Citation Nr: 21074766 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 17-33 179 DATE: December 16, 2021 ORDER Entitlement to a compensable rating for allergic rhinitis is denied. Entitlement to a 10 percent rating, but no higher, for left knee degenerative arthritis is granted. Entitlement to a 10 percent rating, but no higher, for right knee degenerative arthritis is granted. REMANDED Entitlement to service connection for a sleep disorder is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to a compensable rating for residuals of a traumatic brain injury (TBI) is remanded. Entitlement to a compensable rating for actinic keratosis is remanded. Entitlement to a compensable rating for ingrown toenails is remanded. Entitlement to an initial rating higher than 10 percent for migraine headaches is remanded. FINDINGS OF FACT 1. The Veteran's allergic rhinitis manifests with sneezing, coughing, and nasal congestion. He has not been found to have greater than 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. 2. The Veteran's left knee degenerative arthritis manifests with painful motion, but it has not been shown to have flexion limited to 45 degrees or extension limited to 10 degrees. 3. The Veteran's right knee degenerative arthritis manifests with painful motion, but it has not been shown to have flexion limited to 45 degrees or extension limited to 10 degrees. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for allergic rhinitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.97, Diagnostic Code 6522. 2. The criteria for a 10 percent rating, but no higher, for left knee degenerative arthritis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260, 5261. 3. The criteria for a 10 percent rating, but no higher, for right knee degenerative arthritis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260, 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1991 to August 2016. This case comes to the Board of Veterans' Appeals (Board) from November 2016, July 2017, and September 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office. This case was previously remanded by the Board in February 2019. In a July 2020 rating decision, entitlement to service connection for thyroid enlargement was granted, which constitutes a full grant of the benefit sought, and that issue is no longer on appeal. The decision also increased the evaluation for pes planus to 30 percent, effective September 1, 2016. This rating exceeds the rating requested by the Veteran on his December 2016 Notice of Disagreement. This issue is therefore also considered a full grant of the benefit requested by the Veteran, and it is no longer within the jurisdiction of the Board. Allergic Rhinitis The Veteran has requested a compensable rating for allergic rhinitis. He has written that the condition impacts every aspect of his life, because he is constantly sneezing, coughing, and blowing his nose, and that it also affects his ability to sleep. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity in civil occupations. See 38 U.S.C. § 1155; 38 C.F.R. § Part 4. The Veteran's allergic rhinitis is rated under Diagnostic Code 6522, for allergic or vasomotor rhinitis. A 10 percent rating is assigned when there is greater than 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side, but without polyps. A 30 percent rating is assigned when there are polyps. 38 C.F.R. § 4.97, Diagnostic Code 6522. The Veteran attended a VA examination in October 2016. He reported having occasional sneezing, runny nose, and nasal congestion with post-nasal dripping. He did not have greater than 50 percent obstruction of the nasal passage, complete obstruction of either side, permanent hypertrophy of the nasal turbinates, or nasal polyps. There were no granulomatous conditions. The evidence therefore clearly shows that the Veteran has not met the criteria for a 10 percent rating for allergic rhinitis under Diagnostic Code 6522. There is no other evidence in the VA, military, or private treatment records that the Veteran has ever been found to have 50 percent obstruction on both sides of the nasal passage, or complete obstruction on one side, and the Veteran has never alleged that this has been found. The Veteran also was not found to have any polyps. The Board has considered whether any other diagnostic codes could be applied which would allow for a compensable rating, but does not find that rating by analogy is appropriate in this case. Allergic rhinitis is specifically listed in the Rating Schedule, and when a condition is specifically listed in the Schedule, it may not be rated by analogy. Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). There are separate rating criteria for sinusitis, which allowed for higher ratings based on incapacitating and non-incapacitating episodes of sinusitis, but the Veteran has not been diagnosed with sinusitis, and though he has non-incapacitating episodes of symptoms, these are not "episodes of sinusitis," which is specified in these rating criteria. 