Citation Nr: 21062592 Decision Date: 10/08/21 Archive Date: 10/08/21 DOCKET NO. 17-29 006 DATE: October 8, 2021 ORDER Entitlement to an initial 30 percent rating effective June 24, 2019, for bilateral plantar fasciitis is granted. Entitlement to a disability rating greater than 20 percent for lumbar strain is denied. Entitlement to a disability rating greater than 30 percent prior to March 1, 2017, and greater than 70 percent thereafter, for posttraumatic stress disorder (PTSD) is denied. Entitlement to an initial compensable rating for a traumatic brain injury (TBI) is denied. Entitlement to an initial rating greater than 30 percent prior to March 3, 2017, and as 50 percent thereafter, including on an extraschedular basis, for headaches is denied. FINDINGS OF FACT 1. The record evidence shows that, prior to March 3, 2017, the Veteran's service-connected bilateral plantar fasciitis is manifested by, at worst, complaints of bilateral foot pain. 2. The record evidence shows that, between March 3, 2017, and June 24, 2019, the Veteran's service-connected bilateral plantar fasciitis is manifested by, at worst, complaints of recurrent bilateral foot pain with pain accentuated on use and in weight-bearing. 3. The record evidence shows that, effective June 24, 2019, the Veteran's service-connected bilateral plantar fasciitis is manifested by, at worst, objective evidence of marked deformity, pain on manipulation and use accentuated, and characteristic callosities. 4. The record evidence shows that the Veteran's service-connected lumbar strain is manifested by, at worst, forward flexion to 40 degrees during flare-ups. 5. The record evidence shows that, prior to March 1, 2017, the Veteran's service-connected PTSD is manifested by, at worst, complaints of anger, suicidal ideation, normal speech, an anxious/depressed mood, linear thought content, and adequate insight and judgment. 6. The record evidence shows that, effective March 1, 2017, the Veteran's service-connected PTSD is manifested by, at worst, complaints of increased irritability and memory problems at home and at work, impaired impulse control, and suicidal ideation; there is no evidence of total occupational and social impairment. 7. The record evidence shows that the Veteran's service-connected TBI is manifested by, at worst, subjective cognitive symptoms which are attributable to his service-connected PTSD. 8. The record evidence shows that, prior to March 3, 2017, the Veteran's service-connected headaches are manifested by, at worst, complaints of headaches with pain on both sides of the head lasting less than 1 day with nausea and sensitivity to light and characteristic prostrating attacks of migraine headache pain more frequently than once per month. 9. The record evidence shows that, effective March 3, 2017, the Veteran's service-connected headaches are manifested by, at worst, very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability. 10. The disability picture presented by the Veteran's service-connected headaches effective March 3, 2017, is neither exceptional nor unusual with marked interference with employment or frequent periods of hospitalization such that extraschedular consideration is warranted. CONCLUSIONS OF LAW 1. The criteria for an initial 30 percent rating effective June 24, 2019, for bilateral plantar fasciitis have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.71a, Diagnostic Code (DC) 5279-5276 (2020). 2. The criteria for a disability rating greater than 20 percent for lumbar strain have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.71a, DC 5237 (2020). 3. The criteria for a disability rating greater than 30 percent prior to March 1, 2017, and greater than 70 percent thereafter, for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, DC 9411 (2020). 4. The criteria for an initial compensable rating for a TBI have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, DC 8045 (2020). 5. The criteria for an initial rating greater than 30 percent prior to March 3, 2017, and as 50 percent thereafter, including on an extraschedular basis, for headaches have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.124a, DC 8100 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from September 2000 to October 2001 and from June 2005 to May 2006, including in combat in Iraq in support of Operation Iraqi Freedom. The Veteran appointed his current attorney to represent him before VA by filing a signed VA Form 21-22a at the Agency of Original Jurisdiction (AOJ) in November 2016. This appeal has a long procedural history. Most recently, in April 2020, the Board remanded the currently appealed claims to the AOJ for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. The Board directed that the AOJ obtain additional treatment records for the Veteran and medical opinions concerning various aspects of his service-connected disabilities. Additional records subsequently were associated with the claims file. And the requested opinions were obtained in May 2020. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Having reviewed the record evidence, the Board finds that the issues on appeal should be characterized as stated above. The Board acknowledges that the rating criteria for evaluating musculoskeletal criteria were revised effective February 7, 2021. These revisions created a new DC 5269 for evaluating plantar fasciitis. This DC provides a single 10 percent rating for unilateral or bilateral plantar fasciitis, a single 20 percent rating for unilateral plantar fasciitis with no relief from both non-surgical and surgical treatment, a single 30 percent rating for bilateral plantar fasciitis with no relief from both non-surgical and surgical treatment, and a 40 percent rating for actual loss of use of the foot. A Note following DC 5269 provides that, if a Veteran has been recommended for surgical intervention but is not a surgical candidate, then the rater is to evaluate plantar fasciitis under the 20 or 30 percent rating criteria whichever is applicable. See 38 C.F.R. § 4.71a, DC 5269 (effective February 7, 2021). There were no other changes relevant to this appeal made by this regulatory revision. The Board also acknowledges that the former rating criteria can be applied before and after the effective date of the revised rating criteria, but the revised rating criteria cannot be applied prior to its effective date. The Board finally acknowledges that the rating criteria most favorable to the Veteran should be applied. Increased Rating 1. Entitlement to an initial 30 percent rating effective June 24, 2019, for bilateral plantar fasciitis The Board finds that the evidence supports granting a 30 percent rating effective June 24, 2019, for bilateral plantar fasciitis. The Veteran contends that his service-connected bilateral plantar fasciitis is more disabling than currently (and initially) evaluated. The Board agrees, finding that the evidence shows that this disability worsened and merits an initial 30 percent rating effective June 24, 2019 (the date of a VA examination showing increased symptoms) under DC 5279-5276. See 38 C.F.R. § 4.71a, DC 5279-5276 (2020). The Board notes initially that, because the former rating criteria for evaluating plantar fasciitis are more favorable to the Veteran, those will be applied to his initial rating claim. The Board next notes that, prior to March 3, 2017, the service-connected bilateral plantar fasciitis is manifested by, at worst, complaints of bilateral foot pain. For example, on VA foot conditions Disability Benefits Questionnaire (DBQ) in April 2015, the Veteran's complaints included bilateral foot pain, left foot greater than right foot. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. The Veteran reported that his pain was "mostly posterior left heel with slight bony prominence." His pain worsened with activity and improved with rest. He also experienced morning bilateral sole stiffness. He denied flare-ups or functional loss or impairment. Physical examination showed mild bilateral plantar fasciitis which did not chronically compromise weight bearing or require arch supports. There was no pain on physical examination of either foot or functional loss of either lower extremity. X-rays did not show arthritis. The diagnoses included bilateral plantar fasciitis. Contrary to the Veteran's lay assertions, the record evidence shows that, prior to March 3, 2017, his service-connected bilateral plantar fasciitis is manifested by, at worst, complaints of bilateral foot pain (as seen on VA examination in April 2015). A minimum 10 percent rating under DC 5279-5276 requires moderate bilateral plantar fasciitis and the April 2015 VA examiner specifically found that the Veteran's service-connected bilateral plantar fasciitis was mild. See 38 C.F.R. § 4.71a, DC 5279-5276 (2020). He otherwise has not identified or submitted any evidence demonstrating his entitlement to a compensable disability rating prior to March 3, 2017, for this disability. Thus, the Board finds that the criteria for a compensable disability rating prior to March 3, 2017, for bilateral plantar fasciitis have not been met. The Veteran also is not entitled to a disability rating greater than 10 percent between March 3, 2017, and June 24, 2019, for his service-connected bilateral plantar fasciitis. The Board acknowledges that the record evidence dated during this time period shows that the symptomatology attributable to this disability worsened and entitled the Veteran to a higher 10 percent rating effective March 3, 2017, for his service-connected plantar fasciitis under DC 5279-5276. Id. There is no indication, however, that a disability rating greater than 10 percent is warranted between March 3, 2017, and June 24, 2019. The record evidence dated during this time period shows that, on VA foot conditions DBQ on March 3, 2017, the Veteran's complaints included recurrent bilateral foot pain, "especially with flare-ups with impact his ability to bear weight and do prolonged standing [and] walking." The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. The Veteran reported that flare-ups of bilateral foot pain impacted function of his feet and caused functional impairment and loss. Physical examination showed of both feet showed pain accentuated on use and pain on weight-bearing. Orthotics had been tried but he remained symptomatic in both feet. The Veteran "reports only minimal relief with inserts since he still has residual pain" in both feet. The diagnosis was bilateral plantar fasciitis. On VA podiatry consult in July 2017, the Veteran's complaints included "debilitating" plantar fasciitis "affecting every aspect of his life. He is a police officer and it is affecting his ability to do his job and therefore his livelihood." Objective examination showed tender plantar medial heel. The diagnosis was left plantar fasciitis. He received a left heel steroid injection. On VA podiatry consult in October 2018, the Veteran's complaints included longstanding bilateral heel pain, "left foot most symptomatic." He was unable to do his job or be on his feet for long due to this pain. Objective examination showed pain in the medial inferior calcaneus on the left foot and spurs in the posterior and inferior calcaneus of the left foot. The diagnosis was chronic plantar fasciitis with a spur in the left foot. The Board again acknowledges that, on VA examination on March 3, 2017, the symptomatology attributable to the Veteran's service-connected bilateral plantar fasciitis worsened and merited the assignment of a higher 10 percent rating on that date under DC 5279-5276. Id. This examination documented that the Veteran's bilateral plantar fasciitis was moderately disabling with pain accentuated on use and pain on weight-bearing despite wearing bilateral heel orthotics. This examination did not indicate that the Veteran experienced severe or pronounced bilateral plantar fasciitis such that a disability rating greater than 10 percent is warranted between March 3, 2017, and June 24, 2019, under DC 5279-5276. Id. He otherwise has not identified or submitted any evidence demonstrating his entitlement to a disability rating greater than 10 percent between March 3, 2017, and June 24, 2019, for his service-connected bilateral plantar fasciitis. Thus, the Board finds that the criteria for a disability rating greater than 10 percent between March 3, 2017, and June 24, 2019, for bilateral plantar fasciitis have not been met. In contrast, the Board finds that the criteria for an initial 30 percent rating effective June 24, 2019, for bilateral plantar fasciitis have been met. Id. The record evidence shows that, effective June 24, 2019, the symptomatology attributable to the service-connected bilateral plantar fasciitis worsened and entitled the Veteran to a 30 percent rating on this date under DC 5276-5279. Id. VA foot conditions DBQ on June 24, 2019, showed that the Veteran's complaints included sharp and dull achy pain in the plantar aspect of both feet. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. The Veteran treated his bilateral plantar fasciitis with physical therapy, steroid injections, daily foot inserts, and etodolac 200 mg twice daily. He experienced a "bad" flare up once a month when "he has much more intense symptoms where he cannot walk and has to miss work [on] those days and also alter his [activities of daily living]." He "cannot stand for long periods of time [and] cannot walk/run or sprint for long periods of time." Physical examination of both feet on June 24, 2019, showed pain accentuated on use, pain accentuated on manipulation, characteristic calluses, extreme tenderness on plantar surfaces of both feet improved with bilateral orthopedic shoes or appliances, decreased longitudinal arch height on weight-bearing, objective evidence of marked deformity, weight-bearing lines fall over or medial to the great toes, inward bowing of the right Achilles tendon, metatarsalgia, excess fatigability, and pain on weight-bearing. The Veteran's bilateral foot pain "gets worse and [he] cannot walk normally and sometimes not at all" during flare-ups. He constantly used in-sole orthotics. The diagnoses included bilateral plantar fasciitis. Consistent with the Veteran's lay assertions, the record evidence shows that the symptomatology attributable to his service-connected bilateral plantar fasciitis worsened on June 24, 2019, and merits the assignment of a higher initial 30 percent rating on that date under DC 5279-5276. Id. VA examination on June 24, 2019, documented the presence of pain accentuated on use, pain accentuated on manipulation, characteristic calluses, and objective evidence of marked deformity in each of the Veteran's feet. These physical examination findings support the assignment of an initial 30 percent rating for bilateral plantar fasciitis under DC 5279-5276. Id. The Board acknowledges that this examination also showed extreme tenderness of the plantar surfaces of the bilateral feet (one of the criteria for a higher 50 percent rating for bilateral plantar fasciitis under DC 5279-5276) but this finding was relieved by the Veteran's constant use of in sole orthotics. A higher 50 percent rating requires extreme tenderness of the plantar surfaces of the bilateral feet not improved by orthopedic shoes or appliances. Id. In summary, and after resolving any reasonable doubt in the Veteran's favor, the Board finds that the criteria for an initial 30 percent rating effective June 24, 2019, for bilateral plantar fasciitis have been met. 2. Entitlement to a disability rating greater than 20 percent for lumbar strain The Board next finds that the preponderance of the evidence is against granting the Veteran's claim of entitlement to a disability rating greater than 20 percent for lumbar strain. Contrary to the Veteran's lay assertions, the record evidence shows that this disability is manifested by, at worst, forward flexion to 40 degrees during flare-ups (as seen on VA examination conducted during the appeal period). For example, on VA back (thoracolumbar spine) conditions DBQ in February 2014, the Veteran's complaints included constant daily low back pain. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. The Veteran treated his low back pain with over-the-counter Naproxen, a TENS unit, and heat. During flare-ups of low back pain, "His mobility is limited more. He is up at night with flare ups. He says his productivity is decreased. He is less active." Range of motion testing showed forward flexion to 80 degrees with no objective evidence of painful motion and no additional limitation of motion on repetitive testing. He experienced functional loss or impairment due to less movement than normal and pain on movement. Physical examination showed tenderness to palpation "to the left of the lower lumbar spine in the paraspinous muscles," muscle spasm not resulting in an abnormal gait or spinal contour, 5/5 muscle strength, normal deep tendon reflexes and sensation, negative straight leg raising bilaterally, and no intervertebral disc syndrome. X-rays were normal. He reported missing "about 6 days" of work in the previous year due to his low back pain. "He says he is less productive at work." The diagnosis was lumbosacral strain. On VA back (thoracolumbar spine) conditions DBQ in April 2015, the Veteran's complaints included back pain in the upper back between the shoulder blades and lower back and sensitivity to touch in the low back. He denied flare-ups. Range of motion testing showed forward flexion to 45 degrees with objective evidence of painful motion beginning at 45 degrees and no additional limitation of motion on repetitive testing. There was no functional loss or impairment. Physical examination showed tenderness to palpation with exaggerated superficial tenderness in the bilateral sacroiliac joint area, normal muscle strength, reflexes, and sensation, and no intervertebral disc syndrome. The VA examiner was unable to perform straight leg raising testing. X-rays showed no arthritis. There was "[s]ubjective pain with activity or prolonged posture like prolonged sitting in [a] car or at [a] desk." The VA examiner stated that he could not "rule out voluntary (poor effort) limiting [range of motion] on exam." This examiner also stated that he was "unable to confirm bilateral sciatica on today's exam due to Veteran's symptom magnification." The diagnosis was lumbar strain. On VA back (thoracolumbar spine) conditions DBQ in March 2017, the Veteran's complaints included recurrent back pain. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. The Veteran reported flare-ups of low back pain, functional loss, and functional impairment "which impact his ability to bend, lift, and to do prolonged sitting, standing, [and] walking." Range of motion testing showed forward flexion to 80 degrees with pain and no additional limitation of motion on repetitive testing. Physical examination showed tenderness to palpation not resulting in an abnormal gait or spinal contour, 5/5 muscle strength, normal deep tendon reflexes and sensation, negative straight leg raising bilaterally, and no ankylosis or intervertebral disc syndrome. The VA examiner stated that he could not perform Correia testing because it was medically inappropriate to do so "as it could cause injury to the Veteran." The diagnosis was lumbar strain. On VA back (thoracolumbar spine) conditions DBQ in July 2019, the Veteran's complaints included back pain. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. The Veteran stated that flare-ups of low back pain "occur multiple times per month," were severe, and lasted from 1 day to several days. He experienced functional loss or impairment due to back pain, stiffness, limited range of motion, difficulty with heavy lifting, bending, prolonged walking, or climbing stairs. Range of motion testing showed forward flexion to 55 degrees with pain. There was additional limitation of motion on repetitive testing with forward flexion to 50 degrees due to pain and lack of endurance. Repeated use over time would limit forward flexion to 45 degrees. During flare-ups, pain and lack of endurance limited forward flexion to 40 degrees. Physical examination showed no pain with weight bearing, 5/5 muscle strength, normal deep tendon reflexes and sensation, negative straight leg raising bilaterally, and no ankylosis or intervertebral disc syndrome. He occasionally wore a back brace. There was objective evidence of pain on passive range of motion testing and in non-weight bearing. The diagnosis was lumbar strain. Contrary to the Veteran's lay assertions, the record evidence shows that his service-connected lumbar strain is manifested by, at worst, forward flexion to 40 degrees during flare-ups (as seen on VA examinations conducted during the appeal period). The consistent physical examination findings support the 20 percent rating currently assigned for the service-connected lumbar strain under DC 5237. See 38 C.F.R. § 4.71a, DC 5237 (2020). Multiple VA examinations of the Veteran's lumbosacral spine conducted during the appeal period found no ankylosis (whether favorable or unfavorable) of the entire thoracolumbar spine or the entire spine as is required for a disability rating greater than 20 percent under DC 5237. Id. These examinations also found no evidence of intervertebral disc syndrome so rating the service-connected lumbar strain under DC 5243 is not appropriate here. See 38 C.F.R. § 4.71a, DC 5243. The Veteran otherwise has not identified or submitted any evidence demonstrating his entitlement to a disability rating greater than 20 percent for his service-connected lumbar strain. In summary, the Board finds that the criteria for a disability rating greater than 20 percent for lumbar strain have not been met. 3. Entitlement to a disability rating greater than 30 percent prior to March 1, 2017, and greater than 70 percent thereafter, for PTSD The Board next finds that the preponderance of the evidence is against granting the Veteran's claim of entitlement to a disability rating greater than 30 percent prior to March 1, 2017, and greater than 70 percent thereafter, for PTSD. Contrary to the Veteran's lay assertions, the record evidence does not support assigning an increased rating for his service-connected PTSD during either period of time at issue in this appeal. Prior to March 1, 2017, the record evidence shows that this disability is manifested by, at worst, complaints of anger, suicidal ideation, normal speech, an anxious/depressed mood, linear thought content, and adequate insight and judgment. For example, on VA PTSD DBQ in September 2015, his complaints included difficulty with concentration and memory at work. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. The Veteran reported being married for 1 12 years to his wife, getting along "okay" with his parents, and not having "much contact with either" of his siblings. He had "a couple close friends but I don't really do a lot of socializing." He reported hunting and fishing occasionally but felt "apathy" about hobbies. He was employed as an investigator with the State Bureau of Investigation and previously worked as a law enforcement officer. He reported "run-ins with supervisors and co-workers and said people complain that he is 'rude'" at his former law enforcement officer job but "reported no issues or concerns since he changed jobs." He denied any current mental health treatment. "[The] Veteran was reluctant to discuss suicidal thoughts but said he does not believe he would ever kill himself, in part because he has already lost two friends to suicide." He reported occasional drinking and denied illegal drug use. His PTSD symptoms were a depressed mood, anxiety, suspiciousness, chronic sleep impairment, and mild memory loss. Mental status examination of the Veteran in September 2015 showed he was clean, neatly groomed with good hygiene, casually dressed, normal eye contact, cooperative and pleasant manner although he "lost his train of thought or was mentally distracted a couple times" but there was no impulsivity, restlessness, or overt hypervigilance, normal speech, full orientation, logical and goal-directed thought processes, no looseness of associations, appropriate thought contact, no auditory or visual hallucinations or delusions, a depressed and irritable mood, and intact judgment and insight. "[The] Veteran appeared to be a good and credible historian with respect to recent and past personal history." The VA examiner concluded that the Veteran's service-connected PTSD resulted in occupational and social impairment with an occasional decrease in work efficiency and intermittent inability to perform occupational tasks. The diagnosis was PTSD. On private outpatient treatment in March 2016, the Veteran "states that he is aware of PTSD impacting his work. [He] fears 'losing it' feeling rage and acting out at work. [It] has happened on several occasions outside of work but not at work yet." In April 2016, the Veteran reported significant apathy, anhedonia, and suicidal ideation although "he is determined not to act on [it]." In May 2016, the Veteran reported "struggling at work." He was encouraged to talk about his experience of being involved in an improved explosive device (IED) explosion "and its effect on his team" during service. He "acknowledged tightness in his chest when he spoke about this. I observed him rubbing his head and asked about sensations there. He was unaware of any discomfort." He also reported feeling "a lot of survivor guilt" at times. Mental status examination of the Veteran showed he was well groomed, normal speech, an anxious/depressed mood, linear thought content, and adequate insight and judgment. The Veteran's Global Assessment of Functioning (GAF) score was 50, indicating serious symptoms or any serious impairment in social, occupational, or school functioning. The Axis I diagnosis was chronic PTSD. Contrary to the Veteran's lay assertions, the record evidence does not support assigning a disability rating greater than 30 percent prior to March 1, 2017, for his service-connected PTSD. VA examination in September 2015 documented the presence of, at worst, moderately disabling PTSD symptoms including a depressed and irritable mood. The September 2015 VA examiner concluded that the Veteran generally was functioning satisfactorily with normal routine behavior, self-care, and conversation. Private outpatient treatment records dated during this time period show that the Veteran had normal speech, an anxious/depressed mood, linear thought content, and adequate insight and judgment. He also reported being aware of his PTSD impacting his work but he denied having any anger outbursts at work. These reported symptoms are consistent with the GAF score of 50 noted on private outpatient treatment in May 2016. Taken together, the record evidence as a whole supports the 30 percent rating currently assigned prior to March 1, 2017, for the Veteran's service-connected PTSD. There also is no indication that he experienced symptoms of similar frequency, severity, and duration as is required for a disability rating greater than 30 percent prior to March 1, 2017, under DC 9411. Id.; see also Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The Board acknowledges that he complained of significant suicidal ideation on private outpatient treatment in April 2016 although "he [was] determined not to act on" these ideas at that time. He did not report any suicidal ideation before or after this outpatient treatment visit in May 2016. In other words, there is no indication that the single report of significant suicidal ideation (but no plan) reported in April 2016 supports the assignment of a higher 70 percent rating prior to March 1, 2017, for service-connected PTSD although suicidal ideation is among the symptoms for a 70 percent rating under DC 9411. Id. The Veteran otherwise has not identified or submitted any evidence demonstrating his entitlement to a disability rating greater than 30 percent prior to March 1, 2017, for his service-connected PTSD. In summary, the Board finds that the criteria for a disability rating greater than 30 percent prior to March 1, 2017, for PTSD have not been met. The Veteran also is not entitled to a disability rating greater than 70 percent effective March 1, 2017, for his service-connected PTSD. The Board acknowledges that VA PTSD DBQ on March 1, 2017, showed that the symptomatology attributable to this disability worsened and supported the assignment of a higher 70 percent rating under DC 9411. See 38 C.F.R. § 4.130, DC 9411. There is no indication that, effective March 1, 2017, the Veteran experienced total occupational and social impairment (i.e., a 100 percent rating under DC 9411) such that a disability rating greater than 70 percent is warranted during this time period. Id. The record evidence shows instead that, effective March 1, 2017, the service-connected PTSD is manifested by, at worst, complaints of increased irritability and memory problems at home and at work, impaired impulse control, and suicidal ideation. On VA PTSD DBQ on March 1, 2017, the Veteran's complaints included becoming physically aggressive with his wife during sleep, nightmares of Iraq, short-term memory difficulties, daily triggers with "various sights, sounds, and smells," frequently interrupted sleep, cold sweats, heart pounding, social isolation, and worsening memory and irritability "when he becomes stressed." The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. The Veteran still was married to his wife and they "had a baby girl in July 2016." "He reports that his memory difficulties cause[] distress in his marriage." He worked as a local law enforcement officer in Plano, Texas. "He reports since working in Plano he has had memory issues and also has been in physical altercations with other staff in the police department and has been verbally aggressive towards people he has stopped and arrested." He reported drinking alcohol "to help him relax prior to sleeping." The Veteran's PTSD symptoms were a depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, impairment of short and long term memory, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, impaired impulse control, and intermittent inability to perform activities of daily living. Mental status examination of the Veteran showed he was neatly and casually dressed, no suicidal or homicidal ideation, no delusions or hallucinations, and full orientation. The VA examiner stated: [The Veteran] had several words written on his hand which he states he does not help him with his memory. He also brought typed notes of things that he wanted to remember to tell about his symptoms. He was somewhat distressed when he arrived because of being a few minutes late, but calmed down and was pleasant and cooperative during the evaluation. This examiner concluded, "His anxiety and depression are symptoms of his PTSD. He is very concerned about his memory and aggressiveness." This examiner also concluded, "The irritability, sleep issues, and memory issues are causing more problems for him at work and in his marriage." The diagnosis was PTSD. On VA outpatient treatment in April 2017, the Veteran's complaints included being "always on edge, not able to relax, and in a constant state of hypervigilance." He reported that unexpected noises or smells, especially burning smells, brings back memories for him. He also reported continuing nightmares, intrusive thoughts, restless sleep, and constant anxiety. He denied panic attacks or being depressed. His mood was "more irritable, angry, and [he] gets upset easily." He was working in law enforcement "but there are several episodes when he has trouble controlling his anger." He still was married and had a 9-month-old daughter. "No specific hobbies reported." He described himself as "a weekend drinker, 2 3 times per week. He said that sometimes he drinks heavily especially at the anniversary that he relates to his friends' death." He denied any use of illegal drugs. Mental status examination of the Veteran showed fair grooming and hygiene, fair eye contact, logical thought process, no suicidal or homicidal ideation, no auditory or visual hallucinations or paranoia, and good judgment and insight. The diagnoses included PTSD. In May 2017, the Veteran reported that his PTSD was improved with medication although prazosin made him dizzy. He was "very pleased with [his] treatment plan [and] feels that the 'edge is off' [and] doing better." He still lived with his wife and daughter and remained employed as a police officer. Psychiatric evaluation showed he was pleasant and cooperative. The assessment included PTSD which was improved. He was encouraged to hydrate to deal with his reported dizziness with prazosin. In June 2017, the Veteran reported that he was "more calm and less edgy on current" medications. He continued to have nightmares and intrusive thoughts "but they are less intense." He still lived with his wife and daughter and remained employed as a police officer. "No specific hobbies reported. He considers himself a weekend drinker, 2 4 beers plus a few shots once or twice per week." He denied any illegal drug use. Mental status examination of the Veteran showed fair grooming and hygiene, fair eye contact, logical thought process, no suicidal or homicidal ideation, no auditory or visual hallucinations or paranoia, and good judgment and insight. The diagnoses included PTSD with a noted improvement in mood and PTSD symptoms. On VA PTSD DBQ in June 2019, the Veteran's complaints included "difficulties in his marriage due to irritability and memory problems. Irritability also affects relationship with [his] daughter." He still was married to his wife and they were expecting a son in November 2019. "Has no friends he hangs out with or is in contact with as all his friends from the military are in different states and 2 of them had committed suicide" in the past. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. The Veteran denied any "activities or leisure pursuits because there is nothing he enjoys." He still worked as a police officer. "Has had disciplinary issues for outbursts with coworkers, unexcused absences, or leaving work early. He has memory/concentration problems and can't recall details of events to document them. He has to watch videos repeatedly in order to complete reports, which makes him inefficient and takes a long time." He denied any psychiatric hospitalizations or suicide attempts. He drinks several scotch whiskeys 2 3 nights a week. The Veteran's PTSD symptoms were a depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, impairment of short and long-term memory, flattened affect, difficulty in understanding complex commands, impaired judgment and abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, suicidal ideation, and impaired impulse control. Mental status examination of the Veteran showed good appearance and hygiene, full orientation, and adequate concentration. "He was serious and noticeably irritable and though he apologized to the examiner saying 'it's not your fault' he complained about having to do the exam and talking about these topics again. At times he looked like he may become tearful. However, he answered all questions asked of him." The VA examiner also stated: [The] Veteran reported having flashbacks daily with dissociation. He has problems with onset insomnia, nightmares at least twice a week, and frequent awakening. He averages 5-6 hours of sleep a night and drinks a lot of caffeine to stay awake during the day. He described his daily mood as agitated, numb, and apathetic. He has low energy, interest, and motivation. He used to enjoy sports and other activities but now nothing brings him pleasure. He tends to overeat and has some loss of sexual drive with performance issues. He reported experiencing sadness during times he is alone or not distracted. His self-esteem is low and he has survivor's guilt, which causes him to have passive thoughts of suicide such as "I shouldn't be here." He said the 2 friends he lost to suicide were unexpected and "you never would've thought." He denied any current intent but reported having intent in the past with a plan to shoot himself with a gun. He thinks about the aftermath of this and sometimes he doesn't care but then he thinks about his military friends and his kid and he is able to talk himself out of it. There is no immediate danger but risk is moderate. His memory is very poor and he has to write everything down, sometimes even on his hands. His wife said his memory has gotten worse since his last exam and that 30 seconds after talking to her will ask her what she said again and this happens about 5 times during the span of their morning. He checks doors/locks every night but can't remember if he checked them so he'll recheck. He's also driven away from home and couldn't remember if he closed the garage and went back to make sure. [The] Veteran's anger has gotten so bad to where he's had instances of road rage where he's confronted people/strangers. He's also thrown and broke[n] things. [H]e avoids crowds or any trauma reminders. Overall, Veteran reported that since his last exam, his irritability, sleep disturbance, memory problems, and lack of sexual desire have all increased. The examiner concluded that the Veteran "continues to evidence significant symptoms PTSD affecting nearly all areas of daily functioning." The diagnosis was PTSD. The Board again acknowledges that, effective March 1, 2017, the symptomatology attributable to the Veteran's service-connected PTSD worsened and supported the assignment of a higher 70 percent rating on that date under DC 9411. Id. The record evidence shows that this disability is manifested by, at worst, complaints of increased irritability and memory problems at home and at work, impaired impulse control, and suicidal ideation during this time period. VA examinations and outpatient treatment visits conducted since March 1, 2017, all show that this disability is manifested by occupational and social impairment with deficiencies in most areas (i.e., a 70 percent rating under DC 9411). Id. The Veteran was employed as a police officer throughout this time period and married to his wife although he reported increasing problems at both his job and in his marriage due to increased irritability and memory problems. Impaired impulse control and suicidal ideation were noted on VA examinations on March 1, 2017, and in June 2019. The Veteran consistently reported increased irritability at work and at home (in his relationship with his wife and daughter) at both of the examinations conducted during this time period. His complaints and the consistent findings of increased PTSD symptoms also are reflected in the outpatient treatment visits conducted during this time period. Taken together, the record evidence supports the 70 percent rating currently assigned effective March 1, 2017, for the service-connected PTSD under DC 9411. Id. There is no indication that the Veteran experienced symptoms of similar frequency, severity, and duration as is required for a disability rating greater than 70 percent under DC 9411. Id.; see also Vazquez-Claudio, 713 F.3d at 112. Despite the Veteran's consistent reporting of increased problems at work, he remained employed full-time as recently as the June 2019 VA examination as a police officer. He still was married to his wife and they were expecting another child at the time of the June 2019 VA examination. He otherwise has not identified or submitted any evidence demonstrating his entitlement to a disability rating greater than 70 percent effective March 1, 2017, for his service-connected PTSD. In summary, the Board finds that the criteria for a disability rating greater than 70 percent effective March 1, 2017, for PTSD have not been met. 4. Entitlement to an initial compensable rating for a TBI The Board next finds that the preponderance of the evidence is against granting the Veteran's claim of entitlement to an initial compensable rating for a TBI. Contrary to the Veteran's assertions, the record evidence shows that his service-connected TBI does not result in any compensable disability. For example, on VA TBI DBQ in April 2015, the Veteran's complaints included TBI residuals of poor memory, irritability, and headaches. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. The Veteran reported being exposed to multiple blasts from rocket propelled grenades (RPGs) and improvised explosive devices (IEDs) while deployed to Iraq during service. There was objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment. The VA examiner stated, "[The Veteran] claims he has become reliant upon writing lists to keep up with details." Judgement was normal. Social interaction was routinely appropriate. There was always full orientation. Motor activity was normal. Visual spatial orientation was normal. There was subjective symptoms which did not interfere with work, instrumental activities of daily living, or work, family, or other close relationships. The examiner stated, "The Veteran claims headaches and impulsiveness but is still able to work." There were 1 or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them. The examiner stated, "The Veteran has faced disciplinary issues due to irritability with a previous employment as a Police officer. He is still able to work." The Veteran was able toc communicate by spoken and written language and to comprehend spoken and written language. Consciousness was normal. His headaches were due to his TBI. The diagnosis was TBI. On VA TBI DBQ in March 2017, the Veteran's complaints included headaches since an in-service TBI. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. The Veteran reported incurring a TBI during active service in Iraq following an IED blast while he rode in a Humvee which "caused him to hit his head against the side of the vehicle." There was a complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing. He reported "problems with short term as well as long term memory loss, and decrease[d] concentration, which have had an impact on his line of work and personal life." There was moderately impaired judgment. "[The] Veteran reports problems with judgement such as making decision[s] related to his work as well as personal life." Social interaction was frequently inappropriate. "[The] Veteran states he does not like to be around people, or in large crowds." He always had full orientation. Motor activity was normal. Visual spatial orientation was normal. There were three or more subjective symptoms reported that mildly interfere with work, instrumental activities of daily living, or work, family, or other close relationships. "[The] Veteran reports problems with tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity light, and frequent headaches, all of which impact his work and personal life." There was one or more neurobehavioral effects present that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them. "[The] Veteran reports problems with apathy, increase[d] irritability, increase[d] verbal aggression, physical aggression, and moodiness, as well as [a] lack of cooperation." He was able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language. Consciousness was normal. He experienced headaches as a residual of his TBI. The diagnosis was TBI. On VA TBI DBQ in August 2019, the Veteran's complaints included ongoing headaches and cataracts following an in-service TBI. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. There was a complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing. He had difficulty with recall, attention, and concentration. Judgment was normal. Social interaction routinely was appropriate. Full orientation always was present. Motor activity was normal. Visual spatial orientation was mildly impaired. He had to have a global positioning system (GPS) device in his car "or he gets lost easily." There were three or more subjective symptoms reported that mildly interfere with work, instrumental activities of daily living, or work, family, or other close relationships. He described his subjective symptoms as intermittent dizziness, daily headaches and tinnitus, and frequent insomnia. His headaches were associated with light and sound hypersensitivity. There was one or more neurobehavioral effects present that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them. He reported intermittent irritability, impulsivity, lack of motivation, verbal aggression, belligerence, apathy, and moodiness. He was able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language. Consciousness was normal. He experienced hearing loss/tinnitus, headaches, and dizziness/vertigo as residuals of his TBI. The VA examiner concluded that dizziness and tinnitus were at least as likely due to his in-service TBI. This examiner also concluded that, since the Veteran's TBI was mild in severity, his remaining symptoms were attributable to his service-connected PTSD. The diagnosis included TBI. In a May 2020 opinion, a VA clinician opined that it was less likely than not that the Veteran's subjective symptoms noted on the August 2019 VA TBI DBQ was due to his TBI. The rationale was based on a review of the claims file. The rationale also was that dizziness was a symptom of prazosin and the Veteran was on prazosin. The rationale further was based on a review of medical literature. The clinician concluded that the Veteran's subjective symptoms instead were attributable to his service-connected PTSD. The rationale for this opinion was that, although the Veteran's recent cognitive testing showed a lower than expected score, "[c]ognitive performance would not be expected to decline over time following a mild TBI or concussion. Thus, the variable results [on cognitive testing] are symptomatic of his underlying PTSD and related symptoms." The Board recognizes that the Veteran experienced a TBI while in combat in Iraq and does not doubt that he finds his ongoing memory, concentration, and attention problems (consistently reported at his VA TBI examinations) to be frustrating and, at times, debilitating. Nevertheless, the record evidence does not support assigning an initial compensable rating for his service-connected TBI. The Board also recognizes that the Veteran reported multiple subjective symptoms which he attributed to his mild TBI at the examinations conducted during the appeal period. Several of the facets of cognitive impairment (which form the basis for rating a service-connected TBI) initially suggest that the Veteran may experience compensable disability as a result of his service-connected TBI. See 38 C.F.R. § 4.124a, DC 8045. Unfortunately, the May 2020 VA clinician specifically found that all of the subjective symptoms reported by the Veteran are attributable to his service-connected PTSD and not his service-connected TBI. This clinician concluded that the Veteran's reported dizziness was due to prazosin prescribed to treat his service-connected PTSD. After acknowledging the record evidence showed a recent decline in the Veteran's cognitive functioning, this clinician also concluded that this decline (and the increased symptoms reported by the Veteran at his VA TBI examinations which demonstrated evidence of cognitive decline) was attributable to his service-connected PTSD. All of these opinions were fully supported. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Board already has found that the Veteran is compensated adequately for the symptomatology attributable to his service-connected PTSD (as discussed above). Assigning an initial compensable rating for the Veteran's service-connected TBI based on the same symptoms would constitute impermissible pyramiding of VA compensation benefits. The Veteran otherwise has not identified or submitted any evidence demonstrating his entitlement to an initial compensable rating for his service-connected TBI. In summary, the Board finds that the criteria for an initial compensable rating for TBI have not been met. 5. Entitlement to an initial rating greater than 30 percent prior to March 3, 2017, and as 50 percent thereafter, including on an extraschedular basis, for headaches The Board finally finds that the preponderance of the evidence is against granting the Veteran's claim of entitlement to an initial rating greater than 30 percent prior to March 3, 2017, and as 50 percent thereafter, including on an extraschedular basis, for headaches. The Veteran essentially contends that his service-connected headaches are more disabling than currently (and initially) evaluated throughout the appeal period (i.e., before and after March 3, 2017). The record evidence does not support his assertions. It shows instead that the Veteran is compensated adequately for the severity of the disability he experiences as a result of his service-connected headaches throughout the appeal period. Prior to March 3, 2017, the Veteran's service-connected headaches are manifested by, at worst, complaints of headaches with pain on both sides of the head lasting less than 1 day with nausea and sensitivity to light and characteristic prostrating attacks of migraine headache pain more frequently than once per month. For example, on VA polytrauma consult in October 2010, the Veteran's complaints included headaches since being involved in an IED blast while on active service in Iraq. Neurologic examination was normal. The diagnoses included "likely combination post-concussive and common tension headaches related to sleep and behavioral issues." On VA headaches DBQ in April 2015, the Veteran's complaints included headaches since being involved in an IED blast while on active service in Iraq. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. The Veteran experienced headache pain on both sides of the head lasting less than 1 day with nausea and sensitivity to light. He had characteristic prostrating attacks of migraine headache pain more frequently than once per month but no very frequent prostrating and prolonged attacks. The diagnosis was migraines. Contrary to his lay assertions, the record evidence does not support assigning an initial rating greater than 30 percent prior to March 3, 2017, for the Veteran's service-connected headaches. It shows instead that this disability is manifested by, at worst, complaints of headaches with pain on both sides of the head lasting less than 1 day with nausea and sensitivity to light and characteristic prostrating attacks of migraine headache pain more frequently than once per month (as seen on VA examination in April 2015). The Board acknowledges that the Veteran experiences headaches as a result of his involvement in an IED blast while in combat in Iraq. The findings on VA examination in April 2015 show that he is compensated adequately for the level of disability which he experiences prior to March 3, 2017, as a result of his service-connected headaches. See 38 C.F.R. § 4.124a, DC 8100. There is no indication that, prior to March 3, 2017, he experiences very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability such that an initial rating greater than 30 percent is warranted during this time period. Id. The Board notes in this regard that the Veteran was employed as a police officer throughout this time period. He otherwise has not identified or submitted any evidence demonstrating his entitlement to an initial rating greater than 30 percent for his service-connected headaches. Thus, the Board finds that the criteria for an initial rating greater than 30 percent for headaches have not been met. The Veteran also is not entitled to an initial rating greater than 50 percent effective March 3, 2017, for his service-connected headaches. The Board acknowledges here that the symptomatology attributable to the service-connected headaches worsened on VA examination on March 3, 2017, and supported the assignment of a higher initial 50 percent rating on that date under DC 8100. Id. This examination specifically found that the Veteran experienced very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability. The Board also acknowledges that a 50 percent rating is the maximum disability rating available under DC 8100 for migraines (or headaches). Id. Nevertheless, the record evidence does not support finding that extraschedular consideration for an initial rating greater than 50 percent effective March 3, 2017, for the service-connected headaches is warranted. See 38 C.F.R. § 3.321; Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008). An extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that initial 50 percent rating assigned effective March 3, 2017, for the Veteran's service-connected headaches is not inadequate in this case. And the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's service-connected headaches during this time period. This is especially true because the 50 percent rating currently (and initially) assigned for the service-connected headaches effective March 3, 2017, contemplates severe disability. See 38 C.F.R. § 4.124a, DC 8100. Moreover, the evidence does not demonstrate other related factors such as marked interference with employment and frequent hospitalization. The Board acknowledges here that the VA examiner concluded at the March 3, 2017, examination that the service-connected headaches impact the Veteran's ability to work "because it affects his concentration and social interaction." The Veteran reported at other VA examinations conducted in March 2017 that he continued to be employed full-time as a police officer. He does not contend and the evidence does not show that he experienced marked interference with his job as a police officer as a result of his service-connected headaches. He also does not contend and the evidence does not show that he was hospitalized for treatment of his service-connected headaches at any time during the appeal period. In other words, the Board finds that the criteria for submission for consideration of the assignment of an extraschedular rating for headaches effective March 3, 2017, pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In summary, the Board finds that the criteria for an initial rating greater than 50 percent effective March 3, 2017, on an extraschedular basis have not been met. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael T. Osborne, 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.