Citation Nr: 20006826 Decision Date: 01/29/20 Archive Date: 01/27/20 DOCKET NO. 18-33 252 DATE: January 29, 2020 ORDER Entitlement to service connection for left wrist condition (non-dominant) is denied. Entitlement to service connection for right wrist condition (dominant) is denied. Entitlement to an effective date prior to August 13, 2015 for right hip iliotibial band syndrome with painful motion is denied. Entitlement to an effective date prior to August 13, 2015 for right hip iliotibial band syndrome with limitation of extension is denied. Entitlement to a rating in excess of 30 percent prior to April 2, 2015 is denied. Entitlement to a rating in excess of 50 percent is denied. Entitlement to a rating of 70 percent for posttraumatic stress disorder with major depressive disorder, is granted. Entitlement to an effective date prior to January 15, 2013 for posttraumatic stress disorder is denied. Entitlement to an effective date prior to January 15, 2013 for migraine headaches is denied. Entitlement to an effective date prior to January 15, 2013 for lumbosacral strain is denied. Entitlement to an effective date prior to January 15, 2013 for left hip strain with limitation of flexion is denied. Entitlement to an effective date prior to January 15, 2013 for left hip strain with painful motion is denied. Entitlement to individual employability is granted. REMANDED Entitlement to a higher rating for right hip iliotibial band syndrome with painful motion, currently evaluated as 0 percent disabling is remanded. Entitlement to a higher rating for right hip iliotibial band syndrome with limited flexion, currently evaluated as 10 percent disabling is remanded. Entitlement to a higher rating for lumbar strain, currently evaluated as 10 percent disabling is remanded. Entitlement to a higher rating for left hip strain with limitation of extension, currently evaluated as 0 percent disabling is remanded. Entitlement to a higher rating for left hip strain with limitation of flexion, currently evaluated as 0 percent disabling is remanded. FINDINGS OF FACT 1. The Veteran was discharged from service on January 14, 2013. 2. A left wrist disability was not demonstrated while on active duty, and the preponderance of the competent, probative evidence is against finding a relationship between such a disorder and the Veteran’s active duty service. 3. A right wrist disability was not demonstrated while on active duty, and the preponderance of the competent, probative evidence is against finding a relationship between such a disorder and the Veteran’s active duty service. 4. VA received an informal claim for entitlement to service connection for right hip iliotibial band syndrome on August 13, 2015. 5. The Veteran’s migraine heads were characteristic prostrating attacks occurring on average once a month over last several months from January 15, 2013 to April 1, 2015. 6. The Veteran’s migraine headaches are assigned the maximum schedular rating, 50 percent, from April 2, 2015. 7. The Veteran’s migraine headaches are reasonably contemplated by the scheduled rating criteria. 8. The Veteran’s posttraumatic stress disorder was manifested by occupational and social impairment, with deficiencies in most areas, but not by total occupational and social impairment. 9. The Veteran was discharged from military service on January 14, 2013. The January 15, 2013 effective date assigned for the grant of service connection for a posttraumatic stress disorder is the earliest date permitted under law. 10. The Veteran was discharged from military service on January 14, 2013. The January 15, 2013 effective date assigned for the grant of service connection for migraine headaches is the earliest date permitted under law. 11. The Veteran was discharged from military service on January 14, 2013. The January 15, 2013 effective date assigned for the grant of service connection for lumbosacral strain is the earliest date permitted under law. 12. The Veteran was discharged from military service on January 14, 2013. The January 15, 2013 effective date assigned for the grant of service connection for left hip strain with painful motion is the earliest date permitted under law. 13. The Veteran was discharged from military service on January 14, 2013. The January 15, 2013 effective date assigned for the grant of service connection for left hip strain with limitation of flexion is the earliest date permitted under law. 14. The Veteran’s service-connected disabilities combine to preclude substantially gainful employment. CONCLUSIONS OF LAW 1. A left wrist condition was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. A right wrist condition was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 3. The criteria for entitlement to an effective date prior to August 13, 2015, for service connection for right hip iliotibial band syndrome with painful motion have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400. 4. The criteria for entitlement to an effective date prior to August 13, 2015, for service connection for right hip iliotibial band syndrome with limitation of flexion have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400. 5. The criteria for a rating higher than 30 percent disabling from January 15, 2013 and higher than 50 percent disabling for migraine headaches, from April 2, 2015, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8100. 6. The criteria for an initial 70 percent rating for posttraumatic stress disorder were met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. 7. The criteria for entitlement to an effective date prior to January 15, 2013, for service connection for posttraumatic stress disorder have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400. 8. The criteria for entitlement to an effective date prior to January 15, 2013, for service connection for migraine headaches have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400. 9. The criteria for entitlement to an effective date prior to January 15, 2013, for service connection for lumbosacral strain have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400. 10. The criteria for entitlement to an effective date prior to January 15, 2013, for service connection for left hip strain with limitation of flexion have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400. 11. The criteria for entitlement to an effective date prior to January 15, 2013, for service connection for left hip strain with painful motion have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400. 12. The criteria for entitlement to total disability due to individual unemployability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from January 2008 to January 2013. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Generally, service connection for a disability requires evidence of: (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 Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be also established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). A lay person is competent to report on the onset and reoccurrence of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). When considering whether lay evidence is competent, the Board must determine, on a case by case basis, whether a veteran’s particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA’s policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. See 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 1. Entitlement to service connection for left wrist (non-dominant) and right wrist conditions (dominant). The Veteran states that bilateral wrist disabilities had their onset during her active duty service. A review of the Veteran’s service treatment records shows do not show complaints, symptoms, or treatment of a bilateral wrist disability. The Veteran’s private medical records show a diagnosis of carpal tunnel syndrome in February 2014. Subsequent diagnostic testing in March 2014 show normal findings with no electrical evidence of carpal tunnel syndrome During a VA examination in May 2015, the examiner found carpal tunnel syndrome in both wrists and a contusion in the right wrist. The examiner documented the Veteran’s reports of pain shooting up from her wrist to her arm, as well as her February 2014 evaluation for complaints of bilateral wrist pain. The examiner noted that the EMG performed was interpreted as negative for any evidence of carpal tunnel syndrome. The examiner also noted the Veteran’s medical records detailing reports that she had fallen post-service, landing on her right wrist, requiring subsequent evaluation by a private examiner. The Veteran was afforded a VA examination of her wrists in June 2018. The examiner opined that the Veteran’s bilateral wrist disability did not have onset during service and was not related to any incident of her military service. The examiner noted that the Veteran’s service treatment record did not show diagnosis or symptoms suggestive of carpal tunnel syndrome. A June 2018 VA examination for a peripheral nerve condition found that the while the Veteran had pain, paresthesias, and numbness, she did not have peripheral neuropathy or a peripheral nerve condition in either wrist. The Board has reviewed all of the evidence of record and finds that the most probative evidence preponderates against finding that a bilateral wrist disability was incurred in or related to service. The Board acknowledges the Veteran’s lay statements that she had developed a wrist disability following her duties as a parachute packer in service. However, carpal tunnel syndrome is not a “chronic” disorder which would allow for service connection to be granted for a condition noted during service and subsequent manifestations of that disorder without a medical nexus. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board therefore requires evidence of a medical nexus between anything the Veteran experienced in service and her current disorder. While the Veteran may sincerely believe that her current bilateral wrist disability is related to her service, her testimony as to the etiology of the disorder is not competent evidence in light of her lack of medical training in the field of gastroenterology. While lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition, the diagnosis of a carpal tunnel syndrome and its etiology involve complex medical questions which extend beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be within the competence of lay witnesses. The evidence therefore preponderates against entitlement to service connection for a right or left wrist disability. The Board finds that the most probative medical evidence of record indicates that the Veteran’s current bilateral wrist disability is not related to service. As the preponderance of the probative and competent evidence weighs against the claim, the claim must be denied. In reaching this determination, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the appellant’s claim, the doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990), 38 C.F.R. § 3.102. Effective Date The law regarding effective dates provides that, unless specifically provided otherwise, the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a). Further, unless specifically provided otherwise, the effective date for a grant of service connection is the day after separation from service or day entitlement arose, if a claim is received within one year of separation from service; otherwise, the date of receipt of claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i). The essential elements for any claim, whether formal or informal, are “(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing.” Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009); see 38 C.F.R. § 3.155. Although VA has amended the claims filing process to require the filing of proper standard forms, the “informal claim” provisions are for proper application given the time period in which the Veteran’s claims were filed. 2. Entitlement to an effective date prior to August 13, 2015 for right hip iliotibial band syndrome with limitation of flexion. The Veteran claims that her effective date for service connection for right hip iliotibial band syndrome with limitation of flexion should be prior to August 13, 2015. However, the Veteran was discharged from active duty in January 2013 and the date of claim of entitlement to service connection for right hip iliotibial band syndrome is August 13, 2015, the date an informal claim was received. Because the veteran did not file a formal or informal application for service connection prior to August 13, 2015, VA is precluded, as a matter of law, from granting an effective date prior to August 13, 2015, for service connection for this disability. As such, this appeal must be denied because the RO has already assigned the earliest possible effective date provided by law. Thus, the claim must be denied. 3. Entitlement to an effective date prior to August 13, 2015 for right hip iliotibial band syndrome with painful motion. The Veteran claims that her effective date for service connection for right hip iliotibial band syndrome with painful motion should be prior to August 13, 2015. However, the Veteran was discharged from active duty in January 2013 and the date of claim of entitlement to service connection for right hip iliotibial band syndrome is August 13, 2015, the date an informal claim was received. Because the veteran did not file a formal or informal application for service connection prior to August 13, 2015, VA is precluded, as a matter of law, from granting an effective date prior to August 13, 2015, for service connection for this disability. As such, this appeal must be denied because the RO has already assigned the earliest possible effective date provided by law. Thus, the claim must be denied. 4. Entitlement to an effective date prior to January 15, 2013 for posttraumatic stress disorder. The Veteran contends she is entitled to an earlier effective date for service connection for posttraumatic stress disorder. Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement to an award arose, whichever is the later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The earliest possible effective date for entitlement to an award of disability compensation to a veteran is the day following the date of her separation from service if an application for disability benefits is filed within one year of her separation date. 38 U.S.C. § 5110 (b)(1). In this case, the Veteran separated from service on January 14, 2015. Since her application was filed within one year of separation (April 12, 2013), the Veteran was awarded service connection for posttraumatic stress disorder with an effective date of January 15, 2013, the day following the date of her separation from service. There is no provision in the law for awarding an earlier effective date in this case. Prior to January 15, 2013, the Veteran had not yet been separated from service (and by definition was not yet a Veteran; see 38 U.S.C. § 101 (2)). Therefore, by law, she would not have been entitled to compensation for service-connected disability (as such benefit is restricted to veterans; see 38 U.S.C. § 1110). 5. Entitlement to an effective date prior to January 15, 2013 for migraine headaches. The Veteran contends she is entitled to an earlier effective date for service connection for migraine headaches. Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement to an award arose, whichever is the later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The earliest possible effective date for entitlement to an award of disability compensation to a veteran is the day following the date of her separation from service if an application for disability benefits is filed within one year of her separation date. 38 U.S.C. § 5110 (b)(1). In this case, the Veteran separated from service on January 14, 2015. Since her application was filed within one year of separation (April 12, 2013), the Veteran was awarded service connection for migraine headaches with an effective date of January 15, 2013, the day following the date of her separation from service. There is no provision in the law for awarding an earlier effective date in this case. Prior to January 15, 2013, the Veteran had not yet been separated from service (and by definition was not yet a Veteran; see 38 U.S.C. § 101 (2)). Therefore, by law, she would not have been entitled to compensation for service-connected disability (as such benefit is restricted to veterans; see 38 U.S.C. § 1110). 6. Entitlement to an effective date prior to January 15, 2013 for lumbosacral strain. The Veteran contends she is entitled to an earlier effective date for service connection for lumbosacral strain. Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement to an award arose, whichever is the later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The earliest possible effective date for entitlement to an award of disability compensation to a veteran is the day following the date of her separation from service if an application for disability benefits is filed within one year of her separation date. 38 U.S.C. § 5110 (b)(1). In this case, the Veteran separated from service on January 14, 2015. Since her application was filed within one year of separation (April 12, 2013), the Veteran was awarded service connection for lumbosacral strain with an effective date of January 15, 2013, the day following the date of her separation from service. There is no provision in the law for awarding an earlier effective date in this case. Prior to January 15, 2013, the Veteran had not yet been separated from service (and by definition was not yet a Veteran; see 38 U.S.C. § 101 (2)). Therefore, by law, she would not have been entitled to compensation for service-connected disability (as such benefit is restricted to veterans; see 38 U.S.C. § 1110). 7. Entitlement to an effective date prior to January 15, 2013 for left hip strain (flexion). The Veteran contends she is entitled to an earlier effective date for service connection for left hip strain (flexion). Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement to an award arose, whichever is the later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The earliest possible effective date for entitlement to an award of disability compensation to a veteran is the day following the date of her separation from service if an application for disability benefits is filed within one year of her separation date. 38 U.S.C. § 5110 (b)(1). In this case, the Veteran separated from service on January 14, 2015. Since her application was filed within one year of separation (April 12, 2013), the Veteran was awarded service connection for left hip strain (flexion) with an effective date of January 15, 2013, the day following the date of her separation from service. There is no provision in the law for awarding an earlier effective date in this case. Prior to January 15, 2013, the Veteran had not yet been separated from service (and by definition was not yet a Veteran; see 38 U.S.C. § 101 (2)). Therefore, by law, she would not have been entitled to compensation for service-connected disability (as such benefit is restricted to veterans; see 38 U.S.C. § 1110). 8. Entitlement to an effective date prior to January 15, 2013 for left hip strain (extension). The Veteran contends she is entitled to an earlier effective date for service connection for left hip strain (extension). Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement to an award arose, whichever is the later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The earliest possible effective date for entitlement to an award of disability compensation to a veteran is the day following the date of her separation from service if an application for disability benefits is filed within one year of her separation date. 38 U.S.C. § 5110 (b)(1). In this case, the Veteran separated from service on January 14, 2015. Since her application was filed within one year of separation (April 12, 2013), the Veteran was awarded service connection for left hip strain (extension) with an effective date of January 15, 2013, the day following the date of her separation from service. There is no provision in the law for awarding an earlier effective date in this case. Prior to January 15, 2013, the Veteran had not yet been separated from service (and by definition was not yet a Veteran; see 38 U.S.C. § 101 (2)). Therefore, by law, she would not have been entitled to compensation for service-connected disability (as such benefit is restricted to veterans; see 38 U.S.C. § 1110). Increased Rating 9. Entitlement to an increased rating for migraine headaches, currently evaluated as 30 percent disabling effective January 15, 2013 and 50 percent disabling effective April 2, 2015. The Veteran asserts that her migraine headaches are more severe than currently rated. The Veteran’s headaches are evaluated under Diagnostic Code (DC) 8100, which provides a 10 percent disability evaluation is warranted for characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent disability rating is assigned for migraine headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months. A 50 percent rating is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The Veteran’s migraines are evaluated as 30 percent disabling from January 15, 2015 and 50 percent disabling from April 2, 2015. The currently assigned 50 percent rating constitutes the maximum schedular rating available under Diagnostic Code 8100, migraines, and there is no other diagnostic code pertaining to migraine headaches. Therefore, with regard to the period after April 2, 2015, the Board will consider whether referral for extraschedular consideration is warranted. A review of the Veteran’s medical record reveals a June 2013 treatment note documenting the Veteran’s report of having migraine headaches once a month. In an August 2014 VA examination, the Veteran reported headaches that were pulsating, and throbbing, with constant pain on both sides of her head causing nausea, vomiting, sensitivity to light and sound, changes in vision, and sensory changes, and occurring one or two times a week. The headaches did not require medication. Additionally, the Veteran had prostrating attacks of headache pain occurring once a month that were not productive of severe economic inadaptability. The Veteran reported that she was not able to perform employment requirements during migraine headaches because her migraine disability requires rest in a quiet darkened room. At a subsequent VA examination in May 2015, the Veteran’s headaches were described as pulsating, and throbbing, with constant pain either unilaterally or on both sides of her head causing nausea, vomiting, sensitivity to light and sound, changes in vision, and sensory changes and occurring one or two times a week, which required medication. The Veteran reported that if she were employed, she would most likely have been fired due to her illness. The examiner documented that the Veteran’s headaches were productive of severe economic inadaptability. An April 2017 VA examination the Veteran reported nausea, vomiting, sensitivity to light and sound, changes in vision, dizziness, poor concentration, and “seeing stars”. The Veteran reported that the migraines last between 4 and 48 hours. She also reported daily prostrating headaches on both sides of his head that last more than once a month. As stated above, the Veteran is currently in receipt of a 30 percent rating for her headache disability beginning January 15, 2013 and 50 percent since April 2, 2015. The Board finds that the evidence of record does not support a rating in excess of 30 percent beginning January 15, 2013. While the Veteran described painful headaches, she did not have headaches that were very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability prior to April 2, 2015. The Veteran reported prostrating attacks of headache pain occurring once a month that were not productive of severe economic inadaptability. Additionally, the VA examiner did not opine that the Veteran’s headaches caused severe economic inadaptability or are very frequently completely prostrating, nor does a review of the Veteran’s VA treatment records support such finding. In light of the foregoing, the Board finds that the preponderance of the evidence is against entitlement to a higher rating for headaches. 10. Entitlement to a higher rating for posttraumatic stress disorder with major depressive disorder, currently evaluated as 50 percent disabling. The Veteran contends that her posttraumatic stress disorder was more severe than the assigned rating 50 percent rating. Disability evaluations are determined by comparing a veteran’s present symptomatology with criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. See 38 U.S.C. § 5107(b). A veteran’s entire history is reviewed when making a disability determination. 38 C.F.R. § 4.1. When a veteran timely appeals an initial rating for a service-connected disability within one year of the rating decision, VA must consider whether the veteran is entitled to “staged” ratings to compensate him for periods of time since the filing of his claim when his disability may have been more severe than others. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran’s posttraumatic stress disorder is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. VA regulations establish a general rating formula for mental disabilities. See 38 C.F.R. § 4.130. Notably, the term “such as” in 38 C.F.R. § 4.130 precedes lists of symptoms that are not exhaustive, but rather serve as examples of the type and degree of symptoms and their effects that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms listed. Instead, VA will consider all symptoms of a claimant’s disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM –V). Diagnostic Code 9411 provides for a 10 percent rating for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent rating is assigned where there is 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 activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; 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 disability rating is warranted for posttraumatic stress disorder when there are 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; and memory loss for names of close relatives, own occupation, or own name. Id. The Veteran’s posttraumatic stress disorder is currently assigned a 50 percent disability. After reviewing the evidence of record the Board finds that her posttraumatic stress disorder warrants a 70 percent rating, but no higher. The Veteran was afforded a VA examination in June 2014. Following that examination, the examiner opined that the appellant’s posttraumatic stress disorder was productive of occupational and social impairment with reduced reliability and productivity. Significantly, however, the examiner noted that the Veteran suffered from a depressed mood, a flattened affect, anxiety, chronic sleep impairment and panic attacks that occur weekly or less often. Her sleep was highly impaired. Moreover, the Veteran had difficulty establishing and maintaining effective work and social relationships. Subsequently, in April 2015, a VA examiner documented the Veteran’s irritable behavior and angry outbursts, problems with concentration, and noted that the Veteran’s symptoms cause clinically significant distress or impairment in social occupational, or other important areas of functioning. A May 2015 health assessment documents the Veteran’s feelings of hopelessness about the present or future and thoughts about taking her life. A May 2017 examiner observed that the Veteran has hypervigilance, exaggerated startle response, difficulty concentrating, irritability or outbursts of anger. He also documented that the Veteran has suicidal ideation, and panic attacks more than once a week. The examiner opined that the Veteran had occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. The Board finds that under the doctrine of reasonable doubt the evidence warrants a 70 percent rating for posttraumatic stress disorder. In this regard, it is well to observe that the symptoms listed for a 70 percent rating are not exclusive. Rather they serve as examples of the type and degree of symptoms and their effects that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Here the appellant’s posttraumatic stress disorder was found by the May 2017 examiner to be severe, and she was found to be unable to maintain meaningful gainful employment. While the symptoms presented did not equate to total occupational and social inadaptability, i.e., there was no evidence of symptoms such as a gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; evidence that the appellant had suicidal idea, panic attacks more than once a week, and inability to establish and maintain effective relationships; the examiner’s opinion supports the assignment of a 70 percent rating. See Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) (“By requiring only an ‘approximate balance of positive and negative evidence’ the Nation, ‘in recognition of our debt to our veterans,’ has ‘taken upon itself the risk of error’ in awarding ... benefits.”). 11. Entitlement to TDIU is granted. A total disability rating may be assigned, where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as the result of service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.16. Consideration may be given to a veteran’s level of education, special training, and previous work experience in arriving at a conclusion, but not to her age or the impairment caused by any nonservice-connected disabilities. See 38 C.F.R. §§ 4.16, 4.19. To meet the schedular requirements, there must be one disability ratable at 60 percent or more, or, if more than one disability, at least one disability ratable at 40 percent or more and a combined disability rating of 70 percent. 38 C.F.R. § 4.16 (a). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, “entitlement to a TDIU is based on an individual’s particular circumstances.” Rice, 22 Vet. App. 447, 452 (2009). Therefore, in adjudicating a TDIU claim, VA must take into account the individual veteran’s education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164, 168 (1991). The Veteran stopped working in full-time employment in April 2014. During the claims period, the Veteran has been service connected for posttraumatic sleep disorder, rated 50 percent disabling, effective January 15, 2013; migraine headaches, rated 30 percent disabling effective January 15, 2013, and rated 50 percent disabling, effective April 2, 2015; lumbosacral strain, rated 10 percent disabling, effective January 15, 2013, left hip iliotibial band syndrome with painful motion, rated 10 percent disabling, effective January 15, 2013; right hip iliotibial band syndrome with painful motion, rated 10 percent disabling, effective August 13, 2013; left hip iliotibial band syndrome with limited flexion, rated 0 percent disabling, effective January 15, 2013; and right hip iliotibial band syndrome with limited flexion, rated 0 percent disabling, effective August 13, 2013. She has had a combined rating of 80 percent since April 2, 2015, and 70 percent from January 15, 2013. As noted above, the Veteran’s May 2017 examination found that the Veteran had inability to establish and maintain effective relationships, difficulty adapting to stressful circumstances, including work or a work like setting, and prevent her from maintaining substantially gainful employment. An April 2017 migraine headaches examination also notes that the Veteran's migraines are debilitating and impact daily life including the ability to maintain gainful employment. The Board finds the Veteran is unable to establish or maintain gainful employment. Specifically, the Board finds that the combined effects of the Veteran’s posttraumatic stress disorder, migraine headache symptoms, hip and back disabilities prevent her from establishing or maintaining gainful employment. Therefore, entitlement to TDIU is granted. REASONS FOR REMAND 11. Entitlement to a higher rating for right and left hip and lumbar strain disabilities, are remanded. After examining the record, the Board concludes that further assistance to the Veteran is required. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). The Board finds that the August 2014 VA examinations, which are over five years old, are inadequate for the purpose of readjudicating the Veteran’s appeal. The Court in Correia v. McDonald, 28 Vet. App. 158 (2016), held that the final sentence of 38 C.F.R. § 4.59 (2016) requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing. While additional delay is regrettable, the holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. In this case a review of the file reveals that the August 2014 VA examination reports each include range of motion findings, but these findings do not specify whether such findings reflect active or passive motion. In addition, the VA examination reports do not specify whether the range of motion findings are weight-bearing or nonweight-bearing. Additionally, in Sharp the Court held that before a VA examiner opines that he or she cannot offer an opinion as to additional functional loss during flare-ups without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner must “elicit relevant information as to the veteran’s flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran’s functional loss due to flares based on all the evidence of record, including the veteran’s lay information, or explain why she could not do so.” Here, although the previous VA examiners acknowledged the Veteran’s complaints of flare-ups and functional limitation, the examiners did not estimate the additional functional loss during periods of flare-up. Thus, an additional VA opinion is necessary to adjudicate this claim. The examiner must address the reported flare-ups and symptoms from such, as well as the impact they had on any additional functional loss to the Veteran’s hips or back disabilities. See Sharp v. Shulkin, 29 Vet. App. 26, 33. In light of the fact that these examination reports do not fully satisfy the requirements of Sharp, Correia and 38 C.F.R. § 4.59, a VA examination should be obtained before a decision can be rendered on his claim. The matters are REMANDED for the following action: 1. The Veteran should be scheduled for appropriate VA examinations for the purpose of determining the prior and current frequency and severity of her service-connected left and right hip and back disabilities. 2. In examining the Veteran’s bilateral hip and back disabilities, the examiner is to document any limitation of motion (in degrees), to include providing the point at which painful motion begins. The examiner must test the range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing. If the 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 examiner should describe any pain, weakened movement, excess fatigability, instability of station, and incoordination present in the Veteran’s bilateral hip and back disabilities. The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups she experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment she experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Booker, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.