Citation Nr: 21000020 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 16-26 537 DATE: January 4, 2021 ORDER Entitlement to an initial rating in excess of 20 percent for a back disability is denied. Entitlement to an initial rating in excess of 10 percent for a right knee disability is denied. Entitlement to an initial rating in excess of 10 percent prior to December 2, 2018, for a left shoulder disability is denied. Entitlement to a rating of 20 percent from December 2, 2018, for a left shoulder disability is granted. Entitlement to increased initial disability ratings for a headache disorder, presently rated as noncompensable prior to January 31, 2020, and 30 percent disabling thereafter is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. The Veteran’s low back disability has not resulted in forward flexion of the thoracolumbar spine to 30 degrees or less, nor has it shown any actual or functional ankylosis. 2. The Veteran’s right knee disability has demonstrated no less than 70 degrees of limited motion based on flexion, with painful motion; he has not shown any limitation of extension or instability of the knee. 3. Prior to December 2, 2018, the Veteran’s left shoulder disability did not limit motion of the arm to shoulder level or less. 4. From December 2, 2018, the Veteran’s left shoulder disability has limited motion of the arm between 30 degrees and shoulder level. 5. Prior to January 31, 2020, the Veteran’s cluster headaches did not result in prostrating attacks. 6. From January 31, 2020, the Veteran’s cluster headaches have not resulted in completely prostrating or prolonged attacks productive of severe economic inadaptability. 7. The Veteran does not meet the schedular criteria for TDIU; his service-connected disabilities do not combine to render him unemployable on their own. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for lumbar strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5237. 2. The criteria for a rating in excess of 10 percent for right knee arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DCs 5003, 5010, 5260. 3. The criteria for a rating in excess of 10 percent for a left shoulder disability have not been met prior to December 2, 2018. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5201. 4. The criteria for a rating of 20 percent, but no more, for a left shoulder disability have been met from December 2, 2018. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5201. 5. Prior to January 31, 2020, the criteria for a compensable rating for a headache disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 8100. 6. From January 31, 2020, the criteria for a rating in excess of 30 percent for a headache disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 8100 7. The criteria for TDIU have not been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1980 to May 1983. This matter comes before the Board of Veterans Appeals (Board) on appeal from a May 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2018, the Veteran testified before the undersigned Veterans Law Judge at a hearing held at the RO. A transcript of that hearing is of record. These issues previously came before the Board in March 2019, at which time they were remanded for further development. They are now returned to the Board for further appellate consideration. As was noted in the prior Board remand, a claim of entitlement to TDIU is part and parcel of an increased rating claim, when the Veteran asserts that his service connected disabilities on appeal contribute to his inability to obtain and maintain gainful employment. See Rice v. Shinseki, 22 Vet. App. 447 (2009). As such, a claim of TDIU remains part of the appeal presently before the Board. Increased Rating Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran’s entire history is reviewed when making disability evaluations. See generally, Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where, as in the case of the claims presently on appeal, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of staged ratings are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Further, “[w]here 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.” 38 C.F.R. § 4.7. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. 1. Entitlement to an initial rating in excess of 20 percent for a back disability The Veteran’s low back disability is rated as 20 percent disabling for the entire period on appeal. He seeks a higher rating. The Board finds that claim should be denied. The Veteran’s lumbar strain is rated under Diagnostic Code (DC) 5237, which compensates for lumbosacral or cervical strains, and applies the General Rating Formula for Diseases and Injuries of the Spine. Under the applicable rating criteria, a 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, DC 5237. A 40 percent rating requires a showing of forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A rating of 50 percent requires a showing of unfavorable ankylosis of the entire thoracolumbar spine. Finally, unfavorable ankylosis of the entire spine is assigned a 100 percent rating. Id. Objective neurological abnormalities are to be rated separately under an appropriate diagnostic code. Id., Note (1). The record does not confirm a present diagnosis of any neurological complications associated with the Veteran’s lumbar strain, and therefore such ratings are not for consideration in this matter. An alternate method for rating spine disabilities rates based on incapacitating episodes due to intervertebral disc syndrome (IVDS). Id., DC 5243. As no such pathology is found in the record, the Board will not consider that rating criteria. Turning to the evidence of record, although the Veteran filed his claim for service connection of a low back disability in 2012, because that claim was initially denied, appealed, and ultimately granted in the 2016 rating decision now on appeal, he was not afforded a VA examination in connection with that claim until April 2015. Looking at the available medical records, the Board has not identified any specific evidence which it may use to evaluate the Veteran’s low back disability during the period on appeal. The Board does note some discussion of back spasms in 2011, although it is unclear if that applies to the upper or lower back. Regardless, spasms, at most, give rise to a 20 percent rating under the applicable rating criteria. In April 2015, the Veteran presented for a thoracolumbar spine examination. The Veteran reported current daily lower back pain exacerbated by picking up objects and sudden movements. He treated his back pain with over the counter medications. He reported having intramuscular injections in approximately 2005. He did report flare-ups, as being exacerbated by lifting and sudden movement. Forward flexion was to 60 degrees with combined range of motion of 160 degrees with pain on motion. Pain caused the observed degrees of functional loss. Pain with weight bearing was described as midline tenderness in the lumbar area. The Veteran did report some additional functional limitations with repetitive use over time, although such loss was not demonstrated upon repetitive use testing at the time of the examination. The examination was neither medically consistent nor inconsistent with the Veteran’s reports of flare-ups. The Veteran did not demonstrate guarding. Factors limiting functional use included less movement than normal, disturbances of locomotion, and interference with standing. Muscle strength was normal. Reflexes were normal. Sensory testing was normal. He did not have radiculopathy or other neurological abnormalities. There was no evidence of ankylosis. He did not have IVDS. He did not use any assistive devices. Functionally, the examiner stated that his condition negatively affected his ability to work. Private treatment records from November 2018 showed complaints of muscle cramps, muscle aches and back pain with stiffness. He stated that his knees, left shoulder and back “hurt all the time,” although he denied loss of muscle strength. He showed lumbar pain with the left leg raised at 15 degrees, although maximum ranges of motion were not provided, and the Board notes that range of motion testing with leg raises is not a rating metric under the statutory rating criteria. During his hearing before the undersigned, the Veteran did not attest to any specific loss of range of motion or fixation of the spine, although he was observed to use a cane to ambulate. At most, the Veteran stated that his pain had increased. During the hearing, the undersigned explained that for a rating in excess of 20 percent for his spine disability, he would need to show some significant or marked limitations in his back, and the Veteran expressed understanding. In February 2020, the Veteran was afforded a new VA examination in connection with his claim for a higher rating. The Veteran denied having seen a medical provider for his back in over 10 years, and treated his ongoing pain with over the counter medications. The examiner stated that regarding the severity of his symptoms, the Veteran moaned and talked about pain with walking and sitting, difficulty standing and moving during the examination. However, the examiner noted that following the examination he walked the Veteran and his spouse to the X-ray room, and the Veteran did not exhibit any of the severe symptoms he asserted in the examination, but rather walked with a fast paced, normal manner. Such a brisk, normal walk does not align with his reported poor functional abilities. The Veteran reported flare-ups during cold weather, which he reported as resulting in an inability to walk greater than 15 minutes, inability to stand more than 15 minutes, sleep interruption, inability to bend, and inability to walk in a store. Forward flexion was to 55 degrees and combined range of motion was 195 degrees. No pain was noted on examination. There was no evidence of pain with weight bearing. There was some evidence of localized tenderness between L2 and L4. The Veteran was unable to perform repetitive use testing due to assertions of pain, however, the examiner asserted that factors such as pain, weakness, fatigability or incoordination did not limit functional ability with repeated use over time or during periods of flare. He did show some muscle spasms, but they did not result in abnormal gait or spinal contour. He did not show guarding. Muscle strength was normal and complete. Reflexes and neurological testing were all normal. He did not have any signs of radiculopathy or ankylosis. He did not have IVDS. He did not require the use of an assistive device. The examiner stated that the examination was not conducted during a flare-up, but that range of motion deficits would likely increase to an unknown degree during a flare-up of the condition. Specifically, the examiner could not give any specific loss measurements because, based on the Veteran’s history and current subjective complaints, combined with the examination itself and observation of the Veteran following the examination where he walked with a brisk pace, specific losses could not be estimated. It was noted that the Veteran only experienced flare-ups in the winter months, and they only resulted in increased pain. No specific loss of range of motion was described by the Veteran. In light of this evidence, the Board finds that the Veteran’s low back disability has not manifested to such a degree as to warrant a rating in excess of the 20 percent already assigned. In this regard, the Veteran has not been shown to have forward flexion of the spine limited to 30 degrees or less. Neither has he shown any evidence of ankylosis or other fixation of the lumbar region. This conclusion includes consideration of the medical evidence of record, as well as the Veteran’s own reports of severity of his symptoms. To the extent that the Veteran has exhibited difficulty with lifting and bending, he has not asserted that he cannot bend at all or lift at all, which would likely involve flexion greater than 30 degrees. Further, to the extent that he did complain of some significant impairments during his most recent examination, the examiner found those assertions to be less than credible, particularly given the Veteran’s sudden improvement in symptoms following the completion of the examination, and the fact that the Veteran was told a higher rating would require more significant symptoms by the undersigned in his hearing. Therefore, to the extent that the Veteran has asserted significant functional losses in his most recent VA examination, the Board finds these assertions to be less than credible for purposes of rating his low back disability, and therefore, the Board must rely more heavily on the range of motion testing as recorded in the examination itself. See Caluza v. Brown, 7 Vet. App. 498 (1995). In sum, the Board finds that the Veteran’s low back disability has not manifested to such a significant degree as to warrant a rating in excess of 20 percent. Therefore, the claim is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 2. Entitlement to an initial rating in excess of 10 percent for a right knee disability The Veteran’s right knee disability has been rated as 10 percent disabling. He seeks higher ratings for that disability. The Board finds that the claim should be denied. The Veteran’s knee disability is presently rated under DC 5010-5260. Hyphenated Diagnostic Codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. In the present matter, DC 5010 implies arthritis due to trauma, which is to be rated as degenerative arthritis, and DC 5260 indicates limitation of flexion of the knee. Degenerative arthritis is rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a , DC 5003. Under the applicable rating criteria for limitation of flexion, flexion limited to 45 degrees is assigned a 10 percent rating. Rating limited to 30 degrees is assigned a 20 percent rating. Finally, flexion limited to 15 degrees or less is assigned a 30 percent rating. 38 C.F.R. § 4.71a, DC 5260. When rating based on limitation of flexion, a separate rating may be assigned for knee disabilities based on limitation of flexion as well as limitation of extension of the knee. Likewise, separate ratings may be assigned based on limitation of motion, as well as instability or subluxation, if found. See VAOPGCPREC 23-97 (Multiple Ratings for Knee Disability). Limitation of extension to 5 degrees or less is assigned a noncompensable rating. Extension limited to 10 degrees is assigned a 10 percent rating. Extension limited to 15 degrees is assigned a 20 percent rating. Extension limited to 20 degrees is assigned a 30 percent rating. Extension limited to 30 degrees is assigned a 40 percent rating. Finally, extension limited to 45 degrees or greater is assigned a 50 percent rating. 38 C.F.R. § 4.71a , DC 5261. When slight impairment of the knee due to recurrent subluxation or lateral instability is found, a 10 percent rating is assigned. Moderate recurrent subluxation or lateral instability is granted a 20 percent rating. Severe recurrent subluxation or lateral instability is assigned a 30 percent rating. 38 C.F.R. § 4.71a , DC 5257. Words such as “severe,” “moderate,” and “mild” are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6 Also relevant to disabilities of the knees are diagnostic codes pertaining to ankylosis (5256), dislocation or removal of the cartilage (5258, 5259), impairment of the tibia and fibula (5262), and genu recurvatum (5263). The evidence in this matter does not support a finding that such pathology has been shown, and therefore they are not applicable in this matter. The Veteran was first afforded a VA examination in March 2015. At that time he reported intermittent right knee pain and swelling exacerbated by prolonged weight bearing. He used a cane for ambulation during flare-ups. Flexion and extension were both full and complete (0 to 140 degrees), with pain on movement, although pain was not found with weight bearing. Tenderness was noted along the medial aspect of the knee. There was no crepitus. No additional functional loss was observed following repetitive use testing. The examiner stated that the examination was neither medically consistent nor inconsistent with the Veteran’s statements regarding functional loss after repetitive use over time or during flare-ups. The examiner could not state without resort to speculation whether or not factors such as pain, weakness, fatigability or incoordination caused additional functional loss as such symptoms were note demonstrated during the examinations. Strength was complete and full. There was no muscle atrophy or ankylosis. Stability testing was all normal and he did not have any evidence of instability or subluxation. He occasionally used a cane for ambulation. Functionally, the examiner stated that the knee condition negatively impacted his ability to work. Private treatment records from November 2018 noted a history of knee pain, treated with over the counter medications, but did not give any range of motion findings. In December 2018, he was noted to have moderate crepitus in his bilateral knees, but no loss of range of motion was found. In his hearing before the undersigned, the Veteran testified to increasing pain in his knees, and it was observed that he used a cane to ambulate. The Veteran was afforded a new VA examination in January 2020 following his hearing before the undersigned. During his examination the Veteran moaned and talked about pain with walking and sitting, difficulty standing and moving. However, following the examination, the examiner walked the Veteran to the X-ray room and noted that he walked with a brisk, normal walk (described as both fast-paced and brisk) which did not align with his reports of poor functional abilities in the examination. Flare-ups were reported to occur with cold weather. Flexion was to 70 degrees. Extension was complete to 0 degrees. No pain was noted upon examination, nor with weight bearing. There was some medial lateral tenderness noted upon palpation. No additional loss was noted following repetitive use testing. The examination was not conducted during a flare-up, however, the examiner stated that factors such as pain, weakness, fatigability or incoordination would not significantly limit functional ability during such period of flare. No additional factors contributed to the disability. Muscle strength showed active movement against some resistance on flexion. There was no muscle atrophy or ankylosis. Joint stability testing was completely normal. Functionally, the examiner referred to the Veteran’s reports of being able to walk or stand for greater than 15 minutes, and determined that the condition did affect his ability to obtain and maintain employment. In light of the above, the Board finds that a rating in excess of 10 percent is not supported. Specifically, at most, the Veteran has shown flexion of the knee to 70 degrees which is noncompensable under the rating criteria. He has not shown any limitation of extension or instability of the knee. When painful motion is found which does not rise to a compensable level, a single 10 percent rating is assigned pursuant to DC 5003. This conclusion is reached in consideration of all evidence of record, to include the examination reports, VA and private treatment records, and the Veteran’s own assertions regarding severity of his symptoms, to include his reports of severity during periods of flare. In this regard, the Veteran reports pain with standing or walking greater than 15 minutes, particularly during periods of cold weather, however, there is no indication that his flexion has been limited to 30 degrees or less which is required for a rating in excess of 20 percent. Neither has he alleged limitation of flexion or instability. As such, a single 10 percent rating based on painful motion is supported. In sum, the Board finds that the Veteran’s right knee has not met the criteria for a rating in excess of 10 percent based on limitation of flexion, nor has he met the criteria for a separate rating based on limitation of extension or instability. As such, the claim for an increased rating is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 3. Entitlement to an initial rating in excess of 10 percent for a left shoulder disability The Veteran’s left shoulder bursitis has been rated 10 percent disabling from the date of service connection. He seeks a higher rating. The Board finds that prior to December 2, 2018, a rating in excess of 10 percent is not warranted. However, affording the Veteran the benefit of the doubt, the Board will grant a 20 percent rating from that date forward. The Veteran’s left shoulder disability is presently rated under DC 5201-5019. In the present matter, DC 5019 implies bursitis; DC 5201 compensates based on limitation of arm motion. It is noted that the Veteran’s left arm is his non-dominant or minor extremity. Under the applicable rating criteria, a 20 percent rating is assigned for limitation of motion to either the midway between the side and shoulder level, or to the shoulder level itself. Limitation of arm movement to 25 degrees or less is awarded a maximum 30 percent rating. 38 C.F.R. § 4.71a, DC 5201. Other rating criteria applies to ankylosis affecting scapulohumeral articulation, impairment of the humerus, or impairment of the clavicle or scapula. As such pathology is not show in this matter, those DCs are not for consideration at this time. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The Veteran was initially evaluated in March 2015. At that time, the Veteran reported intermittent left shoulder pain for several days each week, exacerbated by lifting, carrying objects, and raising his left hand above his head. He treated his pain with deep muscle rubs, and over the counter medication. Flare-ups were noted as pain when lifting his hand above his head. Flexion and abduction were both limited to 160 degrees (180 degrees maximum). External and internal rotation were both complete and full at 90. Pain was found to limit movement at the terminal degrees of motion on flexion and abduction. No additional loss was found on repetitive use testing. The examiner noted that additional functional loss was reported with use over time and during flare ups, but was not demonstrated upon examination. Factors contributing to his level of disability were less movement than normal. Muscle strength was complete and full and there was no evidence of muscle atrophy. He did not have ankylosis or any fixation of the shoulder. There was no evidence if instability. He did not use an assistive device. Functionally, his condition negatively affected his ability to work. Private treatment records from November 2018 noted left shoulder pain but did not discuss actual limitations due to that pain. In December 2018, the Veteran was noted to have shoulder limitation due to pain with the left arm raised to 30 degrees. In his hearing before the undersigned, the Veteran testified to increased pain in his left shoulder. In February 2020, the Veteran was afforded a new VA examination. He reported treating his pain with over the counter medications and asserted flare-ups during periods of cold weather. Specifically, he stated that he could not raise his arm to the level of his shoulder, unable to grab high objects, and unable to lift more than 5 pounds. Left shoulder range of motion was abnormal our outside of normal range of motion, although no pain was noted on examination. There was no evidence of pain in weight bearing, crepitus or localized tenderness. He was able to perform repetitive use testing. No additional loss was noted due to factors such as pain, weakness, fatigability or incoordination contributed to the disability, to include during periods of flare. Muscle strength was complete and full. No ankylosis or fixation was found. No instability was observed. He did not use an assistive device. Functionally, he was unable to lift above his head, and the Veteran reported being limited to moving his arm beyond shoulder level. The examiner stated that he had no basis upon which to offer additional levels of loss due to periods of flare, as the Veteran only reported flare-ups during winter months which resulted in increased pain. In light of the above, the Board declines to grant a rating in excess of 10 percent already assigned prior to December 2, 2018. In this regard, prior to that date, he had not shown limitation of motion to less than shoulder level. Indeed, prior to that date, he was able to raise his arm above shoulder level, albeit with pain. As limitation to shoulder level is required for a rating greater than 10 percent, prior to December 2, 2018, the claim is denied. This conclusion includes consideration of the Veteran’s own reports of pain and symptoms during that period of time. However, from December 2, 2018, the Board will grant a 20 percent rating for the Veteran’s shoulder bursitis, based upon two factors. First, the Board recognizes the private treatment record from that date which noted painful motion limiting movement of the shoulder to 30 degrees, which at least implies limitation to a compensable level, but not so much as to meet the 30 percent criteria (25 degrees or less). The Board further notes that, although the examiner in the 2020 examination did not give specific range of motion findings for the Veteran’s shoulder disability, the examiner did record the Veteran’s own assertion that his shoulder disability limited movement to shoulder level. Shoulder level is the maximum level of movement which is compensated by a 20 percent rating under the Diagnostic Code. Therefore, the Board will grant a 20 percent rating, but no higher, because the Veteran himself admitted in the examination that his movement is not limited to 25 degrees or less. In sum, the Board finds that prior to December 2, 2018, the criteria for a rating greater than the 10 percent already assigned is not met. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. However, from that date forward, a 20 percent rating, but no higher, should be granted. 4. Entitlement to increased initial disability ratings for a headache disorder, presently rated as noncompensable prior to January 31, 2020, and 30 percent disabling thereafter The Veteran’s headache disorder is presently rated as noncompensable prior to January 31, 2020, and 30 percent disabling thereafter. He seeks higher ratings. The Board finds that the claim should be denied. The Veteran’s cluster headaches are rated under DC 8199-8100. DC 8199 does not exist in the Diagnostic Code, but implies a disability manifested by headaches. DC 8100 compensates for migraine headaches. In this case, the hyphenated DC implies a headache disorder, most closely evaluated as migraine headaches. It is noted that there is no other specific DC which compensates for headaches other than migraines, and the Veteran’s pathology is not more closely aligned with any other code. Under the applicable criteria, a noncompensable rating is assigned for headaches with less frequent attacks than once every 2 months. A 10 percent rating is assigned for characteristic prostrating attacks averaging once every 2 months over the prior several months. A 30 percent rating is assigned for characteristic prostrating attacks occurring on an average once a month over the last several months. Finally, a 50 percent rating is assigned with very frequent completely prostrating and prolonged attacks productive of severe economic adaptability. 38 C.F.R. § 4.124a, DC 8100. The Board notes that the rating criteria do not define the term “prostrating.” See 38 C.F.R. § 4.124a , Diagnostic Code 8100. Clinically, “prostrating” is defined as “extreme exhaustion or powerlessness.” Dorland’s Illustrated Medical Dictionary 1554 (31st ed. 2007). In nonmedical terms, prostrating is defined as lying flat or at full length, to reduce to physical weakness or exhaustion, or to reduce to helplessness. The Veteran was initially evaluated in March 2015. At that time, the Veteran reported daily headaches that begin on the left side of his face, treated with over the counter medications. Pain usually lasted less than one day, but were not found to be characteristically prostrating in nature. It is noted that there are no specific private or VA treatment records pertaining to headaches between the date of service connection in 2012 and the March 2015 examination. Nonetheless, the Board notes that records through 2010 indicate that the Veteran generally denied any such symptoms or pathology. During his October 2018 hearing before the undersigned, the Veteran testified to increased headache symptoms, although not describing the nature of his symptoms. Private treatment records from November and December 2018 document ongoing complaints of headaches, but do not describe the nature or severity of his symptoms. On January 31, 2020, the Veteran was afforded a new VA examination in connection with his claim. At that time, he was found to have constant, pulsating or throbbing head pain in the left temple to frontal. Symptoms included sensitivity to light and changes in vision, lasting 4-5 hous at a time. The examiner found them to be prostrating in nature, occurring three times a week. His headaches were treated with darkness and over the counter medication. Notably, the examiner stated that based on the evidence, he believed the Veteran’s response to be false for migraines. Prior to January 31, 2020, the Board finds that the criteria for a compensable rating have not been met. Although the Veteran asserted, and the examiner confirmed regular headaches, they were not found to be “prostrating” in nature. There was no indication that they resulted in extreme exhaustion or required laying down at full length due to weakness or exhaustion. Indeed, they seemed to be responsive to over the counter medications. As