Citation Nr: 21026133 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 16-03 856A DATE: April 29, 2021 ORDER Entitlement to service connection for left foot tendonitis is denied. Entitlement to service connection for bilateral pes planus is granted. Entitlement to service connection for metatarsalgia is granted Entitlement to a rating of 70 percent for posttraumatic stress disorder (PTSD) is granted. Prior to December 23, 2015, entitlement to a rating in excess of 30 percent for migraines is denied. From December 23, 2015, entitlement to 50 percent rating for migraines is granted. Entitlement to a rating in excess of 30 percent for asthma is denied. REMANDED Entitlement to service connection for a neck condition (claimed as chest/back pain and back strain) is remanded. Entitlement to service connection for a right trapezius (claimed as back and neck trapezius strain and a right shoulder disorder) is remanded. Entitlement to service connection for a back condition (claimed as check/back pain and back strain) is remanded. Entitlement to service connection for a right knee condition is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The evidence does not show a diagnosis of left foot tendonitis during the appeal period. 2. The evidence is conflicting as to whether the Veteran’s pre-existing pes planus was aggravated in service. 3. The evidence is conflicting as to whether the Veteran’s current metatarsalgia is related to her in-service diagnosis. 4. For the entire appeal period, the Veteran’s PTSD manifested in in deficiencies in most areas including work, school, family relations, judgment, and mood due to near continuous panic affecting her ability to affecting the ability to function appropriately, impaired impulse control, and difficulty adapting to stressful circumstances. 5. Prior to December 2015, the Veteran’s migraines manifested in headache prostrating attacks occurring more than once a month; very frequent, completely prostrating and prolonged attacks are not shown. 6. From December 2015, the Veteran’s migraines manifested in very frequent, completely prostrating attacks capable of producing severe economic inadaptability. 7. The Veteran’s asthma manifested in no worse than an FEV-1 of 62 percent, FEV-1/FVS of 93 percent, and daily inhalational therapy. CONCLUSIONS OF LAW 1. The criteria for service connection for left foot tendonitis have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), (c). 2. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for bilateral pes planus have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), (c), 3.306. 3. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for metatarsalgia have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), (c). 4. The criteria for a 70 percent rating for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411. 5. Prior to December 23, 2015, the criteria for a rating in excess of 30 percent for migraines have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.21, 4.124a, Diagnostic Code 8100. 6. From December 23, 2015, the criteria for a 50 percent rating for migraines have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.21, 4.124a, Diagnostic Code 8100. 7. The criteria for a rating in excess of 30 percent for asthma have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.69, 4.97, DC 6602. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from June 1998 to June 2006. Service Connection To establish service connection for a disability, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). For certain chronic disorders service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. See 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. When a disease listed at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 1. Entitlement to service connection for left foot tendonitis. The Veteran claims entitlement to service connection for left foot tendonitis. To be considered for service connection, a claimant must first have a disability. This requirement “is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that a claimant may be granted service connection even though the disability resolves prior to the Secretary’s adjudication of the claim.” McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In addition, symptoms such as pain alone, that do not result in functional impairment, do not constitute a disability for VA compensation purposes. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Here the preponderance of the evidence shows that the Veteran did not have a diagnosis of left foot tendonitis during the appeal period. An August 1999 service treatment note indicates the Veteran complained of foot pain and swelling off and on for a month. She reported pain on the top of the foot an along the 4th metatarsal and lateral malleolus. The diagnosis was tendonitis. During a September 2006 VA examination, the examiner noted that there was no diagnosis because the Veteran’s left foot tendonitis had resolved. In December 2014, the Veteran submitted a Foot Disability Benefits Questionnaire (DBQ) completed by a private physician, which was is silent for any foot diagnoses beside pes planus. The private and VA treatment records are silent for a diagnosis of left foot tendonitis and the November 2019 VA examination was silent for a diagnosis of left foot tendonitis. As a current diagnosis has not been shown during the appeal period, service connection for left foot tendonitis is not warranted. 2. Entitlement to service connection for bilateral pes planus. The Veteran claims service connection for bilateral pes planus. Every veteran is presumed to be in sound condition upon entry except as to any injury or disease noted at the time of enlistment. 38 U.S.C. § 1111; Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). In determining whether a specific condition is “noted” on entry, the Board's analysis is limited to whether the condition was recorded in the enlistment examination report. 38 C.F.R. § 3.304 (b). Here, the Veteran’s December 1997 enlistment examination noted a diagnosis of mild bilateral pes planus. As such the presumption of soundness does not apply. Under 38 U.S.C. § 1153; 38 C.F.R. § 3.306 a preexisting disability well be considered to have been aggravated by active military service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. Aggravation will be rebuttably presumed where there is affirmative evidence of in-service worsening. Conversely, aggravation will not be conceded where the preexisting disability underwent no discernible increase in severity in service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306 (b); see also Falzone v. Brown, 8 Vet. App. 398, 402 (1995). Mere “temporary or intermittent flare-ups” of a preexisting condition are generally insufficient to show that in-service worsening has occurred. See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993). However, the degree of in-service worsening need not be so great as to warrant compensation in order for the presumption of aggravation to attach. Browder v. Derwinski, 1 Vet. App. 204, 207 (1991). Notably, once the presumption of aggravation does attach, the government bears the burden of showing, by clear and unmistakable evidence, “that the increase in disability is due to the natural progress of the disease.” 38 U.S.C. § 1153; 38 C.F.R. § 3.306; Wagner, 370 F. 3d at 1096 (Fed. Cir. 2004). Here, the evidence is conflicting as to whether the Veteran’s pes planus was aggravated in service. Although the Veteran’s December 1997 entrance examination shows a diagnosis of mild pes planus, the Veteran denied any history of foot trouble. Service treatment records show numerous complaints of bilateral foot pain. In a February 2003 report of medical history, the Veteran reported experiencing “fallen arch” in Portsmouth. During the September 2006 VA examination, the Veteran denied pain at rest related to her foot condition. She did not have any pain, weakness, stiffness, swelling, or fatigue. However, she reported pain while walking or standing. A May 2009 VA treatment note indicates the Veteran reported she wore orthotics in service and denied current foot pain. However, post service treatment records also show numerous complaints of foot pain, which she attributes to “fallen arches” in service. In the December 2014 notice of disagreement, the Veteran reported that when she was in boot camp a physician told her, “her arches broke.” She reported she never had any problems with her feet before service. The Veteran submitted a December 2014 foot DBQ that was completed by a private physician, M.F. Notably, the medical service provider claimed that the date of diagnosis was November 2013. Dr. M.F. stated that the Veteran’s severe pes planus symptoms on the right side has significantly impacted right knee and low back pain and dysfunction. Dr. M.F. also repeated the Veteran’s reports that she began having foot problems in boot camp. The Veteran was afforded a VA examination in November 2019, and the examiner erroneously provided a medical opinion addressing direct service connection. In a September 2020 addendum medical opinion, the examiner opined that the Veteran’s preexisting pes planus was not aggravated in service. The examiner reasoned that there is no documentation in the Veteran’s medical record of any temporary or intermittent flare-ups or changes in treatment of her bilateral pes planus during military service that worsened, aggravated, or altered the natural progression of the condition. Notably, the examiner failed to address the complaints of bilateral foot pain in the Veteran’s service treatment records and the Veteran’s statements that she did not have foot pain until service and that her pain has persisted since. As the evidence is conflicting, the Board resolves reasonable doubt in the Veteran’s favor. Service connection for pes planus is granted. 3. Entitlement to service connection for metatarsalgia. The Veteran claims entitlement to service connection for metatarsalgia. The October 2019 VA examination report shows a current diagnosis. Thus, the issue that remains disputed is whether the Veteran’s metatarsalgia had its onset in service or is otherwise related to service. To this end, the evidence is conflicting. A September 1999 service treatment note shows the Veteran complained of bilateral pain in both feet. In December 1999, the Veteran was diagnosed with bilateral metatarsalgia. Although the service treatment records do not show continued treatment for metatarsalgia specifically, throughout the Veteran’s service she had complaints of bilateral foot pain. During the September 2006 VA examination, the examiner noted that metatarsalgia was not present. Notably, the Veteran provided December 2014 foot DBQ completed by a private physician and the only foot diagnosis noted was pes planus. In addition, post service treatment records show the Veteran reported foot pain but are silent for a diagnosis of metatarsalgia. The October 2019 VA examination showed a diagnosis of metatarsalgia. The examiner opined that the Veteran’s metatarsalgia was at least as likely as not incurred in or caused by service. The examiner noted that the medical record noted metatarsalgia within one year of separation and the current VA examination is consistent with the 2006 record. The Board finds the examiner’s opinion probative to the question at hand. See Nieves-Rodriguez, 22 Vet. App. at 295. The Board acknowledges that metatarsalgia is not a chronic condition within the meaning of 38 C.F.R. § 3.309 to warrant presumptive service connection. However, the Board finds the fact that the Veteran was diagnosed for and treated for metatarsalgia in service and was also treated for the same disability close to separation persuasive. Thus, resolving reasonable doubt in the Veteran’s favor, service connection for metatarsalgia is granted. Increased Rating Disability evaluations are determined by comparing a Veteran’s symptoms with criteria set forth in VA’s Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran is presumed to be seeking the maximum possible evaluation. AB v. Brown, 6 Vet. App. 35 (1993). Separate ratings can be assigned for separate periods of time based on the facts found – a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. 4. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). The Veteran asserts that her PTSD is more disabling that reflected in her current 50 percent rating. The Veteran’s condition is rated under VA’s General Rating Formula for Mental Disorders. Under the formula, a 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411. Under the formula, a 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9411. The criteria for a 70 percent rating for PTSD are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent rating is warranted when there is 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; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9411. Ratings are assigned according to the manifestation of symptoms. However, the use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The United States Court of Appeals for the Federal Circuit has acknowledged the “symptom-driven nature” of the General Rating Formula and that “a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116 (Fed. Cir. 2013). The Federal Circuit has explained that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating.” Id. at 117. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability during the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation based on social impairment. 38 C.F.R. § 4.126(b). The preponderance of the evidence shows that for the entire appeal period the Veteran’s PTSD more nearly approximated the criteria for a 70 percent rating. In a March 2012 statement, the Veteran reported that she started to experience panic attacks often while watching movies or the news. She reported experiencing panic attacks and crying fits at work. The Veteran submitted two April 2012 lay statements from co-workers describing how her mental health symptoms manifest at work. D.A. described a severe anxiety attack she had at work that manifested in shortness of breath, crying, and shaking. The office called the paramedics. C.G.W. also reported that the Veteran has mood swings and is often hyper, agitated, and anxious. An October 2013 VA mental health note indicates the Veteran reported nightmares, anxiety, avoidance behaviors, sleep disturbance, irritability, difficulty concentrating, hypervigilance, and strong startle response. She reported being able to suppress outward display of irritability by smiling or laughing. She reported difficulty with concentration and stated that she is easily distracted at work. During the evaluation she was casually dressed and appropriately groomed. She showed linear, goal directed cognition; there was no evidence of a thought disorder or psychosis. Speech was normal. She denied past or current suicidal or homicidal ideation. During a December 2013 VA mental health evaluation, the Veteran reported that her PTSD primary impacts her sleep and mood and results in panic attacks and some social discomfort. She reported she is able to work full time in her Human Resources position. She reported he has had a panic attack at work but has very supportive work environment and co-workers. The examiner concluded that her PTSD manifested in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. Additional symptoms included anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, impairment of short and long term memory, disturbances of motivation and mood, difficulty in establishing and maintain effective work and social relationships, and obsessional rituals which interfere with routine activities. She reported panic attacks occur twice a week. She reported that since service she tried to attend school approximately 8 times but was unable to complete a degree. She reported she has trouble focusing and has trouble with her memory. In the December 2014 notice of disagreement, the Veteran reported that her panic attacks were occurring even more frequently. She reported having them on a daily basis including when driving. She reported sometimes she is unable to drive due to her severe anxiety. She reported irritability and hypervigilance. During a June 2015 VA psychological evaluation, the examiner concluded that the Veteran’s PTSD manifested in occupational and social impairment with reduced reliability and productivity. The Veteran reported depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation or mood, difficulty establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, and inability to establish and maintain effective relationships. During the examination her affect was anxious and shaky. There was no evidence of psychotic thinking. Her thought content and though processing were intact. Her judgment and insight were fair. A January 2016 letter from the Veteran’s Vet Center therapist indicates the Veteran reported daily intrusive thoughts, nightmares, hypervigilance, poor concentration, sleep disturbance, and emotional numbing. She reported significant episodes of panic especially while driving. In an April 2016 statement, the Veteran’s co-worker F.J. indicated that the Veteran has displayed outbursts of rage and anger at work. F.J. reported that the Veteran has been involved in several altercations with coworkers in the organization due to her emotional state. The record also includes a disciplinary memorandum describing an incident in which the Veteran acted unprofessionally. An August 2016 VA mental health treatment note indicates the Veteran reported experiencing several significant stressors lately including a finalized divorce and a best friend dying from cancer. She reported that despite the stressors she has been able to continue doing well at work and is not having significant interpersonal problems there lately. She reported sleep is variable. She denied suicidal or homicidal ideation. A March 2017 VA mental health crisis intervention note indicates the Veteran called stating that she is “overwhelmed, exhausted, and at her breaking point.” She reported that she needed to see someone as soon as possible. She denied current suicidal thoughts but reported having suicidal thoughts the day before. A September 2018 mental health note indicates the Veteran was undergoing several significant social changes in the past several months; she had recently become guardian of her 2 adolescent nephews and had surgery to remove a mass on her kidney. A February 2019 mental health note shows the Veteran continued to manage numerous life stressors including taking custody of a niece and nephew, work stress, and the death of her father. She reported having low mood, poor sleep, poor appetite, and low energy. A September 2019 private psychosocial assessment indicates the Veteran reported feelings of restlessness, sensations of muscular tension, fears of losing control, difficulty concentration, depersonalization, excessive worrying, irritability, and difficulty falling asleep. She also reported poor appetite, fatigue, sadness, and lack of interest. She denied suicidal plans or intentions. She reported attending church on a weekly basis and singing in the praise and worship team. During the examination the Veteran’s speech was normal. There was no evidence of hallucinations, delusions, or other indicators of psychotic process. Associations were intact, thinking was logical, and thought content appeared appropriate. She was well groomed. A September 2019 mental health crisis intervention note indicates the Veteran called to report that she had been crying and having a hard time making it through the day. She reported that being there to care for her nephew was the only thing keeping her alive. She reported she felt like she was having a break down and needed to be seen immediately. During a November 2019 VA mental health assessment, the examiner concluded that the Veteran’s PTSD resulted in occupational and social impairment with reduced reliability and productivity. The Veteran reported depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, impaired judgment, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances. During the evaluation the Veteran was cooperative, casually dressed, and well-groomed. She maintained good eye contact and was tearful throughout the evaluation. She was logical and goal directed. Her speech was normal. She denied suicidal ideation, homicidal ideation, or psychotic symptoms. The Veteran also reported feeling very overwhelmed. She reported frequent panic attacks. She reported she began to seek out more mental health treatment since May 2019 because her anxiety and irritability have worsened. She reported she did not want to get out of bed in the morning or shower and go to work. A March 2020 private treatment note indicates that due to her PTSD, the Veteran periodically experiences flare ups of anxiety and panic when triggered by external stressors. It was noted that she was engaging in medication management and psychotherapy for her conditions and was requesting a work accomodation of telework for 4 to 5 days per week. An October 2020 private mental health assessment indicates the Veteran’s PTSD manifested in occupational and social impairment due to extreme difficulty adapting to work, angry outbursts at work, need for accommodations and absences from work due to anxiety/depressive symptoms, and difficulty maintaining/establishing work relationships due to irritability, trouble focusing, and trouble adapting. Her symptoms also included difficulty adapting to stressful circumstances leading to near constant state of panic and very frequent utility of the healthcare system; impaired impulse control; frequent confusion and spatial disorientation; difficulty maintaining personal hygiene; severe insomnia and nightmares; trouble focusing; troubled with memory; frequent crying spells and depressive episodes; and mood swings. In an October 2020 statement, the Veteran’s cousin M.B. reported she has severe anxiety and is sometimes withdrawn. M.B. reported that the Veteran expressed thoughts of suicide to her. In a November 2020 statement the Veteran reported that she only gets about 3 hours of broken sleep a night. She reported she wakes up in a sweat, rage, panic, crying, with total body pains due to nightmares. She reported feeling isolated and battling suicidal thoughts. She reported that her symptoms make her work and personal interactions challenging. The Board finds that for the entire appeal period, the Veteran’s PTSD manifested in deficiencies in most areas including work, school, family relations, judgment, and mood due to near continuous panic affecting her ability to affecting the ability to function appropriately, impaired impulse control, and difficulty adapting to stressful circumstances. The evidence consistently showed that the Veteran’s severe anxiety resulted in outbursts and altercations at work. She also showed difficulty adapting to stressful situations and challenges in judgment. Thus, the Veteran’s symptoms more nearly approximated the criteria for a 70 percent rating. A rating in excess of 70 percent is not warranted. As the Veteran reported occasional suicidal thoughts, the majority of the criteria for a 100 percent rating are not shown. The evidence does not show total occupational and social impairment. There is no evidence of hallucinations, delusions, or gross impairment in thought processes or communication. The Veteran’s thought and communication were consistently normal. There is no evidence of grossly inappropriate behavior. There is also no evidence she is in persistent danger of hurting others. The evidence consistently shows that the Veteran can complete activities of daily living without assistance. There was no evidence of disorientation. During the appeal period the Veteran was able to continue working with accommodations and reported significant involvement with church and family members. As such, there is not total social impairment shown, based on this evidence. In sum, for the entire appeal period a 70 percent rating for PTSD is warranted. 5. Entitlement to a rating in excess of 30 percent for migraines. The Veteran asserts that her headache condition is more disabling than reflected in her current 30 percent rating under 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8100. Under DC 8100, a 30 percent rating is warranted with characteristic prostrating attacks occurring on an average once a month over last several months. Id. The rating schedule does not define “prostrating.” “Prostration” has been defined as “complete physical or mental exhaustion.” MERRIAM-WEBSTER’S NEW COLLEGIATE DICTIONARY 999 (11th ed. 2007). “Prostration” has also been defined as “extreme exhaustion or powerlessness.” DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1534 (32nd ed. 2012). According to Stedman’s Medical Dictionary, 27th Edition (2000) 1461, “prostration” is defined as “a marked loss of strength, as in exhaustion.” See Eady v. Shinseki, No. 11-3223, 2013 WL 500460 (Vet. App. Feb. 12, 2013) (the Board adopts the Court’s definition as its own). A 50 percent rating is warranted with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. “Very frequent” is not defined by the regulations. Because the criteria for a 30 percent rating requires prostrating attacks for an average of once a month, the Board finds that “very frequent” must require at least 2 or more completely prostrating and prolonged attacks per month. “Completely prostrating” is also not defined by VA regulations. “Complete” is defined as “total, absolute.” MERRIAM-WEBSTER’S NEW COLLEGIATE DICTIONARY ONLINE. It is also defined as “to the greatest extent.” OXFORD DICTIONARIES ONLINE. Similarly, while “prolonged” is not defined by VA regulations, Oxford Dictionaries defines “prolonged” as “continuing for a long time or longer than usual; lengthy.” OXFORD DICTIONARIES ONLINE. Finally, the phrase “productive of severe economic inadaptability” has also not been clearly defined by regulations or by case law. The United States Court of Appeals for Veterans Claims (Court) has noted that “productive of” can either have the meaning of “producing” or “capable of producing.” Pierce v. Principi, 18 Vet. App. 440, 445 (2004). Thus, migraines need not actually “produce” severe economic inadaptability to warrant the 50 percent rating. Id. at 445-46. Further, “economic inadaptability” does not mean unemployability, because it would undermine the purpose of regulations pertaining to a total disability rating based on individual unemployability (TDIU). Id. at 446; see also 38 C.F.R. § 4.16. The Board notes, however, that the migraines must be, at minimum, capable of producing “severe” economic inadaptability. An October 2013 VA treatment note indicates the Veteran reported having increased incidence of headaches since an MVA that occurred a few days earlier. She reported headaches occurring daily and throughout the day. During the October 2013 VA examination the Veteran reported headaches mostly occur in the front of her head and radiate to the sides. She reported that headaches last about 8 hours. Symptoms include pulsating or throbbing head pain, sensitivity to light, and changes to vision. Pain worsens with physical activity. She reported she vomited once during a migraine but usually does not experience nausea or vomiting. The Veteran reported prostrating attacks more than once a month. She denied very frequent prolonged prostrating attacks. She reported that when she had headache pain at work, she goes into the conference room to work where it is quiet and dark. In the November 2014 notice of disagreement, the Veteran reported that she experiences migraines on a daily basis that last hours at a time. She reported she sometimes takes leave from work due to the severity of her migraine pain. She reported she must sometimes wears sunglasses at work because of the light sensitivity her migraines cause. She reported migraines sometimes manifest in loss of balance. During the June 2015 VA examination, the Veteran stated that her headaches impacted her ability to work. She reported she often has to leave work due to difficulty focusing and photophobia. She also reported pulsating or throbbing head pain on both sides of the head, nausea, and sensitivity to sound. She reported head pain typically lasts less than a day. She reported prostrating attacks occur more than once a month. She denied very frequent prostrating and prolonged attacks of migraine headache pain. A December 2015 VA treatment record indicates the Veteran reported more frequent headaches for the previous 3 months. Headache pain at severity of level of 10 out of 10. She reported having headaches 4 to 5 days a week. Light makes it worse and she goes to a quiet place. She reported having to call out of work 4 days in the previous week. She requested a prescription change. In the February 2016 VA Form 9, the Veteran reported that because of her headaches she can only work with the lights off and wearing sunglasses. She reported that she has also missed days of work and had to leave early because of her migraines. She reported that her migraines are so bad that when walking she losses her balance. She indicated this happens 2 to 3 times a week. A September 2016 VA treatment note indicates the Veteran reported headache pain manifested in light and sound sensitivity and occasionally nausea. She reported having a sensation of imbalance and light headedness. Headaches are aggravated by activity but not relieved by rest or lying down. She reported headaches occur 3 to 4 times per week and last anywhere from 2 hours to 1.5 days. She uses Excedrin or Tylenol migraine for pain with variable relief. During the November 2019 VA examination, the Veteran reported headaches occur 3 to 4 times a week lasting 4 hours. She reported medication helps alleviate pain. She reported that due to light sensitivity she has to leave work twice a month or go in a dark room for relief. She reported nausea, vomiting, sensitivity to sound, and changes in vision; pain worsens with physical activity. She reported head pain typically lasts less than 1 day. She denied prostrating attacks of migraine pain. Based on the evidence of record, that the Veteran’s migraines more nearly approximate the criteria for 30 percent rating prior to December 23, 2015 and more nearly approximate the criteria for a 50 percent rating thereafter. Prior to December 23, 2015, the Veteran’s migraine disability manifested in persistent headaches and prostrating attacks more than once a month. However, the evidence does not show that the prostrating attacks are very frequent or prolonged. During the October 2013 VA examination she reported headache pain lasted about 8 hours and denied very frequent prolonged attacks. Similarly, during the June 2015 VA examination, the Veteran reported that headache pain typically lasted less than a day and she denied very frequent prolonged prostrating attacks. The Veteran reported that she sometimes had to miss work due to headache pain suggesting that the she may have experienced “very prostrating attacks” – headaches causing complete and total exhaustion and powerlessness to the greatest extent. However, the evidence consistently shows that prior to December 23, 2015, the attacks were not prolonged. Furthermore, as previously noted, “productive of” can either have the meaning of “producing” or “capable of producing.” Pierce, 18 Vet. App. at 445. Thus, migraines need not actually “produce” severe economic inadaptability to warrant the 50 percent rating. Id. at 445-46. The Board finds that the nature and frequency of the Veteran’s headaches indicates that they are not capable of producing severe economic inadaptability. The Veteran reported that she would often work in a dark room or where sunglasses to adapt to her work setting despite headache pain. She also indicated that her prostrating attacks typically lasted less than a day. While the Veteran did endorse throbbing head pain and sensitivity to light and sound, to the extent that the Veteran’s current symptoms are capable of producing economic inadaptability, the economic inadaptability would be at worse mild. Prior to December 23, 2015 symptoms did not rise to the level required to show they are capable of producing severe economic inadaptability. As such, entitlement to a rating in excess of 30 percent for migraines is not warranted. The record shows the Veteran experienced worsening symptoms from December 23, 2015. The December 2015 VA treatment record indicates the Veteran was experiencing headache pain at severity of level of 10 out of 10 for 4 to 5 days a week. She reported having to call out of work 4 days in the previous week. Similarly, in the February 2016 VA Form 9, she reported that she has also missed days of work and had to leave early because of her migraines. She reported that her migraines are so bad that when walking she lose her balance. She indicated this happens 2 to 3 times a week. In September 2016 the Veteran reported headache pain lasts anywhere from 2 hours to 1.5 days. As such, the Board finds that the evidence shows that from December 23, 2015 the Veteran was experiencing more severe headache pain lasting for prolonged periods requiring her to miss work more consistently. Thus, from December 23, 2015, the Veteran’s migraine condition more nearly approximated the criteria for a 50 percent rating. The Board has also considered whether an effective date prior to December 23, 2015 is warranted for the assignment of a 50 percent maximum rating. However, December 23, 2015 – the date of the VA treatment note showing a worsening of symptoms – is the earliest date upon which it is factually ascertainable that the Veteran met the criteria for a 50 percent rating. 6. Entitlement to a rating in excess of 30 percent for asthma. The Veteran asserts that her asthma is more disabling that reflected in her current 30 percent rating. The Veteran’s condition is evaluated under DC 6602, which provides a 30 percent evaluation for an FEV-1 of 56 to 70 percent of predicted value, or, an FEV-1/FVC of 56 to 70 percent, or, daily inhalational or oral bronchodilator therapy, or, inhalational anti-inflammatory medication. A 60 percent evaluation is warranted for an FEV-1 of 40 to 55 percent of predicted value, or, an FEV-1/FVC of 40 to 55 percent, or, at least monthly visits to a physician for required care of exacerbations, or, intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. 38 C.F.R. § 4.97, DC 6602. A maximum 100 percent disability rating is assigned for an FEV-1 less than 40 percent of the predicted value, or, FEV-1/FVC less than 40 percent, or, more than one attack per week with episodes of respiratory failure, or, requires daily use of systemic (oral or parenteral) high dose corticosteroids or immune-suppressive medications. 38 C.F.R. § 4.97, DC 6602. Pulmonary Function Test (PFT) results are generally reported before and after the administration of bronchodilator therapy. VA regulations require the use of post-bronchodilator results in determining disability ratings for DC 6600, 6603, 6604, 6825-6833, and 6840-6845, unless post-bronchodilator results are poorer than pre-bronchodilator results. 38 C.F.R. § 4.96 (d)(4). There are no regulations specifying whether pre- or post-bronchodilator results should be used when determining disability ratings under DC 6602. As a matter of convenience, this decision relates pre- and post-bronchodilator scores alike in summarizing PFT studies. For the entire appeal period, the Veteran’s asthma more nearly approximates the criteria for a 30 percent rating. During an October 2013 VA examination the Veteran reported waking up with shortness of breath. She reported treating her asthma with two inhalers and a daily oral medication. Her asthma did not require use of oral or parenteral corticosteroid medication. Her condition did not require use of oral bronchodilators, antibiotics, or outpatient oxygen therapy. The Veteran did not have an episodes or respiratory failure in the prior 12 months; she also did not require physician visits for exacerbations. PFTs showed a pre-bronchodilator FVC of 56 percent predicted, FEV-1 of 62 percent predicted and an FEV-1/FVC of 92 percent. Post-bronchodilator PFT results show FVC of 71 percent predicted, FEV-1 of 79 percent predicted, and FEV-1/FVC of 93 percent predicted. The examiner noted that the FEV-1 test result most accurately reflected the Veteran’s level of disability. A February 2014 VA emergency room indicates the Veteran was treated with prednisone for an asthma flare. In the November 2014 notice of disagreement, the Veteran reported having trouble breathing while walking, descending and ascending steps, singing, and talking. She reported has three inhalers to control her asthma. During the October 2019 VA examination, the Veteran reported that her asthma currently manifests in heavy breathing and coughing. The Veteran’s asthma did not require the use of oral or parenteral corticosteroid medication. The Veteran reported intermittent inhalation bronchodilator therapy and daily inhalation anti-inflammatory medication. The Veteran’s asthma did not require use of oral bronchodilators, antibiotics, or outpatient oxygen therapy. The Veteran did not have asthma attacks with respiratory failure in the prior 12 months and did not require physician visits for exacerbations. PFTs showed a pre-bronchodilator FVC of 87 percent predicted, FEV-1 of 73 percent predicted and an FEV-1/FVC of 89 percent. Post-bronchodilator PFT results show FVC of 89 percent predicted, FEV-1 of 89 percent predicted, and FEV-1/FVC of 107 percent predicted. The examiner noted that the FEV-1/FVC test result most accurately reflected the Veteran’s level of disability. For the entire appeal period, the Veteran’s asthma manifested in no worse than an FEV-1 of 62 percent and an FEV-1/FVS of 93 percent. Although the Veteran’s asthma required daily inhalational therapy, there is no evidence of monthly visits to a physician for required care of exacerbations, or, intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids to warrant an increased rating. As such, a rating in excess of 30 percent for asthma is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a low back disability. In October 2018, the Board remanded the Veteran’s claim for a VA examination and medical opinion addressing whether the Veteran’s current low back condition was related to complaints of back pain in service. The Veteran was afforded the requested examination in October 2019. The examiner opined that the conditions were not related to service because “there are no findings in the Veteran’s service records or immediately following service to ascribe service correlation to her current diagnosis.” However, the examiner fails to consider the Veteran’s in-service complaints of low back pain and the lay reports of continuity of symptoms. Thus, an addendum medical opinion is warranted. In addition, The Veteran submitted a December 2014 foot DBQ that was completed by a private physician, M.F. Dr. M.F. stated that the Veteran’s severe pes planus symptoms on the right side has significantly impacted low back pain and dysfunction. As the decision herein grants service connection for pes planus, remand for a medical opinion addressing secondary service connection is warranted. 2. Entitlement to service connection for a right knee disability The Veteran submitted a December 2014 foot DBQ that was completed by a private physician, M.F. Dr. M.F. stated that the Veteran’s severe pes planus symptoms on the right side has significantly impacted right knee pain and dysfunction. As the decision herein grants service connection for pes planus, remand for a medical opinion addressing secondary service connection is warranted. 3. Entitlement to service connection for a neck condition (claimed as ches/back pain and back strain) is denied. 4. Entitlement to service connection for a right trapezius (claimed as back and neck trapezius strain and a right shoulder disorder) is denied. In October 2018, the Board remanded the Veteran’s claims for service connection for a neck condition and right shoulder condition for VA examination and medical opinions addressing whether the Veteran’s current neck and shoulder conditions were related to complaints of pain in service. The Veteran was afforded the requested examinations in October 2019. The examiner opined that the conditions were not related to service because “there are no findings in the Veteran’s service records or immediately following service to ascribe service correlation to her current diagnosis.” However, the examiner fails to consider the Veteran’s in-service complaints of neck and shoulder pain and the lay reports of continuity of symptoms. Furthermore, the record shows that the Veteran complained of neck and shoulder pain in connection with her service-connected condition of thoracic outlet syndrome. As such, an addendum opinion medical opinion is also needed to address whether the Veteran’s neck and right shoulder strain are secondary to her service-connected thoracic outlet syndrome. 5. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. A claim for an increased evaluation includes a claim for a finding of TDIU where there are allegations of worsening disability and unemployability. Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, evidence suggests that the Veteran’s mental health symptoms impact her ability to work. In November 2019, she put in a request to invoke intermittent leave under the Family and Medical Leave Act (FMLA) due to mental health symptoms. As such, TDIU is before the Board. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion regarding the Veteran’s low back condition addressing (a) whether it is at least as likely as not (50 percent probability or higher) the Veteran’s low back condition had its onset in service or is related to complaints of low back pain in service, and (b) whether it is at least as likely as not that the Veteran’s low back disability is caused by or aggravated by (i.e., permanently worsened beyond the natural progression) her service-connected pes planus. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The need for a medical examination is left to the examiner’s discretion. 2. Obtain an addendum medical opinion regarding whether it is at least as likely as not that the Veteran’s right knee disability is caused by or aggravated by (i.e., permanently worsened beyond the natural progression) her service-connected pes planus. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The need for a medical examination is left to the examiner’s discretion. 3. Obtain an addendum medical opinion regarding (a) whether it is at least as likely as not (50 percent probability or higher) the Veteran’s neck condition had its onset in service or is related to complaints of neck pain in service; and (b) whether it is at least as likely as not that the Veteran’s neck disability is caused by or aggravated by (i.e., permanently worsened beyond the natural progression) her thoracic outlet syndrome. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The need for a medical examination is left to the examiner’s discretion. 4. Obtain an addendum medical opinion regarding (a) whether it is at least as likely as not (50 percent probability or higher) the Veteran’s right shoulder condition had its onset in service or is related to complaints of shoulder pain in service; and (b) whether it is at least as likely as not that the Veteran’s right shoulder disability is caused by or aggravated by (i.e., permanently worsened beyond the natural progression) her thoracic outlet syndrome. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The need for a medical examination is left to the examiner’s discretion. 5. Provide the Veteran with appropriate notice regarding the TDIU claim and request that she complete a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. Explain what is needed to establish entitlement to TDIU due to her service-connected disabilities. Ask the Veteran to submit any additional evidence in support of a TDIU claim, to specifically include information on her work history, salary, and educational history. 6. Adjudicate the Veteran’s TDIU claim. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.A. Williams, 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.