Citation Nr: 20007787 Decision Date: 01/31/20 Archive Date: 01/29/20 DOCKET NO. 06-25 230 DATE: January 31, 2020 ORDER Entitlement to service connection for an eye condition, to include cataracts and dry eye syndrome, is denied. Entitlement to an evaluation in excess of 40 percent for a lumbar spine disability is denied. Entitlement to an initial evaluation in excess of 10 percent for a left ankle disability is denied. Entitlement to a compensable initial evaluation for a headache condition prior to September 18, 2018 is denied. Entitlement to an initial evaluation in excess of 30 percent for a headache condition from September 18, 2018 is denied. REMANDED Entitlement to a compensable initial evaluation for nephrolithiasis is remanded. Entitlement to service connection for a dizzy spell condition is remanded. Entitlement to service connection for hypertension is remanded. FINDINGS OF FACT 1. The competent medical evidence does not demonstrate that either the Veteran’s cataracts or his dry eye syndrome was incurred in service or are otherwise attributable to his service; furthermore, diagnosed esophoria is a congenital condition for which service connection is not warranted absent superimposed service-related disability. 2. For the entire period of the appeal, the Veteran’s lumbar spine disability was manifested by forward flexion of no less than 15 degrees; however, no ankylosis has been documented during this period, and the Veteran’s condition has not required physician-prescribed bed rest. 3. For the entire period of the appeal, the Veteran’s left ankle disability was productive of moderate limitation of motion, without any evidence of ankylosis or instability. 4. Prior to September 18, 2018, the competent medical evidence of record does not suggest that the Veteran experienced prostrating attacks of headache pain with any degree of frequency 5. From September 18, 2018, the competent medical evidence of record shows that the Veteran experienced prostrating attacks of headache pain no more frequently than once per month. CONCLUSIONS OF LAW 1. Service connection for an eye condition, to include cataracts and dry eye syndrome, is not warranted. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. § 3.303. 2. The criteria for entitlement to a rating in excess of 40 percent rating for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5239-5242. 3. The criteria for an initial rating in excess of 10 percent for a left ankle disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5271. 4. The criteria for a compensable initial evaluation for a headache condition prior to September 18, 2018 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, 4.124a, Diagnostic Code 8100. 5. The criteria for a rating in excess of 30 percent for a headache condition from September 18, 2018 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, 4.124a, Diagnostic Code 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from March 1964 to January 1968 and from May 1974 to December 1980. He later served in the United States Air Force from November 1993 to January 2003. These matters were last before the Board in October 2017, whereupon they were remanded to the Regional Office for further development of the record. In an August 2019 rating decision, the Regional Office granted a 30 percent initial evaluation for the headache condition effective September 18, 2018. Concurrently, in August 2019 the Regional Office also issued a supplemental statement of the case denying a compensable rating for the headache condition prior to September 18, 2018, further denying a rating in excess of 30 percent for the condition from that date, and also continuing the previous denials of each of the other enumerated claims listed above. All of these issues were then returned to the Board for its adjudication. The Board notes that the Veteran testified before the undersigned Veterans Law Judge in a February 2011 Travel Board hearing; a copy of the transcript of that hearing is of record. As mentioned, in an August 2019 rating decision, the Regional Office granted a 30 percent initial rating for the headache condition, effective September 18, 2018. As the 30 percent award does not represent a full grant of the benefits sought, entitlement to a higher initial rating for the headache condition is still on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board also notes that the Regional Office granted service connection for a right ankle condition in a June 2019 rating decision, which does represent a full grant of the benefits sought; accordingly, the Board does not have further jurisdiction over this issue, despite the fact that entitlement to an increased rating for the disability was addressed by the Regional Office in the August 2019 supplemental statement of the case. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). In particular, the Board refers to its prior discussion in the October 2017 decision regarding the issue of whether entitlement to a total disability rating due to individual unemployability (TDIU) was before it then, and similarly concludes that entitlement to an earlier effective date for the grant of a TDIU is not at issue presently. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). Service Connection for an Eye Condition The Veteran contends that he has an eye condition that is attributable to service. Currently, he is diagnosed with dry eye syndrome, cataracts, and esophoria; he asserts that one or all of these conditions is attributable generally to his service and seeks entitlement to service connection on this basis. The question for the Board is whether one or more of the Veteran’s diagnosed eye conditions began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran is currently diagnosed with a variety of eye conditions, the preponderance of the evidence is against a finding that any eye condition began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). At the outset, the Board notes that the Veteran’s esophoria is characterized as a congenital disorder for which service connection is not warranted absent superimposed service-related disability. See VAOPGCPREC 82-90 (observing that even congenital defects “can be subject to superimposed disease or injury” and that “if during an individual’s military service, superimposed disease or injury does occur, service-connection may indeed be warranted for the resultant disability”). As such, the Board’s analysis will focus on the other eye conditions that the Veteran has been diagnosed with since service. A review of available service treatment records reflects that the Veteran was noted as having a history of esophoria, a congenital condition, on his February 1964 enlistment examination and corresponding Report of Medical History. There are no further notations of a treatment for or diagnosis of esophoria in the subsequent service treatment records. The Board does acknowledge that the Veteran did have a “2” listed on the PULHES chart for his eyes on physical profiles dated in February and March of 1994. As an aside, the Board observes that physical examinations in the services are often reported through means of Physical Profile Ratings. PULHES represents the six categories into which a Physical Profile is divided. Pertinent to this appeal, the E stands for eyes. This factor concerns visual acuity and diseases and defects of the eye. The number 2 indicates that an individual possesses some medical condition or physical defect that may require some activity limitations. The individual should receive assignments commensurate with his or her physical capability for military duty. See 9-3(c)(1) Army Regulation 40-501, Change 35; Hanson v. Derwinski, 1 Vet. App. 512 (1991); Odiorne v. Principi, 3 Vet. App. 456, 457 (1992). This being stated, there is no indication as to whether the Veteran was actually placed on a profile restricting his activities as due to any specific eye symptomology or diagnosed condition, and no records dating from this time period or in the nearly 10 years thereafter that he remained in service document any treatment for eye symptomatology. No eye condition or symptoms were noted on any subsequent examinations or Reports of Medical History leading up to the Veteran’s eventual discharge in 2003. Following service, the only medical records documenting any treatment for the Veteran’s eyes is a November 2009 optometry consultation, during which the Veteran reported experiencing some blurriness and daily watering during allergy season. After an evaluation, the Veteran was diagnosed with a refractive error with presbyopia, meibomitis without symptoms, and mild cataracts, and was prescribed eyeglasses. Thereafter, VA and private medical records do not reflect that the Veteran received any specific treatment for eye symptomatology, and no eye condition was listed on his general problem list at any point during his course of treatment at his local VA medical center. During the February 2011 hearing, the Veteran reiterated his contention that he developed vision problems in service that were documented in service treatment and personnel records. The Veteran was first afforded a VA eye examination to evaluate the nature and etiology of his eye condition in June 2012, during which he reported that he had a history of esophoria diagnosed in service that had not been symptomatic, and was also diagnosed with small cataracts in 2009. After an in-person evaluation, the examiner confirmed the diagnosis of a small esophoria, and further commented that it was well controlled and caused no difficulties. The examiner then opined that it was less likely than not that the condition was incurred in or caused by service but offered no rationale in support of this determination. As such, any opinion as to etiology to by gleaned from this opinion has little probative value. Sklar v. Brown, 5 Vet. App. 140 (1993). Pursuant to the Board’s October 2014 remand instructions, the Veteran was scheduled for a new VA eye examination in April 2015 to evaluate the nature and likely etiology of his eye condition. He acknowledged that his eyes were marked as having an abnormality while in service, but he noted that he did not remember why this was the case. He also detailed that he did not have any diagnosed eye condition at the time of the examination. After an in-person examination, the examiner confirmed the diagnoses of esophoria and cataracts, and additionally diagnosed a dry eye syndrome. Regarding the etiology of the esophoria, the examiner found that it was a congenital condition that could not be characterized as a defect or disease. As for the cataracts, the examiner opined that it was less likely than not that they were related to service and supported that determination by noting that there was no evidence of cataracts in service and for nearly 