such, the Board finds that a compensable rating is not supported by the medical or lay evidence of record prior to January 31, 2020. From January 31, 2020, the Veteran has been granted a 30 percent rating. The Board finds that a rating in excess of that is also not supported. In this regard, while the VA examination on that date did find evidence of prostrating attacks, occurring up to three times per week, the Board does not find evidence that these attacks are completely prostrating in nature. While he may require use of a dark room while such an attack is occurring, the attacks are generally short in nature (3-4 hours maximum), and respond to over the counter medications. Indeed, the examiner noted that he believed the Veteran’s reports of severity to be false for migraines, and noted that responsiveness to medication as a key factor in that conclusion. Ultimately, the Board finds that such prostrating attacks, if and when they occur are not completely prostrating, and certainly not prolonged, as is anticipated by a 50 percent rating under the diagnostic criteria. He generally responds well to medication and his attacks are fairly brief in nature when they occur. In sum, the Board finds that a compensable rating prior to January 31, 2020, and a rating in excess of 30 percent thereafter are not supported and the claim is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102.   Total Disability 5. Entitlement to a total disability rating based on individual unemployability (TDIU) A TDIU is assigned when a veteran’s service-connected disability or disabilities are of such severity that the veteran cannot secure or follow a substantially gainful occupation solely because of that disability or disabilities. 38 C.F.R. § 4.16. Generally, TDIU is awarded on a schedular basis, which requires that, if there is only one service-connected disability, this disability shall be ratable at 60 percent or more. If there is more than one disability, there must be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more 38 C.F.R. § 4.16 (a). In the instant matter, even considering the increased rating for his shoulder disability, as granted above, the Veteran’s combined rating does not exceed 60 percent disabling for any period on appeal; he does not have a single disability rated as 60 percent disabling. As such, the schedular criteria are not met for TDIU and a grant is generally precluded. Under Roberson v. Principi, 251 F.3d 1378 (2001) and Rice v. Shinseki, 22 Vet. App. 447 (2009), the Board must also consider TDIU even when the schedular criteria are not met. VA policy is that all Veterans unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated as totally disabled. 38 C.F.R. § 4.16 (b), rating boards should refer to the Director of Compensation and Pension Service for extraschedular consideration all cases where Veterans are unemployable by reason of service-connected disabilities but who fail to meet the percentage requirements set forth in 38 C.F.R. § 4.16 (a). Although the Board cannot assign an extraschedular TDIU in the first instance, it is not precluded from specifically adjudicating whether to refer a case for an extraschedular evaluation when the issue is either raised by the claimant or is reasonably raised by the record. See Wages v. McDonald, 27 Vet. App. 233, 236 (2015). Here, the evidence of record indicates referral for extraschedular consideration is not warranted. In light of its findings addressed above, the Board now finds that, based on all evidence of record, the record does not support a finding that the Veteran is unemployable exclusively due to this service-connected disabilities and therefore will not remand the issue for extraschedular consideration in the first instance. Although the Veteran has not worked for over 10 years, the evidence suggests that his unemployability is primarily due to non-service-connected disabilities such as glaucoma, adjustment disorders, depression and substance use. The Veteran’s service-connected physical disabilities do not completely preclude use of any limb or the spine, and are generally treated with over-the-counter medications. They do not completely preclude physical activity and would certainly not preclude basic sedentary employment. His headaches attacks, although more frequent and severe in nature in recent years, tend to be short in duration and also respond well to over-the-counter medications. His attacks are not completely prostrating and do not result in severe economic adaptability. In short, there is simply inadequate evidence at this time to find that his headaches, spine, shoulder and knee disabilities exclusively combine to render the Veteran unemployable on their own. As such, the Board will decline to refer the claim for further extraschedular consideration. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 510 ; 38 C.F.R. § 3.102. B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Pryce, 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.