PTSD DUE TO COMBAT

TANYA SMITH · 2026 · Case ID: A26036086

MIXED

Summary

The veteran, who served in the United States Army from June 2002 to April 2014 with multiple periods of service, appeals the denial of increased ratings for PTSD, lumbar strain, right shoulder strain, and right knee strain, as well as the reduction of his headache rating. The Board granted a separate 10 percent rating for right knee instability. For PTSD, the veteran sought a rating higher than the current 70 percent, but the Board found total occupational and social impairment was not demonstrated, denying the increase. Regarding lumbar strain, the veteran's forward flexion was limited to 30 degrees, supporting the existing 40 percent rating, and the Board found no basis for a higher rating or for unfavorable ankylosis. For the right shoulder, the veteran's flexion/abduction was limited to 90 degrees, consistent with the current 20 percent rating, and no evidence supported a higher rating. For the right knee, the veteran's flexion was limited to 40 degrees, consistent with the existing 10 percent rating for strain, but the Board granted a separate 10 percent rating for instability based on the veteran's testimony of his knee giving out and buckling, which was deemed consistent with slight recurrent instability. Finally, the Board found the reduction of the headache rating from 30 percent to 0 percent improper, restoring the 30 percent rating as the evidence did not support sustained improvement.

Rationale

Total occupational and social impairment not shown; Maintains full-time employment; Maintains stable relationships

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

200331-79424

Full Decision Text

Citation Nr: A26036086
Decision Date: 04/17/26 Archive Date: 04/17/26

DOCKET NO. 200331-79424
DATE: April 17, 2026

ORDER

Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied.

Entitlement to a rating in excess of 40 percent for lumbar strain, anterior thoracic spine T8 and T9 is denied.

Entitlement to a rating in excess of 20 percent for right shoulder strain (dominant) is denied.

Entitlement to a rating in excess of 10 percent for right knee strain, patellofemoral spurring is denied.

Entitlement to a separate 10 percent rating under Diagnostic Code (DC) 5257 for right knee instability is granted.

The reduction of the Veteran's headache rating from 30 percent to 0 percent effective February 10, 2020 was not proper; restoration of the 30 percent rating effective February 10, 2020 is granted.

FINDINGS OF FACT

1. The Veteran's PTSD symptoms have manifested as depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work-like setting; total occupational and social impairment is not shown.

2. The Veteran's lumbar strain, anterior thoracic spine T8 and T9 has resulted in his forward flexion being limited to 30 degrees following repeated use over time; the evidence does not support ankylosis of the spine or the functional equivalent thereof.

3. The Veteran's right shoulder strain causes range of motion limited to 90 degrees flexion/abduction.

4. The Veteran's right knee strain, patellofemoral spurring manifests flexion limited to 40 degrees.

5. The Veteran's right knee strain and pain has led to degeneration of the medial meniscus causing noted instability.

6. During the period at issue, there was no sustained improvement of the Veteran's headaches.

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?(DC)?9411.

2. The criteria for a rating in excess of 40 percent for lumbar strain, anterior thoracic spine T8 and T9 have not been met. 38 U.S.C. §§ 1155, 5107(b);?38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59, 4.71a, DC 5237.

3. The criteria for a rating in excess of 20 percent for right shoulder strain (dominant) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.71a, DC 5201.

4. The criteria for a rating in excess of 10 percent for right knee strain, patellofemoral spurring have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59, 4.71a, DC 5260.

5. The criteria for a separate 10 percent rating under DC 5257 for right knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59, 4.71a, DC 5257.

6. The criteria for restoration of the 30 percent rating for the Veteran's headaches effective February 10, 2020 have been met. 38 U.S.C. §§ 1110, 1155; 38 C.F.R. §§ 3.105(e), 3.321, 3.344, 4.1-4.14, 4.124a, DC 8100.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from June 2002 to August 2002, February 2003 to August 2003, and February 2004 to April
4.71a, DC 5257.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from June 2002 to August 2002, February 2003 to August 2003, and February 2004 to April 2014.

In the March 31, 2020 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on July 16, 2024.

Therefore, the Board may only consider the evidence of record at the time of the March 2020 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

I. Increased Rating

Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1.?

Pertinent regulations also provide that it is not necessary for all of the individual criteria to be present as set forth in the Rating Schedule, but that findings sufficient to identify the disability and level of impairment be considered. 38 C.F.R. § 4.21. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3.?