30 years after service. In conclusion, the examiner found it far more likely that the cataracts were age related. In contrast to the June 2012 examiner’s opinion, this opinion is probative, as it is based on a thorough review of the claims file and a reference to the Veteran’s documented medical history. Sklar, supra. More recently, pursuant to the Board’s October 2017 Remand directives, the Veteran was afforded a new VA eye examination in October 2018 to reevaluate the nature and likely etiology of the purported eye condition. Specifically, the Board needed clarification as to whether the Veteran had a diagnosable dry eye condition, and, if so, whether that condition was attributable to service independent of the Veteran’s other diagnosed ophthalmological conditions. After an in-person examination, the examiner continued the diagnoses of esophoria and cataracts, noting as well that the Veteran had left eye cataract surgery a year prior. The examiner also confirmed the diagnosis of a dry eye syndrome and opined that it was less likely than not that the syndrome was related to service. In support thereof, the examiner noted that the dry eye symptomatology did not arise until 2009 as indicated on VA medical records from that time. The examiner concluded by stating that it was far more likely the dry eye syndrome was age-related. Once again, this opinion is probative, as it is based on a thorough review of the claims file and a reference to the Veteran’s documented medical history. Sklar, supra. The Board acknowledges that the Veteran has asserted that he has a diagnosable eye condition that is attributable to service. The Veteran is competent to testify as to when his symptoms began. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the fact that the claims file does not contain a diagnosis of a non-congenital eye condition until the 2009 diagnosis of cataracts, nearly 30 years after his discharge from service, is persuasive evidence tending to demonstrate that there is no continuity of symptomatology after service. The Veteran has provided no objective medical evidence in support of his assertion that he had a diagnosable eye condition distinct from the esophoria that was noted upon his entrance to service other than physical profiles that show that he was noted to have an unspecified eye abnormality. Without any additional evidence to help clarify what abnormality was noted at this time in service, the Board cannot conclude that the eye condition first noted almost 30 years after service had indeed manifested while in service. The absence of such evidence coupled with the lack of a diagnosis at any point strongly suggests that no eye condition distinct from congenital esophoria began in service. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). As such, the preponderance of the evidence is against the claim of service connection for an eye condition distinct on both a direct basis under 38 C.F.R. § 3.303(a) or based on continuity of symptomatology under 38 C.F.R. § 3.303(b). The Veteran may still be entitled to service connection for an eye condition if all of the evidence establishes that the condition is otherwise attributable to an in-service occurrence. 38 C.F.R. § 3.303(d). As stated above, however, the Veteran has presented no objective medical evidence to support a determination that the diagnosed cataracts and dry eye syndrome are attributable to an in-service injury or event, other than the PULHES chart on the above-noted physical profiles issued during service. The Board ascribes much probative value to the April 2015 and October 2018 VA examiner opinions of record, as those opinions are supported by the weight of the evidence which shows that the Veteran was never evaluated as having a diagnosable eye condition in service distinct from esophoria and did not receive a diagnosis of an eye condition for nearly 30 years after service. The Board further notes that there is no evidence in the record showing that the Veteran has the medical training, credentials, or other expertise to competently conclude that any diagnosed eye condition is attributable to service. Jandreau v. Nicholson, 491 F.3d 1372 (Fed. Cir. 2007). Ultimately, the Board finds that the two VA examiner opinions of record that are supported by a rationale substantially outweigh the lay evidence and unclear medical evidence of record, in light of the rationale presented and the absence of training or credentials on the part of the Veteran. Therefore, the preponderance of the evidence is against the claim for service connection for an eye condition, the benefit-of-the-doubt standard of proof does not apply, and the claim is denied. 38 U.S.C. § 5107(b). Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, multiple (“staged”) ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In every instance where the rating schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. An increase in disability compensation may be granted from the earliest date on which it is factually ascertainable that an increase in disability occurred if the claim for an increase is received within one year from that date. 38 U.S.C.§ 5110(b)(2); 38 C.F.R. § 3.400(o)(2). When the increase in disability occurred prior to one year from the date of filing, an effective date of award cannot be awarded prior to the date of the application. Harper v. Brown, 10 Vet. App. 125, 126-27 (1997); 38 C.F.R. § 3.400(o)(2); VAOPGCPREC 12-98 (Sept. 23, 1998). In addition, when assessing the severity of musculoskeletal disabilities that are at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent (“flare-ups”) due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. 1. Entitlement to an increased evaluation for a lumbar spine disability. The Veteran is in receipt of a 40 percent rating for a lumbar spine disability, effective May 4, 2011, the date that he filed his claim seeking an increased evaluation of the condition. He seeks a higher rating for the condition for the entire period of the appeal, which was initiated via a claim for an increased rating dated on April 10, 2012. The current rating was assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5239-5243. Hyphenated Diagnostic Codes are utilized 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. In this particular case, the hyphenated Diagnostic Codes are all evaluated under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. The Board also notes that spinal conditions may also be evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (Formula for Rating IVDS), and that the method that results in the higher evaluation when all disabilities are combined should be utilized. 38 C.F.R. §§ 4.25, 4.71a, Diagnostic Code 5242. The General Rating Formula provides for a 40 percent rating for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243). Ankylosis is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). According to the Formula for Rating IVDS, a 40 percent rating is warranted for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent rating requires evidence of incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS. An “incapacitating episode” is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). If IVDS is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment will be evaluated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. Id. at Note (2). The Board has reviewed the relevant evidence of record, specifically including VA examinations from July 2011, August 2012, and September 2018, as well as VA and private treatment records. While the Veteran was shown in August 2012 to have flexion limited to 15 degrees, consistent with the 40 percent evaluation, this is the highest evaluation that can be assigned solely on the basis of loss of motion. See 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 208. No ankylosis has been documented during this period, and the Veteran’s condition has not required physician-prescribed bed rest. Put simply, the record presents no basis for a rating higher than 40 percent, and the claim must be denied. The Board has taken into consideration the copious lay evidence of record, to include the Veteran’s own statements as well as statements from his friends and family. While this lay testimony does confirm what has been reflected by the objective medical evidence, namely, that the Veteran experiences significant back pain resulting in loss of range of motion of his spine and varying degrees of functional impairment, the lay evidence of record does not raise the suggestion that the Veteran’s lumbar spine symptomatology is of such severity as to be commensurate with the criteria for an increased 50 percent evaluation, that is, either unfavorable ankylosis of the thoracolumbar spine, or incapacitating episodes requiring doctor-prescribed bed rest having a total duration of at least 6 weeks during the past 12 months. Therefore, the Board finds the assigned rating adequately contemplates the functional impairment resulting from the Veteran’s lumbar spine disability. The Board notes that the evidence of record does not show additional neurologic disorders associated with the Veteran’s lumbar spine disability other than the assigned ratings for right and left lower extremity radiculopathy for which he is already being compensated for and which are not at issue here. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). Accordingly, in light of the fact that neither the Veteran nor his representative has raised any other issues that are associated with the lumbar spine disability increased rating claim, nor have any other issues been reasonably raised by the record, the Board will not proceed to consider any alternative form of entitlement to this particular benefit. Doucette, supra. 2. Entitlement to an increased initial evaluation for a left ankle disability. The Veteran is in receipt of a 10 percent initial rating for a left ankle disability effective October 22, 2004. He seeks an increased rating for the entire period of the appeal. The 10 percent rating was assigned pursuant to 38 C.F.R. § 4.71, Diagnostic Code 5271, which concerns limited motion of the ankle. Under Diagnostic Code 5271, marked limitation of motion warrants a 20 percent rating, whereas moderate limitation of motion warrants a 10 percent rating. What is meant by “moderate” and “marked” limited motion is not defined by the diagnostic criteria; however, as a point of comparison, VA considers normal ankle dorsiflexion to be from 0 to 20 degrees and normal plantar flexion to be from 0 to 45 degrees. See 38 C.F.R. § 4.71, Plate II. The severity of the left ankle condition was first evaluated in an April 2005 VA ankle examination, during which the Veteran reported that he experienced chronic burning left ankle pain along the plantar aspect of his mid arch. According to the Veteran, his left foot would flop when he walked without shoes, causing him to hobble. He denied experiencing any swelling, popping, grinding or giving way. Range of motion testing revealed dorsiflexion to 15 degrees and plantar flexion to 40 degrees with pain at the extreme of plantar flexion on the left. There was no additional limitation of range of motion with repetitive use, and no tenderness throughout the left ankle. An X-ray examination of the left foot revealed a plantar calcaneal spur with no other abnormalities. The examiner concluded by diagnosing a plantar calcaneal spur on the left as well as residuals of an injury to the fifth metatarsals with mild degenerative changes. During a June 2012 VA ankle examination, the Veteran again reported experiencing chronic left ankle pain, especially with ambulation. He also endorsed experiencing flare-ups of additional pain occurring almost weekly. Range of motion testing revealed dorsiflexion to 15 degrees and plantar flexion to 40 degrees with pain beginning at 30 degrees of plantar flexion. There was no additional limitation of range of motion with repetitive use, and no further abnormalities. An X-ray examination revealed calcaneal enthesophytes, but otherwise showed no abnormalities. Regarding functional loss, the examiner noted that the left ankle condition contributed to less movement than normal as well as pain on movement bilaterally; however, the examiner ultimately concluded that the condition did not have any functional impact on the Veteran’s ability to work or on his daily activities. Pursuant to the Board’s October 2017 remand directives, the Veteran was scheduled for a new VA ankle examination in September 2018, during which he reported that he still experienced chronic left ankle pain, with intermittent flare-ups of increased pain occurring about twice per week lasting up to an hour in duration. According to the Veteran his flare-ups were precipitated by ambulating on uneven terrain. Range of motion testing revealed dorsiflexion to 20 degrees and plantar flexion to 38 degrees, with pain noted but no contributing to additional limitation of motion. There was no additional limitation of range of motion with repetitive use, although the examiner did note some mild tenderness to palpation of the joint. It was the examiner’s impression that the Veteran did not experience any additional limitation of motion during flare-ups. An X-ray examination once again revealed calcaneal enthesophytes, but otherwise showed no abnormalities. In summation, the examiner found that although there was no clear indication that the left ankle condition had worsened since the prior examination, the left ankle condition would nevertheless impair the Veteran’s occupational functioning as due to the aforementioned increase in pain while ambulating on uneven terrain. A review of available VA medical records shows that during a May 2011 consultation the Veteran complained of a long history of experiencing numbness and burning of his feet from the ankles that recently increased in severity. After an evaluation this neurological symptomatology was attributed to lower extremity radiculopathy and/or neuropathy, which the Board has already noted is a condition for which the Veteran is separately service connected. There are no additional VA medical records reflecting any treatment for left ankle pain specifically. Upon consideration of the record, the Board finds that the disability picture for the left ankle condition does not warrant a rating in excess of 10 percent at any point during the appeal. While the Veteran has exhibited some reduction of dorsiflexion and plantar flexion motion, this reduction is encompassed within the currently assigned 10 percent rating, which corresponds to moderate limitation of motion. Also, the September 2018 VA examination revealed no additional limitation of motion with repetitive use. Furthermore, the Board notes that at no point has the Veteran reported experiencing any instability of his left ankle, nor did any of the three VA examiners who evaluated him find evidence of left ankle instability. The Board also has considered other potentially applicable Diagnostic Codes that provide for the assignment of higher evaluations for the Veteran’s left ankle disability. At no time throughout the appeal period has there been evidence of ankylosis, or the functional equivalent, of the left ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5270. Moreover, there is no evidence of arthritis of the left ankle. Although the 10 percent rating currently assigned is the minimum rating available for this condition, the rating was granted with consideration of the functional loss stemming from the Veteran’s left ankle pain, as painful motion of a joint equates to limited motion. As stated, for any additional functional loss to warrant a higher rating, that loss must rise to the level of the more restricted plantar flexion and/or dorsiflexion represented by the 20 percent rating, which has not been shown. Therefore, the Board finds that the 10 percent rating adequately contemplates the functional impairment resulting from the Veteran’s left ankle condition for the entire period of the appeal. See 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 208. 3. Entitlement to an increased initial evaluation for a headache condition. The Veteran is currently service-connected for a headache condition, with a noncompensable evaluation effective October 22, 2004 and an increased rating of 30 percent effective September 18, 2018. He seeks a higher rating for the entire period of the appeal. The ratings at issue were assigned pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8100. Under Diagnostic Code 8100, a 10 percent disability rating is warranted for headaches with characteristic prostrating attacks occurring on an average of once every two months over the last several months, while a 30 percent disability rating is warranted for prostrating attacks occurring once every month. 38 C.F.R. § 4.124a, Diagnostic Code 8100. Headaches manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability warrant a 50 percent disability rating. 38 C.F.R. § 4.124a, Diagnostic Code 8100. VA regulations do not define “prostrating,” nor has the United States Court of Appeals for Veterans Claims (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). However, the Board notes that according to MERRIAM WEBSTER’S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), “prostration” is defined as “complete physical or mental exhaustion.” A similar definition is found in DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st Ed. 2007), in which “prostration” is defined as “extreme exhaustion or powerlessness.” VA regulations also do not define “economic inadaptability.” However, the Court has noted that nothing in Diagnostic Code 8100 requires the Veteran to be completely unable to work in order to qualify for a 50 percent rating. See Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004). The Veteran was afforded a VA headache examination in June 2012, during which he reported that he had been experiencing headaches intermittently since receiving the anthrax vaccine in 1999. He detailed that the headaches were dull and that he experienced them on most days on top of his head. After an in-person examination, the VA examiner noted that the headache pain was localized to one part of the head and worsened with physical activity; the examiner also noted that the Veteran experienced associated dizziness. The typical duration of headache pain was listed as less than one day, and the examiner further found that the Veteran did not have any history of frequent prostrating and prolonged attacks of severe headache pain. In summation, the examiner found that the headache condition did not have any impact on the Veteran’s occupational functioning or daily activities. Pursuant to the Board’s October 2017 remand directives, the Veteran was afforded a new VA headache examination in September 2018 to reevaluate the severity of the condition, during which he reported that he experienced dull headache pain at the top of his head twice daily that lasted for 30 minutes at a time. He further endorsed the following symptoms: pulsating or throbbing pain on both sides if his head, dizziness, sensitivity to light and sound, vision changes, and prostrating attacks of severe headache pain once every month. The examiner noted that the condition was stable, and that the Veteran controlled the headache pain with daily use of over-the-counter pain medication. A review of available VA and private medical records does not reflect that the Veteran has received any specified treatment for or diagnosis of a headache condition at any point during the appeal period. The Veteran submitted a letter from a Dr. S.B. dated in January 2011, in which he confirmed that the Veteran complained of experiencing chronic headaches. Dr. S.B. did not provide any detail as to the severity of the headaches. While the Veteran has endorsed experiencing severe headaches with sufficiently debilitating symptomatology to be considered prostrating in nature, it is unclear from the available evidence to what degree of regularity he experiences these headaches. The only clear indication of how often the Veteran experienced prostrating headaches was his own self-reporting on the June 2012 and September 2018 VA examinations; as this is the only clear picture of the severity of the Veteran’s headache in the claims file, the Board must rely on that self-reporting, as transcribed by VA examiners, as the most probative evidence of record. On this basis, the Board finds that there is no lay or medical evidence of record which suggests that the Veteran’s headache symptomatology rose to a compensable level prior to September 18, 2018, the earliest date that VA was made aware that the Veteran was experiencing headaches of such severity to be characterized as prostrating in nature. The evidence from this period is not suggestive of either characteristic prostrating attacks occurring on an average of once every two months over the last several months, or commensurate symptoms. Rather, the headaches were noted to be dull and not impacting occupational functioning or daily activities. The Board thus finds that the criteria for an initial 10 percent evaluation have not been met prior to the noted date. 38 C.F.R. § 4.31. As for the period beginning on September 18, 2018, the Veteran’s own self-report supports the currently assigned 30 percent rating, and there is no additional lay or medical evidence to suggest that the Veteran experiences any symptomatology which would warrant a rating in excess of that 30 percent. Prostrating attacks were noted to occur once per month, with no indication of very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Accordingly, the Board finds that prior to September 18, 2018, the Veteran did not exhibit headache symptomatology of a severity sufficient to warrant a compensable initial rating, as there was no competent evidence that he was experiencing prostrating attacks of headache pain, or commensurate symptoms; from that date, the evidence of record supports a finding that the Veteran’s headache condition results in prostrating attacks of headache symptomatology no more than once every month, which corresponds to a 30 percent rating. The appeal must be therefore denied as to this staged rating. REASONS FOR REMAND 1. Entitlement to service connection for a dizzy spell condition is remanded. Pursuant to the Board’s October 2017 remand instructions, the Veteran was scheduled for an October 2018 VA audiology examination with a corresponding opinion regarding the likely etiology of the claimed dizzy spell condition. Specifically, the Regional Office was directed to confirm the proper diagnosis to account for the Veteran’s dizziness symptomatology and then set forth an opinion as to the likely etiology of that symptomatology that served to reconcile prior conflicting etiology opinions. The conflicts identified by the Board were, firstly, that a June 2012 VA examiner attributed the Veteran’s dizziness to a vaccination he received in service in 1999, which the subsequent May 2015 examiner dismissed, and, secondly, that the same May 2015 examiner declined to provide a rationale for why it was less likely than not that the dizziness symptomatology was secondary to the service-connected headache condition. In the October 2018 opinion, the examiner confirmed that it was less likely than not that the dizziness symptomatology was attributable to the 1999 vaccination and provided a thorough rationale that focused on the transient nature of the Veteran’s dizziness symptomatology in service; as such, that theory of entitlement is not at issue presently. However, regarding the question of whether the dizziness symptomatology was secondary to the headache condition, the examiner did not utilize the proper standard, as they did not opine as to whether that symptomatology was aggravated by that disability. 38 C.F.R. § 3.310. Unfortunately, this standard was also not utilized by the VA examiner in the subsequent August 2019 addendum opinion. This must be corrected on remand. 2. Entitlement to service connection for hypertension is remanded. Pursuant to the Board’s October 2017 remand instructions, the likely etiology of the Veteran’s hypertension was evaluated by a VA examiner, who issued a negative opinion in October 2018. While the October 2018 examiner did address the query specified by the Board in its remand instructions, namely, whether the hypertension was secondary to the service-connected nephrolithiasis, the examiner did not provide any rationale for the conclusion that it was less likely than not that the hypertension was secondary to the nephrolithiasis. Without a rationale to explain the examiner’s conclusion, the opinion has little probative value, especially in light of the determination on an October 2018 VA kidney examination that the nephrolithiasis resulted in renal dysfunction, which is a known causative factor in the development in hypertension as outlined in the Board’s prior remand directives. This must also be corrected on remand. 3. Entitlement to a compensable evaluation for nephrolithiasis The rating criteria for nephrolithiasis include consideration of hypertension symptoms. As such, the Board finds that this evaluation claim is inextricably intertwined with the claim for service connection for hypertension, and consideration of it will be deferred by the Board until the hypertension issue is further addressed on remand. The matters are REMANDED for the following action: Provide the claims file to the October 2018 VA examiner (who also issued the August 2019 addendum opinion regarding hypertension), or, if not available, to another qualified examiner, in order to elicit an addendum opinion regarding the etiology of the dizzy spell condition and hypertension. The entire claims file, including this REMAND, must be made available. The chosen examiner must set forth an opinion as to whether it is it at least as likely as not (a 50 percent probability or higher) that the dizzy spell condition and/or the hypertension had its onset during service or is otherwise related to active service. In addition, irrespective of the answer to the above, the examiner is also requested to provide an opinion as to whether it is at least as likely as not that the dizzy spell condition and/or the hypertension was caused or aggravated by one or more service-connected disabilities (as listed in an August 2019 rating decision). Specifically, the examiner should evaluate the likelihood that the dizzy spell condition is secondary to the service-connected headache condition and the likelihood that hypertension is secondary to service-connected nephrolithiasis. If the opinion is that a service-connected disability or combination of service-connected disabilities aggravated either condition, the examiner should specify, so far as possible, the degree of disability resulting from such aggravation. All opinions must be supported by a rationale. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher M. Collins, 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.