Citation Nr: 21062466 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 17-32 351 DATE: October 7, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for a left ankle disorder is denied. Entitlement to an initial rating in excess of 10 percent for a right ankle disorder is denied. Entitlement to an initial compensable rating for temporal headaches is denied. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's left ankle disorder was manifested by, at most, a moderate limitation of range of motion even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, swelling, lack of endurance, and incoordination, or as a result of repetitive motion and/or flare-ups without ankylosis of the ankle or subastragalar or tarsal joint, malunion of the calcis or astragalus, or an astragalectomy. 2. Throughout the period on appeal, the Veteran's right ankle disorder was manifested by, at most, a moderate limitation of range of motion even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, swelling, lack of endurance, and incoordination, or as a result of repetitive motion and/or flare-ups without ankylosis of the ankle or subastragalar or tarsal joint, malunion of the calcis or astragalus, or an astragalectomy. 3. Throughout the period on appeal, the impairment associated with the Veteran's temporal headaches have been productive of less frequent attacks. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for a left ankle disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.40, 4.45, 4.71a, Diagnostic Code 5271. 2. The criteria for an initial rating in excess of 10 percent for a right ankle disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.40, 4.45, 4.71a, Diagnostic Code 5271. 3. The criteria for an initial compensable rating for temporal headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.124a, Diagnostic Code 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from July 2010 to April 2014. These matters come to the Board of Veterans' Appeals (Board) on appeal from an April 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction of this appeal is currently with the RO in Los Angeles, California. This case was most recently before the Board in February 2019, at which time the appeal was remanded to the Agency of Original Jurisdiction (AOJ) for further development. The case has now been returned to the Board for appellate action. INCREASED RATING Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant's current symptoms. See Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). When an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable Diagnostic Code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). 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. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 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; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claims. 1. Left and Right Ankles The Veteran seeks entitlement to higher initial ratings for his left and right ankle disorders. Specific argument in support of this appeal has not been provided. The Veteran has been assigned initial 10 percent ratings for his left and right ankles each under Diagnostic Code 5271. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. The Board notes that effective February 7, 2021, the criteria for schedule of ratings for the musculoskeletal system was revised. See 86 Fed. Reg. 8142 (Feb. 4, 2021) (codified at 38 C.F.R. pt. 4). In regard to the ankle, changes were made to Diagnostic Code 5271 only. As such, the Board will apply the old rating criteria prior to February 7, 2021 and will apply the more favorable criteria from February 7, 2021. Prior to February 7, 2021 under Diagnostic Code 5271, a rating of 10 percent is warranted when limitation of motion of the ankle is moderate. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. The maximum rating of 20 percent disabling is available under Diagnostic Code 5271 where the limitation of motion in the ankle is marked. Id. Normal ankle motion is dorsiflexion to 20 degrees, and plantar flexion to 45 degrees. 38 C.F.R. § 4.71a, Plate II. Notably, the terms "moderate" and "marked" are not defined under VA regulations. Those terms also do not appear to have a generally accepted medical definition. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "moderate" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Also included within 38 C.F.R. § 4.71a are multiple Diagnostic Codes that evaluate ankle disabilities based on other manifestations, including Diagnostic Code 5270 (ankylosis of the ankle), Diagnostic Code 5272 (ankylosis of the subastragalar or tarsal joint), Diagnostic Code 5273 (malunion of the os calcis or astragalus), and Diagnostic Code 5274 (astragalectomy). Since February 7, 2021 a 10 percent rating is warranted for moderate limitation of the ankle (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion) The maximum 20 percent rating is warranted for marked limitation of the ankle (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion). Normal ankle movement is defined as 20 degrees of dorsiflexion and 45 degrees of plantar flexion. Turning to the evidence of record, July 2015 and September 2015 VA treatment records indicate the Veteran complained of bilateral ankle pain, pain on weight-bearing, intermittent swelling, with pain worse on the left ankle. The Veteran was afforded a VA examination in May 2017. At that time, the examiner diagnosed lateral collateral ligament sprain bilaterally. The Veteran reported that his ankles gave out daily and the conditions had worsened since active service. He reported grinding, severe pain, throbbing at night, and disturbed sleep due to pain. The Veteran endorsed flare-ups of the left ankle that was described as constant pain and giving out precipitated flare-ups. The Veteran endorsed flare-ups of the right ankle that he believed were precipitated by overuse of the right ankle to compensate for left ankle pain. He reported functional loss of the ankles as inability to stand on his feet for too long and giving out. Upon physical examination at the May 2017 VA examination, range of motion measurements of the left ankle were as follows: dorsiflexion was to 10 degrees; and plantar flexion was to 35 degrees. Range of motion measurements of the right ankle were all normal and were as follows: dorsiflexion was to 20 degrees; and plantar flexion was to 35 degrees. Range of motion itself did not contribute to a functional loss. Pain was noted bilaterally on dorsiflexion and plantar flexion but did not result in or cause a functional loss. There was no objective evidence of localized tenderness or pain on palpation of the bilateral ankles. There was no objective evidence of crepitus bilaterally. There was no evidence of pain with weight-bearing bilaterally. The Veteran was able to perform repetitive-use testing with at least three repetitions for both ankles; there was no additional loss of function or range of motion after three repetitions. The Veteran was not being examined immediately after repetitive use over a period of time. Pain, weakness, fatigability, or incoordination was not shown to significantly limit functional ability with repetitive use over a period of time. The examination was conducted during a flare-up of the bilateral ankles. Pain, weakness, fatigability, or incoordination was not shown to significantly limit functional ability during a flare-up bilaterally. There were no other additional factors that contributed to the disability of either ankle. Muscle strength testing in May 2017 was normal bilaterally; there was no reduction in muscle strength. The Veteran did not have muscle atrophy. Ankylosis was not shown. Instability and dislocation were not suspected in either knee. The Veteran did not have or ever had "shin splints", stress fractures, Achilles' tendonitis, Achilles' tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or talectomy (astragalectomy). There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The Veteran denied the use of any assistive device as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. The examiner noted the Veteran's ankles would impact his ability to work due to difficulty with running, prolonged walking, and standing. The examiner remarked that there was objective evidence of pain on passive range of motion testing bilaterally; there was no evidence of pain with non-weight-bearing testing bilaterally. The Veteran was afforded a VA examination in September 2020. At that time, the examiner diagnosed lateral collateral ligament sprain bilaterally. The Veteran reported his ankles would throb to his eyes and were aggravated by cold weather. He stated he "cranked" his ankle to get relief. The Veteran reported his ankles would give out easily. Current symptoms included intermittent pain on the right side with giving out, with more aching noticeable in the last five years. If the weather changed, he would be unable to sleep due to the pain in his ankles. He stated he would have to tap the foot or ankle to try to relieve the throbbing. The Veteran endorsed swelling, and more pain with inactivity. The Veteran endorsed flare-ups of the right ankle that was described as occurring once a month to once every other month; lasting a week; severe; precipitated by his ankle giving out or without reason; relieved with a chiropractor, applying ice or heat, cracking it with rotations, heat rubs, and CBD cream. The Veteran endorsed flare-ups of the left ankle that was described as occurring one to two times a month; lasting one to one and half weeks in duration; severe; precipitated by his ankle giving out on walking or without reason; relieved with a chiropractor, applying ice or heat, cracking it with rotations, heat rubs, and CBD cream. The Veteran reported functional loss described as impaired prolonged walking and sitting due to aggravation of pain. Upon physical examination at the September 2020 VA examination, range of motion measurements of the left ankle were as follows: dorsiflexion was to 20 degrees; and plantar flexion was to 35 degrees. Range of motion measurements of the right ankle were as follows: dorsiflexion was to 20 degrees; and plantar flexion was to 30 degrees. Range of motion itself did not contribute to a functional loss. Pain was noted on plant flexion bilaterally and caused a functional loss. There was no objective evidence of localized tenderness or pain on the right knee; there was objective evidence of localized tenderness or pain on the lateral and medical collateral ligaments and insertions of the left Achilles that was moderate. There was evidence of pain with weight-bearing bilaterally; there was objective evidence of crepitus bilaterally. The Veteran was able to perform repetitive-use testing with at least three repetitions for both ankles; there was no additional loss of function or range of motion after three repetitions. The Veteran was not being examined immediately after repetitive-use over a period of time; the examination was medically consistent with the Veteran's statements describing a functional loss with repetitive-use over time. Pain was shown to significantly limit functional ability with repetitive use over a period of time. The examiner was able to describe in terms of range of motions as follows: for the right ankle, dorsiflexion to 20 degrees and plantar flexion to 25 degrees; for the left ankle, dorsiflexion to 20 degrees and plantar flexion to 30 degrees. The Veteran was not examined during a flare-up; the examination was medically consistent with the Veteran's statements describing functional loss during a flare-up. Pain was shown to significantly limit functional ability during a flare-up. The examiner was able to describe in terms of range of motion as follows: for the right ankle, dorsiflexion to 15 degrees and plantar flexion to 25 degrees; and for the left ankle, dorsiflexion to 15 degrees and plantar flexion to 25 degrees. There were no other additional factors that contributed to the disability of either ankle. Muscle strength testing in September 2020 was normal bilaterally; there was no reduction in muscle strength. The Veteran did not have muscle atrophy. Ankylosis was not shown. Instability and dislocation were not suspected in either knee. The Veteran did not have or ever had "shin splints", stress fractures, Achilles' tendonitis, Achilles' tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or talectomy (astragalectomy). There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The Veteran denied the use of any assistive device as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. The examiner noted the Veteran's ankles impacted his ability to work due to functional limitation with prolonged sitting, standing more than 30 minutes without breaks, and walking and running for 100 yards without breaks. The examiner remarked there was objective evidence of pain when the bilateral ankles were used in non-weight-bearing; and passive range of motion measurements were the same as active range of motion. In addition to the September 2020 physical examination, the VA examiner opined that there was limited objective clinical evidence to suggest progression of his service-connected left and right ankles at present. In this regard, the examiner noted the Veteran's service treatment records, continuing post-service treatment records, and VA examination reports for his ankles. The examiner noted that the medical evidence suggested stable bilateral ankles and continued to show the same diagnosis of bilateral ankle sprain. The examiner noted there was a mild decrease in the range of motion of the bilateral ankles, with pain, on both active and passive range of motion testing, and in weight-bearing and non-weight-bearing. The Veteran's lay statements reported were noted, and the estimate of range of motion during repetitive use and flare-ups were also mildly decreased. Moreover, the examiner noted that a retrospective opinion regarding limitations due to repetitive-use and flare-ups since April 2014 was not applicable at this time because, the examiner could only opine, based on the records, on the picture of chronicity of the ankle disability and recent physical examination. The examiner noted that such evidence was the basis for the conclusive opinions rendered. Furthermore, the September 2020 examiner noted on the recent physical examination, there was mild decreased in range of motion of the bilateral ankles with pain noted both on active and passive testing, as well as in weight bearing and non-weight-bearing exam. There was no fatigue, weakness or lack of endurance felt at that time. The examination was not conducted during flare-up. The examiner provided an estimate for specific measurement regarding flare-ups based on the clinical history, medical records and recently conducted physical examination. Considering all evidence, the examiner opined that the Veteran's current ankle condition would limit prolonged sitting, and standing for more than 30 minutes without breaks, and walking and running for 100 yards without breaks. Further review of the record shows that the Veteran receives VA treatment and from private treatment providers for various disabilities, to include his left and right ankles. However, there is no indication from the treatment notes of record that the Veteran has reported ankle symptoms that are worse than those noted in the various VA examination reports of record and there are no ranges of motion measurements documented in the VA treatment notes of record. For the foregoing reasons, the Board finds that the Veteran is not entitled to initial ratings in excess of 10 percent for his left and right ankles at any time during the period on appeal or when considered the new and old regulations. In this regard, there is simply no evidence of record to suggest that the Veteran had marked limitation of the right ankle; as such, a 20 percent rating is not warranted. Specifically, at his VA examinations, the Veteran reported pain, limited range of motion, and interference with some movements, to include walking, sitting, or standing. Range of motion measurements are as noted above. There was no additional loss of function or range of motion found after repetitive-use testing at the May 2017 VA examination; the estimated loss of function or range of motion after repetitive-use testing and during flare-ups at the September 2020 VA examination are noted above. Accordingly, the Board finds that the Veteran's left and right ankle disorders manifested, at most, in a moderate limitation of range of motion even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, swelling, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. The Veteran's belief that he is entitled to a higher rating for his left and right ankle disorders is outweighed by the objective medical findings of record. That is, the Board assigns greater probative value to the pertinent objective findings on the VA examination reports and treatment records that were recorded following physical examinations of the Veteran, than to the Veteran's general belief that he is entitled to higher ratings. Ultimately, on objective examinations, range of motion measurements of the left ankle showed, at worst, dorsiflexion to 15 degrees and plantar flexion to 20 degrees; and the right ankle showed, at worst, dorsiflexion to 15 degrees, and plantar flexion to 25 degrees. Moreover, to the extent that the Veteran alleges that he is entitled to a higher rating due to pain and other symptoms reported, the Board notes that such symptoms are contemplated under the current rating assigned. The Board acknowledges the Veteran's statements that his left and right ankle disorder symptoms are more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. See, e.g., Layno v. Brown, supra and Grottveit v. Brown, supra. The Board finds, however, that neither the Veteran's statement nor medical evidence demonstrates that the criteria for an initial rating in excess of 10 percent have been met. The Board also acknowledges that the Veteran's VA treatment records note complaints of and treatment for his ankles. However, these records do not address the specific rating criteria necessary to substantiate a higher rating. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. The criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, supra. As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. Nevertheless, the Board acknowledges the Veteran's assertions that his bilateral ankle pain, fatigue, and restricted movements impact his physical activity. However, again, the Board notes that such symptoms are contemplated under the current rating assigned. This argument is therefore without merit. In addition, the Board has considered whether a higher or separate rating could be awarded under an alternative diagnostic code for the Veteran's left and right ankle disorders. 38 C.F.R. § 4.71a, Diagnostic Codes 5270 to 5274. At his VA examinations, the examiner found that the Veteran does not exhibit ankylosis in the ankles. As such, Diagnostic Code 5270 does not apply. Similarly, it has not been shown that the Veteran had, and has never been diagnosed with, either os calcis or astragalus, nor has he ever undergone an astragalectomy in either ankle. These findings preclude consideration of Diagnostic Codes 5272, 5273, and 5274, respectively. Under 38 C.F.R. § 4.71a, there are no other diagnostic codes available to evaluate disabilities of the ankle. The Board has also considered the effects of repeated use over time and flare-ups along with the adequacy of the VA examinations in light of the Court's holdings in Correia and Sharp. See Correia v. McDonald, supra and Sharp v. Shulkin, supra. In this case, the effect of pain on range of motion is described above at both May 2017 and September 2020 VA examinations. Regarding repeated use over time, the Board notes that May 2017 and September 2020 VA examiners conducted repetitive-use testing and concluded that there was no additional limitation in range of motion; the estimated limited range of motion after repetitive-use and during flare-ups was described at the September 2020 VA examination. Therefore, the Board finds that all information required for rating purposes was provided. The May 2017 and September 2020 VA examiners indicated that the Veteran reported pain, weakness, stiffness, swelling, instability, rolling on occasion, fatigability, lack of endurance, and interference with walking. The May 2017 and September 2020 VA examinations reflected measurements for active and passive range of motion as well as range of motion testing in weight-bearing and non-weight-bearing. The Veteran reported flare-ups at his September 2020 VA examinations, and the VA examiner estimated the range of motion during such flare-ups. Therefore, the examinations of records are adequate for rating purposes. The Board has also considered whether a staged rating under Hart, supra, is appropriate for the Veteran's service-connected left and right ankle disorders. However, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning a staged rating for such disorders is not warranted. Further, the Veteran and his representative have not raised any other issues, nor have any other issues been reasonably raised by the record, with regard to such claim. Doucette v. Shulkin, supra. Finally, the Board notes the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran is employed. As such, Rice is inapplicable in this case. Accordingly, the Board finds that a preponderance of the evidence is against the assignment of initial ratings in excess of 10 percent for left and right ankle disorders, and the claims are denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 2. Temporal Headaches The Veteran seeks entitlement to an initial compensable rating for his temporal headaches. Specifically, he asserts that the severity of his headaches results in prostrating attacks of headache pain that require him to lay down due to feeling that the room is spinning. See Appellate Brief and lay statement, September 24, 2018. Moreover, the Veteran and his former attorney assert that the September 2018 private medical opinion by Dr. H.S., showing prostrating attacks of one two times a week, most accurately reflects the severity of his temporal headaches. Id. In this regard, his former representative asserted the Veteran's headaches warranted at 50 percent disability rating. Id. The Veteran has been assigned an initial noncompensable rating for his temporal headaches under Diagnostic Code 8100. See 38 C.F.R. § 4.124a, Diagnostic Code 8100. Under Diagnostic Code 8100, a noncompensable rating is warranted for less frequent attacks than as follows. A 10 percent rating is warranted where the disorder manifests with characteristic prostrating attacks averaging one in two months over the last several months. A 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average of once a month over the last several months. A maximum 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Governing case law and regulations have not defined "prostrating." For reference, the Board notes that "prostration" is defined as "extreme exhaustion or powerlessness." See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1531 (32d. ed. 2012). The use of the conjunctive "and" in a statutory provision means that all of the conditions listed in the provision must be met. Melson v. Derwinski, 1 Vet. App. 334 (1991); Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for a higher rating to be assigned). Here, each of the criteria listed in the 50 percent rating must be met in order to warrant a 50 percent rating. Tatum v. Shinseki, 23 Vet. App. 152 (2009). Turning to the evidence of record, of record is an August 2015 VA treatment record that indicates the Veteran denied headaches. Of record is a February 2017 lay statement submitted by the Veteran's wife, E.R. In her statement, in pertinent part, E.R. stated the Veteran experienced daily headaches that would typically last throughout the day; and twice a week would experience headaches that were severe and incapacitating. During episodes of severe headache pain, the Veteran would experience light and sound sensitivity, and would be dizzy and lightheaded. He required medication and laying down in a dark quiet room. The Veteran was afforded a VA examination in May 2017. At that time, the examiner diagnosed migraine headaches. The Veteran reported his headaches are so severe that he has to lay down and the whole room begins to spin. His treatment plan included ibuprofen. Current symptoms included headache pain that was pulsating or throbbing head pain, bitemporal; non-headache symptoms associated with headaches included nausea, vomiting, sensitivity to light, and sensitivity to sound. Typical head pain lasted less than one day in duration and was located on both sides of the head. The Veteran was not shown to have characteristic prostrating attacks of migraine or non-migraine headache pain. The Veteran did not have very prostrating and prolonged attacks of migraines or non-migraine pain productive of severe economic inadaptability. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner noted the Veteran's headaches impacted his ability to work due to being less productive than his peers. Of record is a September 2018 private headache disability benefits questionnaire (DBQ) completed by Dr. H.S. At that time, the Veteran reported he experienced one to two prostrating migraine headache attacks a week, lasting up to 12 hours in duration, and required him to lie down in a dark environment for relief. His prostrating migraine attacks were accompanied with nausea, vomiting, disturbed concentration, blurred vision, and dizziness. He rated the severity of his headaches at a 5 out of 10 intensity. Symptoms included pulsating or throbbing head pain, pain located on one side of the head, and pain that worsened with physical activity; non-headache symptoms associated with headaches included nausea, vomiting, sensitive to light, sensitivity to sound, changes in vision, disturbed concentration, and dizziness. Typical head pain lasted less than one day in duration and was located on both sides of the head. Dr. H.S. found the Veteran had characteristic prostrating attacks of migraine headache pain that occurred more frequently than once per month, and that the Veteran had very frequent prostrating and prolonged attacks of migraine headache pain. The Veteran did not have prostrating attacks of non-migraine headache pain, nor very frequent prostrating and prolonged attacks of non-migraine headache pain. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. Dr. H.S. noted the Veteran's headaches would impact his ability to work due to suffering prostrating attacks of migraine pain, accompanied with occasional nausea and vomiting, and reduced power of concentration. In addition to the physical examination, Dr. H.S. opined that, after review of the medical records and interview of the Veteran, the Veteran experienced prostrating migraine attacks that occurred one to two times a week, lasting up to 12 hours in duration. Dr. H.S. found the Veteran suffered from severe nausea, vomiting, and reduced power of concentration; the prostrating attacks rendered the Veteran incapacitated and forced him to lie down in a dark environment for hours at a time. Dr. H.S. found that the May 2017 VA examination report did not indicate the Veteran's headaches had worsened nor that the Veteran required lying down with sensation of spinning surroundings. After review, Dr. H.S. opined that the Veteran's prostrating headaches were debilitating and impacted his daily life, including the ability to maintain gainful employment. The Veteran was afforded a VA examination in September 2020. At that time, the examiner diagnosed temporal headaches. At this time, the Veteran reported pain with throbbing on the temples and pressure all over the head; he treated with over-the-counter oral medications. He stated his headaches had been appearing regularly. Current symptoms included headaches three to four times a week, described as severe, with constant pain for the last two years. He stated that with severe pain he wanted to sleep; but that the kids would want to play with him, and this interferes with his ability to interact with his children. He reported nausea, and on closing his eyes he had a sensation that his surroundings were spinning. He reported blurred vision and sensitivity to sound. The Veteran described his headaches as a pulsating or throbbing pain on both sides of his head, which worsened with physical activity, and extended to the right eye; his headaches were associated with sensitivity to light and typically lasted less than one day in duration. The Veteran reported he had to transition to self-employed security work so that he could tailor his schedule to his headaches. The Veteran's treatment plan did not include taking medication for the diagnosed condition. Symptoms attributable to his headaches in September 2020 included constant head pain; pulsating or throbbing head pain; pain on both sides of the head; pain that worsened with physical activity; and pain extending to the right eye. Non-headache symptoms associated with headaches included nausea; sensitivity to light; sensitivity to sound; sensation of spinning surroundings; and blurred vision. Head pain typically lasted less than one day in duration and was located on both sides of the head. The Veteran was shown to have characteristic prostrating attacks of migraine or non-migraine headache pain with less frequent attacks. The Veteran did not have very prostrating and prolonged attacks of migraines or non-migraine pain productive of severe economic inadaptability. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner noted the Veteran's headaches impacted his ability to work due to being functionally limited by activities that involved full concentration and completion of tasks during headaches; otherwise, no restrictions physically except during flare-ups of headaches. In addition to physical examination, the examiner noted that the Veteran reported headaches that occurred daily, lasted throughout the day, occurring twice weekly, and with severity resulting in incapacitation. The examiner noted that the conflicting medical evidence indicated that the Veteran reported, on occasion, that he did not suffer from chronic headaches. Overall, the examiner noted that a review of the medical evidence showed control of temporal headache with over-the-counter pain medications, absence of step-up medications, no neurology consults, and no radiographic exam of the brain. Therefore, the examiner opined there was no progression of the service-connected headaches. Further review of the record shows that the Veteran receives VA treatment and from private treatment providers for various disabilities. However, there is no indication from the treatment notes of record that the Veteran has reported headache symptoms that are worse than those noted in the various VA examination reports of record. For the foregoing reasons, the Board finds that an initial compensable rating for the entire period on appeal for temporal headaches is not warranted. In this regard, a next-higher rating of characteristic prostrating attacks averaging one in two months over the last several months has not been shown. Here, there is no evidence that the Veteran experienced headaches to such a degree. Specifically, at his May 2017 VA examination, the Veteran was not shown to have characteristic prostrating attacks. Moreover, at his September 2020 VA examination, the Veteran was shown to have characteristic prostrating attacks that occurred less frequently. The Board acknowledges the Veteran's statements, the statements of his wife, and his former attorney's arguments, that his temporal headaches are more severe than evaluated, to warrant a 50 percent rating. The Veteran is competent to report his symptoms and has presented credible statements in this regard. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The Board finds, however, that neither the Veteran's statement nor medical evidence demonstrates that the criteria for higher ratings than assigned have been met. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. Nevertheless, the Board acknowledges the Veteran's reports of headache pain that cause dizziness, light sensitivity, difficulty concentrating, required lying down in the dark, and sensations that his surroundings were spinning. However, the criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. This argument is therefore without merit. The Board also acknowledges the September 2018 private DBQ submitted by Dr. H.S. that indicates the Veteran experienced prostrating attacks that occurred more frequently than once a month, and that he had very frequent and prolonged attacks of migraine headache pain productive of severe economic inadaptability. However, the Board finds the September 2018 private DBQ incongruous with the medical evidence of record. In this regard, Dr. H.S. did not adequately address the Veteran's denials of experiencing chronic headaches in continuing post-service treatment records, relied on inaccurate facts, and was internally inconsistent. In this regard, the Board notes that the Veteran denied experiencing chronic headaches on occasion, and that the medical evidence does not show prescription of step-up medications, neurology consults, nor radiographic exam of the brain. See e.g., VA examination report, September 17, 2020. Moreover, Dr. H.S. seemed to rely solely on the statements of the Veteran and his wife, and incorrectly indicated that the May 2017 VA examination report did not reflect the Veteran's contentions that his headaches required him to lie down in a dark room. Additionally, Dr. H.S. opined that the severity of the Veteran's headaches manifested in severe economic inadaptability. However, the Veteran himself asserted at his September 2020 VA examination that he was able to continue working, with some accommodations. Therefore, the Board finds that the September 2018 private DBQ by Dr. H.S. does not accurately reflect the severity of the Veteran's headaches, and is therefore, afforded little if any probative weight. The Board has considered whether a staged rating under Hart, supra, is warranted, however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning a staged rating is not warranted. Further, neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, supra. Finally, the Board notes the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran is employed. As such, Rice is inapplicable in this case. Accordingly, the Board finds that the preponderance of the evidence is against the claim for an initial compensable rating for temporal headaches and the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. D. SMART Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, 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.