1. Entitlement to a rating in excess of 70 percent for PTSD.

The Veteran was granted service connection for PTSD in a July 2016 rating decision, evaluated at 30 percent effective January 23, 2016. In October 2019, the Veteran filed a supplemental claim requesting a review of his PTSD evaluation. He was given a VA examination for such in February 2020 wherein he was diagnosed with PTSD and persistent depressive disorder with anxious distress. The examiner opined that it was not possible to differentiate between the symptoms of the two psychiatric conditions and that the Veteran had occupational and social impairment with reduced reliability and productivity. With regard to symptoms, the examiner found the Veteran to suffer from depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, and inability to establish and maintain effective relationships. The Veteran's behavioral observations were noted as alert, cooperative, well-groomed, irritable and anxious, affect was constricted, speech was normal, he maintained good eye contact, his thought process
ined that it was not possible to differentiate between the symptoms of the two psychiatric conditions and that the Veteran had occupational and social impairment with reduced reliability and productivity. With regard to symptoms, the examiner found the Veteran to suffer from depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, and inability to establish and maintain effective relationships. The Veteran's behavioral observations were noted as alert, cooperative, well-groomed, irritable and anxious, affect was constricted, speech was normal, he maintained good eye contact, his thought process was logical and relevant, his insight, judgment, and memory were all intact, and he did not report any current intention of suicide or homicide. However, the Board notes that the examiner had previously noted within the report that the Veteran had attempted suicide a year ago. Based on these findings, the AOJ issued a March 2020 rating decision increasing the Veteran's PTSD evaluation to 70 percent, effective October 24, 2019, the date of his claim. The instant appeal ensued.

As noted above, the Veteran testified at a Board hearing in July 2024. Here, he reported that he was still working full-time, but that without his medication he "would easily snap." Specifically, the Veteran's representative indicated that he was sending the Veteran for a private examination by his psychologist and would submit a report indicating that the Veteran's PTSD symptoms could put him in the 100 percent evaluation range. However, to date no such report has been submitted.

PTSD is evaluated under 38?C.F.R. §?4.130, DC 9411. Under the General Rating Formula For Mental Disorders, to include PTSD, a 70 percent evaluation 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; 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 work-like setting); and inability to establish and maintain effective relationships. A 100 percent evaluation is assignable where 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; and memory loss for names of close relatives, own occupation, or own name. Id.??

The persuasive evidence does not show that the Veteran suffers from total occupational and social impairment. At his most recent VA examination, the Veteran reported maintaining a good relationship with his parents and a close relationship with his sister as well as two friends that he occasionally hangs out with at his house. He reported working full-time in a graphics job since July 2009 and denied any verbal or written reprimands or any conflict with his coworkers and boss. At his hearing, the Veteran reported working at his current job where he runs "a production facility for making signs and stuff" for around seven years. Finally, the Veteran's behavioral observations were all within normal limits. Total occupational and social impairment has not been shown. Accordingly, entitlement to a rating in excess of 70 percent for PTSD is denied.

2. Entitlement to a rating in excess of 40 percent for lumbar strain, anterior thoracic spine T8 and T9.

In a May 2014 rating decision, the Veteran was granted service connection for lumbar spine, anterior thoracic spine T8 and T9, evaluated at 20 percent, effective April 28, 2014. In January 2016 the Veteran requested a higher rating for his back condition and was given another VA examination in April 2016. Following this examination, the AOJ issued a July 2016 rating decision continuing his 20 percent evaluation.

In October 2019, the Veteran again requested a higher rating for his back. He was given another VA examination for such in February 2020. Here, the examiner noted the onset of the Veteran's back condition as 2005 following a rollover military vehicle accident in Iraq which has since worsened. The Veteran's current symptoms were listed as pain, stiffness, and burning, and he was noted to use a TENS unit as needed. With regard to range of motion testing, the Veteran was found to have forward flexion to 75 degrees, extension to 5 degrees, right and left lateral flexion to 15 degrees, and right and left lateral rotation to 10 degrees. The examiner noted pain on examination that causes functional loss on all ranges of motion. Range of motion testing was not completed following observed repetitive use due to fear of pain, but following repeated use over time, the Veteran's forward flexion was limited to only 30 degrees. No flare-ups were reported, but the Veteran was noted to have muscle spasm not resulting in abnormal gait or abnormal spinal contour. No muscle atrophy, radiculopathy, ankylosis, or intervertebral disc syndrome was found. The examiner noted that the Veteran constantly uses a back brace and occasionally uses a cane. With regard to functional impairment, the examiner noted that the Veteran's back is painful and stiff causing difficulty sitting, standing, and walking. Based on these findings, the AOJ issued a March 2020 rating decision increasing the Veteran's back evaluation to 40 percent effective October 24, 2019, the date of his application. The instant appeal ensued.

The Veteran's lumbar spine, anterior thoracic spine T8 and T9 is rated under DC 5237 for lumbosacral strain, which falls under the general rating formula for diseases and injuries of the spine. Under?38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, for ratings for the thoracolumbar spine, a 40 percent rating is assigned if there is forward flexion of the thoracolumbar spine of 30 degrees or less or if there is favorable ankylosis of the entire thoracolumbar spine; a 50 percent rating is assigned if there is unfavorable ankylosis of the entire thoracolumbar spine. Finally, a 100 percent rating may be assigned if there is unfavorable ankylosis of the entire spine.

As the February 2020 VA examination showed, the Veteran's forward flexion to be limited to 30 degrees following repeated use over time, pursuant to DC 5237 a 40 percent rating is warranted. The Board notes no other relevant medical evidence regarding the current severity of the Veteran's back condition is within the record. Thus, the Board finds that the record does not support a?rating in excess of 40 percent?for the Veteran's lumbar spine, anterior thoracic spine T8 and T9. The Veteran is in receipt of the maximum evaluation available for limitation of motion of the spine under the rating schedule. Also, a 40 percent rating is assigned for favorable ankylosis or the functional equivalent thereof. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. See?38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). Thus, the 40 percent rating contemplates episodes in which the Veteran believes his disability is so severe that he cannot move his back. Unfavorable ankylosis is a condition in which the entire thoracolumbar spine or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. See?38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). The Board does not find that the medical evidence and the Veteran's description of the functional impairment he experiences demonstrates the level of disability associated with unfavorable ankylosis of the thoracolumbar spine or the functional equivalent thereof, which is the criteria associated with the next higher rating of 50 percent.

3. Entitlement to a rating in excess of 20 percent for
due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. See?38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). The Board does not find that the medical evidence and the Veteran's description of the functional impairment he experiences demonstrates the level of disability associated with unfavorable ankylosis of the thoracolumbar spine or the functional equivalent thereof, which is the criteria associated with the next higher rating of 50 percent.

3. Entitlement to a rating in excess of 20 percent for right shoulder strain (dominant).

The Veteran was granted service connection for a right shoulder strain in a May 2014 rating decision, evaluated at 0 percent, effective April 28, 2014. In January 2016, he requested a higher rating for his right shoulder. Following a VA examination, he was granted a 10 percent evaluation for his right shoulder in a July 2016 rating decision.

In October 2019, the Veteran again requested an increased rating for his right shoulder. He was given a VA examination for such in February 2020. Here, the examiner continued to diagnose a right shoulder strain with onset in 2006 following deployment to Iraq. The examiner noted that the Veteran's shoulder was worsening and his current symptoms were pain, burning, and stiffness and he used heating pads as needed. The examiner noted that the Veteran was right hand dominant and reported flare-ups once or twice a month that lasted 3-6 hours following increased use of his shoulder or heavy lifting. He was noted to have impaired range of motion and difficulty lifting with his right arm, as well as with holding or lifting objects. Range of motion testing showed the Veteran's flexion and abduction to be both to 180 degrees, and external and internal rotation to be both to 90 degrees. Pain was noted on exam, but it was not noted to cause functional loss. The Veteran did not do range of motion testing following observed repetitive use due to fear of pain. With regard to repeated use over time and during flare-ups, the examiner noted "Following further review of the Veteran's records and giving consideration to their subjective complaints and objective exam findings, given my clinical knowledge and medical expertise, there remains no rational basis to make a notation regarding any additional losses of function or motion when it comes to repeated use over time." No muscle atrophy or ankylosis was found, nor was shoulder instability or a joint condition noted. Objective evidence of pain was noted on both passive range of motion testing and non-weight bearing. Based on these findings, the AOJ issued a March 2020 rating decision increasing the Veteran's shoulder evaluation to 20 percent, effective October 24, 2019, the date of claim. The instant appeal ensued.

The Veteran's right shoulder strain is evaluated under DC 5201 for arm, limitation of motion. Under DC 5201 a 20 percent rating is warranted for limitation at the shoulder level (flexion and/or abduction limited to 90 degrees) for either the major or the minor arm. The next higher rating is 30 percent for the major arm, but remains at 20 percent for the minor arm, when limitation of motion is midway between side and shoulder level (flexion and/or abduction limited to 45 degrees). Ratings under DC 5201 differ depending on whether the dominant (major) or non-dominant (minor) extremity is being rated. In this case, the Veteran is right-hand dominant, so his right shoulder is his major extremity.

The Board notes that the evidence of record shows that the Veteran's right shoulder flexion/abduction is limited to 90 degrees, which is consistent with the already assigned 20 percent rating under DC 5201. The night higher rating of 30 percent is not warranted unless the Veteran's right shoulder flexion/abduction is limited to 45 degrees, there is no medical evidence to support this. At his Board hearing, the Veteran complained of shoulder pain and struggling to lift with his right shoulder but testified "I get up to about my shoulder area and then if I try to get past that it starts to really hurt. I put my arm behind my back a few times. I get about probably a 90 degree, 45- to 90-degree angle before it actually starts hurting depending on the day." Thus, the Board finds the Veteran's testimony to be consistent with the already assigned 20 percent rating. The Board finds no other diagnostic code suitable for rating the Veteran's right shoulder strain. Accordingly, entitlement to a rating in excess of 20 percent for right shoulder strain (dominant) is denied.

4. Entitlement to a rating in excess of 10 percent for
of shoulder pain and struggling to lift with his right shoulder but testified "I get up to about my shoulder area and then if I try to get past that it starts to really hurt. I put my arm behind my back a few times. I get about probably a 90 degree, 45- to 90-degree angle before it actually starts hurting depending on the day." Thus, the Board finds the Veteran's testimony to be consistent with the already assigned 20 percent rating. The Board finds no other diagnostic code suitable for rating the Veteran's right shoulder strain. Accordingly, entitlement to a rating in excess of 20 percent for right shoulder strain (dominant) is denied.

4. Entitlement to a rating in excess of 10 percent for right knee strain, patellofemoral spurring.

5. Entitlement to a separate 10 percent rating under DC 5257 for right knee instability.

The Veteran was granted service connection for a right knee strain, patellofemoral spurring in a May 2014 rating decision, evaluated at 10 percent, effective April 28, 2014. In January 2016, he requested a higher rating for his right knee. Following a VA examination, the AOJ issued a September 2016 rating decision continuing to evaluate the Veteran's right knee at 10 percent.

In October 2019, the Veteran again requested a higher rating for his right knee. He was given a VA examination for such in February 2020. Here, the examiner diagnosed right knee strain, patellofemoral spurring beginning in 2006 and other meniscus derangement, unspecified meniscus, right knee beginning in 2012. The examiner noted the Veteran's knee injury was due to a military vehicle accident while deployed in Iraq, indicating multiple rounds of physical therapy and worsening since onset causing symptoms of pain, stiffness, and instability. The Veteran was noted to use a TENS unit, heating pad, and ice pack all as needed for treatment. Range of motion testing showed flexion to 100 degrees with pain noted on examination that causes functional loss. The Veteran did not engage in range of motion testing following observed repetitive use due to fear of pain, however following repeated use over time the Veteran's flexion was limited to 40 degrees. The examiner noted that the Veteran denied flare-ups. No muscle atrophy or ankylosis was found, and joint stability testing was normal. The examiner noted no history of recurrent subluxation, lateral instability, or recurrent effusion, but did note shin splints on the right. With regard to meniscal conditions, the examiner noted other writing "degeneration of posterior horn medial meniscus per MRI R knee Aug 9, 2012." With regard to assistive devices, the examiner noted that the Veteran constantly uses a brace and occasionally uses a cane. No degenerative or traumatic arthritis was documented and the examiner noted that the Veteran's functional impact as "pain in right knee impairs ability to stand, sit, ambulate for prolonged periods". Objective evidence of pain was noted on passive range of motion testing and non-weight bearing. Finally, the examiner noted that the Veteran's other meniscus derangements, unspecified medial meniscus, right knee was a new diagnosis directly due to his right knee sprain. As rationale he noted "ongoing right knee strain and pain led to degeneration of the medial meniscus." Based on these findings, the AOJ issued a March 2020 rating decision continuing to evaluate the Veteran's right knee at 10 percent. The instant appeal ensued.

When rating disabilities of the knee, separate ratings may be assigned for limited knee motion in flexion (under Diagnostic Code 5260) and in extension (under Diagnostic Code 5261), as well as for instability (under Diagnostic Code 5257). VA Gen. Counsel. Prec. 23-97 (July 1, 1997).

Under Diagnostic Code 5257, a rating of 10 percent is warranted when there is slight recurrent subluxation or lateral instability; a 20 percent rating is warranted when there is moderate recurrent subluxation or lateral instability; and a 30 percent rating is warranted when there is severe recurrent subluxation or lateral instability.

According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree.

Under Diagnostic Code 5260, a 0 percent (noncompensable) rating is assigned for leg flexion limited to 60 degrees. A 10 percent rating is assigned for leg flexion limited to 45 degrees. A 20 percent rating is assigned for leg flexion limited to 30 degrees. A maximum 30 percent
and a 30 percent rating is warranted when there is severe recurrent subluxation or lateral instability.

Under Diagnostic Code 5260, a 0 percent (noncompensable) rating is assigned for leg flexion limited to 60 degrees. A 10 percent rating is assigned for leg flexion limited to 45 degrees. A 20 percent rating is assigned for leg flexion limited to 30 degrees. A maximum 30 percent rating is assigned for leg flexion limited to 15 degrees.

The Board notes that some of these diagnostic codes were amended in February 2021, however the period at issue in the case at hand is before the amendments went into effect.

The Veteran's limitation of flexion to 40 degrees is consistent with the already assigned 10 percent rating under DC 5260. The evidence of record does not support a finding that the Veteran's flexion is limited to 30 degrees or less which is required for the next higher rating of 20 percent. The Board does find, however, that the Veteran's newly diagnosed other meniscus derangements, unspecified medial meniscus, right knee warrants a separate rating under DC 5257 for slight recurrent subluxation or lateral instability. While the Board notes that the February 2020 examiner did not note any recurrent subluxation or lateral instability, "instability" was listed as one of the Veteran's current knee symptoms. Moreover, at his Board hearing, the Veteran testified

I know I've told my doctor a few times, but like out of the blue, my knee will give out, like the one place I was living in before I moved had stairs and occasionally I'd be walking down the stairs and my knee would just give out and I've fallen down the stairs multiple times just walking around just in general my knee will give out on random occasions and it -- I just go right into the ground.

The Veteran further testified that his knee will buckle, and he wears a brace and leans on walls to help support his knee. The severity, frequency, and duration of the Veteran's symptoms are consistent with at most slight recurrent instability. Thus, resolving reasonable doubt in favor of the Veteran the Board finds that entitlement to a separate 10 percent rating under DC 5257 for right knee instability is warranted.

II. Reductions

Disability ratings are intended to represent the average impairment of earning capacity resulting from a disability.?38 U.S.C. § 1155;?38 C.F.R. §§ 3.321(a), 4.1. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned.?38 C.F.R. § 4.7.

The regulations pertaining to the reduction of a disability rating are contained in?38 C.F.R. § 3.344(a). They provide that rating agencies will handle cases affected by changes of medical findings or diagnosis so as to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension. It is essential that the entire record of examination and the medical-industrial history be reviewed to ascertain whether the recent examination is full and complete, including all special examinations indicated as a result of general examination and the entire case history. Examinations less full and complete than those on which payments were authorized or continued will not be used as a basis of reduction. Ratings for diseases subject to temporary or episodic improvement will not be reduced on the basis of any one examination, except in those instances where all of the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Moreover, where material improvement in the physical or mental condition is clearly reflected, the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life.?38 C.F.R. § 3.344(a).

However, the provisions of?38 C.F.R. § 3.344(c) specify that the above considerations are required for ratings that have continued for long periods at the same level (five years or more), and that they do not apply to disabilities which have not become stabilized and are likely to improve. Therefore, reexaminations disclosing improvement, physical or mental, in these disabilities will warrant a reduction in rating.?38 C.F.R. § 3.344(c).

Under?38 C.F.R. § 3.105(e), when a reduction in evaluation of a service-connected disability is considered warranted and
improvement will be maintained under the ordinary conditions of life.?38 C.F.R. § 3.344(a).

Under?38 C.F.R. § 3.105(e), when a reduction in evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. The beneficiary will be notified at his or her latest address of record of the contemplated action and furnished detailed reasons therefor, and will be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at their present level. Unless otherwise provided in paragraph (i) of this section, if additional evidence is not received within that period, final rating action will be taken and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires. 38 C.F.R. § 3.105(e).

6. The reduction of the Veteran's headache rating from 30 percent to 0 percent effective February 10, 2020 was not proper; the 30 percent rating is restored.

The Veteran was granted service connection for headaches in a May 2014 rating decision, effective April 28, 2014, evaluated at 0 percent. The Board notes that at the time, the Veteran was given a June 2013 VA examination wherein he reported that his headaches began in 2008 and described them as "sticking pain in the frontal forehead area that occurs spontaneously." The Veteran reported that when headaches occur, he is able to work but requires medication. He reported experiencing headaches twice a week for approximately two hours long, including vision changes.

In January 2016, the Veteran requested an increased rating for his headaches. He was given a VA examination for such in April 2016. Here, the examiner diagnosed migraine, including migraine variants. The Veteran reported his headache medication was no longer working and stated that "his headache will go away quicker if he is in a dark room light makes his headache worse." The Veteran further reported loss of hearing and a buzzy noise in his ear with headaches, which are located in the front or middle top of his head. Under symptoms, the examiner noted constant headache pain on both sides of the head, sensitivity to light, and loss of hearing/buzzing sound for headaches that typically last less than one day. The examiner further opined that the Veteran had headaches that were characteristic prostrating attacks at least once every month, but not capable of severe economic inadaptability. With regard to functional impact, the examiner noted "Veteran states during his headache he must be in a dark room and stop doing whatever he is doing. He is unable to concentrate. If headache occurred during work he would have to take like an hour break." The Board notes that under remarks, the examiner referenced other examination findings and medical records to support his findings. Based on these findings, the AOJ issued a July 2016 rating decision increasing the Veteran's headache evaluation to 30 percent effective January 23, 2016.

In October 2019, the Veteran again requested an increased rating for his headaches. He was given another VA examination for such in February 2020. Here, the examiner noted the onset of the Veteran's headaches as 2011 following an IED explosion injury and the course since onset as worsening. However, under symptoms the examiner only noted pain localized to one side of the head, nausea, and sensitivity to light with a typical duration of less than one day. This examiner also found the Veteran to have headaches with characteristic prostrating attacks but noted the frequency to be "with less frequent attacks." No very prostrating and prolonged attacks of migraine pain productive of severe economic inadaptability were found. With regard to functional impact, the examiner noted "impaired ability to concentrate, sensitivity to light with nausea makes difficult to work due to migraine headache." The Board notes that the examiner did not include any additional medical records or findings. Based on these findings, the AOJ issued a March 2020 rating decision decreasing the Veteran's 30 percent headache evaluation to 0 percent, effective February 10, 2020, the date of the VA examination. Within the rating decision, the AOJ found that the newest VA
found the Veteran to have headaches with characteristic prostrating attacks but noted the frequency to be "with less frequent attacks." No very prostrating and prolonged attacks of migraine pain productive of severe economic inadaptability were found. With regard to functional impact, the examiner noted "impaired ability to concentrate, sensitivity to light with nausea makes difficult to work due to migraine headache." The Board notes that the examiner did not include any additional medical records or findings. Based on these findings, the AOJ issued a March 2020 rating decision decreasing the Veteran's 30 percent headache evaluation to 0 percent, effective February 10, 2020, the date of the VA examination. Within the rating decision, the AOJ found that the newest VA examination showed that the Veteran's disability had improved and noted that "This reduction does not result in a reduction in the overall benefits you will receive, so we are providing you with contemporaneous notification of this decision."

While the Board finds no procedural error in the reduction, a review of the evidence does not support the finding that the Veteran's headaches have improved. Moreover, the Board finds that the January 2016 VA examination was more thorough than the most recent February 2020 examination wherein improvement was supposedly shown. Finally, as noted above, the Veteran was given a Board hearing in July 2024 wherein he testified that his headaches had not improved and if anything they had worsened. Specifically, the Veteran testified that he currently gets headaches about five times per week during which he has to go to a dark area for 15-20 minutes until the pain dulls. The Veteran further testified to light sensitivity and nausea caused by his headaches as well as plainly stating that his "headaches never got better." Accordingly, the Board finds that there was no decrease in the Veteran's headache symptoms, nor sustained improvement as required for a rating reduction. The reduction was improper; thus, entitlement to restoration of the 30 percent rating for headaches effective February 10, 2020 is granted.

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TANYA SMITH

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board K. Ruiz, 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.

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