Citation Nr: 18158272 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 16-52 272 DATE: December 14, 2018 ORDER Entitlement to service connection for bilateral pes cavus is denied. Entitlement to service connection for costochondritis (rib pain) is denied. Entitlement to an initial rating in excess of 10 percent for right wrist tendonitis is denied. Entitlement to an initial rating in excess of 10 percent for left wrist tendonitis is denied. Entitlement to an initial compensable rating for onychomycosis of the left big toenail is denied. Entitlement to an initial rating in excess of 30 percent for migraine headaches is denied. Entitlement to an initial rating in excess of 70 percent for post-traumatic stress disorder (PTSD) is denied. REMANDED Entitlement to an initial rating in excess of 20 percent for lumbar strain is remanded. Entitlement to an initial rating in excess of 10 percent for patellofemoral pain syndrome, left knee is remanded. Entitlement to an initial rating in excess of 10 percent for patellofemoral pain syndrome, right knee is remanded. Entitlement to an initial compensable rating for right ankle strain prior to July 14, 2016, and in excess of 10 percent on and after July 14, 2016 is remanded. Entitlement to an initial compensable rating for left ankle strain prior to July 14, 2016, and in excess of 10 percent on and after July 14, 2016 is remanded. Entitlement to an effective date earlier than July 14, 2016 for the assignment of a 10 percent rating for right ankle strain is remanded. Entitlement to an effective date earlier than July 14, 2016 for the assignment of a 10 percent rating for left ankle strain is remanded. FINDINGS OF FACT 1. The Veteran has not had pes cavus at any time during the claim and appeal. 2. The Veteran has not had costochondritis at any time during the claim and appeal. 3. The Veteran's right wrist tendonitis has been manifested by complaints of pain and objective evidence of tenderness and decreased range of motion, but not ankylosis. 4. The Veteran’s left wrist tendonitis has been manifested by complaints of pain and objective evidence of tenderness and decreased range of motion, but not ankylosis. 5. The Veteran's onychomycosis of the left toenail has not affected at least 5 percent of the exposed or unexposed areas, and has not required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than 6 weeks during any 12-month period. 6. The Veteran's migraine headaches have not resulted in frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 7. Throughout the entire period on appeal, the Veteran's PTSD most nearly approximates deficiencies in most areas of work, school, family relationships, thinking, judgment, and mood without total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for pes cavus have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for costochondritis (rib pain) have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. The criteria for an initial rating in excess of 10 percent for right wrist tendonitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5024-5215. 4. The criteria for an initial rating in excess of 10 percent for left wrist tendonitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5024-5215. 5. The criteria for an initial compensable rating for onychomycosis of the left big toenail have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, DC 7820. 6. The criteria for an initial rating in excess of 30 percent for migraine headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.10, 4.124a, Diagnostic Code 8100. 7. Throughout the entire period on appeal, the criteria for a disability rating in excess of 70 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.130 Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 2008 to July 2012. This matter comes before the Board of Veterans’ Appeal (hereinafter Board) on appeal from a November 2012 rating decision, which granted service connection for PTSD, rated as 50 percent disabling; service connection for lumbar strain, rated as 20 percent disabling; service connection for left and right wrist tendonitis, each rated as 10 percent disabling; service connection for right knee chondromalacia, rated as 10 percent disabling; service connection for left knee tendonitis, rated as 10 percent disabling; service connection for right and left ankle tendonitis, rated as 0 percent disabling; service connection for onychomycosis of the left big toenail, rated as 0 percent disabling; and service connection for migraine headaches rated as 0 percent disabling. That rating decision also denied service connection for bilateral pes cavus and service connection for costochondritis. The Veteran perfected a timely appeal to the ratings assigned and the denial of service connection. By a Decision Review Officer's (DRO) decision, dated in August 2016, the RO increased the rating for PTSD from 50 to 70 percent disabling, effective July 31, 2012; the RO also increased the rating for migraine headaches from 0 to 30 percent, effective July 31, 2012; and the rating for left and right ankle strain was increased from 0 to 10 percent each, effective July 16, 2016. As the maximum benefit was not granted, the issues remain in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). In the November 2012 rating decision, the RO granted service connection for tinnitus and assigned a 10 percent rating; the RO assigned an effective date of July 31, 2012 for the grant of service connection for PTSD, lumbar strain, bilateral wrist tendonitis, bilateral knee patellofemoral pain syndrome, tinnitus, bilateral ankle strains, onychomycosis of the left big toenail, and migraine headaches. A notice of disagreement (NOD) was received in November 2013. A statement of the case (SOC), addressing those issues was issued in August 2016. However, on her substantive appeal (VA Form 9), received in October 2016, the Veteran indicated that she was appealing everything, except for an increased rating for tinnitus and the effective dates for service connection; she indicated that she was dropping her pursuit of these claims. Therefore, these issues are not in appellate status and will not be addressed by the Board at this time. See 38 U.S.C. §§ 7104, 7105 (2012); 38 C.F.R. §§ 20.101, 20.200, 20.201, 20.202 (2017). Service Connection The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (a) (2017). "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) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). With any claim for service connection (under any theory of entitlement), it is necessary for a current disability to be present. See Brammer v. Derwinski, 3 Vet. App. 223 (1992); see also McClain v. Nicholson, 21 Vet. App. 319 (2007) (service connection may be warranted if there was a disability present at any point during the claim period, even if it is not currently present); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (when the record contains a recent diagnosis of disability immediately prior to a veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency). The Veteran can provide competent reports of factual matters of which he has first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Similarly, laypersons are competent to diagnose and provide nexus opinions to some extent, notably where the diagnosis or opinion is not of a complex nature. Id., see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. Entitlement to service connection for bilateral pes cavus The Veteran essentially contends that she developed pes cavus as a result of her duties in service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of bilateral pes cavus and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The November 2011 VA examiner evaluated the Veteran and determined that, while she experienced subjective symptoms of pain, stiffness and swelling, there was no pathology to render a diagnosis of pes cavus. Further, despite consistent treatment from September 2012 to October 2015 VA and private treatment records do not contain a diagnosis of bilateral pes cavus. As the examiner reviewed the record, physically examined the Veteran, and conducted appropriate testing, the Board finds the assessment probative. Lacking a current diagnosis for bilateral pes cavus, the cornerstone element of service connection has not been met. Brammer v. Derwinski, 3 Vet. App. at 225. As such, service connection is not warranted on any basis. While the Veteran believes that she has a current bilateral pes cavus disability, she is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education/knowledge of the orthopedic system. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). As the evidence does not show that the Veteran has any expertise in medical matters involving complex medical questions, the Board concludes that the Veteran’s assertions in this regard are not competent and therefore not probative of whether she currently has costochondritis that is related to service. Consequently, the Board gives more probative weight to the competent medical evidence. The Board has considered the Veteran’s description of symptoms but finds that she does not have a current disability of pes cavus due to disease or injury, either disease or injury at the time of service, or since. In light of the evidence, the Board finds that the preponderance of the evidence does not support service connection for pes cavus. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not helpful to this claimant. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. 2. Entitlement to service connection for costochondritis (rib pain) The Veteran maintains that he has a chest condition, namely costochondritis, which had its onset in service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of costochondritis and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303 (a), (d). The November 2011 VA examiner evaluated the Veteran and determined that, while she experienced subjective symptoms of constant chest pain, there was no pathology to render a diagnosis of costochondritis. Further, despite regular treatment from September 2012 to October 2015, VA treatment records do not contain a diagnosis of costochondritis. As the examiner reviewed the record, physically examined the Veteran, and conducted appropriate testing, the Board finds the assessment probative. Lacking a current diagnosis for costochondritis, the cornerstone element of service connection has not been met. Brammer v. Derwinski, 3 Vet. App. at 225. As such, service connection is not warranted on any basis. While the Veteran believes that she has a current diagnosis of costochondritis, she is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education/knowledge of the musculoskeletal system. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). As the evidence does not show that the Veteran has any expertise in medical matters involving complex medical questions, the Board concludes that the Veteran's assertions in this regard are not competent and therefore not probative of whether she currently has costochondritis that is related to service. Consequently, the Board gives more probative weight to the competent medical evidence. The Board has considered the Veteran's description of symptoms but finds that she does not have a current disability of costochondritis due to disease or injury, either disease or injury at the time of service, or since. In light of the evidence, the Board finds that the preponderance of the evidence does not support service connection for costochondritis. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not helpful to this claimant. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. Increased Rating 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 determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). 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). The Board observes that the words "slight," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2017). It should also be noted that use of descriptive terminology such as "mild" by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 U.S.C. § 7104 (a) (2012); 38 C.F.R. §§ 4.2, 4.6. 3. Entitlement to an initial rating in excess of 10 percent for right and left wrist tendonitis The Veteran's right and left wrist tendonitis are each currently rated as 10 percent disabling under Diagnostic Codes 5024-5215 for limitation of motion of the wrists. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Diagnostic Code 5024 pertains to tenosynovitis and provides for rating the service-connected disability based on limitation of motion of the affected part as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5024. Degenerative arthritis is evaluated under Diagnostic Code 5003 and provides a rating of 10 percent for noncompensable limitation of motion of an involved joint confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Limitation of motion of the wrist is rated under Diagnostic Code 5215 and provides for maximum 10 percent ratings for limited palmar flexion and limited dorsiflexion in the major and minor wrists. 38 C.F.R. § 4.71a, Diagnostic Code 5215. The Veteran is already in receipt of a 10 percent rating for limitation of motion due to his right and left wrist tendonitis and a higher initial evaluation is therefore not possible for either wrist under Diagnostic Codes 5003, 5024, or 5215. A higher rating is possible under Diagnostic Code 5214 for ankylosis of the wrists, but the record clearly shows that neither the Veteran’s right or left wrist is ankylosed. In this regard, the Veteran was afforded two VA examinations in connection with her claim, one in November 2011 and subsequently in July 2016; the examiners who physically examined the Veteran's wrists in November 2011 and July 2016 concluded that she did not have ankylosis. The VA examinations and VAMC treatment records show some findings of reduced motion and complaints of pain with use of the right wrist, as well as some weakness. However, even with consideration of all relevant functional factors, it is clear that the Veteran has retained useful motion of her wrists throughout the claims period. Additionally, as the Veteran is already in receipt of the highest available rating based on restriction of motion, the provisions regarding pain in 38 C.F.R. §§ 4.40 and 4.45 do not apply. Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Thus, the assignment of an increased rating for the service-connected right and left wrist tendonitis based on ankylosis under Diagnostic Code 5214 is not appropriate and the claim for a higher initial rating is denied. Based on the foregoing, the Board concludes a rating in excess of 10 percent rating is not appropriate for either of the Veteran's service-connected wrist disabilities. 4. Entitlement to an initial compensable rating for onychomycosis of the left big toenail The Veteran seeks entitlement to a compensable rating for onychomycosis of her left big toenail. This disability is rated pursuant to DC 7820 for infections of the skin not listed elsewhere (including bacterial, fungal, viral, or impairment of function). 38 C.F.R. § 4.118. Under DC 7820, the skin disability is to be rated as dermatitis (DC 7806) depending upon the predominant disability. Under DC 7806, a non-compensable evaluation is warranted where the condition involves at least 5 percent of the entire body or less than 5 percent of exposed areas affected; and, no more than topical therapy required during a 12-month period. A 10 percent rating requires that at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas be affected, or intermitted systemic therapy such as corticosteroids or other immunosuppressive drugs be required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating requires that 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas be affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs be required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating requires that more than 40 percent of the entire body or more than 40 percent of exposed areas be affected, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs be required during the past 12-month period. 38 C.F.R. § 4.118, DC 7806. In November 2011, the Veteran underwent a VA general medical examination. Upon evaluation of the Veteran's skin, the examiner noted a thicken and discolored left big toenail, diagnosed as onychomycosis; there was no scar based on the skin examination. The examiner noted that the onychomycosis affected 0 percent of exposed areas and 1 percent of the total BSA (body surface area). More recently, in July 2016, the Veteran underwent a DBQ examination to determine the current severity of her onychomycosis of the left great toenail. At that time, the Veteran reported that she has never had treatment. She states that the nail is slightly discolored, but she had no pain. She indicated that she always wears nail polish. The examiner indicated that he was unable to fully examine the left toenail as polish was covering it. It is noteworthy that VA treatment records do not document any treatment in the dermatology clinic for this condition, nor do the records document the use of any medications for the disability. In light of the foregoing, the Board finds that the criteria for a compensable rating for onychomycosis of the left big toenail is not warranted. More specifically, the probative evidence of record does not otherwise demonstrate that the Veteran's onychomycosis affected at least 5 percent of her entire body. Accordingly, entitlement to an initial compensable rating for onychomycosis of the left big toenail is denied. Based on the foregoing, the Board concludes that the preponderance of the evidence is against the claim, and the claim for an initial compensable rating for onychomycosis of the left big toe is denied. There is no reasonable doubt to be resolved in this case. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. 5. Entitlement to an initial rating in excess of 30 percent for migraine headaches The Veteran essentially contends that he migraine headaches warrant a rating in excess of the 30 percent currently assigned. The Veteran's service-connected migraine headaches is currently evaluated 30 percent disabling under 38 C.F.R. § 4.124 (a), Diagnostic Code 8100. Migraine headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months warrant a 30 percent rating. A 50 percent rating is warranted for migraine headaches with very frequent completely prostrating and prolonged attacks, productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2017). In Pierce v. Principi, 18 Vet. App. 440, 446 (2004), the Court held that "nothing in [Diagnostic Code] 8100 requires that the claimant be completely unable to work in order to qualify for a 50 [percent] rating." The rating criteria do not define "prostrating;" nor has the Court. Cf. Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack.). By way of reference, the Board notes that according to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), in which "prostration" is defined as "extreme exhaustion or powerlessness." The rating criteria clearly provide that it is not solely the frequency of headaches that impact a rating but also the nature or severity of the headaches. See DC 8100. After careful review of the evidentiary record, the Board finds that the evidence does not support an initial rating in excess of 30 percent for migraine headaches. Significantly, on examination in November 2011, the Veteran reported getting headaches once a day; she noted that the symptoms nausea and vomiting. While the examiner reported a diagnosis of migraine headaches, he stated that there were no objective factors associated with the headaches. The examiner also noted that the Veteran was able to work during the headaches but required medication. Subsequently, in July 2016, the Veteran reported having headaches 3 to 4 times per week; and, she noted that she has to lie down 2 to 3 hours to calm down. The Veteran indicated that the headaches produced constant pain on both sides of the head, and she experienced vomiting and sensitivity to light. Consequently, while the Veteran’s headaches are described as frequent, they have not been described as completely prostrating. The Board further finds that this description of the Veteran's headaches is not such that they are productive of severe economic inadaptability. At no time does the Veteran contend that his headaches occur with such severity as to meet the specific criteria for a schedular evaluation of 50 percent. Moreover, the examiners have specifically stated that the Veteran’s headache condition does not impact her ability to work. Consequently, the Board finds that an initial rating in excess of 30 percent for migraine headaches is not warranted. See 38 C.F.R. § 4.124a, Diagnostic Code 8100. 6. Entitlement to an initial rating in excess of 70 percent for post-traumatic stress disorder (PTSD) The Veteran contends that a disability rating in excess of 70 percent is warranted for service-connected PTSD. At the outset, the Board notes that a TDIU rating has already been assigned throughout the entire period on appeal, and as such, entitlement to TDIU need not be discussed herein. The severity of the Veteran's PTSD is determined by 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the general rating formula, a 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine actives; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating requires 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; or memory loss for the names of close relatives, own occupation, or own name. The Global Assessment of Functioning score is a score reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). A GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 is defined as moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). A GAF score of 61 to 70 is defined as some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. A score of 71 to 80 indicates that, if symptoms are present at all, they are transient and expectable reactions to psychosocial stressors with no more than slight impairment in social and occupational functioning. See Carpenter v. Brown, 8 Vet. App. 240, 242-244 (1995). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has emphasized that the list of symptoms under a given rating is a nonexhaustive list, as indicated by the words "such as" that precede each list of symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). In Vazquez-Claudio, the Federal Circuit held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration. Id. at 118. Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 116. As the Veteran is currently rated 70 percent for PTSD throughout the period on appeal, the question now is whether the Veteran's PTSD more nearly approximates total social and occupational impairment. Significantly, in conjunction with her claim, the Veteran was afforded a VA examination in November 2011. Following a mental status examination, the examiner reported a diagnosis of PTSD. The examiner noted that the effects of PTSD symptoms on the Veteran’s employment and overall quality of life including problems sleeping, isolation, hypervigilance, panic attacks and loss of interest in activities that were once enjoyed. The examiner noted that the Veteran currently had difficulty establishing and maintaining effective work/school and social relationships because she is hypervigilant and suspect of other's motives it makes her less likely to establish and maintain relationships necessary for work and social relationships. Currently, she has difficulty maintaining effective family role functioning because depressive symptoms make interacting more difficult. The examiner further noted that the Veteran had difficulty understanding complex commands because she notes that her memory and concentration have been impacted by her depression and anxiety. She has problems remembering and following through with things she used to do before. Based upon the examination, the claimant needs to seek follow up treatment. The claimant requires ongoing individual and group therapy. She would also benefit from ongoing medication management. The Veteran did not appear to pose any threat of danger or injury to self or others. More recently, the Veteran was afforded a DBQ examination for review of her PTSD in July 2016. The examiner noted that the Veteran’s PTSD is manifested by depressed mood, anxiety, suspiciousness, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, disturbance of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a worklike setting. On mental status examination, the Veteran was described as fully alert and oriented in all spheres. Speech was logical and goal directed. Affect was appropriate to thought content. No hallucinations or delusions were noted. No suicidal or homicidal ideations were noted. The Veteran acknowledged being distractible at times. Insight and judgment were intact. The examiner noted that the Veteran appeared to be exhibiting moderate limitations in the areas of social interaction and adaptation; he explained that, in a work-related environment, she may exhibit occasional difficulty in responding to real or perceived negative feedback, interacting with co-workers with little difficulty, and responding appropriately to changes/stress in her environment. The examiner further noted that, in a work-related environment, she may have some difficulty in carrying out detailed instructions, attending to tasks for extended periods of time, working in close proximity to others, and completing a workday/week without being disrupted from psychologically-based symptomology. After a review of the evidence of record, the Board finds that an initial rating in excess of 70 percent for PTSD is not warranted for any portion of the rating period on appeal. The evidentiary record clearly demonstrates that the Veteran has been diagnosed with PTSD, and she has exhibited symptoms of depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, disturbance of motivation and mood, difficulty establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances. She has also had irritable behavior and angry outbursts. Such symptoms are contemplated by the 70 percent evaluation. 38 C.F.R. § 4.130, Diagnostic Code 9411. The record does not show, however, that the Veteran has total occupational and social impairment as is contemplated in the criteria for a 100 percent rating. In this regard, the November 2011 VA examiner stated that the Veteran’s current psychiatric symptoms caused occupational and social impairment with reduced reliability and productivity. The examiner also stated that the Veteran did not appear to pose any threat of danger or injury to self or others. Moreover, in July 2016, the DBQ examiner also opined that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. Furthermore, the Veteran does not have most of the symptoms listed as examples in the criteria for a 100 percent rating. In this regard, the evidence does not suggest that she has gross impairment in thought process or communication, grossly inappropriate behavior, or memory loss, or disorientation to time or place. Moreover, the Veteran has not been shown to be in persistent danger of hurting In viewing the totality of the evidence, the preponderance of the evidence is against a 100 percent disability evaluation for her psychiatric disability. Consequently, the Board finds that the preponderance of the evidence weighs against a finding of entitlement to an initial rating in excess of 70 percent for PTSD. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for an initial rating in excess of 70 percent for PTSD must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). REASONS FOR REMAND After examining the record, the Board concludes that further assistance to the Veteran is required in order to comply with the duty to assist as mandated by 38 U.S.C. § 5103A. The specific bases for remand are set forth below. 1. Entitlement to an initial rating in excess of 20 percent for lumbar strain is remanded. The Veteran essentially contends that her service-connected lumbar strain is more disabling than reflected by the currently assigned rating. In a statement dated in October 2016, the Veteran’s attorney argued that the July 2016 examination was inconsistent and or contradictory. Specifically, he noted that while the examiner marked ‘yes’ in response to the question of whether the Veteran had guarding of the lumbar spine, he nonetheless proceeded to mark ‘none’ for muscle spasm and guarding. The attorney further noted that, while the examiner reported that the Veteran was unable to complete the straight leg raising test, he stated that she had no radicular pain despite her complaints of numbness in another part of the examination. As noted by her attorney, the Veteran was last provided a DBQ examination in connection with her service-connected lumbar strain in July 2016 and a subsequent addendum medical opinion offered in November 2016. This is fairly recent. However, in light of the contentions regarding the inconsistencies in the examination report, and that the back condition is more severe than reflected, the Board concludes that a remand is necessary to afford the Veteran another VA examination. Moreover, since the July 2016 DBQ examination, the U.S. Court of Appeals for Veterans Claims, in Correia v. McDonald, 28 Vet. App. 158 (2016), held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the Court's holding in Correia establishes requirements that must be met prior to finding that a VA examination is adequate, that have not been met in this case. Neither the July 2016 examination report, nor the November 2016 addendum, fully satisfy the requirements of 38 C.F.R. § 4.59. As such, a new examination must be provided to the Veteran to assess her service-connected lumbar spine disability. 2. Entitlement to an initial rating in excess of 10 percent for patellofemoral pain syndrome, right and left knee is remanded. The Veteran seeks a rating in excess of 10 percent for her left and right knee disorders. She maintains that her left and right knee disabilities are more disabling than reflected by the ratings currently assigned. In his October 2016 statement, the Veteran’s attorney noted that the July 2016 DBQ examiner reported that the Veteran could not complete the range of motion testing due to severe pain. He noted that this indication of pain at a much higher level of severity than mild, the level at which the Veteran is currently assigned, means that she warrants a higher rating for her bilateral painful knees. The attorney pointed out that the examiner did not attribute the severe pain to a non-service connected origin. The Veteran was most recently afforded a DBQ examination for evaluation of her bilateral knee disorder in July 2016. Since that time, the Court of Appeals for Veterans' Claims (CAVC) has held "that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities." Correia v. McDonald, 28 Vet. App. 158 (2016). The CAVC also stated that in order "to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59." Id. at 169-70. Here, it does not appear the range of motion testing conducted on the July 2016 DBQ knee examinations is in accord with this requirement. Thus, a remand is necessary in order to afford the Veteran a new VA examination to determine the severity of her left and right knee disabilities and addresses the CAVC's directive. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (when VA undertakes to provide a medical examination, it must ensure that the examination and opinions therein are adequate). 3. Entitlement to an initial compensable rating for right and left ankle strain prior to July 14, 2016, and a rating in excess of 10 percent on and after July 14, 2016. The Veteran essentially contends that her service-connected bilateral ankle disorder is more disabling than reflected by the currently assigned ratings. In a statement dated in October 2016, the Veteran’s attorney maintains that while she reported having ankle strain flare ups, which included throbbing pain that made it impossible for her to stand for long periods of time, the examiner indicated that she was not being evaluated during a period of flare up. Therefore, it is requested that the Veteran be revaluated for her bilateral ankle condition during a period of flare up in symptomatology. Alternatively, the attorney maintains that a VA examiner should opine on the additional range of motion loss during a period of flare ups. The Board notes that the Veteran underwent a DBQ examination in July 2016 for evaluation of her service-connected right and left ankle sprain. Following the July 2016 examination, in Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases involving assessment of joint disabilities. The final sentence provides that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." The Court found that, to be adequate, a VA joint examination must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. Upon review, the Board notes that the July 2016 VA examination did not include passive range of motion testing, or weight-bearing and nonweight-bearing, and they therefore do not comply with Correia. Accordingly, the Veteran must be afforded a new VA examination to correct the deficiencies noted. Also, in Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that the Board may accept a VA examiner's assertion that he or she cannot offer such an opinion without resorting to speculation only after it determines that the examiner's conclusion is not based on the absence of procurable information or on a particular examiner's shortcomings or general aversion to offering an opinion on issues not directly observed. It must be clear that such an opinion is not procurable based on a lack of knowledge among the "medical community at large" and not merely on a lack of expertise, insufficient information, or unprocured testing on the part of the specific examiner. Accordingly, an examiner must do all that reasonably should be done to become informed before concluding that a requested opinion cannot be provided without resorting to speculation. To be adequate, an examination although acknowledging that the Veteran was not then suffering from a flare of any conditions, must also ascertain adequate information; i.e. frequency, duration, characteristics, severity, or functional loss-regarding flares by alternative means. Furthermore, the examiner must offer an estimate as to additional functional loss during flares regardless of whether the veteran was undergoing a flare-up at the time. Sharp v. Shulkin, 29 Vet. App. 26 (2017). 4. Entitlement to an effective date earlier than July 14, 2016 for the assignment of 10 percent ratings for the right and left ankle strain. By a Decision Review Officer’s (DRO) decision, dated in August 2016, the RO increased the rating for left and right ankle strain each from 0 to 10 percent, effective July 14, 2016. A notice of disagreement (NOD) with the effective date of the assigned rating was received in August 2017. The Board notes that a statement of the case (SOC) addressing the matter of entitlement to an effective date earlier than July 14, 2016, for the assignment of 10 percent ratings for the right and left ankle strain has not yet been issued. Therefore, a remand for this action is necessary. See Manlincon v. West, 12 Vet. App. 238 (1999). The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any existing VA treatment records not already associated with the claims file. 2. Then, ensure that the Veteran is scheduled for examinations of both knees, both ankles and his thoracolumbar spine, to determine all manifestations of and the severity of his ankles, knees, and thoracolumbar spine. The claims file must be reviewed by the examiner(s) in conjunction with the examination(s). The examiner(s) must test and record the range of motion for both knees, both ankles, and the thoracolumbar spine in active motion, passive motion, weight-bearing, and nonweight-bearing. If any examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The extent of any incoordination, weakened movement, and excess fatigability on use must be described. To the extent possible, the functional impairment due to incoordination, weakened movement, and excess fatigability must be assessed in terms of additional degrees of limitation of motion. If this is not feasible, the examiner must so state and explain why. The examiner must express an opinion concerning whether there would be additional limits on functional ability on repeated use or during flare-ups, and, if feasible, express this in terms of additional degrees of limitation of motion on repeated use or during flare-ups. The examiner must provide a rationale for any opinion rendered. If the Veteran is not undergoing a flare-up at the time of the examination, the examiner must also ascertain adequate information; i.e. frequency, duration, characteristics, severity, or functional loss-regarding flares by alternative means. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). . 3. The AOJ must issue the Veteran a statement of the case (SOC) addressing the issue of entitlement to an earlier effective date for the assignment of increased ratings for the right and left ankle strain. Advise the Veteran of the time period in which to perfect her appeal. If the Veteran perfects her appeal of that issue in a timely fashion, then return the case to the Board for its review, as appropriate. 4. Then, readjudicate the claims for higher ratings that are the subject of this Remand. If any benefit sought is not granted in full, provide to the Veteran and her attorney a supplemental statement of the case (SSOC) and allow an appropriate opportunity to respond thereto before returning the case to the Board. JAMES G. REINHART Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs