Citation Nr: 1124385 Decision Date: 06/28/11 Archive Date: 07/06/11 DOCKET NO. 07-35 978 ) DATE ) ) On appeal from the Department of Veterans Affairs Hartford Regional Office in Newington, Connecticut THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a disability rating in excess of 10 percent for a right ankle disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. Haddock, Associate Counsel INTRODUCTION The Veteran had active military service from March 1966 to February 1969 and from February 1991 to July 1991. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision by the Department of Veterans Affairs (VA) Hartford Regional Office (RO) in Newington, Connecticut. FINDINGS OF FACT 1. The occupational and social impairment from the Veteran's PTSD has more nearly approximated total than reduced reliability and productivity or deficiencies in most areas for the entire period on appeal. 2. Right ankle traumatic arthritis is manifested by marked limitation of motion. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 100 percent for a psychiatric disability have been met for the entire period on appeal. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2010). 2. The criteria for a disability rating of 20 percent, but not higher, for right ankle traumatic arthritis have been met for the entire period on appeal. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5003, 5010, 5270, 5271 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2010), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2010), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The record reflects that prior to the initial adjudication of the claims, the Veteran was mailed a letter in October 2006 advising him of what the evidence must show and of the respective duties of VA and the claimant in obtaining evidence. The October 2006 letter also provided the Veteran with appropriate notice with respect to the disability-rating and effective-date elements of his claims. The Board also finds the Veteran has been afforded adequate assistance in response to his claims. The Veteran's service treatment records (STRs) are on file, VA Medical Center and private treatment notes have been obtained, and the Veteran has been afforded appropriate VA examinations. Neither the Veteran nor his representative has identified any outstanding evidence, to include medical records, which could be obtained to substantiate the claims. The Board is also unaware of any such evidence. Accordingly, the Board will address the merits of the claims. Legal Criteria General Disability Rating Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2010). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2010). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2010). Where there is a question as to which of two evaluations shall 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. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. 38 C.F.R. § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Court has held that evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate 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. See, in general, DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that the disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. According to this regulation, it is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, the regulations state that the functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran 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. The provisions of 38 C.F.R. § 4.45 state that when evaluating the joints, inquiry will be directed as to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. 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. 38 C.F.R. § 4.59. PTSD PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411 which utilizes the general rating formula for mental disorders. Under this code a 50 percent disability rating is warranted for a mental disorder when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty 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; and difficulty in establishing effective work and social relationships. A 70 percent disability rating is warranted for a mental disorder when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. The maximum schedular rating of 100 percent is warranted for a mental disorder when there is total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. Ankle Disability Traumatic arthritis is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of motion for the ankle is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5271. Under this code, a moderate limitation of motion of the ankle is rated as 10 percent disabling; and marked limitation of motion of the ankle is rated as 20 percent disabling. Ankylosis of an ankle warrants a 20 percent evaluation if it is in plantar flexion, at less than 30 degrees. A 30 percent evaluation is warranted if the ankylosis is in plantar flexion, between 30 and 40 degrees, or in dorsiflexion, between 0 and 10 degrees. A 40 percent evaluation is authorized for ankylosis of an ankle if the ankylosis is in plantar flexion at more than 40 degrees, in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity. 38 C.F.R. § 4.71a, Diagnostic Code 5270. Burden of Proof Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2010) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Evaluation of PTSD In April 2007, the Veteran was afforded a VA psychiatric examination. At that time, the Veteran reported experiencing frequent and intrusive thoughts about the war, which he stated had become worse since the wars began in Iraq and Afghanistan. He reported having distressing nightmares about his experiences in Vietnam at least three times per week. The Veteran reported experiencing flashbacks of the war and that ever since he has had more time on his hands because of his retirement, he has been thinking more often about his combat experiences. The Veteran reported that he did try to avoid thinking about his combat experiences and that he did not discuss them with other people. He reported that he typically tried to avoid combat-related material on television, but that he did still watch CNN despite having to turn it off at times due to his level of distress. The Veteran reported that he was quite detached emotionally from his family members and that he had very few friends, other than those individuals who were with him in the military. He also reported that he had no interest in leisure activities and that he spent almost all of his time isolating himself from other people. He reported that he was relatively noncommunicative with his wife and son. The Veteran reported that he experienced ongoing sleep disturbances, in that he got up 2-3 times per night with difficulty returning to sleep. He reported that he averaged approximately four hours of sleep per night and that he experienced significant fatigue during the day. The Veteran reported experiencing great difficulties with concentration and that he drifted off at times into his own thought. He reported that he sometimes even lost time when drifting in his own thoughts. The Veteran reported that his concentration problems had caused him problems at work. The Veteran also reported that his irritability level had increased. He reported that he was not speaking with his son as a result of his PTSD symptoms because he frequently became angry and yelled at both his wife and his son over unimportant things. The Veteran also reported that he had been in frequent confrontations with co-workers because of his high level of irritability. He reported that he often isolated himself from others in an effort to keep himself from getting into confrontational situations. The Veteran reported that he also experienced symptoms of hypervigilance. The Veteran described his mood as "up and down," but he also admitted to experiencing more long-standing periods of depression. He reported decreased appetite with unintended weight loss, poor sleep and concentration, and significant survivor's guilt. He stated that he "may be better off dead." He reported that he drank approximately 3-4 drinks per day because they made him feel better. He reported that since he had retired, he spent most of his time at home watching television. The Veteran reported that he had worked for 17 years in quality assurance and that he took a retirement in January 2007. He reported that he had been out for some time prior to his retirement due to a knee replacement, but that when he went back he simply could not handle dealing with people and retired early. He described flying off the handle at his co-workers and that he had received verbal reprimands for his behavior. The Veteran reported that he had no plans to return to work and the examiner noted that the Veteran seemed to be rather pessimistic regarding his ability to function with other people in an occupational environment. Upon mental status examination, the Veteran was noted to be accompanied by a friend whom he called his "driver." The Veteran's mood was irritable and depressed and he was quite restricted in range. The examiner noted that the Veteran appeared depressed and somewhat hopeless. The Veteran did not report any suicidal or homicidal ideations, though he did admit to significant feelings of guilt and worthlessness. The Veteran's thought process was logical and goal directed, though at times, it appeared that the Veteran was distant and lost in thought when touching upon his military service and the loss of his brother in the Republic of Vietnam. The Veteran did not report any auditory or visual hallucinations. His cognition was not formerly tested, but his insight was fair and his judgment was good. The examiner confirmed the diagnosis of PTSD and assigned a Global Assessment of Functioning (GAF) score of 46. In summary, the examiner reported that the Veteran presented with chronic symptoms of PTSD representing all symptom clusters of the disorder. He reported that the Veteran's current presentation matched his description from the medical records and indicated that the Veteran's symptoms appeared to be worsening somewhat, particularly in the realm of irritability, isolative behaviors, and concurrent mood-related problems. The examiner also reported that he felt that the Veteran may have been abusing alcohol, but minimizing his report of drinking. The examiner reported that even though the Veteran has continued with treatment, his symptoms have shown little to no improvement over time and the examiner noted that the record noted significant occupational and social complications secondary to the Veteran's PTSD and related behaviors. The examiner further noted that the Veteran remained quite emotionally and socially isolated. At this juncture, the Board notes that GAF scores are based on 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), p. 32]. The GAF score is based on all of the Veteran's psychiatric impairments. A GAF score of 31-40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or a 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 score of 41-50 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 score of 51-60 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 GAF score of 61-70 represents 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. While particular GAF scores are not contained in the VA schedule of ratings for mental disorders, 38 C.F.R. § 4.130, they are a useful tool in assessing a Veteran's disability and assigning disability evaluations. However, they are just one of many factors considered when determining an evaluation. In September 2008, the Veteran was afforded another VA psychiatric examination. At that time, the Veteran was noted to report symptoms quite similar to those that he had reported at his April 2007 VA examination. The Veteran reported that he spent almost all of his time isolating from others in his home and that his symptoms limited his ability to engage in leisure and social activities. The Veteran described increased nightmares related to Vietnam, reporting that they occurred almost nightly and that they were quite distressing to him. The Veteran reported multiple distressing reminders of the war, including news reports of the current wars and rainy weather. The Veteran also reported occasional flashbacks. The examiner reported that the Veteran's symptoms of avoidance remained severe, including his attempts to avoid thoughts and reminders of the war and avoidance of discussions with others. The Veteran reported that he remained quite detached from others, including his family members, and stated that he had no friends other than some connection with a few other Veterans. The Veteran displayed a significantly restricted range of affect and reported a sense of foreshortened future. The Veteran also reported that his sleep was quite poor, as a result of the above mentioned nightmares, and that once he awoke, he had difficulty returning to sleep. He reported experiencing significant fatigue during the day. The Veteran reported that his level of irritability continued to increase and that it continued to cause problems in his relationships with his wife and son. He reported that he would still fly off the handle, even more frequently than before, and that he felt guilty about this. He also reported that he preferred to spend most of his time alone so that he could avoid verbal outbursts towards others. He stated that he, "would feel better if he could live in the middle of nowhere." The Veteran reported ongoing hypervigilance and stated that he rarely went out and engaged in activities, preferring the safety of his own home. He also reported an exaggerated startle response and ongoing difficulties with concentration. The Veteran reported ongoing depressive symptoms, including daily depressed mood, low motivation and energy levels, and significant frustration and sadness related to his medical conditions. He stated that "life kind of sucks." The Veteran reported that he has had passive suicidal thoughts in the past, but did not report any current plan or intent. The Veteran reported that he spent most of his time at home watching television or reading the newspaper. Upon mental status examination, the Veteran's mood was depressed and irritable. His affect was dysphoric and highly restricted in range. There was no current evidence of a thought disorder. His thought process was logical and goal directed. There were no auditory or visual hallucinations noted or reported. His cognition was not formally tested, though the Veteran did describe difficulties with concentration. His insight and judgment were good. The examiner continued the diagnosis of PTSD and assigned a GAF score of 44. In summary, the examiner noted that the Veteran reported chronic and severe PTSD symptoms, as well as symptoms of depression. The examiner noted that the symptoms appeared to be similar to those reported at his last VA examination. The examiner noted that the Veteran's symptoms of avoidance, irritability, and re-experiencing were significantly severe and tended to cause difficulties in all areas of the Veteran's daily functioning. Finally, the examiner reported that even though the Veteran remained connected with his mental health treatment provider at the VA Medical Center, his overall gains in treatment had been noted to be somewhat limited. In January 2009, the September 2008 VA examiner was asked to provide an opinion regarding the Veteran's employability. The examiner reported that a review of the VA Medical Center treatment notes and the recent VA examination reports tended to indicate that the Veteran, among other symptoms, experienced significant problems with irritability and anger outbursts, concentration difficulties, and isolative behavior. The examiner reported that these symptoms had negatively impacted the Veteran's work performance and while the Veteran's physical disabilities have certainly played a large part in his retirement, his PTSD symptoms alone made it highly unlikely that the Veteran would be able to obtain and maintain gainful employment. A review of the record also shows that the Veteran receives mental health treatment at the VA Medical Center. The treatment notes of record show that the Veteran tends to report experiencing symptoms of depression, anger, irritability, social isolation, avoidant behaviors, feelings of worthlessness, and worry. It is well documented that the Veteran has not responded especially well to mental health treatment and that the Veteran's PTSD is severe. The Board finds that the Veteran is entitled to a 100 percent disability rating for PTSD for entire period on appeal. In this regard, the Board notes that the Veteran retired early from his job and the April 2007 and September 2008 VA examiner clearly stated that the Veteran's symptoms of PTSD alone are enough to render the Veteran unable to obtain and maintain gainful employment. Additionally, it is well documented that the Veteran's symptoms are severe. Also, a review of the record shows that the Veteran has little to no social interaction, even with his wife and son. The Veteran rarely leaves the house and maintains very few friendships. Additionally, the Veteran has been assigned GAFs in the low to mid 40s, indicating that the Veteran is rather seriously impaired by his PTSD. In combination, the Veteran's symptoms during the period on appeal have produced impairment that more nearly approximates total occupational and social impairment than deficiencies in most areas. The Board acknowledges that the results of the VA examinations and the symptoms described in the VA examination reports and various mental health treatment notes do not indicate that the Veteran experiences all of the symptoms associated with a 100 percent disability rating for a psychiatric disability. However, the Court has held that the symptoms enumerated under the schedule for rating mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, a finding that there is total occupational and social impairment is sufficient to warrant a 100 percent disability rating for the entire period on appeal even though all the specific symptoms listed for a 100 percent rating are not manifested. Evaluation of Right Ankle Disability With his October 2006 claim for increase, the Veteran submitted a report of an October 2006 private computed tomography (CT) scan of his right ankle. The CT scan revealed severe degenerative changes in the Veteran's right ankle. In November 2006, the Veteran was afforded a VA examination. At that time, the Veteran reported experiencing daily ankle pain that was worse with standing and weight bearing. The Veteran described swelling on the lateral aspect of the ankle and reported that he experienced ankle weakness and stiffness. The Veteran denied experiencing heat, redness, instability, giving way, locking, fatigability, and lack of endurance. It was reported that the Veteran used a cane for ambulation and that he received steroid injections in the past for treatment with temporary relief. It was noted that the Veteran did not experience flare-ups of joint disease and he did not use crutches, a brace, or corrective shoes. He did not have a history of ankle surgery and did not have any episodes of dislocation or recurrent subluxation. However, the Veteran did report that his right ankle disability limited his ability to walk and do physical activity. Upon physical examination of the right ankle, there was objective evidence of painful motion, tenderness, and edema. There was no evidence of effusion, instability, weakness, redness, heat, abnormal movement, or guarding of movement. Range of motion measurements were as follows: dorsiflexion to 10 degrees with pain and plantar flexion to 20 degrees with pain. The examiner noted that joint function was not additionally limited by pain, fatigue, weakness, or lack of endurance after repetition. There was evidence of valgus angulation of the os calcis in relationship to the long axis of the tibia and fibula. In November 2007, the Veteran was afforded another VA examination. A review of this examination report shows that the findings were identical to those recorded at the November 2006 VA examination. In August 2008, the Veteran was afforded another VA examination. At that time, the Veteran reported that he experienced swelling and pain in his right ankle after as little as 10-15 minutes of use. He reported that right ankle fusion was recommended to him by his treating provider, but that he had declined. The Veteran reported that the pain was intermittent, that he experienced stiffness with flexion and extension, that he experienced swelling at least once a week, and that the ankle became increasingly painful when fatigued. The Veteran denied weakness, instability, and locking in his right ankle. The Veteran reported that his right ankle disability limited his walking to about 10-15 minutes at a time. Upon physical examination of the right ankle, there was no evidence of painful motion, edema, effusion, instability, weakness, tenderness, redness, heat, abnormal movement, or guarding of movement. Range of motion measurements were as follows: dorsiflexion to 10 degrees and plantar flexion to 45 degrees. There was no varus or valgus angulation noted. The examiner noted that the range of motion was not limited by pain and that the Veteran was not additionally limited by pain, weakness, lack of endurance, or fatigue upon repetitive use. The Board notes that the August 2008 VA examiner did not appear to take the Veteran's subjective complaints into account regarding his right ankle pain and fatigability. Additionally, the August 2008 VA examination report tends to indicate that the Veteran has little to know functional impairment as a result of the severe degenerative changes in his right ankle. This is markedly inconsistent with the previous examinations of record. Therefore, the Board finds that this examination report is inadequate for adjudication purposes. The Board notes that the Veteran is seen at the VA Medical Center for treatment of his various disabilities. However, the Veteran does not receive extensive treatment for his right ankle at the VA Medical Center. In this regard, the Board notes that several of the Veteran's other physical and psychiatric ailments tend to be more severe and are what the Veteran is predominantly treated for at the VA Medical Center. Regardless, the treatment notes of record are negative for any range of motion measurements for the Veteran's right ankle. The Board finds that the Veteran is entitled to a 20 percent disability rating for his right ankle disability. In this regard, the Board notes that the VA examination report discussed above indicates that the Veteran has only 10 degrees of dorsiflexion and 20 degrees of plantar flexion in his right ankle. This is a rather significant limitation of motion. Additionally, the Veteran experiences significant right ankle pain and there is evidence of record indicating that an ankle fusion procedure has been recommended to the Veteran. Therefore, the Board finds that the Veteran's right ankle disability picture, when considered as a whole, more closely approximates that of a marked limitation of motion than that of a moderate limitation of motion. This is the highest disability rating allowed for this disability. 38 C.F.R. § 4.71a, Diagnostic Code 5271. The Board has considered whether there is any other schedular basis for granting the Veteran a rating in excess of 20 percent, but has found none. In particular, the Board notes that the Veteran's right ankle is not ankylosed so a higher rating under Diagnostic Code 5270 is not warranted. Consideration has been given to assigning a staged rating; however, at no time during the period in question has the disability warranted a compensable schedular rating. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has also considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(a) (2008). In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case the manifestations of the Veteran's right ankle disability are contemplated by the schedular criteria. Therefore, referral for extra-schedular consideration is not warranted. ORDER The Board having determined that the Veteran's PTSD warrants a 100 percent disability rating for the entire period on appeal, the benefit sought on appeal is granted, subject to the criteria applicable to the payment of monetary benefits. The Board having determined that the Veteran's right ankle disability warrants a 20 percent disability rating for the entire period on appeal, the benefit sought on appeal is granted to this extent and subject to the criteria applicable to the payment of monetary benefits. ____________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs