Citation Nr: 21076187 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 14-17 048 DATE: December 22, 2021 ORDER Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a 20 percent rating for varicocele / hydrocele is granted, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to a compensable initial rating for costochondritis is remanded. Entitlement to service connection for a right knee disability, to include as secondary to service-connected disability, is remanded. Entitlement to service connection for a left knee disability, to include as secondary to service-connected disability, is remanded. Entitlement to service connection for headaches, to include as secondary to service-connected disability, is remanded. Entitlement to a TDIU for the period prior to April 5, 2017 is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's PTSD manifested in occupational and social impairment with deficiencies in most areas, but not in total social impairment. 2. Throughout the period on appeal, the Veteran's varicocele / hydrocele was manifested by pain, tenderness, and swelling. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for a 20 percent rating, but no higher, for varicocele / hydrocele are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 1.04, Diagnostic Code 7120. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 2005 to November 2009, to include service in Iraq. These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In May 2017, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Travel Board hearing. A transcript of his testimony is of record. These matters were last before the Board in May 2021, when they were remanded for additional development. Duty to Assist In a September 2021 correspondence, the representative asserted that there had not been substantial compliance with the remand directives and that VA did not fulfill its duty to assist duty in obtaining the Veteran's private treatment records. Specifically, the representative asserted that she was never notified that there had been "some problem retrieving" the Veteran's private records. Nevertheless, the Board finds that there was substantial compliance, and that VA satisfied the duty to assist. 38 U.S.C. § 5103A (2012) and 38 C.F.R. § 3.159(c) (2020). The May 2021 remand directed that the Veteran provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities and, after securing any necessary releases, request any relevant records identified. In May 2021 letters to the Veteran and his representative, VA requested the submission of a fully completed VA Form 21-4142 identifying all medical care providers who had treated the Veteran for his disabilities, including Dr. Nessetti, his non-VA psychologist, and the local Vet Center. Neither the Veteran nor the representative submitted the requested information. As the Veteran and his representative did not provide the necessary information for VA to request the private records, the Board finds that the agency of original jurisdiction (AOJ) substantially complied with the prior remand directive and VA satisfied its duty to assist regarding the claims adjudicated herein. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) ("The duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence."). Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2020). 1. Entitlement to an initial rating in excess of 70 percent for PTSD The Veteran and his representative assert that a 100 percent rating is warranted for his PTSD. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130 (2020). The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 100 percent. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2020). A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. Id. A February 2010 VA record indicates that the Veteran endorsed insomnia, anxiety, and memory problems. A March 2010 VA record indicates that the Veteran was oriented, his hygiene was adequate, his behavior was controlled, and his speech was coherent. His thought process was goal directed without any evidence of looseness of association or flight of ideas. His thought content was rational without any evidence of delusions or hallucinations. He denied any suicidal or homicidal ideation. Regarding social relationships, he reported that his wife was supportive, he had a good relationship with his siblings, and had two local friends who he saw on rare occasion. A June 2010 VA record notes that the Veteran endorsed increased irritability and marital problems. Mental status examination indicated that the Veteran had adequate hygiene, that his thought content was free of any disturbances, his memory and concentration were adequate, and he denied any suicidal ideation or homicidal ideation. An August 2010 VA PTSD examination report indicates that the Veteran reported irritability, anger outbursts, difficulty concentrating, difficulty sleeping, and intrusive memories. He reported that he was married, that he maintained regular but brief contacts with his parents and siblings, and positive email and phone contact with a few members of his Army unit. He reported that he was a full-time college student. Upon mental status examination, he was noted to be oriented, neatly groomed, and appropriately dressed. His speech was coherent, his thought process and content were unremarkable, his memory was within normal limits, and he was noted to understand the outcome of his behavior. The examiner stated that the Veteran had fair impulse control, no history of violence, and denied suicidal or homicidal ideation. A May 2013 VA record noted that the Veteran reported that anxiety, depression, anger, social withdrawal, and suicidal ideation. The Veteran "adamantly denied accompanying intent or plan." Upon mental status examination, the clinician noted that the Veteran was oriented, displayed adequate hygiene, and no thought abnormalities such as delusion or hallucinations. A May 2014 VA record notes that the Veteran reported insomnia, frequent suicidal ideation without plan or intent, and increased anxiety and anger. He also endorsed difficulty concentrating and noted that it negatively impacted his college studies. He noted that he was verbally aggressive with family members without cause. He stated that he self-isolated to avoid such outbursts. He stated that he feared his wife would leave him because of his mood and behavior. VA records from December 2014 and January 2015 indicate that the Veteran's main PTSD symptoms were hypervigilance, depression, social anxiety, and sleep disturbances. He denied having anger outburst and current suicidal or homicidal ideation. He endorsed a history of suicidal ideation but indicated that he had no plan or intent to act upon these thoughts because he loved his family. The clinician opined that the Veteran did not represent a credible suicide risk at this time. A February 2015 VA record notes that the Veteran was oriented, appropriately dressed and groomed, and displayed linear thought content free of any evidence of delusions or hallucinations. His speech was coherent, and his memory, concentration, judgment, and insight were observed to be adequate and/or intact. An April 2015 VA caregiver monitoring record noted that the Veteran's wife reported that the Veteran had problems with irritability, anger, and sleeping. She noted that he tended to shut down. She indicated that he denied suicidal ideation. Regarding social engagement, she stated that the Veteran attended the gym with a high school friend and had recently gone camping with family. VA records from May 2015, August 2015, and September 2015 note that the Veteran had increased anxiety, irritability, anger, and difficulty sleeping following the death of his infant son. Mental status examination indicated that the Veteran was oriented, appropriately groomed and dressed, and that his speech and thought content were coherent, linear, and free of any evidence of delusions or hallucinations. The Veteran noted past suicidal ideation but denied any current suicidal or homicidal ideation. The clinician opined that the Veteran was not a high risk for harming himself or others. VA records from June 2016 indicate that the Veteran was oriented and displayed good hygiene and grooming. He was noted to be irritable. His speech was coherent and there was no evidence of delusions or hallucinations. A July 2016 record from AllCare Medical Center notes that the Veteran endorsed depression, irritability, hypervigilance, difficulty sleeping, and difficulty concentrating and remembering information. In a March 2017 statement, the Veteran reported that he had difficulty focusing and a very hard time making friends or being social while in college. A May 2017 VA PTSD examination report indicated that the Veteran continued to report variable PTSD symptoms that negatively impacted his social and occupational functioning, including intrusive thoughts, anxiety, irritability, hypervigilance, and poor concentration. He noted that he had broken items in his home out of anger. Socially, the Veteran reported that he was married and had four children. He described his relationship with his wife as "good" but noted that it had ups and downs. He described his relationship with his children as "difficult" due to his irritability and inability to engage in activities with them due to his health limitations. He noted that he rarely spoke with his siblings and had not maintained contact with his military friends. He noted that he was in contact with his best friend from high school, but he stated that relationship was limited to texting. The Veteran reported that he was taking one college class but had been unemployed for two months. He noted that he had relational difficulties at his last job and his supervisor "railroaded" him when he required time off for his sick son. The examiner opined that the Veteran's PTSD symptoms included depressed mood, anxiety, chronic sleep impairment, mild memory loss, impairment of short and long-term memory, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective relationships, difficulty adapting to stressful circumstances, suicidal ideation, impaired impulse control, and neglect of personal appearance and hygiene. VA records from January 2018, April 2018, June 2018, and August 2018 note that the Veteran reported significant irritability, anxiety, agitation, and insomnia. His speech, thought process, and thought content were within normal limits. He was assessed to be a low risk of harm to self or others. An August 2018 vocational rehabilitation record noted that the Veteran was socially and occupationally restricted due to his PTSD. He endorsed symptoms including irritability, anxiety, nightmares, depression, hypervigilance, and flashbacks. A December 2018 VA record notes that the Veteran reported increased irritability. The Veteran was noted to be oriented and appropriately dressed and groomed. His speech was clear, and goal directed. There was no evidence of disturbances in his thought content or process. It was noted that the Veteran denied suicidal and homicidal ideation, intent, or plan. VA records from January 2019 and February 2019 noted that the Veteran reported that he was increasingly anxious with changes in his schooling. He noted that he felt increasingly distant and emotionally numb from his wife. Upon mental status examination, he was noted to be oriented and appropriately dressed and groomed. His speech and thought content were unremarkable. He denied suicidal or homicidal ideation and was assessed to be a low risk for self-harm. In a February 2020 statement, the Veteran's wife stated that he was no longer outgoing and social with family and friends, he was easily angered, irritable, and had trouble sleeping. She noted that the Veteran did not talk about his suicidal thoughts, but she was aware he had them, and she was afraid he was going to hurt himself in 2013 after their son died. A March 2021 VA record notes that the Veteran was oriented and casually groomed. His speech was appropriate, and his thought process was organized, logical, and free of any evidence of perceptual disturbances. His insight and judgement were assessed to be good, and he was deemed to be a low risk of suicidality. After a review of the record, the Board finds that the Veteran's symptoms more closely approximated the symptoms and level of impairment associated with a 70 percent rating. VA and private treatment records as well as the VA examination reports, and the Veteran's lay statements show that the Veteran's PTSD was manifested by depressed mood, anxiety, chronic sleep impairment, mild memory loss, impairment of short and long-term memory, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective relationships, difficulty adapting to stressful circumstances, suicidal ideation, impaired impulse control, and neglect of personal appearance and hygiene. His symptoms did not cause the level of impairment required for a disability rating of 100 percent. There is no evidence the Veteran had gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting others; disorientation to time or place; or memory loss for names of close relatives, own occupation or name. The Board acknowledges the representative's assertion that a 100 percent rating is warranted because the Veteran is a persistent danger of hurting himself. See February 2020 correspondence. The record indicates that the Veteran reported suicidal ideation. While persistent danger of self-harm is contemplated by the 100 percent criteria, the severity, frequency, and duration of the Veteran's suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. Specifically, the Veteran consistently denied having intent or plans to harm himself and various medical professionals indicated that he did not pose a credible risk of self-harm. See e. g., May 12, 2015, May 3, 2016, September 6, 2018, January 14, 2019. Accordingly, the evidence is against finding that the Veteran was a persistent danger of hurting himself. Likewise, while there were isolated records indicating that Veteran neglected his personal appearance and hygiene, his hygiene was usually noted as adequate. See e.g., February 24, 2010, April 5, 2012, February 6, 2015, June 15, 2016, September 6, 2018, December 3, 2018, January 14, 2019. Thus, the Board finds the severity, frequency, and duration of the Veteran's symptoms more closely approximate the symptoms contemplated by a 70 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. See 38 C.F.R. § 4.126. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 100 percent rating. The criteria for a 100 percent or higher rating are not met and the appeal must be denied. 2. Entitlement to a rating in excess of 10 percent for varicocele / hydrocele The Veteran is currently in receipt of a 10 percent rating for his varicocele / hydrocele under 38 C.F.R. § 4.104, Diagnostic Code 7599-7120 (2020). As an initial matter, the Board notes that varicocele is a swelling and widening of the veins in the scrotum that run along the spermatic cord. See Medline Plus Medical Encyclopedia, https://medlineplus.gov/ency/article/001284.htm (last visited October 21, 2021). A hydrocele occurs when fluid fills the scrotum and causes it to swell. Id. at https://medlineplus.gov/ency/article/000518.htm (last visited October 21, 2021). Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2020). The hyphenated diagnostic code here indicates that the Veteran is service connected for an artery and vein disability rated analogously as varicose veins. Under Diagnostic Code 7120, a noncompensable evaluation for varicose veins is warranted when it is asymptomatic, palpable or there are visible varicose veins. A 10 percent evaluation is warranted for intermittent edema of the extremity or aching and fatigue in the leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery. A 20 percent evaluation is warranted for persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema. A 40 percent evaluation is assigned for persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. A 60 percent evaluation is assigned for persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration, and a 100 percent evaluation is warranted for massive board-like edema with constant pain at rest. 38 C.F.R. § 4.104, Diagnostic Code 7120 (2020). A June 2016 VA record notes that the Veteran reported that his testicle pain had worsened in the last 8 to 10 weeks. He reported that his testicle was very sensitive and had continuous radiating pain in the left side. He denied any secondary symptoms such as discharge or pain with urination. He noted that his pain was sometimes worse during and after an erection. He reported that his pain was aggravated when his legs were squished together, such as during walking and driving. He noted that he tried wearing supportive underwear without any improvement. He noted that he took ibuprofen with little improvement and that the pain affected his ability to walk. In a November 2017 statement, the Veteran reported that his varicocele caused pain, discomfort, and swelling. He stated that his symptoms were near constant, and he was always aware of the sensitivity and pain in his testicle. He noted that he had to be conscious of how he sat and the way his pants and underwear fit because it could cause discomfort. He stated that the pain worsened throughout the day and varied from a sharp to dull ache and that it radiated into his abdominal region. He noted it was a similar sensation to being hit in the testicle. He stated that his discomfort was not alleviated by elevating his legs. A December 2017 VA male reproductive conditions examination, noted that the Veteran reported pain when pressure was put on his left testicle. For example, he noted that sitting too long on his testicular area cause pain. He denied any current treatment for his varicocele / hydrocele. During the examination, the Veteran declined physical examination of his testicle. The examiner noted that the Veteran's varicocele / hydrocele did not result in a voiding dysfunction, erectile dysfunction, or retrograde ejaculation. A March 2018 VA record notes that the Veteran reported ongoing testicle pain. In a July 2018 correspondence, the Veteran's representative asserted that the Veteran's varicocele / hydrocele should be rated as 20 percent as his symptoms of pain and swelling were not relieved with the use of compression shorts. The representative stated that the Veteran had near constant pain and swelling of one testicle that was not relieved by rest, elevation, or compression. It was further noted that the Veteran had to constantly attend to how he sat and how his clothing fit. She noted that because the affected location was his testicle, the Veteran could not elevate that area in a manner like an arm or leg. She noted that although the Veteran attempted to relieve his symptoms by elevating his legs, it did not alleviate his symptoms. An August 2018 vocational rehabilitation record noted that the Veteran had testicular pain and discomfort. A June 2019 VA record notes that the Veteran had a left varicocele that caused variable left scrotal discomfort. Upon examination, left varicocele and left spermatocele were noted. The clinician noted that the Veteran had tenderness to palpation but no evidence of scrotal swelling. VA records from December 2020 and March 2021 note that the Veteran continued to have testicle pain. After reviewing the evidence of record and resolving reasonable doubt in the Veteran's favor, the Board finds that a 20 percent rating is warranted. In the present case, the evidence indicates that the Veteran's varicocele / hydrocele results in pain, tenderness, and swelling unrelieved by elevation. While the June 2019 VA record suggests that the Veteran's hydrocele resulted in only intermittent swelling, as noted above, by definition hydrocele involves swelling in the scrotum due to fluid collection. See Medline Plus Medical Encyclopedia, https://medlineplus.gov/ency/article/000518.htm htm (last visited October 21, 2021). Thus, the remaining question is whether the Veteran's symptoms are relieved by elevation. The Veteran reports ongoing symptoms despite elevating his legs. The Board acknowledges that elevating the legs does not strictly comply with the requirements of elevating the affected extremity. Nevertheless, as noted in the December 2020 statement, the Veteran's testicle does not lend itself to elevation in the same manner as an arm or leg. As the Veteran's varicocele / hydrocele is an unlisted condition rated by analogy, VA need not strictly require the same objective symptoms as the analogous condition. Stankevich v. Nicholson, 19 Vet. App. 470, 472 (2006). As such, the Board finds that the Veteran's symptoms, which are incompletely relieved by elevation of the legs, more nearly approximates the criteria for a 20 percent rating. 38 C.F.R. § 4.104, Diagnostic Code 7599-7120 (2020). Nevertheless, it has not more nearly approximated the criteria for a 40 percent rating as there is no evidence of stasis pigmentation, eczema, or any skin symptomatology on the Veteran's scrotum. Id. The Board also considered whether a higher rating was warranted under the Diagnostic Codes associated with disabilities of the genitourinary system. However, the evidence indicates that the Veteran's varicocele / hydrocele did not result in urinary symptoms, renal dysfunction, infections, erectile dysfunction, testicle atrophy, or testicle removal. Accordingly, a higher rating or separate compensable rating is not warranted under the provisions of 38 C.F.R. §§ 4.115A, 4.115B (2020) Thus, resolving reasonable doubt in the Veteran's favor, a 20 percent rating, but no higher, is granted. REASONS FOR REMAND 1. Entitlement to a compensable initial rating for costochondritis is remanded. The August 2019 and May 2021 remands directed that the RO issue a Statement of the Case (SOC) regarding the increased rating claim for costochondritis. While the issue was included in the August 2021 Supplemental SOC, the RO has not issued an SOC addressing this claim. Accordingly, the issue must again be remanded for the RO to issue a SOC. Stegall v. West, 11 Vet. App. 268, 271 (1998); Manlincon v. West, 12 Vet. App. 238, 240-41 (1999); 38 C.F.R. § 19.31(a) (2020) (stating that "[i]n no case will a Supplemental Statement of the Case be used to announce decisions by the agency of original jurisdiction on issues not previously addressed in the Statement of the Case.") 2. Entitlement to service connection for a right knee disability, to include as secondary to service-connected disability, is remanded. 3. Entitlement to service connection for a left knee disability, to include as secondary to service-connected disability, is remanded. Unfortunately, there has not been substantial compliance with the Board's previous remand directives. In pertinent part, the May 2021 remand directed that an addendum opinion be obtained. While an addendum opinion was obtained in August 2021, further clarification is required. As noted in the representative's September 2021 correspondence, the rationale in support of the negative opinion did not explain why the Veteran's service-connected fibromyalgia could not contribute to the limitation of motion in his bilateral knees. Additionally, in addressing direct service connection the examiner appeared to weigh the absence of in-service diagnosis and treatment as substantive negative evidence. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011). Thus, another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). 4. Entitlement to service connection for headaches, to include as secondary to service-connected disability, is remanded. Unfortunately, there has not been substantial compliance with the Board's previous remand directives. In pertinent part, the May 2021 remand directed that the Veteran be provided a VA headache examination. As an initial matter, while a medical opinion was obtained in August 2021, the Veteran was not provided an examination. Additionally, as noted in September 2021 the clinician found that the Veteran did not have a headache disability and, in so finding, incorrectly stated that there was no "clinical diagnoses by licensed medical providers of any chronic and disabling headache conditions." The record contains VA primary care records authored by Dr. F. from March 2, 2018 and October 5, 2018 noting an "impression/plan" of migraine headaches. Likewise, in the August 2010 VA PTSD examination report Dr. R. noted that the Veteran's non-psychiatric illness included inter alia migraine headaches. As the August 2021 clinician did not provide a rationale for discounting those diagnoses, further clarification is required, and another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). 5. Entitlement to a TDIU for the period prior to April 5, 2017 is remanded. The issue of entitlement to a TDIU is inextricably intertwined with the Veteran's claims for service connection discussed herein, that issue is also remanded. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (stating issues are inextricably intertwined when a decision on one issue would have a significant impact on another issue). The matters are REMANDED for the following actions: 1. Provide the Veteran with a VA examination to determine the nature of his headaches and to obtain an opinion as to whether such is possibly related to service and/or his service-connected disabilities. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted, and the results reported. Following review of the claims file and examination of the Veteran, the examiner should: (a.) Identify any disability manifested by headaches and state whether it is at least as likely as not (50 percent probability or greater) that it arose during service or is otherwise related to service, to include his service in the Persian Gulf. The clinician should address the service treatment records from March 2006 and July 2006, the December 15, 2014 VA record noting that the Veteran's medical history included headaches that were consistent with tension type headaches, the VA primary care records from March 2, 2018 and October 5, 2018 noting an "impression/plan" of migraine headaches, July 3, 2017 radiology report noting a differential diagnosis including migraine angiopathy, and the August 2010 VA PTSD examination report noting non-psychiatric illnesses including inter alia migraine headaches. If the examiner finds that the Veteran does not have a diagnosed headache disability, the examiner must provide a complete rationale for discounting the diagnoses of record. (b.) If not related to service, state whether it is at least as likely as not (50 percent probability or greater) that any diagnosed headache disability was caused by the Veteran's service-connected sinusitis, fibromyalgia, and PTSD? (c.) If not caused by the Veteran's service-connected sinusitis, fibromyalgia, and PTSD, is it at least as likely as not that his headache disability is worsened beyond natural progression (aggravated) by his service-connected sinusitis, fibromyalgia, and PTSD? If the clinician finds that the Veteran's headache disability was aggravated by his service-connected sinusitis, fibromyalgia, and PTSD, the clinician should attempt to quantify the level of aggravation beyond the baseline level of the headache disability. In so opining, the clinician should address the treatise evidence of record regarding the etiology of headaches and their relationship to fibromyalgia. A complete rationale should be provided for all opinions and conclusions expressed. 2. Forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's right and left knee claims. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should opine: (a.) Whether it is at least as likely as not (50 percent probability or greater) that any right or left knee disability had its onset during service or is otherwise related to service. The clinician should address the Veteran's January 22, 2010 VA record noting his report of bilateral knee pain, August 2010 VA examination report noting bilateral knee pain without objective evidence of disease, April 20, 2011 record from J. Blackford-Heintz, D.C., noting the Veteran's report of knee pain, the May 4, 2011 magnetic resonance imaging (MRI) report noting "mild softening of the articular cartilage overlying the medial patellar facet," and the December 16, 2014 VA record noting that the Veteran's positive shrug test was "consistent with patellofemoral syndrome / chondromalacia patella." (b.) If not caused by service, state whether it is at least as likely as not (50 percent probability or greater) that any knee disability was caused by his service-connected fibromyalgia? (c.) If not caused by the service-connected fibromyalgia, is it at least as likely as not that any knee disability is worsened beyond natural progression (aggravated) by his service-connected fibromyalgia? If the clinician finds that the Veteran's knee disability was aggravated by his service-connected fibromyalgia, the clinician should attempt to quantify the level of aggravation beyond the baseline level of the knee disability. A complete rationale should be provided for all opinions and conclusions expressed. 3. Provide the Veteran with a statement of the case on the issue of entitlement to an increased initial rating for costochondritis, so that the Veteran may have the opportunity to complete an appeal on the issue of entitlement to an increased initial rating for costochondritis (if he so desires) by filing a timely substantive appeal. The issue should only be returned to the Board if a timely substantive appeal is filed. K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Anderson 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.