38 C.F.R. § 4.97, Diagnostic Code 6514. He has not been diagnosed with sinusitis, and has not been awarded service connection for sinusitis. The Veteran also has not been diagnosed with bacterial rhinitis, which is rated under Diagnostic Code 6523, nor would be meet the criteria for a compensable rating under these criteria either, because he does not have permanent hypertrophy of the turbinates and greater than 50 percent obstruction of the nasal passage of both sides or complete obstruction on one side. 38 C.F.R. § 4.97, Diagnostic Code 6523. The Board has also reviewed the other rating criteria relating to diseases of the nose and throat to see if any other criteria could apply, but as the Veteran has not been found to have service-connected laryngitis, laryngectomy, aphonia, stenosis of the larynx, injury to the pharynx, or granulomatous rhinitis, these other rating criteria also do not apply. See 38 C.F.R. § 4.97, Diagnostic Codes 6515-6521, 6524. The Board has considered the Veteran's assertions that he has sneezing, coughing, runny nose, and congestion caused by his allergic rhinitis. He is competent to report such symptoms, but unfortunately, the presence of these symptoms does not allow for a compensable rating for allergic rhinitis. The Veteran has also asserted that he has a sleep disorder, and that this has been caused or aggravated by his sinus symptoms from allergic rhinitis. The Veteran has submitted this as a separate claim, and the Board has remanded the issue of entitlement to service connection for a sleep disorder, so that this separate disorder can be properly evaluated. The Board therefore finds that there is no evidence that the Veteran has had greater than 50-percent obstruction of the nasal passage on both sides or complete obstruction of one nasal passage at any time. There are also no other applicable diagnostic codes which can be applied to the Veteran's service-connected allergic rhinitis and which would allow for a higher rating. Entitlement to an initial compensable rating for allergic rhinitis is denied. The Board has considered the benefit of the doubt doctrine, but the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107(b). Left and Right Knee Degenerative Arthritis The Veteran wrote in December 2016 that his bilateral knee arthritis caused pain that was sometimes so bad, that it was hard for him to do chores around the house, such as cutting the grass, or even standing to do dishes. 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. It is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). Range of motion of the knee is measured in flexion and extension. For VA purposes, a normal range of knee motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. A limitation of flexion of the leg allows for a 10 percent evaluation when it is limited to 45 degrees, and a 20 percent evaluation when it is limited to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. A limitation of leg extension is evaluated as 10 percent disabling when extension is limited to 20 degrees, and it is 20 percent disabling when extension is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The rating criteria for musculoskeletal disorders under 38 C.F.R. § 4.71a were amended, effective February 7, 2021. The amendments did not alter the rating criteria for evaluating knee extension and flexion under Diagnostic Codes 5260 and 5261. Degenerative arthritis can also be assigned a primary evaluation under Diagnostic Code 5003. When the limitation of motion is noncompensable, a rating of 10 percent may be applied to each major joint or group of minor joints. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Separate ratings for knee disabilities may be assigned for disability of the same joint if none of the symptomatology on which each rating is based is duplicative or overlapping. See VAOPGCPREC 9-04 (2004); 69 Fed. Reg. 59,990 (2004); 38 C.F.R. § 4.14. There are separate rating criteria for symptomatic removal of the semilunar cartilage, dislocated cartilage, recurrent subluxation, lateral instability, ankylosis, malunion/nonunion of the tibia and fibula, and genu recurvatum. The Veteran has not at any time during the appellate term been found to have these disorders, and he has not asserted that he has had any of these disorders. These diagnostic codes are therefore not applicable and will not be further discussed. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5257, 5258, 5259, 5262, 5263. The Veteran attended a VA examination in October 2016. He reported having aching and shooting pain in his knees which was aggravated with standing. He was found to have mild degenerative arthritis in both knees. He did not report any flare ups. Range of motion testing in both knees was normal: 0 degrees of extension to 140 degrees of flexion. No pain was noted on examination, and there was no evidence of pain with weight-bearing. Repetitive use testing found no further loss of function or range. There was no crepitus, atrophy, or ankylosis. Muscle strength and joint stability were normal. There was no history of recurrent subluxation or lateral instability. The Veteran also did not have any meniscus condition. He did not use any assistive devices. While the examiner wrote that it was not possible to determine, without resorting to mere speculation