Citation Nr: 0916385 Decision Date: 05/01/09 Archive Date: 05/12/09 DOCKET NO. 01-06 839A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for sarcoidosis, including as due to Agent Orange exposure. 2. What evaluation is warranted for a left ankle sprain prior to June 18, 2007? 3. What evaluation is warranted for a left ankle sprain from June 18, 2007, currently rated as 10 percent? 4. What evaluation is warranted for a left ankle sprain from April 30, 2008? 5. What disability rating is warranted for post traumatic stress disorder (PTSD) from April 20, 2006, currently 30 percent? 6. Entitlement to an earlier effective date prior to April 20, 2006, for the grant of service connection for PTSD. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARINGS ON APPEAL Appellant and Dr. Craig N. Bash ATTORNEY FOR THE BOARD S. Grabia, Counsel INTRODUCTION The Veteran had active service from February 1966 to December 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Philadelphia , Pennsylvania , Regional Office (RO) of the Department of Veterans Affairs (VA). Jurisdiction now is with the Phoenix, Arizona RO, although the record shows that the appellant now resides in Pennsylvania. By rating action in February 1970 service connection was granted for a left ankle disorder and a rating of 10 percent was assigned. Subsequently by rating action in February 1971 the 10 percent rating was reduced to noncompensable. By rating action in December 2000 service connection was denied for sarcoidosis and PTSD. In addition an increased compensable rating for a left ankle disorder was denied. In a March 2007 rating action entitlement to service connection for PTSD was granted, and a 30 percent evaluation was assigned effective April 20, 2006. The United States Court of Appeals for Veterans Claims (Court) has indicated that a distinction must be made between a veteran's dissatisfaction with the initial rating assigned following a grant of service connection (so-called "original ratings") and dissatisfaction with determinations on later- filed claims for increased ratings. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Inasmuch as the issue of what evaluation is warranted for PTSD was essentially placed in appellate status by a notice of disagreement expressing dissatisfaction with an original rating, the Fenderson doctrine applies. In June 2003 and April 2008, hearings were held at the Board before the undersigned Veterans Law Judge. In addition a personal hearing was held at the RO in February 2002. Transcripts of all three hearings are of record. In January 2009 correspondence the veteran raised a claim of entitlement to service connection for prostate cancer. As the issue of entitlement to service connection for prostate cancer in not before the Board it is referred back to the RO. The issue what disability rating is warranted for a left ankle injury from April 30, 2008, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The most probative and competent evidence of record preponderates against finding that sarcoidosis is related to the veteran's active military service, to include exposure to herbicides. 2. Prior to June 18, 2007, the left ankle disorder was not manifested by objective evidence of a moderate limitation of motion. 3. From June 18, 2007, the left ankle disorder was manifested by evidence of mild to moderate limitation of motion without complaints of pain. 4. Since April 20, 2006, the Veteran's PTSD has not been productive occupational and social impairment with reduced reliability and productivity. 5. The Veteran submitted a claim of entitlement to service connection for PTSD on May 16, 2000. 6. PTSD was first diagnosed during an April 20, 2006 VA examination. CONCLUSIONS OF LAW 1. Sarcoidosis was not incurred in or aggravated by the veteran's active military service, and it may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 1131 (West 2002 and Supp. 2008); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2008). 2. The criteria for a compensable evaluation for a left ankle strain prior to June 18, 2007, were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2008); 38 C.F.R. §§ 3.159(c), 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5271 (2008). 3. The criteria for a rating in excess of 10 percent for a left ankle strain from June 18, 2007 to April 29, 2008, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159(c), 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5271. 4. Since April 20, 2006, PTSD has not met the criteria for an evaluation greater than 30 percent. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.130, Diagnostic Code 9411 (2008). 5. The criteria for an effective date earlier than April 20, 2006 for the award of service connection for PTSD have not been met. 38 U.S.C.A. §§ 5103, 5103A, 5107, 5110 (West 2002); 38 C.F.R. §§ 3.1, 3.102, 3.155, 3.159, 3.400 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The requirements of the Veterans Claims Assistance Act of 2000 (VCAA) have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA did fail to fully comply with the provisions of 38 U.S.C.A. § 5103 prior to the rating decisions in question. The record, however, shows that any prejudice that failure caused was cured by the fact that VA notified the veteran in October 2001, May 2004, and December 2004 correspondence; in May 2001 and November 2007 statements of the case; and in June 2002, September 2007, and November 2007 supplemental statements of the case of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, and notice of what part VA will attempt to obtain. The statements of the case specifically informed the veteran of the rating criteria which would provide a basis for an increased rating. VA fulfilled its duty to assist the claimant in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. The left ankle claim was readjudicated in a September 2007 supplemental statement of the case, while the increased ratings claim and earlier effective date for PTSD was readjudicated in a November 2007 statement of the case. These documents provided adequate notice of how effective dates are assigned. The claimant was afforded a meaningful opportunity to participate in the adjudication of the claims, and in the statement of the case he was provided actual notice of the rating criteria used to evaluate the disorders at issue. The claimant was provided the opportunity to present pertinent evidence and testimony in light of the notice provided. Because the veteran has actual notice of the rating criteria, and because the claim has been readjudicated no prejudice exists. There is not a scintilla of evidence of any VA error in notifying or assisting the appellant reasonably affects the fairness of this adjudication. Indeed, neither the appellant nor his representative has suggested that such an error, prejudicial or otherwise, exists. Hence, the case is ready for adjudication. Regarding the claim for an increased initial rating for PTSD; as service connection, an initial rating, and an effective date have been assigned, the notice requirements of 38 U.S.C.A. § 5103(a) have been met. The decision of the United States Court of Appeals for Veterans Claims in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), spoke only to cases of entitlement to an increased rating. Because there is a distinction between initial rating claims and increased rating claims, Vazquez-Flores is not for application with respect to initial rating claims as notice requirements are met when the underlying claim for service connection is substantiated. Consequently, there is no need to discuss whether VA met the Vazquez-Flores standard in regards to the increased initial rating for PTSD claim. The Board has reviewed all the evidence in the Veteran's claims files that includes lay statements, his written contentions, service treatment and personnel records, private and VA medical records and examination reports. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims files shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). I. Service connection, sarcoidosis Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may also be warranted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including sarcoidosis may be presumed to have been incurred during service if they become manifested to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998) (citing Cuevas v. Principi, 3 Vet. App. 542, 548 (1992)). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status do not constitute competent medical evidence. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). With regard to medical evidence, an assessment or opinion by a health care provider is never conclusive and is not entitled to absolute deference. Indeed, the United States Court of Appeals for Veterans Claims (Court) has provided guidance for weighing medical evidence. The Court has held, for example, that a post service reference to injuries sustained in service, without a review of service medical records, is not competent medical evidence. Grover v. West, 12 Vet. App. 109, 112 (1999). In addition, a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Further, an examination that does not take into account the records of prior medical treatment is neither thorough nor fully informed. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). A bare transcription of lay history, unenhanced by additional comment by the transcriber, is not competent medical evidence merely because the transcriber is a health care professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). Also, a medical opinion is inadequate when unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). Finally, a medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). In sum, the weight to be accorded the various items of medical evidence in this case must be determined by the quality of the evidence and not necessarily by its quantity or source. Lay statements are considered to be competent evidence when describing the symptoms of a disease or disability or an injury that are observable through the senses. However, when the determinative issue involves a question of medical causation, only individuals possessing specialized training and knowledge are competent to render an opinion. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The Veteran claims that he has sarcoidosis due to service. Sarcoidosis may be defined as a chronic, progressive, systemic granulomatous reticulosis of unknown etiology, characterized by hard tubercles, which may occur in almost any organ or tissue. See Dorland's Illustrated Medical Dictionary 1656 (30th ed. 2003). It may manifest in an acute form, which has an abrupt onset and a high spontaneous remission rate, or a chronic form, insidious in onset, which is progressive. Id. As reflected in his hearing testimony and statements, the Veteran asserts that his sarcoidosis is related to service and resulted from exposure to Agent Orange. The DD Form 214 confirms that the Veteran served in Vietnam . A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6)(iii). If so, the veteran is thereby entitled to a presumption of service connection for certain disorders listed under 39 C.F.R. § 3.309(e), even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. The list of these presumptive disorders does not include sarcoidosis. 38 C.F.R. § 3.309(e). VA has determined that there is no positive association between exposure to herbicides and any other condition for which it has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-46 (1994); see also 61 Fed. Reg. 57,586-57,589 (1996); 72 Fed. Reg. 32,345-32,407 (June 12, 2007). Notwithstanding the presumptive provisions, service connection for claimed residuals of exposure to herbicides also may be established by showing that a disorder resulting in disability is, in fact, causally linked to such exposure. See Brock v. Brown, 10 Vet. App. 155, 162-64 (1997); Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994), citing 38 U.S.C.A. §§ 1113 and 1116, and 38 C.F.R. § 3.303. The Veteran had a history of asthma which existed prior to service, and sinusitis. He also occasionally smoked a pipe. Service treatment records reveal complaints of, and treatment for coughs and some upper respiratory infections. The October 1969 separation examination was silent as to any treatment or diagnosis, or any other problems referable to the claimed sarcoidosis. On examination at that time, clinical findings were noted as normal for the lungs and chest. Post-service VA and private treatment records reflect that the first indication of any problem referable to sarcoidosis was in 1982 when the Veteran was hospitalized after a provisional diagnosis of coronary insufficiency. He had left arm and chest pain of unknown etiology. A pulmonary function study was within normal limits. The impression was an allergic reaction of some sort. A fiber optic bronchoscopy and biopsy coincidentally discovered the veteran had sarcoidosis based on a tissue diagnosis of noncaseating granular consistent with sarcoid. In April 2006, a VA examiner was asked whether it was at least as likely as not that sarcoidosis developed during the Veteran's period of service from February 1966 to December 1969, or was present to a compensable degree within the first year after service. In addition, the Veteran was to be evaluated for residuals of sarcoidosis. The claims folder was reviewed and the examiner noted that x-rays on entrance and separation examinations were normal, and there was absolutely no evidence that the Veteran developed sarcoidosis during service. The Veteran was not noted to have sarcoidosis until hospitalized in 1982; and even then it was an incidental diagnosis on a chest x-ray done for other reasons. The claimant could not clearly recall chest x-rays being done between mustering out of service and the 1982 hospitalization when he was found to have sarcoidosis. The appellant did recall being hospitalized for a fever sometime in the 1970s. The examiner then opined that being hospitalized for fever would have provoked a chest x-ray if the claimant did have sarcoidosis in the early 70's and sarcoidosis would have been incidentally found then. He opined further that there was absolutely no evidence that the claimant had sarcoidosis which developed during his military service, within a year of the military service and that sarcoidosis is in no way related to the military service. In a November 2007 medical evaluation, Craig N. Bash, M.D., noted reviewing the claims file including service medical records, post service medical records, imaging reports, and lay statements. Regarding sarcoidosis, he noted an in- service illness with a several month history of coughing, chills, and negative x-rays consistent with the first signs and symptoms of sarcoid. Dr. Bash noted that immediately post service in 1971 the veteran was discovered to have sarcoidosis by his physician Dr. Israel who was now deceased, and whose records were no longer available. His chronic symptoms were again worked up in 1982 and he was again diagnosed with sarcoidosis. Dr. Bash opined that, "His record does not contain a more likely etiology for his current pulmonary problems" In December 2008 a Veterans Health Administration medical expert reviewed the claims file and medical records. He noted that the service medical records revealed normal chest x-rays on entrance and separation from service. The Veteran's records were requested from Queens Hospital Center and the Long Island Jewish Medical Center but neither had any treatment records of the Veteran. The file included a lay statement from the Veteran's current wife noting that he had been hospitalized in 1973, 1981, and 1982 for sarcoidosis. She also stated he had been initially diagnosed by Dr. Israel . An undated lay statement from his ex-wife stated he had been admitted with a high fever in 1970 to Queens General or Hillcrest Hospital . The examiner noted that he had reviewed the available medical documents in regards to sarcoidosis noting that the Veteran claimed to have been diagnosed with sarcoidosis as early as 1970. However, the first medically documented diagnosis was made in 1982. At that time it was incidentally discovered in regards to a hospitalization for a complaint of left arm pain. Pulmonary function studies at that time were normal and he was asymptomatic. There was no evidence of systemic or progressive sarcoidosis and no need for treatment. Records from Dave Petro, M.D., were noted to reveal multiple visits for various reasons. In some notes, sarcoidosis was mentioned, however there was no evidence of treatment for active sarcoidosis. The most recent x-rays were normal. The examiner opined that the Veteran did not currently have manifestations of active sarcoidosis. He noted that the question of whether the Veteran's sarcoidosis had its onset in service was more difficult to answer. He had symptoms of cough and was treated for upper respiratory tract infection in service. These symptoms however were very common and non- specific. He reportedly had symptoms of asthma and allergies since childhood. The most common symptoms of sarcoidosis are coughs and dyspnea. The fact the Veteran had normal chest x- rays did not rule out the diagnosis of sarcoidosis at discharge from service. He could have been in stage 0. Fever of unknown origin can be related to sarcoidosis but usually fever related to sarcoidosis is low grade fever. According to the record the Veteran reported fevers as high as 105 which is not commonly seen as a manifestation of sarcoidosis. Regarding the degree of disease prior to December 1970, the examiner opined that the disease was not manifested to a compensable degree since he had a normal chest x-ray, and since the appellant and did not have persistent symptoms requiring chronic low dose steroids. The examiner noted that even when the Veteran was diagnosed in 1982 it was incidental finding and he was in stage I--hilar adenopathy without parenchymal involvement on chest x ray--with normal pulmonary function tests. Moreover, according to the appellant's then treating pulmonologist he did not have evidence of systemic involvement or progressive disease. In the examiner's review of the documents presented he did not see any treatment for sarcoidosis. The examiner opined that the etiology of sarcoidosis remained unknown at this time but it was thought to result from exposure to specific environmental agents in a genetically susceptible patient. Examples of such agents suggested to be involved in the etiology of sarcoidosis include viruses, some bacteria such as mycobacterium tuberculosis and other mycobacteria, mycoplasma and borrelia burgdorfen. Despite intensive effort, studies were noted to have largely failed to identify an external agent or agents responsible for sarcoidosis. The examiner could not find any study that linked Agent Orange to sarcoidosis. He noted that sarcoidosis is not a presumptive disease based on herbicide exposure. The examiner concluded that based on the above it was less likely that patient's sarcoidosis was caused by exposure to Agent Orange during his Vietnam service. After a full review of the record, the Board finds that the preponderance of the evidence is against granting entitlement to service connection for sarcoidosis. There are no medical records showing a diagnosis of sarcoidosis during service. Further, there is no evidence of sarcoidosis until 1982, 13 years after discharge from service, and at that time the disorder was asymptomatic and discovered coincidentally to another condition. The Veteran's history of no significant prior medical problems inservice of for many years postservice is evidence against a nexus with service. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (service incurrence may be rebutted by the absence of medical treatment for the claimed condition for many years after service). The Veteran and Dr. Bash have provided testimony that he first began to have lung problems in service. During his April 2008 hearing, Dr. Bash referred to the Veteran's coughs and chills in service noting that these were the first signs of sarcoidosis. He also placed great weight on x-rays which the Veteran testified were taken by Dr. Israel in 1972 as well as an accompanying diagnosis of sarcoidosis. The Board must note, however, that those purported records are not now nor have they ever been part of the claims folder, and appear to have been destroyed several years ago. Hence, any statement as to what these x-rays said must be based on the appellant's own recollection of what a doctor told him. Significantly, however, the connection between what a physician said and the layman's account of what he purportedly said, filtered through a layman's sensibilities, is simply too attenuated and inherently unreliable to constitute "medical evidence." Robinette v. Brown, 8 Vet.App. 69, 77 (1995). Hence, any reliance by Dr. Bash on what the appellant told him is not a reliance on medical evidence. The Veteran alleges in essence that chills and fevers he had during service was the first indication of sarcoidosis. The Board notes again, however, that his service records as well as his separation examination from service are entirely silent as to any diagnosis of sarcoidosis Dr. Bash has provided an opinion which attributed the Veteran's sarcoidosis to his military service. His opinion, as noted above, is based to a large extent on nonexistent x- rays, and medical opinion of Dr. Israel from 1972. In addition records from Queens General Hospital and the Long Island Jewish Medical Center where the Veteran allegedly was treated in the 1970s for sarcoidosis, either were destroyed or otherwise do not exist. Once again, Dr. Bash must have relied on the appellant's own account of what these records purportedly showed, rather than his own independent reading of the actual records themselves. In contrast, the April 2006 VA examiner, after examining the Veteran, and the December 2008 Veterans Health Administration expert after reviewing the claim folders, noted that the claims file contained no documentation of any diagnosis of sarcoidosis prior to 1982. Likewise the service and post service record contains no evidence of treatment for sarcoidosis. The examiner and the Veterans Health Administration medical expert both opined that it was unlikely that the Veteran's sarcoidosis was related to his military service to include exposure to herbicides. The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). Here the Board favors the VA examiner's opinion expressed in April 2006, as well as the VHA expert opinion expressed in December 2008 because they are based on an appraisal of the service medical records and all post service records which show that the Veteran did not have a chronic sarcoidosis disability during his military service, or within a year after service. The only other evidence in support of the claim are statements from the Veteran's current and ex-wife, and friends, and the Veteran's own statements and testimony to the effect that his claimed sarcoidosis was the result of herbicide exposure during service. However, as a layperson, he is not competent to provide a probative opinion on a medical matter, such as the etiology of the claimed disorder. See Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Facts are stubborn things; and whatever may be the Veteran's wishes, or his inclinations, they cannot alter the state of the facts and the evidence. Accordingly, the Board finds that, because the more probative facts and evidence of record is against a link between military service and sarcoidosis, service connection for sarcoidosis is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II- Increased ratings The Veteran and his representative contend that his left ankle disorder and PTSD are manifested by symptomatology that warrants the assignment of increased ratings. It is requested that the Veteran be afforded the benefit of the doubt. Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet.App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet.App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield , 21 Vet. App. 505 (2007). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that the rule from Francisco does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability as is the case in the initial increased rating claim for PTSD. Rather, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. a. What evaluation is warranted for a left ankle disorder? Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45. A February 1970 rating decision granted service connection for the left ankle disorder and assigned an initial 10 percent rating under Diagnostic Code 5271. A February 1971 rating decision assigned a noncompensable rating based on a VA examination revealing no gross deformity of the ankle and a full range of motion. The current claim was received in May 2000. Diagnostic Code 5010 rates arthritis by trauma. Traumatic arthritis is rated under Diagnostic Code 5003 as degenerative arthritis. See 38 C.F.R. § 4.71a, Diagnostic Code 5010. Diagnostic Code 5003 provides that degenerative arthritis established by X-ray is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the joint involved. Further, if the limitation of motion of the joint involved is noncompensable, a rating of 10 percent is applicable. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. With any form of arthritis, painful motion is an important factor. It is the intention of the rating schedule to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. A compensable evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5003, and 38 C.F.R. § 4.59 for painful motion is in order where arthritis is established by X-ray findings and no actual limitation of motion of the affected joint is demonstrated. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Where a compensable limitation of motion is demonstrated in the joint, the Lichtenfels rule is not applicable. For VA purposes, normal range of motion for the ankle is 0 to 20 degrees for dorsiflexion, and 0 to 45 degrees for plantar flexion. 38 C.F.R. § 4.71a, Plate II. Limitation of motion of the ankle is rated under Diagnostic Code 5271. 38 C.F.R. § 4.71a. It provides for a 20 percent rating for marked limitation of motion, and a 10 percent rating for moderate limitation of motion. Id. In the absence of evidence of ankylosis, a 20 percent is the maximum rating. 38 C.F.R. § 4.71a, Diagnostic Code 5270. In this regard, the probative evidence shows the veteran's right ankle demonstrates movement in each plane of motion. Hence, the Veteran's left ankle disorder is not manifested by ankylosis. Background At a June 2000 VA examination the Veteran reported a history of a left ankle fracture in service. He complained of pain particularly if the weather was cold or damp. He reported no restrictions in his activities during flare-ups. On examination there was mild swelling with no crepitus, laxity, or instability. Range of motion was plantar flexion to 45 degrees and dorsiflexion was to 25 degrees. There was no evidence of fatigue, incoordination, laxity, or weakened movement. X-rays were normal. The diagnosis was a left ankle strain with restrictive range of motion as shown. At a June 18, 2007 VA examination the Veteran reported a history of left ankle flare-ups in cold or damp weather. He took Tylenol for relief. He had no difficulty walking, used no assistive devices, or had ever undergone surgery on the left ankle. He had no difficulty with employment or other activities. On examination the left ankle looked entirely normal as did his x-rays. Range of motion was plantar flexion to 35 degrees and dorsiflexion was to 15 degrees without pain. There was no laxity demonstrated, no additional limp, fatigue, incoordination, lack of endurance, or weakened movement. In May 2008, the Veteran's representative submitted additional evidence with waiver of RO consideration including a November 2007 medical opinion by Dr. Bash. Dr. Bash stated that he reviewed the medical records and examined the Veteran. He noted that the Veteran walked with a slight limp and the left ankle rolled over due to weakness. His shoe wore unevenly on the left and he occasionally dragged the left foot. Dr. Bash found a tender lateral collateral ligament region, and decreased strength in dorsiflexion, 4/5, due to pain. He opined that the Veteran had weakness, pain, and an abnormal gait. A subsequent letter dated May 2008 submitted by Dr. Bash, noted that prior to the April 2008 Board hearing he reviewed the claims file and examined the Veteran. He found that the Veteran's ankle was unstable, weak, painful to palpation, and demonstrated crepitus in the tibial talar joint on motion. He further noted that the Veteran wore a brace. Analysis The Board finds that in the June 2000 VA examination the Veteran exhibited a full range of motion, with no evidence of fatigue, incoordination, laxity, or weakened movement. In addition, x-rays were normal. Therefore the Board finds that the Veteran's left ankle strain did not warrant a compensable rating under either Code 5010 or 5271 at that time. Subsequently, in the June 18, 2007 VA examination the Veteran exhibited plantar flexion limited to 35 degrees and dorsiflexion limited to 15 degrees without pain. Again the examiner noted no evidence of fatigue, incoordination, laxity, or weakened movement; and x-rays were normal. Still, in light of the decreased range of motion, the appellant's complaints of pain, and the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, the Board finds that the Veteran's left ankle strain warrants a compensable rating under Code 5271 from June 18, 2007. The Board finds, however, that any limitation of left ankle motion is not "marked." Although range of motion was decreased at the June 18, 2007 VA examination, his limitation did not rise to the level of "marked." He retained at least 75 percent of normal dorsiflexion, and at least 60 percent of normal plantar flexion. This is consistent with a 10 percent rating which reflects the presence of mild to moderate impairment. Thus, based on the evidence discussed above, entitlement to a compensable rating for a left ankle disability is not in order prior to June 18, 2007, but a 10 percent rating is in order from June 18, 2007. b. What evaluation is warranted for PTSD from April 20, 2006? Under 38 C.F.R. § 4.130, Diagnostic Code 9411, a 30 percent rating is warranted for occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent rating is warranted for post traumatic stress disorder where 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 in 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; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 46 (4th ed. 1994) (DSM-IV), states that a global assessment of functioning score of between 41 and 50 reflects the presence of "serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friend, unable to keep a job)" and/or "some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; . . .)." A global assessment of functioning score of between 51 and 60 indicates that the veteran has "moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers)." global assessment of functioning score scores ranging between 61 to 70 reflect "some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships." Background The Veteran's initial claim for PTSD was received in May 2000. A December 2000 rating decision denied service connection for PTSD. In making that determination, the RO noted that the Veteran had not been diagnosed with PTSD. Subsequently, a March 2007 rating decision granted service connection for PTSD and assigned a 30 percent rating effective April 20, 2006, the date of a VA examination which diagnosed PTSD. In June 2007 the Veteran filed a notice of disagreement with the effective date of the PTSD rating. He stated that he met all the requirements for a grant of service connection since November 1998. In November 2007 the Veteran submitted an annotated copy of the June 2007 notice of disagreement. In this copy he added a disagreement with the 30 percent evaluation stating that it should be 50 percent. At an April 20, 2006 VA examination the claims file and medical records were reviewed by the examiner who noted that the Veteran served in the Air Force in Vietnam in supply. The appellant reported numerous attacks from the enemy occurring at night, as well as bombings. He also reported stepping on a mortar trigger while on patrol. He stood there for 20 minutes while explosives people attempted to defuse it. He finally gave up and jumped off but nothing happened. Examination revealed the Veteran was friendly, informative, well dressed, and neatly groomed. His speech, psychomotor functions, orientation, memory, and cognitive functions were all normal. His mood was low and affect was sad. His level of anxiety was moderately high. There was no history of hallucinations or evidence of psychotic thinking. He denied suicidal or homicidal ideations. He did have chronic insomnia with sleep interference as well as combat related dreams. His insight and judgment were noted to be very good. The examiner opined that the Veteran had provided sufficient information to establish that he had experienced several episodes of intense combat related trauma. He also noted very prominent PTSD symptoms. The diagnosis was PTSD with depressive features, mild to moderate severity. A global assessment of functioning score of 46 was assigned. The Board notes that the Veteran has claimed that he had been seen for his Psychiatric condition by a Patricia L. Clarke. However he could produce no records other than an invoice listing four counseling sessions in August and September 2002 and reference to glucose, quantitative blood. There is no reference to the reason for the sessions. The medical evidence of file contains no records of treatment or diagnosis of PTSD prior to April 2006. Analysis For the period since April 20, 2006, the evidence preponderates against finding that PTSD caused occupational and social impairment with reduced reliability and productivity. In this regard, while a GAF of 46 was assigned by the VA examiner in April 2006, there is no evidence in the records or in the examiner's report that the Veteran's post traumatic stress disorder is manifested by reduced reliability and productivity due to a flattened affect. His speech is not circumstantial or stereotyped. He has not demonstrated a history of panic attacks more than once a week, and the Veteran does not show difficulty in understanding complex commands. There is no evidence of an impairment of short- and long-term memory, impaired judgment; impaired abstract thinking. Likewise there is no evidence of a disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. In short, the April 20, 2006 VA examination report revealed symptomatology which is not consistent with the assigned global assessment of functioning score. The examination did not find the Veteran to have serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friend, unable to keep a job)" and/or "some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; . . .). as indicated by a global assessment of functioning score of 46. There is no indication that he has moderate symptoms or moderate difficulty in social, occupational, or school functioning. His post traumatic stress disorder appears to have symptoms more reflective of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, but generally functioning pretty well, and has some meaningful interpersonal relationships. As noted by the examiner he was friendly, informative, well dressed, and neatly groomed. His speech was normal, as were psychomotor functions, orientation, memory, and cognitive functions. His insight and judgment were noted to be very good. Accordingly, since April 20, 2006, the Veteran's post traumatic stress disorder warrants no more than a 30 percent evaluation. In reaching this decision, the Board considered the doctrine of reasonable doubt, however, except to the extent that the appeal is granted in part, the preponderance of the evidence is against the appellant's claims, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). III. Entitlement to an earlier effective date prior to April 20, 2006, for the grant of service connection for PTSD. The effective date of an award of service connection based on a claim received more than one year after a veteran's discharge from service will be the later of the date of receipt of claim or the date entitlement arose. 38 U.S.C.A. § 5110; 38 C.F.R. § 3.400. Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a claimant, his duly authorized representative, a Member of Congress, or some person acting as best friend of a claimant who is not sui generis may be considered an informal claim. Such an informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155(a) (2008). The Veteran claims that the effective date for the award of service connection for PTSD should be in November 1998, because he allegedly began filing a claim for PTSD with a veterans' counselor at that time, although PTSD had not yet been diagnosed. The records reveal that the Veteran filed an informal claim for service connection for PTSD in a May 2000 letter to VA. In that letter he described several conditions in detail adding at the bottom of his third paragraph, "I suffer with PTSD also and should get help!" In a May 2000 letter, the RO requested medical and stressor evidence to support his claim. The Veteran did not respond to this request. Subsequently by rating action in December 2000 service connection for PTSD was denied as there was no confirmed diagnosis of PTSD or any treatment for a "nervous condition." At a personal hearing at the RO in February 2002, the Veteran acknowledged that he had not been examined for post traumatic stress disorder, nor was he on the post traumatic stress disorder registry. He was not receiving any treatment for the disorder, and had not been seen in service for post traumatic stress disorder or any other mental disorder. It had apparently been suggested to him by a VA counselor in October 1999 that he might have post traumatic stress disorder. However, it was not part of his initial claim, and he did not pursue it at that time. At a June 2003 Board hearing, he testified, that he began treatment, "A little over a year and a half ago," and explained to the clinician about post traumatic stress disorder but he had not been back to her. He was encouraged to see a local mental health care professional, and it was noted that there was a Vet Center in his area. The Veterans Law Judge asked him if he had sought treatment from any other source for post traumatic stress disorder and he noted that he had not. At a subsequent Board hearing in April 2008, the Veteran testified, that he had begun receiving treatment for post traumatic stress disorder from the VA Medical Center beginning this year. As previously noted, the Veteran was first diagnosed with post traumatic stress disorder during his April 20, 2006 VA examination. There is no evidence revealing that the veteran was diagnosed with post traumatic stress disorder prior to this VA examination. As the record contains no evidence of a diagnosis of post traumatic stress disorder earlier than the date of the VA examination, there is no factual or legal basis to assign an effective date earlier than April 20, 2006. This is the proper effective date for the grant of service connection. In reaching this decision the Board considered the Veteran's testimony concerning nightmares and post traumatic stress disorder symptomatology prior to the date post traumatic stress disorder was diagnosed. The law provides, however, that the date of entitlement to service connection will be the later of the date of receipt of claim or the date entitlement arose. Entitlement did not arise at any time prior to April 20, 2006. The Board considered the benefit- of-the-doubt doctrine with respect to this claim but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. ORDER Entitlement to service connection for sarcoidosis, including as due to Agent Orange exposure is denied. Entitlement to a compensable rating for a left ankle sprain prior to June 18, 2007, is denied. Entitlement to a rating of 10 percent for a left ankle sprain from June 18, 2007, is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a rating in excess of 30 percent for post traumatic stress disorder from April 20, 2006, is denied. Entitlement to an effective date earlier than April 20, 2006 for the grant of service connection for PTSD is denied. REMAND The Veteran is entitled to a new VA examination where there is evidence that his disorder has worsened since the last examination. See Snuffer v. Gober, 10 Vet. App. 400 (1997); VAOPGCPREC 11-95 (1995). A letter submitted by Dr. Bash dated May 2008, noted that on April 30, 2008, prior to the Board hearing, he reviewed the claims file and examined the Veteran. He found that the appellant's left ankle was unstable, weak, painful to palpation, and demonstrated crepitus in the tibial talar joint on motion. He further noted that the Veteran wore a brace. This evidence suggests a worsening of the Veteran's left ankle disorder since he was last examined by VA in June 18, 2007. Hence, in the interest of due process and fairness, the Veteran should be afforded a new VA examination to determine the current severity and all manifestations of his service-connected left ankle disorder. Accordingly, further development is in order. Therefore, this case is REMANDED for the following action: 1. The AMC/RO should obtain the names and addresses of all medical care providers who have treated the Veteran for his left ankle disorder since June 18, 2007. After securing the necessary release, the AMC/RO should obtain any records not already associated with the claims file, including ongoing VA treatment records. Duplicative records should not be added to the file. 2. After the above is complete, and regardless of whether any additional records are obtained, the AMC/RO shall arrange a VA examination by an orthopedist to determine the current severity of the Veteran's service- connected left ankle disorder. The claims files must be made available to the examiner for review as part of the examination. All indicated diagnostic or clinical tests should be conducted. An explanation of any and all opinions rendered must also be furnished. Tests of joint motion against varying resistance must be performed, and the extent of any incoordination, weakened movement and excess fatigability on use must be described. To the extent possible all functional impairment due to incoordination, weakened movement and excess fatigability should be assessed in terms of additional degrees of limitation of motion. If this is not feasible, the examiner should so state. The examiner must opine whether there would be additional limits on functional ability to use the left ankle on repeated use or during any reported flare- ups, and, if feasible, express this in terms of additional degrees of limitation of motion on repeated use or during flare- ups. If this is not feasible, the examiner should so state, and explain why. 3. The Veteran is to be notified that it is his responsibility to report for any VA examination, to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2008). In the event that the Veteran does not report for any ordered examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address prior to the date of the examination. It should also be indicated whether any notice that was sent was returned as undeliverable. 4. After the development requested has been completed, the AMC/RO should review the examination report to ensure that it is in complete compliance with the directives of this REMAND. If any report is deficient in any manner, the AMC/RO must implement corrective procedures at once. 5. Then readjudicate the Veteran's claim in light of the additional evidence obtained. If the claim is not granted to his satisfaction, send him and his representative a Supplemental Statement of the Case and give them an opportunity to respond to it before returning the file to the Board for further appellate consideration. The case should then be returned to the Board for further appellate consideration. The Board intimates no opinion as to the ultimate outcome of this case. The Veteran need take no action unless otherwise notified. VA will notify him if further action is required on his part. He has the right to submit additional evidence and argument concerning the claims the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2008). ____________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs