Citation Nr: 18154890 Decision Date: 12/04/18 Archive Date: 11/30/18 DOCKET NO. 16-17 515 DATE: December 4, 2018 ORDER Restoration of a 10 percent rating for a right hip strain, limitation of flexion is denied. Restoration of a 30 percent rating for migraine headaches is granted. Restoration of a 10 percent rating for right knee strain with residual stress fracture, instability is granted. Restoration of a 10 percent rating for left knee patellofemoral syndrome with chronic strain, instability, is granted. Restoration of a 10 percent rating for left knee patellofemoral syndrome with chronic strain, limitation of flexion, is granted. Restoration of a 10 percent rating for left knee patellofemoral syndrome with chronic strain, limitation of flexion, is granted. An effective date prior to January 31, 2013, for right hip strain, limitation of extension is denied. An effective date for a compensable rating prior to November 4, 2015 for right hip strain, limitation of flexion is denied. An effective date prior to January 31, 2013, for posttraumatic stress disorder is denied. An effective date prior to January 31, 2013, for chronic lumbar strain is denied. An effective date prior to January 31, 2013, for migraine headaches is denied. An effective date prior to January 31, 2013, for left knee patellofemoral syndrome with chronic strain, instability, is denied. An effective date prior to January 31, 2013, for right knee strain with residual stress fracture, instability, is denied. An effective date prior to January 31, 2013, for left knee patellofemoral syndrome with chronic strain, limitation of flexion, is denied. An effective date prior to January 31, 2013, for left knee patellofemoral syndrome with chronic strain, limitation of flexion, is denied. A rating in excess of 10 percent for a right hip strain, limitation of extension is denied. A compensable rating for a right hip strain, limitation of flexion is denied. A rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. A rating in excess of 10 percent for chronic lumbar strain is denied. A rating in excess of 10 percent for left knee patellofemoral syndrome with chronic strain, instability, is denied. A rating in excess of 10 percent right knee strain with residual stress fracture, instability is denied. A rating in excess of 10 percent for left knee patellofemoral syndrome with chronic strain, limitation of flexion, is denied. A rating in excess of 10 percent for right knee strain with residual stress fracture, limitation of flexion, is denied. A rating of 50 percent, but no more, for migraine headaches effective February 5, 2016, is granted subject to the payment of monetary benefits. A rating in excess of 30 percent for migraine headaches prior to February 5, 2016, is. Service connection for chronic fatigue syndrome (CFS) is denied. Service connection for a cyst, bottom of left foot is denied. FINDINGS OF FACT 1. The Veteran had active service from August 2004 to January 2013, including in the Southwest Asia theater of operations. He has been rated at 100 percent disabled based on unemployability since November 2015. 2. At the time of the reduction of rating for a right hip strain, limitation of flexion, from 10 to noncompensable, the Veteran was already compensated for painful limitation of motion for right hip strain, limitation of extension. 3. At the time of the reduction of the rating for migraine headaches from 30 to noncompensable, right and left knee instability, right and left knee limitation of flexion, from 10 percent to noncompensable, the evidence did not demonstrate actual improvement in the Veteran’s ability to function under the ordinary conditions of life and work. 4. The Veteran was service-connected for right hip limitation of extension and flexion, chronic lumbar strain, PTSD, migraine headaches, left and right knee instability, and left and right knee limitation of flexion, on his first day following separation from service. 5. The increase rating for PTSD to 70 percent was effective from the date of the claim. 6. A right hip strain has manifested with subjective complaints of intermittent pain; objective findings include painful motion on flexion and extension. 7. PTSD is manifested by subjective complaints of depression, difficulty sleeping anxiety, avoidance, and trouble maintaining relationships; objective findings include observed depression, irritability, occasional flattened affect, avoidance of PTSD stimuli, nightmares and chronic sleep impairment. 8. Chronic lumbar strain manifested by subjective complaints of pain and painful motion; objective findings include limitation of motion. 9. Left knee disability is manifested by subjective complaints of intermittent pain, stiffness, and instability; objective findings include pain on flexion, extension, and weightbearing, and mild lateral instability. 10. Right knee disability is manifested by subjective complaints of intermittent pain, stiffness, and instability; objective findings include pain on flexion, extension, and weightbearing, and mild lateral instability. 11. Migraine headaches are manifested by subjective complaints of intense head pain, sensitivity to light and sound, nausea during physical activities, and the need to lay down during headaches; objective findings include prostrating migraine headache attacks lasting up to two days or more, that occur multiple times a month, and which have been treated at different points with moderate success by medication. 12. The Veteran does not have a current diagnosis of CFS; his fatigue symptoms are associated with other service-connected disabilities. 13. A left foot cyst was not shown in service and is not causally or etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for restoration of 10 percent rating for right hip strain, limitation of flexion have not been met. 38 U.S.C. § 5112 (2012); 38 C.F.R. §§ 3.105, 3.343-3.344, 4.14 (2017). 2. Resolving reasonable doubt in the Veteran’s favor, the criteria for restoration of a 30 percent rating for migraine headaches have been met. 38 U.S.C. § 5112 (2012); 38 C.F.R. §§ 3.105, 3.343-3.344 (2017). 3. Resolving reasonable doubt in the Veteran’s favor, the criteria for restoration of a 10 percent rating for right knee instability have been met. 38 U.S.C. § 5112 (2012); 38 C.F.R. §§ 3.105, 3.343-3.344 (2017). 4. Resolving reasonable doubt in the Veteran’s favor, the criteria for restoration of a 10 percent rating for left knee instability have been met. 38 U.S.C. § 5112 (2012); 38 C.F.R. §§ 3.105, 3.343-3.344 (2017). 5. Resolving reasonable doubt in the Veteran’s favor, the criteria for restoration of a 10 percent rating for left knee limitation of flexion have been met. 38 U.S.C. § 5112 (2012); 38 C.F.R. §§ 3.105, 3.343-3.344 (2017). 