Citation Nr: 1008564 Decision Date: 03/08/10 Archive Date: 03/17/10 DOCKET NO. 08-35 383 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an increased evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to an increased evaluation in excess of 10 percent for degenerative changes of the right hip. 3. Entitlement to an increased evaluation in excess of 10 percent for degenerative changes of the left hip. 4. Entitlement to an increased evaluation in excess of 10 percent for chondromalacia of the right knee with degenerative changes. 5. Entitlement to an increased evaluation in excess of 10 percent for chondromalacia of the left knee with degenerative changes. 6. Entitlement to service connection for a back disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD David T. Cherry, Counsel INTRODUCTION The Veteran served on active duty from May 1984 to April 1988, from November 1990 to May 1991, from November 2001 to September 2002, and from December 2002 to January 2004. This case comes before the Board of Veterans' Appeals (Board) on appeal from ratings decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In January 2010, the Veteran testified at a Travel Board hearing before the undersigned Acting Veterans Law Judge. A transcript of the hearing is of record. The issue of entitlement to service connection for a back disability 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. From October 25, 2006 to August 17, 2008, the Veteran's PTSD has been manifested by occupational and social impairment with reduced reliability and productivity. 2. From August 18, 2008 to September 26, 2008, the Veteran was hospitalized for his PTSD. 3. Since September 27, 2008, the Veteran's PTSD has been manifested by occupational and social impairment with reduced reliability and productivity. 4. Since January 28, 2007, the Veteran's degenerative changes of the right hip have not been manifested by a limitation of thigh flexion that more nearly approximates to 30 degrees or by limitation of abduction with motion lost beyond 10 degrees. 5. Since January 28, 2007, the Veteran's degenerative changes of the left hip have not been manifested by a limitation of thigh flexion that more nearly approximates to 30 degrees or limitation of abduction with motion lost beyond 10 degrees. 6. Since October 25, 2006, the Veteran's chondromalacia of the right knee with degenerative changes has not been manifested by a limitation of knee flexion that more nearly approximates to 30 degrees, or by limitation of extension to 15 degrees, or a combination of limitation of flexion to 45 degrees with limitation of extension to 10 degrees. 7. Since October 25, 2006, the Veteran's degenerative changes of the left knee with degenerative changes has not been manifested by a limitation of knee flexion that more nearly approximates to 30 degrees, or by limitation of extension to 15 degrees, or a combination of limitation of flexion to 45 degrees with limitation of extension to 10 degrees. CONCLUSIONS OF LAW 1. From October 25, 2006 to August 17, 2008, the criteria for a 50 percent rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.119, Diagnostic Code 9411 (2009). 2. From August 18, 2008 to September 26, 2008, the criteria for a temporary 100 percent disability pursuant to 38 C.F.R. § 4.29 have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.29 (2009). 3. Since September 27, 2008, the criteria for a 50 percent rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.119, Diagnostic Code 9411 (2009). 4. Since January 28, 2007, the Veteran's degenerative changes of the right hip have not met the criteria for an evaluation greater than 10 percent. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 5110 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5252 (2009). 5. Since January 28, 2007, the Veteran's degenerative changes of the left hip have not met the criteria for an evaluation greater than 10 percent. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 5110 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5252 (2009). 6. Since October 25, 2006, the Veteran's chondromalacia of the right knee with degenerative changes has not met the criteria for an evaluation greater than 10 percent. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 5110 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5014, 5260, 5261 (2009). 7. Since October 25, 2006, the Veteran's chondromalacia of the left knee with degenerative changes has not met the criteria for an evaluation greater than 10 percent. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 5110 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5014, 5260, 5261 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2009). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. The Board finds that in this case the requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. VA notified the Veteran in correspondence in November 2007, and March, May, June, July, and November 2008, 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 him, and notice of what part VA will attempt to obtain. He was provided notice of the specific rating criteria used to evaluate the PTSD and the hip and knee disabilities in the May, July, and November 2008 correspondence. The claim was readjudicated in October 2008 statements of the case. VA has a duty to assist the veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that in this case VA has fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. The RO obtained VA treatment records, and the Veteran underwent VA examinations in December 2007, March 2008, and December 2008. In an August 2009 statement, the Veteran's representative notes that the report of the December 2007 VA PTSD examination reflects that the claims file was not available for review. The issue was increased rating for PTSD. In increased rating cases, where the examination report includes the Veteran's accurate history, including history of symptoms, and current complaints, as well as current clinical examination, the presence of the claims file is of less importance, and the absence of a claims file does not by itself render the VA examination inadequate for rating purposes. See VAOPGCPREC 20-95. The representative also adds that the examiner wrote that "it was not possible to describe changes in psychosocial functioning and quality of life or to provide any quantitative value since the last C & P exam because the c-file was not available for review." October 2009 statement of the representative, page 2; see also report of the December 2007 VA PTSD examination, page 5. The report of the December 2007 VA PTSD examination is five pages long, includes thorough history and mental status examination, and describes in great detail the claimant's social and occupational impairment. The Board finds that, even though the claims file was not available for review, the December 2007 VA examination is adequate for rating purposes on the issue of increased rating for PTSD. Barr v. Nicholson, 21 Vet. App. 303 (2007). Furthermore, the Veteran was provided the opportunity to meaningfully participate in the adjudication of his claim and did in fact participate. See Washington v. Nicholson, 21 Vet. App. 191 (2007). Hence, the duties to notify and assist the Veteran have been met with regard to the issues addressed on the merits in this decision, and there is no error or issue that precludes the Board from addressing the merits of this appeal. Increased Rating for PTSD Under the criteria for rating mental disorders, a 30 percent rating is assigned for occupational and social impairment with 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). A 50 percent rating is assigned for 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; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; 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); inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance or minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Global Assessment of Functioning (GAF) Scale is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994). The GAF Scale score is based on all of the veteran's psychiatric impairments. A GAF Scale score of 21 to 30 indicates behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation), or inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). A GAF Scale score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or an 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 GAF Scale score of 41 to 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF Scale score of 51 to 60 represents 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 coworkers). A 61 to 70 GAF Scale score indicates 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. In this decision, the Board considered the rating criteria in the General Rating Formula for Mental Disorders not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has considered the symptoms indicated in the rating criteria as examples or symptoms "like or similar to" the veteran's PTSD symptoms in determining the appropriate schedular rating assignment, and, although noting which criteria have not been met, has not required the presence of a specified quantity of symptoms in the Rating Schedule to warrant the assigned rating for PTSD. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board is initially presented with a record on appeal that demonstrates that, in addition to PTSD, medical professionals have diagnosed alcohol abuse in remission and major depressive disorder. The Board is precluded from differentiating between symptomatology attributed to a non- service-connected disability and a service-connected disability in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Given that the alcohol abuse is in remission and that the December 2007 VA examiner noted that a depressed mood is one of the Veteran's symptoms, the Board will treat all reported psychiatric symptomatology as being attributable to the appellant's service-connected PTSD. Temporary Total Rating for Hospitalization for PTSD Under the applicable criteria, a total disability rating (100 percent) will be assigned without regard to other provisions of the rating schedule when it is established that a service- connected disability has required VA hospital treatment for a period in excess of 21 days. 38 C.F.R. § 4.29. The Veteran was hospitalized at a VA medical center from August 18, 2008, to September 26, 2008, for PTSD. This period of hospitalization was over 21 days. Therefore, from August 18, 2008, to September 26, 2008, the criteria for a temporary 100 percent disability pursuant to 38 C.F.R. § 4.29 have been met. Schedular Rating for PTSD Turning to the periods from October 25, 2006 to August 17, 2008, and since September 27, 2008, the evidence of record, including a report of the December 2007 VA examination and VA treatment records, shows that the Veteran's PTSD has been manifested by occupational and social impairment with reduced reliability and productivity, which more nearly approximates the criteria for a higher disability rating of 50 percent under Diagnostic Code 9411. 38 C.F.R. § 4.130. The report of the December 2007 VA PTSD examination shows that the appellant had a depressed mood. VA mental status evaluations from July to September 2008 reflect that his insight and judgment were only fair. The examiner noted that the claimant had difficulties in his work situation and that his family relationships were hampered by his diminished interest in activities and feelings of detachment. The examiner's comments are evidence of difficulty in establishing and maintaining effective work and social relationships. The Board notes that the Veteran does not have several of the examples listed in the criteria for a 50 percent evaluation. While the Board notes which criteria have not been met, the Board has not required the presence of a specified quantity of symptoms in the Rating Schedule to warrant a higher rating of 70 percent for PTSD. See Mauerhan, 16 Vet. App. 436 (the criteria set forth in the rating formula for mental disorders do not constitute an exhaustive list of symptoms, but rather are examples of the type and degree of the symptoms, or their effects, that would justify a particular rating). Moreover, the GAF scores for the most part are 50, to include the one assigned by the VA examiner. Such a score reflects an occupational and social impairment with reduced reliability and productivity. As to the criteria for a 70 percent disability rating, there is no evidence of obsessive rituals which interfere with routine activities; speech being intermittently illogical, obscure, or irrelevant; spatial disorientation; or neglect of personal appearance and hygiene. As for suicidal ideation, the Veteran was hospitalized briefly during June and July 2008 for suicidal ideation, and he testified that he was later hospitalized again for suicidal thoughts. However, the report of the December 2007 VA examination and the VA treatment records subsequent to the VA hospitalization from June to July 2008 reflect that the Veteran repeatedly denied any suicidal ideation. Therefore, the evidence does not show a constant manifestation of suicidal ideation. While the Veteran has symptoms of panic and depression, there is no evidence that he has near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively. There is no evidence of impaired impulse control. An August 2008 VA treatment record shows that the claimant, who works in a prison, became violent with an inmate and had been attending a domestic- violence-related group. That record, however, reveals that the Veteran merely had arguments with his spouse and that there was no indication that he had assaulted her. A September 2008 mental status evaluation during the VA hospitalization reflects that his impulse control was appropriate. A March 2009 VA treatment record reflects that the Veteran recently assaulted a prisoner, but that he was not disciplined for his actions. Also, the appellant testified at the January 2010 that he had not been physically violent towards anybody in the past few years. As for difficulty adapting to stressful circumstances (including work or a worklike setting), the Veteran asserts in his November 2008 VA Form 9 that he has this symptom. However, the claimant is able to work full time in a prison, albeit in a control room. Moreover, the GAF scores for the most part have been 50, which is consistent with the difficulty adapting to work or work-like setting contemplated by a 50 percent rating, and does not reflect an employment impairment contemplated in a 70 percent disability rating for PTSD. With regard to an inability to establish and maintain effective relationships, while the December 2007 VA examiner noted that the appellant's family relationships seemed hampered by his diminished interest in activities and feelings of detachment, he is currently able to live with his spouse. In other words, the evidence shows that the veteran's PTSD is not manifested by an inability to establish and maintain effective relationships. Moreover, the GAF scores for the most part have been 50, so do not reflect a social impairment contemplated in a 70 percent disability rating for PTSD. 38 C.F.R. § 4.130. While the Board's inquiry is not limited to the criteria found in the VA rating schedule, the Board has not identified any other aspects of the Veteran's service-connected PTSD that would support a finding that the criteria for a 70 percent rating have been more nearly approximated for any period of claim. In addition, the Veteran and his representative have not pointed to any such pathology. As for the criteria for a 100 percent disability rating, there is no objective evidence for any period of increased rating claim of gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, the Veteran being in persistent