to estimate loss of range of motion during flare ups, the Board finds that his response is harmless error, because the Veteran did not report having flare ups. After reviewing all of the evidence of record, the Board finds that initial ratings of 10 percent for each knee can be assigned. The Veteran has credibly reported having pain with movement in both of his knees. Under 38 C.F.R. § 4.45, consideration must be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca, 8 Vet. App. 202 (1995). The Veteran has reported having pain in his knees that does cause functional impairment, including preventing him from performing household chores or standing for extended periods of time. The Board therefore finds that the Veteran has degenerative arthritis in both knees which causes pain resulting in at least some limitation of function, and a 10 percent rating can be assigned under 38 C.F.R. § 4.59. Ratings higher than 10 percent for right or left knee degenerative arthritis are not warranted. At no time was the Veteran found to have flexion limited to 45 degrees or extension limited above 0 degrees. He did not report any flare ups, and while he has stated that he had painful motion, it has not actually caused limitation of motion to less than the normal range for the knees. There is no other medical evidence indicating that the Veteran has ever had extension limited to 10 degrees or greater, or flexion limited to 45 degrees or less. In the absence of such findings, higher ratings are not warranted. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. There are also no other applicable diagnostic codes, as the Veteran has never been found to have any other knee disorders which could receive a separate compensable rating. The Veteran has asserted that he did not believe that his range of motion testing was performed correctly at the VA examination, and that measurements were not taken to identify when pain began during range of motion testing. The Board does not, however, find any evidence indicating that the VA examination was not properly conducted. A VA examiner is presumed to have properly discharged his or her duties as a health professional (presumption of regularity). See Rizzo v. Shinseki, 580 F.3d 1288, 1292 (Fed Cir. 2009). The Veteran did not actually assert that the examiner was not competent or qualified to perform the examination, but only that the examination was not adequately completed. See Francway v. Wilkie, 940 F.3d 1304 (2019) (VA examiners are generally presumed to be competent, but a Veteran may challenge the competency of an examiner.). The Board finds no reason to believe that the October 2016 VA examination was not accurate or that the examiner did not properly measure the Veteran's range of motion. The Board has also considered the Veteran's assertion that he did have pain with movement during the range of motion testing, and that this was not measured independently by the examiner. The Board accepts that the Veteran's assertions of having pain with movement is credible, and this is the basis for the increased 10 percent ratings that have now been assigned. Even if the Board had specific measurements indicating at what flexion and extension the Veteran's pain began, the Board does not find that this would allow for any higher rating, however. The Veteran may have pain with motion, but he is nonetheless not preventing from moving his knees to full flexion and extension, even after repetitive motion. The Board has now assigned the Veteran the minimum compensable ratings for these joints due to painful motion. See 38 C.F.R. § 4.59. The Board does not find that ratings higher than 10 percent are warranted due to painful motion. The Board considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca and Mitchell, which address functional loss due to symptoms such as pain. In the absence of evidence that painful motion, including after repetitive motion or during flare ups, have caused further restricted motion, a higher rating is not warranted. Without clinical medical evidence indicating further functional limitation, the Board is unable to find that the Veteran's pain is so disabling as to actually or effectively limit flexion or extension of the knee to such an extent as to warrant assignment of a higher rating. In sum, the Board finds that the preponderance of the evidence indicates that a 10 percent initial rating, but no higher, can be assigned for both the right and left knees. In reaching this decision, the Board has again considered the applicability of the benefit of the doubt doctrine, but the preponderance of the evidence is against any higher ratings than those now assigned. See 38 U.S.C. § 5107(b). REASONS FOR REMAND Sleep Disorder The Veteran contends that he has a chronic sleep disorder which had its onset during his service. He has written that although he does not have sleep apnea, he nonetheless has problems with sleep, and he is tired all day. He has written that his allergic rhinitis, which causes sneezing and coughing, greatly impairs his ability to sleep. The Veteran's service treatment records show that he was given a provisional diagnosis of organic sleep disorder. In November 2010, he underwent a study because he had loud snoring and felt tired during the daytime. Sleep apnea was suspected, but the study showed no significant sleep related breathing disorder. In November 2015, the Veteran attended a sleep study. There was no significant sleep related breathing disorder, such as sleep apnea, but there was snoring, sleep onset was prolonged, and sleep efficiency was reduced. At a December 2015 follow up visit, the Veteran was noted to have continued symptoms of snoring, frequent nocturnal awakenings, and daytime fatigue. The physician recommended ways to improve sleep hygiene, including using a nasal spray, and wrote that if this was not effective in improving his symptoms, he should pursue further evaluation. The Veteran did report frequent trouble sleeping on his March 2016 Report of Medical History. The Veteran attended a VA examination in October 2016. The examiner found that the Veteran did not have sleep apnea, and there was no objective evidence of a sleep condition. The examiner supported this finding by noting that a December 2010 sleep study was negative for a sleep condition. The Board finds the October 2016 VA examination to be inadequate. At the outset, it appears to have relied on the results of a November 2010 sleep study, which was not even the most recent sleep study at the time, and which is now over ten years old. Since then, the Veteran has been diagnosed with organic sleep disorder, and he has reported worsening symptoms. The Veteran has also alleged that he has insomnia or other disorder which prevents sleep, and which has been caused or aggravated by his service-connected allergic rhinitis. The Board therefore remands this issue so that the Veteran can be afforded a new, adequate VA examination. Right Hip and Right Ankle Disability The Veteran contends that he has a right hip disorder and a right ankle disorder that began during his military service. The Veteran wrote in December 2016 that his problems with his ankle began during the last 5 years of his military service, and that it was difficult for him to walk on unstable or hilly areas. In March 2017, the Veteran wrote that it was difficult to walk long distances or carry heavy things due to hip pain, and that he has flare ups several times a year that make it nearly impossible to walk. In August 2017, he wrote that his right hip disorder started in service and was still going, and that he did not believe that the examiner properly measured his range of motion. The Veteran's service treatment records show that in July 1998, he was treated for a concussion and right ankle sprain. He was also noted to have slight hip pain. In December 2011, he was treated for joint pain localized in the hip. In August 2015, he was treated for right ankle pain due to posterior tibial tendonitis. At an October 2016 VA ankle examination, the Veteran reported intermittent aching right ankle pain that was aggravated with movements and alleviated with sitting. The examiner found, however, that the right ankle was normal. The Veteran attended a VA hip examination in July 2017, and although he reported having pain and stiffness in his hips which caused decreased mobility and problems with lifting and carrying, the examiner found that there was no objective evidence of a hip condition on examination. The Board finds that these medical opinions are not adequate, and the issues are remanded. The VA examiners did not find that the Veteran had current right hip or right ankle disabilities, but they did not consider whether there was nevertheless any functional impairment in these joints, including consideration of the Veteran's reports that he has pain, limited mobility, and decreased stamina for standing and other physical activities. The Board finds that this should be reevaluated in light of Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), which held that where pain alone result in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. These issues are therefore remanded so that a new VA examination can be conducted. The Veteran has also submitted a December 2011 treatment record from St. Mary's Hospital showing a diagnosis of sacroiliac joint dysfunction. The examiner is therefore asked to consider whether the Veteran currently has a sacroiliac joint dysfunction disorder which may manifest with right hip pain. TBI The Veteran has requested a compensable rating for his service-connected TBI. The Veteran attended a VA examination in September 2017, conducted by a psychiatrist. The examiner found that while the Veteran had incurred a TBI, his evaluation was normal, and he had no subjective symptoms. The examiner found no current residuals of a TBI. The examiner based these findings on a claims file review. The Veteran wrote in November 2017 that he does have difficulty with memory, including remembering tasks and dates, and that his concentration and ability to follow directions is impaired. He wrote that he still has constant headaches, ringing in his ears, fatigue, dizziness, difficulty sleeping, anxiety, and irritability. He wrote that he did report these issues to the VA examiner. In January 2020, he also wrote that he has trouble with memory, reading maps, and following driving directions, which he did not previously have trouble with. In light of the Veteran's reports, the Board finds that the September 2017 is not adequate to adjudicate the issue at this time. While the Veteran did attend the September 2017 VA examination in person, the examiner did not actually record any of his assertions or make any notations indicating that he had spoken with him. It seems strange that the examiner did not even find that he had any subjective symptoms, as the Veteran has clearly asserted that he does believe he has subjective symptoms associated with his TBI. The Board therefore remands this issue so that the Veteran can attend a new examination to fully assess all of his TBI residuals. Actinic Keratosis The Veteran contends that he should be assigned a compensable rating for his actinic keratosis, because it affects his face and causes disfigurement. In January 2020, he wrote that it is difficult to shave and that he had to constantly put lotion on it. The Veteran attended a VA skin examination in January 2017. The examiner did not find any current skin disorder. The Board accepts that the Veteran is competent to report having problems with his skin, and it is likely that this problem appears intermittently, and may not have been present at the time of the January 2017. The Board will give the Veteran another opportunity to attend a VA examination. Even if the Veteran's skin disorder is not actively causing problems at the time of this new examination, he should attempt to describe the exact nature of his skin disorder to the examiner, and he is requested to provide any medical records which would provide documentation of the current nature and severity of his skin disorder. The examiner should also assess whether the Veteran has any residual scarring that causes disfigurement. Ingrown Toenails The Veteran contends that he should be assigned a compensable rating for ingrown toenails, because they are extremely painful, making it difficult for him to wear boots or tight shoes, or to stand for long periods of time without pain. In January 2020, he wrote that he was unable to run or walk for very long, or stand for extended periods of time. He wrote that he constantly had to dig the sides of his toenails out, which was extremely painful. At an October 2016 VA examination, the Veteran was found to have bilateral foot ingrown toenails which caused pain and tenderness along both sides of the great toenail. The examiner did not discuss whether the condition caused any further functional impairment. Because the Veteran has asserted that he has functional impairment caused by his ingrown toenails, the Board will remand this issue again so that it can be determined whether the Veteran's ingrown toenails actually cause functional impairment which should warrant a compensable evaluation. Migraine Headaches The Veteran has also asserted that his migraine headaches, currently rated as 10 percent disabling, have worsened. In March 2018, the Veteran wrote that he felt that the examiner who performed the September 2017 VA examination did not have an accurate understanding of his headache condition, because his migraines come and go almost daily, and have for many years. He also wrote that he has been receiving treatment for migraines from his primary care doctor at the Patuxent River Medical Clinic. Because the Veteran appears to be asserting that his migraines have worsened, and his last VA examination was over 4 years ago, the Board finds that he should be afforded a new VA examination. Efforts must also be made to obtain these private treatment records, which are relevant to the claim. The matters are REMANDED for the following action: 1. Send to the appellant a letter requesting that he provide sufficient information and a signed and dated authorization, via a VA Form 21-4142 (Authorization and Consent to Release Information) to enable VA to obtain all relevant post-service treatment records, including any treatment received at a private or military facility, and all treatment for migraines at Patuxent River Medical Clinic. He should be informed that he may also submit these records himself. If the appellant provides completed release forms authorizing VA to obtain these treatment records, then attempt to obtain them with at least one follow-up request if no reply is received. 2. Schedule the Veteran for an examination to address the nature and etiology of any current sleep disorder. If feasible, the examination may be held via telehealth during social distancing restrictions, and an opinion can be provided based on other medical evidence of record. The examiner must be provided access to the Veteran's entire claims file and must specify in the report that the claims file has been reviewed. The examiner should then address: a) Does the Veteran have a current sleep disorder, including insomnia? Please discuss the Veteran's reports of having difficulty sleeping and severe daytime fatigue. b) For all diagnoses which are currently present, or for any symptoms causing functional impairment that are found, is it as likely as not that the disorder had its onset during service or is related to any injury or incident in service? Please consider the Veteran's 2015 evaluation for snoring, frequent nocturnal awakenings, and daytime fatigue, and his provisional diagnosis of organic sleep disorder. c) For all diagnoses which are currently present, or for any symptoms causing functional impairment that are found, is it as likely as not that the disorder was either i) caused or ii) aggravated by his service-connected allergic rhinitis? The examiner is reminded that the Veteran is competent to report on symptoms as he has observed them. A complete and fully explanatory rationale must be provided. If any opinion cannot be rendered without resorting to speculation, the examiner must explain why. 3. Schedule the Veteran for an examination to address the nature and etiology of any right ankle and right hip disorders. If feasible, the examination may be held via telehealth during social distancing restrictions, and an opinion can be provided based on other medical evidence of record. The examiner must be provided access to the Veteran's entire claims file and must specify in the report that the claims file has been reviewed. The examiner should then address: a) What are the Veteran's current diagnoses of the right ankle and right hip? b) If no specific, current diagnosis is found for either the right ankle or the right hip, please discuss the functional impact of the appellant's reported pain, impaired mobility, and/or lack of stamina. Discuss the impact, or lack thereof, from pain, focusing on the evidence of functional limitation caused by pain, and if it limits the ability to perform normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. See Saunders, 886 F.3d 1356. c) For all diagnoses which are currently present, or for any symptoms causing functional impairment that are found, is it as likely as not that the disorder had its onset during service or is related to any injury or incident in service? Please consider the Veteran's treatment in July 1998 for right hip and ankle pain, in December 2011 for hip pain and sacroiliac joint dysfunction, and in August 2015 for right ankle pain due to posterior tibial tendonitis. The examiner is reminded that the Veteran is competent to report on symptoms as he has observed them. A complete and fully explanatory rationale must be provided. If any opinion cannot be rendered without resorting to speculation, the examiner must explain why. 4. Schedule the Veteran for a VA examination to evaluate the current residuals and their severity for his service-connected TBI. The examination may be conducted via telehealth or similar service during the social distancing restrictions if possible. The entire claims file must be made available to and reviewed by the examiner. Identify and evaluate the current severity of all residuals of the Veteran's service-connected TBI using the appropriate Disability Benefits Questionnaires. In addition to objective test results, the examiner should fully describe the practical effects caused by the Veteran's TBI residuals, including the effect of his disability on his occupational and daily functioning. The examiner should consider the Veteran's reports that he believes his TBI has caused headaches, impaired concentration, impaired memory, fatigue, dizziness, difficulty sleeping, anxiety, and irritability. 5. Schedule the Veteran for a VA examination to evaluate the current symptoms and their severity for his service-connected actinic keratosis and ingrown toenails. The examination may be conducted via telehealth or similar service during the social distancing restrictions if possible. The entire claims file must be made available to and reviewed by the examiner. a) Evaluate the current severity of the Veteran's actinic keratosis. If no current symptoms are found at the time of the examination, the examiner should assess the Veteran's overall symptoms based on his lay reporting and his medical records. The examiner should also evaluate whether the Veteran has any facial scarring or disfiguration. b) Evaluate the current severity and functional impact of the Veteran's ingrown toenails. The examiner should specifically address whether the Veteran's ingrown toenails cause any functional impairment, including consideration of his reports that they cause pain and prevent him from walking or standing for long periods of time. 6. Schedule the Veteran for a VA examination to evaluate the current symptoms and their severity for his service-connected migraine headaches. The examination may be conducted via telehealth or similar service during the social distancing restrictions if possible. The entire claims file must be made available to and reviewed by the examiner. Evaluate the current severity of the Veteran's migraine headaches, and discuss their frequency and severity throughout the entire appeal period, which is September 1, 2016 to the present. The examiner should consider the Veteran's lay assertions of having daily headaches that are often prostrating. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mary E. Rude, 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.