6. Resolving reasonable doubt in the Veteran’s favor, the criteria for restoration of a 10 percent rating for right knee limitation of flexion have been met. 38 U.S.C. § 5112 (2012); 38 C.F.R. §§ 3.105, 3.343-3.344 (2017). 7. The criteria for an effective date prior to January 31, 2013, for right hip limitation of flexion and extension, PTSD, chronic lumbar stain, migraine headaches, left and right knee instability, and left and right knee limitation of flexion, have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.157, 3.400 (2017). 8. The criteria for a compensable rating for a right hip strain, limitation of extension, prior to November 4, 2015 and in excess of 10 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.59, 4.6, 4.7, 4.10, 4.71a, Diagnostic Code (DC) 5251 (2017). 9. The criteria for a rating in excess for 10 percent for a right hip strain, limitation of flexion, prior to February 5, 2016 and a compensable rating thereafter have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.59. 4.6, 4.7, 4.10, 4.71a DC 5252 (2017). 10. The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.130 DC 9411 (2017). 11. The criteria for a rating in excess of 10 percent for chronic lumbar strain have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.59. 4.6, 4.7, 4.10, 4.71a DC 5237 (2017). 12. The criteria for a rating in excess of 10 percent for left knee patellofemoral syndrome with chronic strain, instability, have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.59. 4.6, 4.7, 4.10, 4.71a DC 5257 (2017). 13. The criteria for a rating in excess of 10 percent for right knee strain with residual stress fracture, instability, have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.59. 4.6, 4.7, 4.10, 4.71a DC 5257 (2017). 14. The criteria for a rating in excess of 10 percent left knee patellofemoral syndrome with chronic strain, limitation of flexion, have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.59. 4.6, 4.7, 4.10, 4.71a DC 5260 (2017). 15. The criteria for a rating in excess of 10 percent for right knee strain with residual stress fracture, limitation of flexion, have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.59. 4.6, 4.7, 4.10, 4.71a DC 5260 (2017). 16. The criteria for a rating in excess of 30 percent for migraine headaches prior to February 5, 2016, have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.124a DC 8100 (2017). 17. The criteria for a rating of 50 percent for migraine headaches from February 5, 2016, have been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.124a DC 8100 (2017). 18. Chronic Fatigue Syndrome was not incurred in or caused by active. 38 U.S.C. §§ 1110, 1112, 1131, 5103(a), 5103A (2012); 38 C.F.R. §§ 3.159, 3.303, 3.309 (2017). 19. A cyst, bottom of left foot was not incurred in or caused by active. 38 U.S.C. §§ 1110, 1112, 1131, 5103(a), 5103A (2012); 38 C.F.R. §§ 3.159, 3.303, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As a procedural matter, the Veteran filed a timely notice of disagreement (NOD) for the issue of an earlier effective date grant of a total disability rating for individual unemployability (TDIU). This appeal has been entered in the VACOLS appeals tracking system as an active appeal at the Regional Office (RO). The RO has fully acknowledged the NOD and is currently in the process of adjudicating the claim. As action by the Board could delay the RO’s action on those appeals, the Board will not take jurisdiction of that issue at this time. Further, the Veteran filed a separate NOD on June 7, 2014, in response to the May 2014 rating decision proposing to reduce the ratings of migraine headaches, right knee strain with residual stress fracture limitation of flexion and instability, and left patellofemoral syndrome with chronic strain limitation of flexion and instability. The NOD included all these issues. The RO informed the Veteran that the portion of his NOD referring to proposed reductions was premature, as it was not yet a final determination. The issues were then reduced in a January 2015 rating decision and the reductions became effective in April 2015. The Veteran, despite indicating in the mistimed NOD he believed the proposed reductions were improper, did not file an NOD after the January 2015 rating decision. Instead, he filed a fully developed claim in November 2015, with included all the issues that had been reduced. The RO thus treated this as an entirely new claim, to include new increased ratings claims for the issues that had been reduced only several months before. Given that he prematurely filed an NOD stating his clear intention to contest the reduction of ratings, and subsequently filed a claim for increased ratings only several months after the ratings were reduced, and resolving all reasonable doubt in his favor to achieve maximum benefit for the Veteran, the Board reads his claim to include contesting the reduction of ratings. Reduction Claims The Veteran contests the reductions of rating for migraine headaches from 30 to noncompensable, and right and left knee instability, right and left knee limitation of flexion, from 10 percent to noncompensable effective April 1, 2015, and the reduction of rating from 10 percent to noncompensable for right hip limitation of flexion from February 5, 2016. Considering first the propriety of the reduction, a veteran’s disability will not be reduced unless an improvement in the disability is shown to have occurred. 38 U.S.C. § 1155. Procedurally, where a reduction in rating of a service-connected disability is considered warranted and the lower rating would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance must be prepared setting forth all material facts and reasons. In addition, the VA Regional Office (RO) must notify the veteran that he has 60 days to present additional evidence showing that compensation should be continued at the present level. He is also to be informed that he may request a predetermination hearing, provided that the request is received by VA within 30 days from the date of the notice. If no additional evidence is received within the 60-day period and no hearing is requested, final rating action will be taken and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the veteran expires. 38 C.F.R. § 3.105(e). In cases where a rating has been in effect for five years or more, the rating agency must make reasonably certain that the improvement will be maintained under the conditions of ordinary life even if material improvement in the physical or mental condition is clearly reflected. See Kitchen v. Brown, 7 Vet. App. 320 (1995). A rating that has been in effect for five years or more may not be reduced on the basis of only one examination in cases where the disability is the result of a disease subject to periodic or episodic improvement. 38 C.F.R. § 3.344(a). The five-year period is calculated from the effective date of the rating to the effective date of the reduction. See Brown v. Brown, 5 Vet. App. 413 (1993). If doubt remains, after according due consideration to all the evidence, the rating agency will continue the rating in effect. 38 C.F.R. § 3.344(b). The above requirements do not apply to ratings that have not continued for long periods of five years or more at the same level or to disabilities which have not become stabilized and are likely to improve. Rather, in such cases, reexaminations disclosing improvement, physical or mental, in those disabilities will warrant a rating reduction. 38 C.F.R. 3.344(c). When an RO reduces a rating without following the applicable regulations, the reduction is void ab initio). Greyzck v. West, 12 Vet. App. 288 (1999). The Board must first address whether the reduction was procedurally adequate. As noted, the RO was required to give the Veteran 60 days to submit additional evidence and to request a predetermination hearing. The RO prepared a rating decision proposing the reduction of ratings for migraine headaches from 30 to noncompensable, and right and left knee instability, right and left knee limitation of flexion, from 10 percent to noncompensable on May 14, 2014, setting forth the rationale of the proposed reduction, and notifying the Veteran. The VA took final action and issued a rating decision on January 21, 2015, reducing the rating effective April 1, 2015. For all reduction claims from the January 21, 2015, rating decision, the Veteran was given notice and 30 days to elect a predetermination hearing and failed to do so. He was given 60 days to submit new evidence, which was considered in the January 21, 2015, rating decision. Therefore, he received proper notice and the benefit of other measures under 38 C.F.R. § 3.105(e). The proposed reduction of rating from 10 percent to noncompensable for right hip limitation or flexion in the March 10, 2016, rating decision was not in fact a reduction, but rather a recharacterization of the Veteran’s benefits, and will be discussed below. As to the rest of the reduction claims, the Board will next address whether the disabilities actually improved, thus substantively warranting a reduction in rating. In this regard, the Veteran contends that the RO erred when it reduced the ratings on appeal because his disabilities had not improved, and the VA examination that precipitated the reductions was inadequate. Migraine Headaches Turning to the individual disabilities, migraine headaches are rated under DC 8100. The Veteran was rated at 30 percent for characteristic prostrating attacks occurring on an average once a month over the last several months. The proposed reduction was due to VA medical records not showing and an April 2014 examiner not finding characteristic prostrating attacks, complaints of headache pain, or medication prescribed to treat migraines. The Veteran has claimed that the April 2014 examiner, whose findings precipitated the proposed reduction, did not address his subjective complaints of pain. During a December 2014 VA examination, the Veteran reported he had migraines once every two weeks, which lasted most of the day, and had to lay down for most of the day, with headache pain all over the head. He reported using Sumatriptan to treat his migraines, which helped somewhat. The examiner found, although did not explain her reasoning, that these were not prostrating attacks. An August 2014 VA treatment note showed that he complained of at-least weekly migraines. Finally, several months after the reduction, a February 2016 examiner found that the Veteran had prostrating attacks of headache pain, more frequently than once a month. If strictly construed, the symptoms reported by the December 2014 examiner and the April 2014 examiner were insufficient for a rating of 30 percent for DC 8100, given the lack of prostrating attacks. As noted above, in a rating reduction case, it is not sufficient to show that an improvement in a disability has actually occurred. That is, it is not sufficient to show that the Veteran’s migraine headache symptoms had decreased in severity. Instead, the evidence must also demonstrate that any such improvement actually reflected an improvement in his ability to function under the ordinary conditions of life and work. See Brown v. Brown, 5 Vet. App. 420-21 (1993). However, the second requirement has not been met in this case. The December 2014 examiner and the subsequent February 2016 examiner described similar symptoms, but only the latter described them as prostrating attacks. The Veteran consistently maintained that he has multiple migraine headaches a month, which caused him to lay down for a day or more due to the pain. The evidence does not show, despite the December 2014 and April 2014 examiners’ contentions, that he did not have prostrating attacks, that his headache symptoms had improved his ability to function under the ordinary conditions of life and work. In totality, the Veteran’s lay assertions, supporting medical evidence, and lack of evidence showing an improvement in his ability to function under the ordinary conditions of life and work do not show improvement sufficient for reduction. For these reasons, and resolving reasonable doubt in the Veteran’s favor, the Veteran’s migraine headaches symptoms have remained relatively consistent throughout the relevant appeal period. As such, the weight of the evidence does not show an improvement of his migraine headaches that are reasonably certain to be maintained under the ordinary conditions of life. Accordingly, restoration of a 30 percent rating is warranted, and the appeal is granted. Bilateral Knee Disability, Limitation of Motion and Instability Next, the Veteran is service-connected for four separate rating for knee disabilities, DC 5260 for flexion and DC 5257 for instability, bilaterally. He was rated at 10 percent for each disability. He was rated under DC 5260 for painful motion and limitation of flexion. The proposed reduction was due to VA medical records not showing and an April 2014 examiner not finding objective evidence of pain on motion or knee instability. The Veteran has claimed that the April 2014 examiner whose findings precipitated the proposed reduction did not address his subjective complaints of pain. A December 2014 examiner also found no objective medical evidence of painful motion or joint instability. A February 2016 examiner following the reduction found significant limitation of motion, and pain of on flexion for both knees, as well as instability of station, with slight lateral instability. The Veteran has maintained he experienced knee pain and knee instability throughout the entire appeals period. As noted above, in a rating reduction case, it is not sufficient to show that an improvement in a disability has actually occurred. That is, it is not sufficient to show that the Veteran’s knee symptoms had decreased in severity. Instead, the evidence must also demonstrate that any such improvement actually reflected an improvement in his ability to function under the ordinary conditions of life and work. See Brown v. Brown, 5 Vet. App. 420-21 (1993). Although there is medical evidence suggesting his condition had resolved during the reduction, the Veteran has provided competent lay evidence that his disabilities were maintained during this period. Further, there is evidence of the symptoms he described shown in the February 2016 VA examination as well as evidence beforehand. While it is theoretically possible that the knee symptoms had resolved in 2014 to 2015, and reemerged in early 2016, it is reasonable to conclude that his lay assertions of knee pain on motion and knee instability during that period were accurate, and therefore that despite objective evidence showing improvement, his knee disabilities had not improved sufficient to reflect an actually improved ability to function under the ordinary conditions of life and work. For these reasons, and resolving reasonable doubt in the Veteran’s favor, the knee disabilities have remained relatively consistent throughout the relevant appeal period. As such, the weight of the evidence does not show an improvement of his knee disabilities that is reasonably certain to be maintained under the ordinary conditions of life. Accordingly, restoration of a 10 percent rating is warranted for all four reduced knee disabilities, and the appeals are granted. Right Hip Strain, Limitation of Flexion The Veteran claims the reduction of the 10 percent rating for limitation of flexion, right hip strain, was improper. Unlike the other reduction issues on appeal and despite the language used by the RO, this is not an actual reduction of rating. A veteran may be entitled to a minimum compensable rating for painful motion of a single joint under 38 C.F.R § 4.59. It was by this provision that the 10 percent rating for right hip strain limitation of flexion was originally assessed. In the same March 10, 2016, rating decision in which the above reduction was effectuated, the RO assigned a 10 percent rating under DC 5251 for limitation of extension of the right hip due to painful motion as described by 38 C.F.R. § 4.59. So, while couched in the language of a reduction, the RO rather recharacterized the compensation to fall under his service-connected limitation of extension rather than flexion. Further, in doing so, given that limitation of flexion was decreased effective February 5, 2016, and the 10 percent for limitation of extension was effective November 4, 2015, the Veteran was in fact compensated for both extension and flexion between those dates. Therefore, rather than a reduction, despite the language used by the RO, this was a recharacterization of benefits on appeal that caused no harm and did not result in a reduction of benefits. The Board considered the Veteran’s lay statements that his disability should not have been decreased, but restoring the rating would doubly compensate him for the same symptoms. 38 C.F.R. § 4.14. Accordingly, restoration of a 10 percent rating for limitation of flexion would be inappropriate given the procedural history and would constitute an additional period of unlawful pyramiding, and the appeal to restore the rating for right hip flexion is denied. Earlier Effective Date Claims Except as otherwise provided, the effective date of an evaluation and award for pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after a final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. A specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by VA. 38 U.S.C. § 5101(a). A “claim” is defined as a formal or informal communication, in writing, requesting a determination of entitlement, or evidencing a belief in entitlement to a benefit. 38 C.F.R. §§ 3.1(p), 3.151. The essentials for any claim, whether formal or informal, are: 1) an intent to apply for benefits; 2) and identification of the benefits sought; and 3) a communication in writing. Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). The date of a receipt of a claim is the date on which a claim, information, or evidence is received by VA. 38 C.F.R. § 3.1(r). The Veteran is currently-assigned an effective date of January 31, 2013, for right hip limitation of flexion and extension, PTSD, chronic lumbar strain, migraine headaches, left and right knee instability, and left and right knee limitation of flexion. That date corresponds to the first date in which he separated from service. He is not entitled to service connection prior to separation. For all disabilities listed other than PTSD and right hip limitation of extension, following the restoration of ratings discussed above, the evaluations have been consistent since separation from service. As such, there are no staged ratings for which the Veteran to argue are entitled to an earlier effective date. As for PTSD, his claim for increase was filed in November 4, 2015, which is also the effective date of his increased 70 percent rating. The RO used this date rather than that of the February 4, 2016, VA examination which precipitated the increase. Given that the medical evidence does not show an increase in the year before filing, the earliest possible effective date for his increased rating claim was the date that the claim was received. As such, he does not warrant an effective date for the increased 70 percent rating for PTSD prior to the date of his claim. The Board has considered statements from the Veteran asserting that he should be entitled to an earlier effective date for his service-connected disabilities. However, the effective date is the date of receipt of the claim or the date entitlement arose, whichever is the later. He does not warrant an effective date that precedes his separation from service. His appeal for an earlier effective date for a right hip strain, limitation of extension, may also be construed to mean the Veteran believes the increase of rating for November 4, 2015, to 10 percent warrants an earlier effective date. However, as noted above, although misconstrued as a reduction and increase of rating, he has been compensated alternatively for right hip strain, limitation of extension and flexion for painful motion. As he is not entitled to a compensable rating for either flexion or extension due to limitation of range of motion alone, painful motion may not be assessed for both without becoming unlawful pyramiding. Therefore, an earlier effective date for the 10 percent rating effective November 4, 2015 of 10 percent is not warranted, and all claims for an earlier effective date are denied. Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Right Hip Strain The Veteran is rated at 10 percent for limitation of flexion under DC 5252 from January 31, 2013, to February 5, 2016, and a noncompensable rating thereafter. He was also rated at zero percent for limitation of extension under DC 5251 from January 31, 2013, to November 4, 2015, and 10 percent thereafter. It should be noted that the 10 percent rating was due to painful motion under 38 C.F.R. § 4.59. The period in which he was assessed 10 percent for both DC 5251 and 5252, was unintentional pyramiding. To warrant a higher rating for a right hip strain, the evidence must show: • favorable ankylosis of the hip in flexion at an angle between 20 and 40 degrees, and slight adduction or abduction (60 percent under DC 5250); • extension of the thigh limited to 5 degrees (10 percent under DC 5251); • flexion of the thigh limited to 45 degrees (10 percent under DC 5252); • flexion of the thigh limited to 30 degrees (20 percent under DC 5252); • limitation of rotation of the thigh, cannot toe-out more than 15 degrees, affected leg (10 degrees under DC 5253); • flail joint, hip (80 degrees under DC 5254); or, • malunion of the femur with moderate knee or hip disability (20 percent under DC 5255). Turning to the evidence, the Veteran has not claimed, VA medical records have not shown, and VA examiners in March 2012, February 2016, and May 2018 have affirmatively not found, any ankylosis of the hip, flail join of the hip, or malunion of the femur. As such, a higher rating under DCs 5250, 5254, and 5255 is not warranted. As to limitation of motion, the evidence does not show sufficient limitation of rotation for a higher rating. Specifically, the March 2012 examiner noted that the limitation of rotation was not such that that Veteran was unable to toe-out more than 15 degrees. The February 2016 examiner measured external and internal rotation limited to 45 degrees, with no change with repetitive use testing. The examination occurred during a flare-up. The May 2018 examiner found no limitation of rotation at all. A review of the VA medical records fails to show any measurement of limitation of rotation sufficient for a higher or separate rating. A such, the medical evidence weighs against a higher rating under DC 5253. Turning next to limitation of flexion, the March 2012 examiner found the Veteran’s flexion to be unlimited, but with painful motion. The February 2016 examiner found flexion limited to 100 degrees. As with rotation, the May 2018 examiner found no limitation of flexion. As for limitation of extension, the March 2012 examiner found no limitation of extension, however the measurement was restricted to 0, 5, or greater than 5 millimeters. As such, there is no precise measurement, although painful motion was noted at “5+.” The February 2016 examiner measured extension as limited to 25 degrees, and the May 2018 examiner found no limitation of extension. A review of the VA medical records does not show any measurements of hip limitation of motion, and only sporadic reports of pain. For example, in August 2015 he complained of some pain in his hips and his knees that was “on and off.” Given the lack of medical evidence that supports a higher rating due to limitation of motion, the medical evidence weighs against a higher rating. PTSD The Veteran filed a claim for an increased rating for PTSD on November 17, 2015. The RO increased his rating from 50 percent to 70 from that date. Accordingly, the Board must determine a rating in excess of 70 for that period is warranted. A 100 percent evaluation for a psychiatric disability is warranted for total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The Veteran was examined twice during the appeals period. The February 2016 examiner diagnosed him with moderate PTSD with occupational and social impairment with deficiencies in most areas. The examiner also noted that some issues with judgment and aggression predated service, and that there were overlapping symptoms as residuals of a traumatic brain injury, as well as due to a history of ADHD. The Veteran’s symptoms included depressed mood, anxiety, suspiciousness, panic attacks more than once per week, chronic sleep impairment, mild memory loss, flattened affect, difficulty in understanding complex commands, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, neglect of personal appearance and hygiene, irritability and anger, and a low appetite. While the examiner noted this broad range of symptoms, none align with the symptomatology required to warrant a 100 percent rating, nor did the examiner’s summation of the occupation and functional impairment caused by the symptoms rise to that level. A May 2018 examiner diagnosed the Veteran with PTSD, but also cannabis and alcohol use disorders, and noted it made it difficult assess PTSD alone given there may be some overlapping symptomatology. The examiner found that the Veteran’s PTSD caused occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, or equivalent to a 30 percent rating. The Veteran noted that he had stopped psychotherapy because he believed medication alone could adequately manage his symptoms. He described good relationships with his girlfriend and children, although stated he did not have friends where he lived. The examiner related symptoms of depressed mood, anxiety, and chronic sleep impairment, with difficulty adapting to stressful circumstances, including work or a worklike setting. Additionally, PTSD caused irritable behavior, sleep disturbance, hypervigilance, recurring dreams, and avoidance of external reminders of stressors. The examiner concluded that the Veteran’s current level of symptoms might cause some reduced reliability in occupation that require a great deal of social contact and interaction with others due to anxiety and avoidance. VA medical records similarly fail to show the degree of impairment necessary for a 100 percent rating. For example, a February 2016 VA treatment note showed he complained of nightmares and fragmented sleep but had no hallucinations, fair memory, full range of affect, and no suicidal or homicidal ideation. During an October 2015 VA psychiatric appointment, symptoms included irritability, nightmares, flashbacks, but he also demonstrated full range of affect, no hallucinations, coherent thought processes and intact associations, with fair memory, insight, and judgment. In June 2017, a VA clinician diagnosed the Veteran with chronic PTSD and major depression, with symptoms of moderate free-floating anxiety, insomnia, nightmares, hyperarousal, anhedonia, panic attacks, but no suicidal or homicidal ideation, no delusions or hallucinations or mania, summarized as moderate symptoms. The PTSD symptoms were deemed moderate. In summation, while the examiners and various medical professionals who treated the Veteran during the appeal period note some variance in the severity of his symptomatology, none found his symptoms caused total occupational and social impairment. Similarly, the symptoms did not include any of the representative symptoms listed in the rating criteria for a 100 percent rating. As such, the medical evidence weighs against the claim. Chronic Lumbar Strain The Veteran claims he is entitled to a rating in excess of 10 percent for a chronic lumbar strain. He is currently rated under DC 5237 and 38 C.F.R § 4.59 for painful motion. To warrant a higher rating the evidence must show: • forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees (20 percent); • combined range of motion of the thoracolumbar spine not greater than 120 degrees (20 percent); • muscle spasms or guarding that is severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis (20 percent); • incapacitating episodes of intervertebral disc syndrome based on incapacitating episodes IVDS having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months (20 percent); or, • in the absence of limitation of motion, degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations (20 percent). Turning to the evidence, VA examiners in May 2018, February 2016, and March 2012 did not diagnose him with IVDS and his treatment records are also absent any such diagnosis. Next, after consulting X-ray evidence, a May 2018 examiner diagnosed the Veteran with lumbar strain – the diagnosis for which he is service-connected – and degenerative disc disease (DDD). However, the VA examiner noted that the DDD was not related to the first diagnosis. As such, while there is a diagnosis of DDD, he is not service connected for that disorder. Further, the evidence does not show X-ray evidence of two major joints, or two or more minor joints with any incapacitating exacerbations consistent with arthritis. Turning to limitation of motion, during the most recent May 2018 examiner found no limitation of motion, flexion combined range of motion, including with pain or after repetitive use. The February 2016 examiner measured forward flexion to 70 degrees, with a combined range of motion of 165 degrees, with no additional loss for pain or repetitive use. Finally, the March 2012 examiner measured flexion to 70 degrees and combined range of motion restricted to 190 degrees, however with a decreased after repetitive use testing to 170. The VA treatment records do not document forward flexion or combined range of motion sufficient for a higher rating. Finally, all three VA examiners did not find muscle spasms or guarding due to a service-connected back disability. A review of his treatment records shows treatment for back pain, but not for muscle spasms or guarding. Similarly, no medical professional has noted that the Veteran had an altered gait due to his service-connected back disability. As such, the medical evidence weighs against warranting a rating in excess of 10 percent. Left Knee Disability The Veteran is rated under DC 5260 for limitation of flexion of the leg and 38 C.F.R. § 4.59 regarding painful motion for both knees, at 10 percent for the entirety of the appeals period, and DC 5257 for instability of the knee rated at 10 percent for the entirety of the appeals period. The Board will also consider all potentially relevant diagnostic codes. In order to warrant a higher rating, the evidence must show: • ankylosis of the knee with a favorable angle in full extension or in slight flexion between 0 and 10 degrees (30% under DC 5256); • moderate recurrent subluxation or lateral instability (20% under DC 5257); • dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint (20% under DC 5258); • flexion of the knee limited to 30 degrees (20% under DC 5260); • extension of the knee limited to 15 degrees (20% under DC 5261); or, • impairment of the tibia or fibula with a moderate knee disability (20% under DC 5262). Turning to the evidence, VA examiners in March 2012, April 2014, December 2014, and February 2016 all found no evidence of ankylosis. Similarly, while the Veteran was treated for left knee pain, at no point did he allege or did a VA or private clinician find that his left knee was ankylosed at any angle. As such, the medical evidence does not support a higher rating under DC 5256. Next, the Veteran is service-connected for left patellofemoral syndrome with chronic strain. He has not claimed, nor does evidence show, that he had meniscal surgery, or has dislocated semilunar cartilage. Each VA examiner confirmed the lack of dislocated semilunar cartilage in his left knee. As such, the medical evidence weighs against a higher rating under DC 5258. Similarly, none of the VA examiners, the Veteran himself, or his treatment records, note any impairment of the tibia or fibula in his left leg. As such, the medical evidence does not support a higher rating under DC 5262. As to limitation of motion, the February 2016 examiner found the Veteran’s left knee flexion and extension as limited to 90 degrees after repetitive use and with pain. The examination purportedly occurred during a flare-up of his disability. The December 2014 and April 2014 examiners found no limitation of motion for flexion or extension of the left knee. Finally, the March 2012 examiner found no limitation of motion for flexion or extension of his left knee. No VA or private medical records showed measurements of limitation of motion sufficient to warrant a higher rating. VA treatment records for the Veteran’s knees, for example in August 2015, December 2014, and August 2014, centered around knee pain, rather than on marked restriction of range of motion. As such, the medical evidence weighs his symptoms warranting a higher rating for limitation of range of motion. Finally, the medical evidence shows some degree of left knee instability. The March 2012 examiner only found instability in his right knee, not left. Similarly, April 2014 and December 2014 examiners found no left knee joint instability. The February 2016 examiner noted instability of station on the left side, and slight lateral instability, with 1+ (0-5 millimeters) of lateral instability. Thus, weight of the evidence does not show lateral instability, and the only one that did measure described his lateral instability as slight. The VA examiners collectively did not find any history of subluxation. As for VA medical records, none show objective tests noting more than the 1+ (0-5 millimeters) of lateral instability measured by the February 2016 examiner. Given that there is insufficient medical evidence in the file showing a moderate degree of lateral instability, the evidence weighs against his symptoms warranting a higher rating under DC 5257. Right Knee Disability The Veteran’s right knee disability is rated under the same two diagnostic codes at 10 percent for painful motion and instability as his left knee. Thus, the same rating criteria apply. Turning to the evidence, VA examiners in March 2012, April 2014, December 2014, and February 2016 all found no evidence of ankylosis in the Veteran’s right knee. Similarly, while he was treated for right knee pain, at no point was did he allege or a VA or private physician state his right knee was ankylosed at any angle. As such, a rating in excess of 10 percent under DC 5256 is not warranted by the medical evidence. Next, the Veteran is service-connected for a right knee strain with residual stress fracture. He has not claimed, nor does evidence show, that he had meniscal surgery, or had dislocated semilunar cartilage in his right knee. Each VA examiner confirmed the lack of dislocated semilunar cartilage in his right knee. As such, the medical evidence weighs against a higher rating under DC 5258. In contrast, he did have a stress fracture and thus potentially a tibial or fibular impairment under DC 5256. The March 2012 examiner noted that the residual of this stress fracture was mild tenderness. However, the March 2012 VA examination occurred prior to separation form service. In the three examinations following separation, no residual from the right leg stress fracture was noted. Similarly, his VA treatment records do not show any separate impairment of the tibia or fibula that is not compensated by the 10 percent ratings for painful motion and instability. As such, a rating in excess of 10 percent under DC 5256 is not warranted and the medical evidence weighs against the claim. As to limitation of motion, the February 2016 examiner measured the Veteran’s right knee flexion and extension as limited to 90 degrees after repetitive use and with pain. The examination purportedly occurred during a flare-up of his disability. The December 2014 and April 2014 examiners found no limitation of motion for flexion or extension of the right knee. Finally, the March 2012 examiner found the Veteran’s right knee flexion was limited to 135, with no change after repetitive-use testing, with painful motion at 100, and no corresponding limitation of extension. No VA or private medical records showed measurements of limitation of motion sufficient to warrant a higher rating. VA treatment records for his knees, for example in August 2015, December 2014, and August 2014, centered around knee pain, rather than on marked restriction of range of motion. As such, the medical evidence weighs against his symptoms warranting a higher rating for limitation of range of motion. Finally, the medical evidence shows some degree of right knee instability. The March 2012 examiner measured anterior and posterior instability at 1+ (0-5 millimeters). However, April 2014 and December 2014 examiners found no right knee joint instability. The February 2016 examiner then noted instability of station on the left side, and slight lateral instability, with 1+ (0-5 millimeters) of lateral instability, but no anterior or posterior instability. Thus, the VA examiners that found evidence of instability, measured it as slight, and only the February 2016 examiner in fact noted lateral instability. The VA examiners collectively did not find any history of subluxation. As for VA medical records, none show objective tests noting more than the 1+ (0-5 millimeters) of lateral instability measured by the February 2016 examiner. Given that there is insufficient medical evidence in the file showing a moderate degree of lateral instability, the evidence weighs against his symptoms warranting a higher rating under DC 5257. Migraine Headaches The Veteran is currently rated at 30 percent under DC 8100 for migraine headaches. To warrant the next highest rating, of 50 percent, the evidence must show very frequent prostrating and prolonged attacks productive of severe economic inadaptability. Turning to the evidence, no VA examiner has characterized the Veteran’s migraine symptoms as very frequent prostrating and prolonged attacks productive of severe economic inadaptability. The March 2012 examiner found that the Veteran took several medications for his headache pain, which manifested with constant head pain, pulsating or throbbing and localized to the right side of his head and that worsens with physical activity and causes nausea and sensitivity to light and sound. The examiner characterized the migraines as prostrating attacks, more frequently than once per month. However, the VA examiner from the first examination occurring after separation from service, in April 2014, found that the Veteran was then taking only Tylenol to treat his migraines, and that sleeping usually helped, and further noted that the Veteran reported if one struck while he was at school, he would, “suck it up,” until it went away. He continued that he had not had one of the full-day bad headaches recently, although he did describe the nature of his headaches similarly to the examination that occurred in service. That he was able to function until headaches faded led the VA examiner to note that he had no characteristic prostrating headaches. He reported to the December 2014 examiner that he had a migraine once every two weeks, and that they lasted most of the day, and that he would go and lay down when they occurred. The examiner construed these as non-prostrating attacks. However, given that his migraines forced him to lay down for most of the day, and that the rating criteria does not define “prostrating attacks,” it is reasonable to find that these migraines were sufficiently incapacitating to qualify as prostrating. However, even if so construed, the frequency of migraines every other week, or approximately twice per month, does not rise to the level of very frequent, especially when combined with the reduced frequency of migraines he reported during the April 2014 VA examination a few months before. During the Veteran’s February 2016 VA examination, he reported that his headaches had worsened. His migraine headaches lasted over two days, occurring spontaneously, and a level of severity such that the examiner found them to be prostrating. The examiner also noted that the attacks were occurring more frequently than once per month, and considered them to be very frequent prostrating and prolonged attacks, with the functional impact that the sensitivity to light and noise made it difficult to focus or participate in activities requiring physical exertion. In combination with other service-connected disabilities, the functional impairment of the Veteran’s migraine headaches contributed to the grant of a total disability rating for individual unemployability. Given that the attacks were considered very frequent, prostrating, and prolonged by a VA examiner, and VA has already adjudged migraine headaches to be partially responsible for the Veteran’s unemployability, a rating of 50 percent is warranted from the February 5, 2016, the date of the examination. With respect to all the increased rating claims, the Board has considered the Veteran’s lay statements that his disabilities on appeal are worse. While he is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, Layno v. Brown, 6 Vet. App. 465, 470 (1994), he is not competent to identify a specific level of disability of these disorders according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which these disabilities are evaluated. Moreover, as the VA examiners have the requisite medical expertise to render medical opinions regarding the degree of impairment caused by the disability and had sufficient facts and data on which to base the conclusion, the Board affords the medical opinions great probative value. As such, these records are more probative than the Veteran’s subjective evidence of complaints of increased symptomatology. In sum, after a careful review of the evidence of record, the benefit of the doubt rule is not applicable and the appeals for increased ratings for a left and right knee disabilities, PTSD, right hip disabilities, and a chronic lumbar strain are denied. As noted above, a rating of 50 percent from February 5, 2016, for migraine headaches, is granted to that extent. Service Connection Claims Service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a presumptive basis for diseases listed in § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may also be granted on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability, including an undiagnosed illness or a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and other functional disorders. The disability must manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than the date designated by statute. An undiagnosed illness is one which, by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317; 81 Fed. Reg. 71, 382-84 (Oct. 17, 2016). Chronic Fatigue Syndrome The Veteran claims he has CFS caused by active duty service. CFS is a chronic multi-symptom illness and thus service connection on a presumptive basis due to qualifying Persian Gulf service may be warranted. Turning first to the evidence, the first element of service connection is a current disability. An April 2014 examiner found no diagnosis of CFS, despite complaints of fatigue during service. Similarly, the Veteran told the examiner he believed his fatigue derived from PTSD. August 2014 and May 2017 VA medical records note insomnia and nightmares caused by psychiatric disorders. May 2018, February 2016, and January 2014 VA examiners all found chronic sleep impairment associated with PTSD. As such, there is no current diagnosis of CFS, and no undiagnosed illness of fatigue given that the symptoms are associated with a separate service-connected disability. The medical evidence therefore weighs against service connection. Cyst, Left Foot The Veteran claims he has a cyst, left foot, caused by active duty service. He has not claimed it was due to a service-connected disability and it is not a presumptive disease. As such, only direct service connect is for application. Turning to the evidence, the first element of service connection – a current disability – is met. An April 2014 examiner diagnosed the Veteran with a nodule mid-arch of left foot. An October 2014 VA MRI showed a soft tissue nodule consistent with plantar fibroma. April 2015 and November 2015 VA medical professionals noted a left foot mass and benight growth suspected to be plantar fibroma respectively. As such, the first element of service connection is met. Next, the second element of service connection – an in-service incurrence – has not been met. A review of the Veteran’s STRs do not show a diagnosis of, treatment for, or complaints of a left foot cyst or plantar fibroma. He was treated for bilateral heel blisters in May 2008, but no growth or mass on the mid-arch of his left foot. As such, service connection on a direct basis is not warranted by the evidence. Similarly, although the Veteran is a Persian Gulf veteran, he has a current diagnosis, and as such may not be service connected for an undiagnosed illness. Plantar fibroma is not a chronic disability or a medically unexplained chronic multi-symptom illness. Therefore, service connected is not warranted due to qualifying service in the Persian Gulf. With respect to the claims for service connection for both a cyst, left foot and CFS, the Board has considered the Veteran’s lay statements that his claims were caused by service. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not competent to offer an opinion as to the etiology of his current disorders due to the medical complexity of the matters involved. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462. Such competent evidence has been provided by the medical personnel who have examined the Veteran during the current appeal and by service records obtained and associated with the claims file. Here, the Board attaches greater probative weight to the examination report and clinical findings than to his statements. As such, the medical records are more probative than the Veteran’s lay assertions of a connection with service. In sum, after a careful review of the evidence, the benefit of the doubt rule is not applicable and the appeals are denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (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). L. HOWELL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Brendan A. Evans, Associate Counsel