Citation Nr: 1124065 Decision Date: 06/24/11 Archive Date: 06/29/11 DOCKET NO. 07-23 856 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to a rating in excess of 20 percent for degenerative joint disease of the right ankle. 2. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the right hip. 3. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the right knee. 4. Entitlement to a rating in excess of 10 percent for plantar fasciitis of the right foot. 5. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) for the period prior to June 4, 2009, and to a rating in excess of 50 percent beginning on that date. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD E. B. Joyner, Counsel INTRODUCTION The Veteran served on active duty from March 1969 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in January 2007 and January 2010, by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The January 2007 rating decision, in part, granted service connection for degenerative joint disease of the right hip and assigned a 10 percent rating, granted service connection for degenerative joint disease of the right knee and assigned a 10 percent rating; granted service connection for degenerative joint disease of the right ankle and assigned a 10 percent rating, granted service connection for plantar fasciitis of the right foot and assigned a 10 percent rating, and granted service connection for PTSD and assigned a noncompensable rating. The Veteran appealed the rating assigned for PTSD and in an October 2008 rating decision, the RO increased the rating to 30 percent for the entire period of the claim. Then, in an August 2009 rating decision, the RO increased the rating from 30 percent to 50 percent, effective June 4, 2009. In October 2009 the Veteran filed claims for entitlement to increased ratings for his degenerative joint disease of the right ankle, degenerative joint disease of the right hip, degenerative joint disease of the right knee, and his plantar fasciitis of the right foot. The January 2010 rating decision on appeal increased the rating for degenerative joint disease of the right ankle to 20 percent, effective the date of the claim for an increased rating. The remaining increased rating claims were denied. In March 2011 the Veteran testified before the undersigned Acting Veterans Law Judge at a Travel Board hearing. A transcript of that hearing is of record. The issues of entitlement to increased ratings for degenerative joint disease of the right ankle, degenerative joint disease of the right hip, degenerative joint disease of the right knee, and plantar fasciitis of the right foot are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. For the period prior to June 4, 2009, the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity, and symptoms summarized by Global Assessment of Functioning (GAF) scores ranging from 80 in 2006 to 60 in early 2008, decreasing to 52 later in 2008; medical opinion disagreeing with the assignment of the GAF score of 80 in 2006 is also of record. 2. For the period beginning on June 4, 2009, the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. CONCLUSIONS OF LAW 1. The criteria for a rating of 50 percent for PTSD have been met for the period prior to June 4, 2009. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 4.126, 4.130, Diagnostic Code 9411 (2010). 2. The criteria for a rating of 70 percent for PTSD have been met for the period beginning on June 4, 2009. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 4.126, 4.130, Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Proper notice under the Veterans Claims Assistance Act of 2000 (VCAA), must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); C.F.R. § 3.159(b)(1). Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Pelegrini, the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice, as required by 38 U.S.C. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. The Court has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must inform a claimant that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. The Board notes that in a September 2006 letter, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate his claim, as well as what information and evidence must be submitted by the Veteran and the types of evidence that will be obtained by VA. Additionally, the notice letter informed the Veteran as to disability ratings and effective dates. However, the Veteran is challenging the initial disability rating assigned following the grant of service connection for PTSD. Service connection was awarded in a January 2007 rating decision. In Dingess v. Nicholson, 19 Vet. App. 473, 490-491 (2006), the Court held that in cases in which service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, VA treatment records and VA examination reports, and private medical evidence. Also of record and considered in connection with the appeal are various written statements submitted by the Veteran and his representative. As discussed above, the Veteran was notified and aware of the evidence needed to substantiate his claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process, identifying pertinent medical evidence and submitting evidence. Thus, he has been provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notice is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Laws and Regulations Pertaining to Initial Disability Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, 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. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. If there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded). Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Because the present appeal arises from an initial rating decision, which established service connection and assigned the initial disability rating, it is not the present level of disability which is of primary importance; the entire period is to be considered to ensure that consideration is given to the possibility of separate ratings for separate periods of time based on the facts found. See Fenderson, 12 Vet. App. 119 (1999). Evaluation of a disability includes consideration of the Veteran's ability to engage in ordinary activities, including employment, and the effect of symptoms on functional abilities. 38 C.F.R. § 4.10. Analysis The Board has reviewed all the evidence in the appellant's claims file. 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 appellant 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 claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). PTSD is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411, which provides that a 30 percent evaluation is warranted 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted 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 and maintaining effective work and social relationships. A 70 percent rating is warranted 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted where there is evidence of 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; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. One factor to be considered is the GAF score which is a scale reflecting the "psychological, social and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM IV), page 32]. A GAF Score of 11 to 20 indicates that there is some danger of hurting oneself or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement), or an occasional failure to maintain minimal personal hygiene, or gross impairment in communication. A GAF score of 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). A GAF Score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech at times illogical, obscure, or irrelevant), or where there is 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 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., few friends, unable to keep a job). A GAF of 51 to 60 indicates moderate symptoms (e.g., flattened 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). A GAF of 61 to 70 indicates some mild symptomatology (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or social functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. While the Rating Schedule does indicate that the rating agency must be familiar with the DSM IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Accordingly, GAF scores do not automatically equate to any particular percentage in the Rating Schedule. Rather, they are but one factor to be considered in conjunction with all the other evidence of record. The Veteran's PTSD is rated as 30 percent disabling prior to June 4, 2009, and as 50 percent disabling beginning on that date. The Veteran claims that he is entitled to higher ratings for his PTSD for both time periods. The Veteran, who sustained shell fragment wounds in service, first sought service connection for a psychiatric disorder in 2006. At that time, VA examination revealed that the Veteran was employed full time, and had a good relationship with supervisors and fellow employees. However, he reported nightmares once weekly, intrusive thoughts, some sleep disturbances, and other symptoms. He did not require treatment or medication for a psychiatric disorder. A GAF score of 80 was assigned. The report of this examination is unfavorable to an evaluation in excess of 30 percent. VA examination was next conducted in March 2008. The report indicates that the Veteran's orientation was within normal limits, and his appearance, hygiene, and behavior were appropriate. His affect and mood were abnormal. His mood was depressed. There was impaired impulse control, and there was also unprovoked irritability. It was noted that the Veteran reported feeling overwhelmed, helpless, and hopeless. His communication was grossly impaired. His concentration was poor. He had panic attacks, but less than once per week. The attacks made the Veteran feel aggravated, agitated, easily overwhelmed, and more anxious. He had no history of delusions, and no delusional behavior was apparent. Additionally, there was no evidence of hallucinations. Obsessional rituals were absent. On objective examination, the Veteran's thought process was appropriate and his judgment was not impaired. His abstract thinking was noted to be normal. It was also noted that his memory was mildly impaired in that he forgot names, directions, and recent events. There were passive thoughts of suicide, but no intention or plan. Homicidal ideation was absent. It was noted that there were behavioral, cognitive, social, affective, and somatic symptoms attributed to PTSD. The Veteran was described as tearful, depressed, and anxious. He had difficulty getting along with others. A GAF score of 60 was assigned. The examiner noted that the Veteran had no difficulty performing activities of daily living. In contrast, he did have difficulty establishing and maintaining effective work and social relationships because of his mistrust of others, his irritability, and his agitation and impatience. He was able to maintain effective family role functioning. He had occasional interference with recreation or leisurely pursuits because he has no hobbies. He had no difficulty understanding commands and posed no threat of persistent danger or injury to himself or others. He was severely depressed, the examiner concluded, and the examiner opined that, as the Veteran got closer to his retirement, the symptoms would worsen. This examination report reflects some symptoms which are consistent with a 30 percent evaluation and some symptoms which are consistent with a 50 percent evaluation. Resolving doubt as to which symptoms preponderate in the Veteran's favor, the criteria for a 50 percent evaluation are met, but not the symptoms for a higher rating. The record also includes a statement from the Veteran's employer indicating that the Veteran's industrial capacity, including his interactions with fellow employees and customers, was declining. The supervisor stated that changes had been primarily noted in the past three years. Because this statement refers to several prior years, it suggests that a 50 percent rating may be warranted prior to 2008. The record also contains a July 2008 letter from a private psychiatrist. This letter notes that the Veteran was neatly dressed. His affect was blunted and guarded at first. Once he became more comfortable, the Veteran's body posture became more relaxed. However, as he became less inhibited, his hand tremors and facial tics began to emerge. He denied paranoid delusions but admitted to feeling depressed and having occasional suicidal ideation. He reported intrusive thoughts at least once a week. He had auditory hallucinations when he is extremely stressed. He was not currently homicidal or suicidal. On examination he was fully oriented and had normal cognitive processing of verbal and written information. He had intact recent and remote recall. He was able to follow complex commands without difficulty, when relaxed. He had insight into his problems and he was aware that his psychological problems were becoming more evident to family, friends, and coworkers. He was concerned about losing focus, which was hampering his work performance. His judgment was impaired. The provider opined that the symptoms were present since 2006. The provider did not assign a GAF score. However, the provider's opinion makes it clear that the provider questioned the accuracy of the GAF score assigned at the time of the 2006 VA examination, and the provider's description of symptoms was consistent with a 50 percent evaluation, although no GAF score was assigned. A September 2008 VA examination report notes that the Veteran reported that his marriage was "distant" and that it had been this way for a while. He had a good relationship with three of his brothers. He had no friendships outside of immediate family. He had lost interest in hunting, his only hobby. He had not attempted suicide. He had several incidents of road rage but no physical altercations. He did not use alcohol or other substances. On examination, he was clean and neatly groomed. Speech and psychomotor activity were both unremarkable. His attitude was cooperative and his affect was normal. His mood was anxious. He was fully oriented and attentive. He had unremarkable thought process and content. There was no evidence of delusions. The Veteran understood the outcome of his behavior. He described having sleep impairment. He had auditory hallucinations, but they were not persistent. He did not exhibit inappropriate behavior. He correctly interpreted a proverb. He had no obsessive or ritualistic behavior. He had panic attacks three times a week, triggered by nightmares. He had homicidal thoughts and suicidal thoughts. His impulse control was fair. He had episodes of anger problems at work; however, there had never been any physical violence. His memory was normal for remote recall. His recent and immediate memory were both mildly impaired. He had feelings of detachment or estrangement from others, restricted range of affect, a sense of foreshortened future, and inability to recall important aspects of his stressor events, and he tried to avoid thoughts, feelings, or conversations associated with the trauma. His symptoms were chronic, daily, and of moderate severity. He had become distant from others, including his wife. He has anger issues and homicidal ideation with coworkers. He has difficulty socializing with coworkers, so he was isolating and keeping to himself, exhibiting a loss of interest in most activities. His hypervigilence prevented him from going to many public places. The examiner stated that the Veteran's PTSD was moderate. He was employed full time. In terms of his occupational functioning, the Veteran's PTSD caused decreased concentration, difficulty following instructions, increased absenteeism, memory loss, and poor social interaction. The examiner assigned a GAF score of 52. His symptoms are moderate; but, there had been an increase in his symptomatology since his last VA examination. Specifically, he reported more nightmares, intrusive recollections, irritability, anger, and emotional numbing, as well as increased problems with his marriage, inability to be around crowds, and increased anger and irritability which isolated him further at work. The examiner stated that there was not total impairment in occupational and social functioning. Deficiencies were not present in most areas such as judgment, thinking, family relations, work, mood, or school. The examiner stated that there was reduced reliability and productivity due to PTSD symptoms. It was noted that at work the Veteran had moved to different departments several times over the years due to his inability to control his anger with coworkers. He reported missing at least a couple of days a month in the last year due to PTSD symptoms such as irritability and sleeplessness. He also reported a great deal of mistrust and suspicion of others, and a blunting of emotions. A July 2009 VA examination report reflects that the Veteran's wife indicated that the Veteran generally minimized his symptoms and did not like others to know his level of distress. The Veteran's wife also indicated that he was more irritable and snappy, verbally. Their communication was lacking significantly. The Veteran socialized at church, but not outside of church. The Veteran had no history of suicide attempts, violence, or assaultiveness. On examination, he was casually dressed. He had repetitive acts and was lethargic in terms of his psychomotor activity. His speech was impoverished. His attitude was indifferent and his affect was flat. His mood was depressed. The Veteran was easily distracted and he had a short attention span. He was unable to spell a word forward and backward and he did not interpret a proverb appropriately. He was fully oriented. But, thought process manifested "paucity of ideas" and his thought content was described as "poverty of thought." There was no evidence of delusions. His judgment was intact and so was his insight. He had sleep impairment, nightly nightmares, and sweats. He would get sleepy during the daytime, which results in decreased concentration. He did not hallucinate. He exhibited inappropriate behavior, and would "fly off the handle" over little things. He had trouble with people at work and with his wife at home. He exhibited obsessive/ritualistic behavior. He had excessive blinking and constantly moved his hand over his face during the examination. He also constantly checked and rechecked things at work. He had panic attacks nearly every day, both at home and at church. He had homicidal and suicidal thoughts but no plan or intent. He has no episodes of violence; however, he snapped at his wife and coworkers over minor issues. If the Veteran's wife did not make him keep up with daily hygiene, he would go days without showering or shaving, she reported. It was noted that the Veteran's remote, recent, and immediate memory were all mildly impaired. The Veteran had difficulty falling and staying sleep. He also exhibited irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. The examiner concluded that the symptoms of PTSD were chronic and severe. The examiner opined that the symptoms had progressively worsened. A GAF score of 47 was assigned. He had lost 35-40 days of work in the last 12-month period due to being tired, feeling run down, and feeling overly stressed. The Veteran's occupational functioning was affected by the following PTSD symptoms: decreased concentration, difficulty following instructions, inappropriate behavior, increased absenteeism, memory loss, and poor social interaction. The Veteran had daily panic attacks, decreased concentration, and difficulty dealing with stressors or changes in routine. He had threatened to kill his coworkers. He avoided crowds and company gatherings. He exhibited decreased productivity, missed work, was mistrustful of others, and had obsessive/compulsive behaviors. The Veteran's social functioning was diminished in that he had problems getting along with others at work, would go days without attending to personal hygiene, and was emotionally distant and had no friends. He had no interests or hobbies other than occasional hunting, and he had lost interest in that as well. He was emotionally numb, unable to feel loving feelings, and distant from others. He was extremely irritable and hypervigilant. The examiner stated that the Veteran's depression was related to his severe PTSD. The examiner also stated that the Veteran was not totally occupationally and socially impaired due to his PTSD signs and symptoms. However, the examiner opined that the Veteran's PTSD resulted in deficiencies in most areas, such as judgment, thinking, family relations, work, and mood. He overreacted to minimal stressors and misinterpreted the actions of others. He threatened to kill coworkers; he reported having a gun in the car at work on several occasions. However, he had no plan, and his wife reported that he no longer had his gun in the car. He had also chased down cars and would tailgate other drivers when he was upset. He had concentration and memory impairments, and passive thoughts of suicide and homicide (but none currently). His affect was flat, he was easily angered, and he had daily panic attacks. An undated letter from the Veteran's employer, received by VA in April 2011, states that the Veteran had difficulty getting work done as a result of memory problems, anger issues, and arguments with other employees. His job performance had dropped to the point that he was in danger of being terminated. Based upon the evidence of record, the Board finds that the Veteran's PTSD signs and symptoms warrant an increased rating of 50 percent prior to June 4, 2009, but no higher evaluation for that period, and an increased rating of 70 percent beginning on June 4, 2009, but no higher evaluation for that period. For the period prior to June 4, 2009, the Board notes that the medical evidence shows that the Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity due to symptoms such as blunted affect, hallucinations, abnormal psychomotor activity, difficulty following instructions, difficulty with proverb interpretations, panic attacks at least three times a week, episodes of violence, mildly impaired memory, homicidal and suicidal thoughts, difficulty concentrating, outbursts of anger, increased absenteeism at work, loss of interest in activities, and serious social isolation. However, this impairment does not meet the criteria for an evaluation in excess of 50 percent, based on the evidence as a whole. The Veteran maintained full-time employment. According to an August 2007 letter from the Veteran's employer, the Veteran lost an average of 40 days of work, or about 8 weeks for every 12 months, during the prior three years. This information from the employer covers a substantial portion of the relevant period, and establishes that the Veteran's time lost from work was substantially less than 50 percent. The evidence establishes that the Veteran's time lost from work during the remainder of the period at issue did not increase significantly. Thus, the Veteran's objective industrial impairment does not warrant an evaluation in excess of 50 percent during this period. In addition, evidence regarding the Veteran's symptoms is unfavorable to a higher, 70 percent rating for the time period prior to June 4, 2009. In this regard, there is no evidence at this time of obsessional rituals, intermittently illogical, obscure, or irrelevant speech, near continuous panic or depression, spatial disorientation, or neglect of personal appearance and hygiene, which are the bulk of the criteria set forth for a 70 percent rating. Although the Veteran did exhibit suicidal ideation during this time, as well as near continuous depression, impaired impulse control (evidenced by his road rage and difficulties with coworkers), and an inability to establish and maintain effective relationships (social isolation, distant relationship with his wife, and difficulty with coworkers), the September 2008 VA examination report clearly states that the Veteran did not exhibit obsessional rituals. Additionally, it was noted at this examination that the Veteran's thought process and thought content were unremarkable with the exception of homicidal ideation. Moreover, during this time period the Veteran remained fully oriented, appropriately groomed and presentable, and his symptoms were described as only moderate in terms of severity. As such, a rating in excess of 50 percent is not warranted for the time period prior to June 4, 2009. With regard to the time period beginning on June 4, 2009, the Board is of the opinion that a higher initial evaluation, increased to 70 percent, is warranted for the Veteran's PTSD. Specifically, the July 2009 VA examination report notes that the Veteran's affect was flat and his mood was depressed. His thought process and content were both deficient. The Veteran exhibited inappropriate behavior and obsessive/ritualistic behavior. It was also noted that he had panic attacks nearly every day, as well as homicidal and suicidal thoughts. Furthermore, it was noted that without his wife's prompting, the Veteran did not take care of personal daily hygiene. In sum, for this time period, the Veteran's symptoms progressively worsened. The examiner stated that the Veteran's PTSD resulted in deficiencies in most areas, such as judgment, thinking, family relations, work, and mood. He overreacted to minimal stressor and misinterpreted the actions of others. He threatened to kill coworkers and reported having had a gun in the car at work on several occasions. Such symptomatology warrants a higher 70 percent rating for the time period beginning on June 4, 2009. However, a higher rating of 100 percent is not warranted for this time period. Notably, the Veteran is still fully employed, albeit with serious impairments in terms of occupational and social functioning. Moreover, no medical professional has ever opined that the Veteran's PTSD renders him totally socially and occupationally impaired. He manifested hallucinations, but these were not persistent. He was not determined to be a persistent danger to himself or others; in fact, the report of July 2009 VA examination reflects that the examiner stated the opposite. He was intermittently unable to perform activities of daily living (minimal personal hygiene), but the evidence discloses no disorientation to time or place. He had memory loss, but the memory loss was medically described as mild and did not include forgetting names of close relatives, own occupation, or own name. Therefore, a higher 100 percent rating is not warranted. Finally, the Veteran's testimony on his own behalf at a March 2011 hearing before the Board establishes that the Veteran remained able to communicate verbally, was able to answer questions logically, and was able to provide logical verbal communication. However, the Veteran did not make eye contact, was reluctant to describe symptoms of PTSD fully, and required support and assistance of his spouse and representative to provide his testimony. The Veteran's demeanor was consistent with his contentions as to the severity of PTSD symptoms. In sum, the preponderance of the evidence supports a 50 percent rating, but no higher rating for the Veteran's PTSD for the time period prior to June 4, 2009, and a 70 percent rating, but no higher, for the period beginning June 4, 2009. Extraschedular Consideration In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the symptoms of PTSD manifested by the Veteran in this case. The Veteran's industrial impairment in particular is contemplated within the rating criteria. The rating criteria are therefore adequate to evaluate the Veteran's disability and referral for consideration of extraschedular rating is not warranted. ORDER Entitlement to an initial rating of 50 percent for PTSD for the period prior to June 4, 2009 is granted, subject to the criteria governing the payment of monetary benefits. Entitlement to an initial rating of 70 percent for PTSD for the period beginning on June 4, 2009 is granted, subject to the criteria governing the payment of monetary benefits. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. At the Travel Board hearing before the undersigned, the Veteran testified that his right ankle, right knee, right hip, and right foot are all weaker and more painful than they were at the most recent November 2009 VA examination. When a claimant asserts that the severity of a disability has increased since the most recent rating examination, additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (holding that a Veteran was entitled to a new examination after a two-year period between the last VA examination and the Veteran's contention that his disability had increased in severity); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous"). As such, a new examination should be conducted in order to assess the current severity of the service-connected degenerative joint disease of the right knee, ankle, and hip, and the plantar fasciitis of the right foot. Ongoing medical records should also be obtained. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). In this regard, the Board notes that the Veteran submitted a VA Form 21-4138 in March 2011, which states that the Veteran was submitting recent VA treatment records. It also states that the Veteran waived initial consideration of such evidence by the RO. However, no additional VA treatment records were submitted along with the VA Form 21-4138. Therefore, such records should be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain copies of all VA treatment records dating from July 2010 to the present, and associate them with the claims file. 2. Afford the Veteran an opportunity to provide evidence as to industrial impairment, including statements of others or objective evidence of time lost from work, such as from employer records of the reasons for time lost from work. 3. Schedule the Veteran for a VA orthopedic/joints examination, by a clinician with the appropriate expertise, in order to determine the current severity of the Veteran's service-connected degenerative joint disease of the right knee, ankle, and hip, and of plantar fasciitis of the right foot. All indicated studies, including X-rays and range of motion studies in degrees of each affected joint (right knee, hip, and ankle) and of the right foot, as needed, should be performed. In reporting the results of range of motion testing, the examiner should identify any objective evidence of pain and the specific excursion(s) of motion, if any, accompanied by pain. To the extent possible, the examiner should assess the degree of severity of any pain. Tests of joint movement against varying resistance should be performed. The extent of any incoordination, weakened movement and excess fatigability on use should also be described by the examiner. If feasible, the examiner should assess the additional functional impairment due to weakened movement, excess fatigability, or incoordination in terms of the degree of additional range of motion loss. The examiner should also express an opinion concerning whether there would be additional limits on functional ability on repeated use or during flare-ups (if the Veteran describes flare-ups), and, to the extent possible, provide an assessment of the functional impairment on repeated use or during flare-ups. If feasible, the examiner should assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. For each range of motion evaluated in each joint and in the right foot, the examiner should describe where pain begins for that motion, evaluated both by the Veteran's subjective report and by objective observation, and should describe where pain ends, evaluated both by the Veteran's subjective report and by objective observation. The examiner should also describe the symptoms and manifestations of plantar fasciitis of the right foot, and state whether the disability is moderate, moderately severe, or severe. The examiner should set forth the complete rationale for all opinions expressed and conclusions reached. 4. Then, after any other indicated development is completed, readjudicate the Veteran's claims. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and provided an appropriate opportunity to respond before returning the case to the Board for further appellate action. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case 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. 2010). ______________________________________________ Tresa M. Schlecht, Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs