial rating in excess of 10 percent for any portion of the period on appeal. A 30 percent rating requires characteristic prostrating attacks occurring on average once a month. Again, there is no evidence, nor is it contended, that the Veteran experiences prostrating attacks. Accordingly, an initial 10 percent evaluation, but no higher, for the Veteran’s posttraumatic headaches is warranted based on the evidence of record at this time; to that extent, the Veteran’s claim is granted and in all other respects that claim is denied at this time. See 38 C.F.R. §§ 4.7, § 4.124a, DC 8100. In so reaching the above conclusions, the Board has appropriately applied the benefit of the doubt doctrine in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND In February 2016, the Veteran expressed displeasure with the examinations rendered for his musculoskeletal claims. He stated that he did not think they were adequate to diagnose his claimed disabilities. He explained that his active service caused wear and tear on nearly every joint in his body. In his March 2017 substantive appeal, the Veteran indicated that he did not think that his examinations were comprehensive enough to determine his disabilities. The Board has reviewed the April 2015 examination reports and observes that, while X-rays were performed of the lumbar and cervical spine, no imaging studies, aside from the cervical and lumbar spines, were performed with respect the Veteran’s claimed musculoskeletal disabilities. The Board further observes that, while April 2015 imaging studies of the lumbar spine were negative for arthritis, service connection for a lumbar spine disability was eventually granted after there was X-ray evidence of arthritis in 2017. Likewise, as there was no X-ray evidence of cervical spine arthritis in 2015, the Board finds that the cervical spine should be examined again. The upper extremity radiculopathy claims are inextricably intertwined with the cervical spine claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The Veteran has competently reported pain. Although there was no limitation of motion during the April 2015 examinations, the United States Court of Appeals for the Federal Circuit recently held in Saunders v. Wilkie, 866 F.3d 1356 (2018), that pain alone in the absence of an underlying pathology can be a disability if it reaches the level of a functional impairment of earning. Further, as the Veteran served in the Southwest Asia theater of operations, consideration should also be afforded as to whether the Veteran’s reports of joint pains indicate the presence of an undiagnosed illness manifested by chronic joint pain and weakness, or a medically unexplained chronic multisymptom illness such as fibromyalgia. 38 C.F.R. § 3.317(a). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matters are REMANDED for the following action: 1. Schedule the Veteran for appropriate examination or examinations to determine the nature and etiology of any and all disabilities of the following: (a) left foot; (b) right foot; (c) left wrist; (d) right wrist; (e) left elbow; (f) right elbow; (g) left shoulder; (h) right shoulder; (i) neck; (j) left knee; (k) right knee; (l) left shin splints; (m) right shin splints; (n) left ankle; (o) right hand, fourth digit; (p) left hamstring; (q) left hip; and (r) right hip. Any related neurologic disabilities, such as radiculopathy or peripheral neuropathy, should also be delineated. Access to the Veteran’s electronic VA claims file should be made available to the examiner for review. (a) Imaging studies should be performed with respect to each, in order to determine whether arthritis is present. (b) The examiner should identify all disabilities currently present, to include, but not limited to, arthritis and radiculopathy. For each diagnosis identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the disorder manifested in or is otherwise causally related to active duty service or any incident therein. (c) If any of the Veteran’s complaints cannot be attributed to any known clinical diagnosis, the examiner should state whether the Veteran exhibits an undiagnosed illness manifested by chronic joint pain and weakness, or a medically unexplained chronic multisymptom illness such as fibromyalgia. If so, the examiner should provide an opinion as to whether any such disorder identified on examination was caused by a supervening condition or event that occurred between the Veteran’s departure from active duty in the Southwest Asia theater of operations and the onset of that disability. (d) For each complaint for which no disorder is diagnosed and is less likely than not an undiagnosed illness or medically unexplained chronic multisymptom illness, the examiner should offer an opinion as to whether it is at least as likely as not that the Veteran experiences pain which is causally related to his active service. If so, the examiner should also describe the functional impairment which results from such pain. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Behlen, Associate Counsel