danger of hurting himself or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), or disorientation to time or place. As noted above, the Veteran's suicidal ideation is not constant and there is no evidence of an actual suicide attempt. The Board has not identified any other aspects of the Veteran's service- connected PTSD that would enable it to conclude that the criteria for a 100 percent rating have been approximated, and neither the Veteran nor his representative has pointed to any such pathology. Extraschedular consideration According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2009). Under Floyd v. Brown, 9 Vet. App. 88, 95 (1996), the Board cannot make a determination as to an extraschedular evaluation in the first instance. See also VAOPGCPREC 6-96. In this case, the RO considered the Veteran's claim for referral under 38 C.F.R. § 3.321(b)(1) in an October 2008 statement of the case. Accordingly, the Board will address the possibility of the assignment of an extraschedular rating for PTSD. Under Thun v. Peake, 22 Vet App 111 (2008), there is a three- step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service- connected PTSD is inadequate. A comparison between the levels of severity and symptomatology of the Veteran's PTSD with the established criteria found in the rating schedule for mental disorders shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. As discussed above, the rating criteria consider the levels of impairment based on occupational and social impairment. The Board further observes that, even if the available schedular evaluations for the disabilities are inadequate (which they manifestly are not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the appellant has required frequent hospitalizations for his PTSD. While the claimant has been hospitalized up to three times for PTSD, he is entitled to a temporary 100 percent disability pursuant to 38 C.F.R. § 4.29 from August 18, 2008 to September 26, 2008 for one long period of hospitalization. Additionally, there is not shown for any period to be evidence of marked interference with employment due to his service-connected PTSD such as to trigger consideration of the extraschedular provisions. The impact of the service- connected disability on the Veteran's employment has been discussed above. There is no indication that his service- connected PTSD markedly interferes with employment, beyond that contemplated in the now-assigned 50 percent disability rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Moreover, there is no evidence in the medical records, described in some detail above, of an exceptional or unusual clinical picture. The Board therefore has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. In summary, for reasons and bases expressed above, it is the Board's decision that a 50 percent disability rating is warranted for the Veteran's service-connected PTSD from October 25, 2006 to August 17, 2008, and from September 27, 2008 to the present, and that a temporary (100 percent) disability rating pursuant to 38 C.F.R. § 4.29 is warranted for the period from August 18, 2008 to September 26, 2008. The appeal is allowed to that extent. Increased Rating for Right and Left Hip Disabilities For the sake of judicial economy, the Board will discuss these two issues together. Under 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5010, traumatic arthritis is rated as degenerative arthritis, which in turn is rated based upon the nature and extent of any limitation of motion. In general, 38 C.F.R. § 4.71, Plate II (2009) provides a standardized description of hip movement, to include showing that normal hip flexion is from 0 to 125 degrees, and normal hip abduction is from 0 to 45 degrees. Under Diagnostic Code 5252, a 10 percent disability rating is assigned for flexion of the thigh limited to 45 degrees. For the next higher 20 percent disability rating there must be limitation of flexion to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5252. 38 C.F.R. § 4.71a. Under Diagnostic Code 5253, where there is a limitation of thigh abduction with motion lost beyond 10 degrees, a 20 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5253. 38 C.F.R. § 4.71a. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to all these elements. 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 it 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 seriously disabled. 38 C.F.R. §§ 4.40, 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In order to receive a rating higher than 10 percent for either hip disorder at any time since January 28, 2007, the evidence must show that the disorder is manifested by a limitation of thigh flexion to 30 degrees (Diagnostic Code 5252), or a limitation of abduction with motion lost beyond 10 degrees (Diagnostic Code 5253). 38 C.F.R. § 4.71a. The March and December 2008 VA examination reports show that thigh flexion in both thighs is to at least 60 degrees and that thigh abduction in both thighs is to at least 20 degrees. At the March 2008 VA examination, active and passive hip flexion was to 60 degrees bilaterally and active and passive hip abduction was to 30 degrees bilaterally. At the December 2008 VA examination, active hip flexion was to 125 degrees bilaterally and active hip abduction was to 45 degrees bilaterally. The Board has considered the holding in DeLuca 8 Vet. App. 202, but finds that schedular evaluations in excess of 10 percent are not warranted. The evaluation of a service- connected disability involving a joint rated on limitation of motion requires consideration of functional loss due to pain under 38 C.F.R. § 4.40, and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. DeLuca at 204-07. The March 2008 VA examiner noted that while there was pain throughout the entire arc of flexion and abduction motion bilaterally, there was no increase in pain or decrease in range of motion with repetitive range of motion testing bilaterally. The December 2008 VA examiner indicated that there was no significant pain on range of motion testing. That examiner added that it was conceivable that pain could further limit function, particularly after being on his feet all day, but that it was not feasible to attempt to express this possibility in terms of any additional limitation of motion because this possibility could not be determined with any degree of medical certainty. Extraschedular consideration The RO considered the Veteran's claims under 38 C.F.R. § 3.321(b)(1) in the October 2008 statement of the case. Accordingly, the Board will address the possibility of the assignment of an extraschedular rating for the hip disorders. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service- connected hip disorders is inadequate. A comparison between the level of severity and symptomatology of the appellant's hip disorders with the established criteria found in the rating schedule for hip disorders shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. As discussed above, the rating criteria consider the levels of impairment based on limitation of motion. The Board further observes that, even if the available schedular evaluations for the disabilities are inadequate (which they manifestly are not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the claimant has required frequent hospitalizations for his hip disorders. Indeed, it does not appear from the record that he has been hospitalized at all for those disabilities. Additionally, there is not shown to be evidence of marked interference with employment due to the hip disorders. The Veteran currently works as full-time as a corrections officer, and there is nothing in the record that suggests that the hip disorders markedly impact his ability to perform a job. There is no indication that he missed any work because of his hip disorders. Moreover, there is no evidence in the medical records, described in some detail above, of an exceptional or unusual clinical picture. In short, there is nothing in the record to indicate that the service-connected hip disabilities cause impairment with employment over and above that which is contemplated in the assigned schedular ratings. See Van Hoose, 4 Vet. App. at 363. The Board therefore has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claims for increased rating for hip disabilities, the doctrine is not for application, and the claims for increased rating for disabilities of the hip must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Increased Ratings for Chondromalacia of the Left and Right Knees For the sake of judicial economy, the Board will discuss these two issues together. The relevant rating criteria provide that osteomalacia shall be rated based on limitation of motion as degenerative arthritis. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5014. Limitation of leg extension is rated 0 percent when limited to 5 degrees, 10 percent when limited to 10 degrees, 20 percent when limited to 15 degrees, 30 percent when limited to 20 degrees, 40 percent when limited to 30 degrees, and 50 percent when limited to 45 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. Limitation of flexion of a leg to 60 degrees is rated as noncompensable (zero percent disabling). Flexion limited to 45 degrees warrants a 10 percent evaluation, and flexion limited to 30 degrees warrants a 20 percent rating. The highest available rating, 30 percent, is warranted when flexion is limited to 15 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Codes 5260 and 5261, a veteran may receive separate ratings for limitations in both flexion and extension, if none of the symptomatology on which each rating is based is duplicative or overlapping. See VAOPGCPREC 9- 2004. Normal extension and flexion of the knee is from 0 degrees to 140 degrees. 38 C.F.R. § 4.71, Plate II (2009). The Veteran is currently assigned 10 percent disability ratings for the knee disabilities of chondromalacia based on limitation of motion, specifically limitation of extension. The Veteran alleges that his knees give out on him. After a review of the evidence, the Board finds that, since October 25, 2006, the Veteran's chondromalacia of the right knee and left knee, both with degenerative changes, have not been manifested by a limitation of knee flexion that more nearly approximates to 30 degrees, as required for a 20 percent rating under Diagnostic Code 5260; or by limitation of extension to 15 degrees, as required for a 20 percent rating under Diagnostic Code 5261; or a combination of limitation of flexion to 45 degrees (as required for a 10 percent rating under Diagnostic Code 5260) with limitation of extension to 10 degrees (as required for a 10 percent rating under Diagnostic Code 5260), so as to warrant separate compensable ratings for flexion and extension. 38 C.F.R. § 4.71a. As to flexion, to warrant a compensable rating, flexion must be limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The December 2007 and December 2008 VA examination reports as well as VA treatment records show that knee flexion in both knees is to at least 90 degrees. A November 2007 VA treatment record shows full range of motion in the left knee. At the December 2007 VA examination, knee flexion was to 140 degrees bilaterally. A February 2008 VA treatment record reflects full range of motion in the right knee. At the December 2008 VA examination, active right knee flexion was to 90 degrees and active left knee flexion was to 110 degrees. Thus, the Veteran does not even have flexion limited to 60 degrees, the level at which only a noncompensable (0 percent) evaluation is warranted under Diagnostic Code 5260. 38 C.F.R. § 4.71a. Additionally, the weight of the evidence does not show extension that more nearly approximates limitation to 15 degrees, which would allow for the assignment of a 20 percent disability rating under Diagnostic Code 5261. 38 C.F.R. § 4.71a. The December 2007 and December 2008 VA examination reports as well as VA treatment records show that knee extension in both knees is to at least 10 degrees. A November 2007 VA treatment record shows full range of motion in the left knee. At the December 2007 VA examination, knee extension was to zero degrees bilaterally. A February 2008 VA treatment record reflects full range of motion in the right knee. At the December 2008 VA examination, active knee extension was to 10 degrees bilaterally. While at the Board personal hearing, the Veteran and his representative asserted that extension was limited to 20 degrees, this was a generalized lay estimation of limitation of motion. The Board places greater weight on the more specifically and objectively measured limitations of motion of the knees, which does not indicate limitation of extension to warrant a higher rating, than on the Veteran's more general assertions and testimony as to degrees of limitation of motion. The Board has considered the holding in DeLuca but finds that schedular evaluations in excess of 10 percent are not warranted. Both the March and December 2008 VA examiners noted that while there was pain in the end points of flexion bilaterally, range of motion did not change with repetition. Both examiners stated that it was conceivable that pain could further limit function, particularly after being on his feet all day, but that it was not feasible to attempt to express this possibility in terms of any additional limitation of motion because this possibility could not be determined with any degree of medical certainty. The Board has also considered whether a separate rating under Diagnostic Code 5257 is warranted, but concludes that it is not. Under Diagnostic Code 5257, a 10 percent disability rating contemplates slight recurrent subluxation or lateral instability, and a 20 percent evaluation is assigned for moderate recurrent subluxation or lateral instability. A 30 percent evaluation is assigned for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2009). While a February 2008 VA treatment record notes that a January 2005 magnetic resonating imaging (MRI) scan of the right knee revealed a partial-thickness tear of the medial aspect of the patellar tendon at the patella attachment, a review of the reports of the December 2007 and December 2008 VA examinations as well as the VA treatment records show no recurrent subluxation or lateral laxity in either knee as to warrant a separate rating under Diagnostic Code 5257. The Veteran was stable to varus/valgus stress, and Lachman's, McMurray's and anterior and posterior drawer tests were negative. Based on this evidence, the Board finds that the specific histories presented during treatment, as well as the specific and objective medical evidence, outweighs the Veteran's general statements regarding the knees giving out on him. Extraschedular consideration The RO considered referral of the Veteran's claims under 38 C.F.R. § 3.321(b)(1) in the October 2008 statement of the case. Accordingly, the Board will address the possibility of the assignment of an extraschedular rating for the knee disabilities. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service- connected knee disorders is inadequate. A comparison between the level of severity and symptomatology of the appellant's knee disorders with the established criteria found in the rating schedule for knee disorders shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. As discussed above, the rating criteria consider the levels of impairment based on limitation of motion. The Board further observes that, even if the available schedular evaluations for the disabilities are inadequate (which they manifestly are not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the claimant has required frequent hospitalizations for his knee disorders. Indeed, it does not appear from the record that he has been hospitalized at all for those disabilities. Additionally, there is not shown to be evidence of marked interference with employment due to the knee disorders. The Veteran currently works as full-time as a corrections officer, and there is nothing in the record that suggests that the knee disorders markedly impact his ability to perform a job. There is no indication that he missed any work because of his knee disorders. Moreover, there is no evidence in the medical records, described in some detail above, of an exceptional or unusual clinical picture. In short, there is nothing in the record to indicate that the service-connected knee disabilities cause impairment with employment over and above that which is contemplated in the assigned schedular ratings. See Van Hoose, 4 Vet. App. at 363. The Board therefore has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claims for increased rating for knee disabilities, the doctrine is not for application, and the claims for increased rating for disabilities of the left and right knees must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. ORDER A 50 percent evaluation, but not higher, from October 25, 2006 to August 17, 2008, and from September 27, 2008 to the present, for PTSD, is granted. A temporary total rating pursuant to 38 C.F.R. § 4.29, based on hospitalization from August 18, 2008 to September 26, 2008, is granted. An evaluation in excess of 10 percent for degenerative changes of the right hip is denied. An evaluation in excess of 10 percent for degenerative changes of the left hip is denied. An evaluation in excess of 10 percent for chondromalacia of the right knee with degenerative changes is denied. An evaluation in excess of 10 percent for chondromalacia of the left knee with degenerative changes is denied. REMAND The Veteran contends that he currently has a back disability that is related to his last period of active service (December 2002 to January 2004) which included about 13 months in Iraq. He contends that carrying a backpack and a 60 caliber machine gun caused back problems during this period of service in 2003, and that he complained of back problems during service and when he was asked to give a history during service, and about six months after service when he was treated by his primary care physician. At the Board personal hearing in January 2010, the representative clarified that, although the Veteran had claimed the back disorder as a presumptive disorder due to undiagnosed illness, because there was a diagnosis of back disability, the Veteran was really only contending direct service incurrence. In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the Court discussed the steps to be taken in determining whether a VA examination is necessary prior to final adjudication of a claim. In disability compensation claims, the Secretary must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. 38 U.S.C.A. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). The Court in McLendon observed that the third prong, which requires that the evidence of record "indicates" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. In this case, a January 2009 VA computed tomography (CT) scan of the lumbar spine shows an impression of degenerative changes involving the right sacroiliac joint. This is some competent evidence of recurrent symptoms of a disability. A December 2003 report of medical assessment during active service shows a finding of low back pain. This reflects some evidence of an event, injury, or disease in service. The Veteran has asserted that his current back disability began in service. an indication that the disability or persistent or recurrent symptoms of a disability This constitutes some competent evidence that the back disability may be associated with service. The Board further finds that there is insufficient competent medical evidence, namely a medical nexus opinion, to make a decision on this issue. For these reasons, the Board finds that a VA medical examination is necessary for the adjudication of the claim for service connection for a back disability. Accordingly, the issue of service connection for a back disability is REMANDED for the following action: 1. The Veteran should be afforded a VA orthopedic examination. The relevant evidence in the claims folder should be made available to the examiner to review. The examiner should offer an opinion as to whether it is at least as likely as not (at least a 50 percent probability) that the Veteran has a current back disability which had its onset in service. The VA examiner should comment on the finding of low back pain noted on the December 2003 report of medical assessment. A complete rationale for any opinion expressed should be provided. 2. Thereafter, the RO should readjudicate the claim of entitlement to service connection for a back disability. If the benefit is not granted, the Veteran and his representative must be furnished with a supplemental statement of the case and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination(s), as failure to do so may result in denial of the claim(s). See 38 C.F.R. § 3.655 (2009). 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. 2009). ______________________________________________ J. Parker Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs