Citation Nr: 1134843 Decision Date: 09/16/11 Archive Date: 09/23/11 DOCKET NO. 06-00 907 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial evaluation in excess of 70 percent for posttraumatic stress disorder. 2. Entitlement to an increased evaluation for traumatic arthritis of the left knee with limitation of flexion currently evaluated as 10 percent disabling. 3. Entitlement to an increased evaluation for limitation of extension of the left knee currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD M. J. In, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1966 to July 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2005, February 2006, February 2008, and July 2011 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. FINDINGS OF FACT 1. The Veteran's posttraumatic stress disorder (PTSD) has been manifested by severe depression, sleep problems with nightmares and violent dream enactment, panic attacks, flashbacks, anger outbursts, anxiety, irritability, hypervigilance, hyper-startle response, avoidance of crowds, social isolation, numbing of general responsiveness, mildly impaired memory, and difficulty concentrating. Objectively, the Veteran has been well groomed, appropriately dressed, alert, fully oriented, cooperative, and with good eye contact. He has exhibited depressed mood, flat and blunted affect, normal speech, logical and coherent thought process, adequate intellectual functioning, good judgment, and fair insight. No evidence of homicidal ideations, delusions, paranoia, or psychosis was found. 2. Manifestations of traumatic arthritis of the Veteran's left knee include daily pain and limitation of motion to, at most, 80 degrees of forward flexion and 25 degrees of extension, with increased pain on prolonged activities; no ankylosis and/or impairment of the tibia and fibula with left knee or ankle disability has been shown. 3. The Veteran's traumatic arthritis of the left knee includes instability which is no worse than moderate. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). 2. The criteria for an evaluation in excess of 10 percent for traumatic arthritis of the left knee, based on limitation of flexion, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5260-5010 (2010). 3. The criteria for an evaluation in excess of 30 percent for limitation of extension of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2010). 4. The criteria for a separate evaluation of 20 percent, but no higher, for impairment of the knee with moderate recurrent subluxation or lateral instability of the left leg have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), 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); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). Proper notice from VA must inform the claimant of any information and medical or lay 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran's claim concerning the proper disability rating to be assigned to his service-connected PTSD arises from his disagreement with the initial disability evaluation assigned to this condition following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice as to this claim is needed under VCAA. With regard to the Veteran's claim for increased ratings for his service-connected left knee disability, the RO's letters, dated in November 2007, September 2008 and July 2010, advised the Veteran of the necessary elements of the notice requirements. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that a VCAA defect may be cured by issuance of a fully compliant notification followed by a re-adjudication of the claim); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Specifically, the RO's September 2008 letter informed the Veteran of what evidence was required to substantiate his claim for increased disability ratings and of his and VA's respective duties for obtaining evidence. The Veteran was also asked to submit evidence or information in his possession to the RO. See Vazquez-Flores v. Shinseki, No. 08-7150 (Fed. Cir. Sep. 4, 2009). With respect to the Dingess requirements, the RO's March 2006 letter provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims, including the opportunity to present pertinent evidence. Thus, the Board finds that the content requirements of the notice VA is to provide have been met. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In addition, the duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's service treatment records, as well as his identified VA and private medical treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Pursuant to the Board's July 2010 remand, the Veteran was afforded VA examinations in September 2010 to determine the severity of his PTSD and traumatic arthritis of the left knee. 38 C.F.R. § 3.159(c)(4). The Board finds that the VA examinations obtained were adequate, as they provided sufficient detail to determine the severity of the Veteran's service-connected disabilities. The VA examiners discussed the history of the Veteran's condition, conducted an examination of the Veteran, and elicited information from the Veteran concerning the functional aspects of his service-connected disabilities. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Based on the foregoing, the Board concludes that there has been substantial compliance with its July 2010 remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. Analysis Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (finding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2010). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2010). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). Where a Veteran appeals the initial rating assigned for a disability, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous. . . ." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id.; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). PTSD Historically, the RO's January 2005 rating decision granted service connection at a 10 percent evaluation for PTSD, effective from January 15, 2004. The Veteran subsequently appealed this decision seeking a higher initial evaluation. In July 2011, the RO issued a rating decision which granted an increased evaluation of 70 percent for the Veteran's service-connected PTSD, effective January 15, 2004. The Veteran continues to seek an increased rating in this matter. See AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). The Rating Schedule establishes a general rating formula for mental disorders. 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase 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 rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). Id. Pursuant to Diagnostic Code 9411, PTSD is rated 70 percent when there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or 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 the inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted 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 of minimal personal hygiene; disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. In evaluating the evidence, the Board has considered the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See DSM-IV; Carpenter v. Brown, 8 Vet. App. 240 (1995). For example, a GAF score of 61-70 reflects some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social or occupational functioning, such as occasional truancy, or theft within the household, but generally functioning pretty well, and has some meaningful interpersonal relationships. A GAF score of 51-60 indicates moderate symptoms, e.g., flat affect, circumstantial speech, occasional panic attacks, or moderate difficulty in social, occupational functioning, e.g., having few friends or having conflicts with peers or co-workers. A GAF score of 41 to 50 is assigned where there are serious symptoms, e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting, or any serious impairment in social or occupational functioning, e.g., no friends, unable to keep a job. DSM-IV at 46-47. A GAF of 31-40 is defined as exhibiting some impairment in reality testing or communication, e.g. speech is at times illogical, obscure, or irrelevant, or any major impairment in several areas, such as work, family relations, judgment, thinking or mood, e.g. a depressed man that avoids friends, neglects family, and is unable to work. DSM-IV at 46-47. A GAF of 21-30 is defined as 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, no friends, no home. Id. A November 2004 VA psychiatric examination was conducted. The Veteran gave a history of military service in Vietnam during which he was in regular combat and witnessed many serious injuries and death. He reported that he had worked for a Texas oil company for the previous 30 years and that his work performance was of excellent quality. He related that he was married with no children. He indicated that he had been treated for sleep problems and was taking antidepressant along with Klonopin for sleep apnea. On psychiatric examination, the Veteran was very cooperative and able to express himself very well verbally. He showed higher than average intelligence and good contact with outside reality; no psychiatric diagnosis was indicated from the cognitive standpoint. The Veteran endorsed nightmares, during which he shouted, fought, jumped over and attacked his wife during his sleep. The diagnosis was very mild PTSD based on witnessing injuries and being included in heavy combat, but otherwise normal mental status examination. A GAF score of 65 was listed. The examiner found that the Veteran was competent to handle his funds. In June 2005, the Veteran's wife stated that she had been married to the Veteran since 1963 and that when the Veteran returned from service, he was not the same person she had known her entire life. She stated that he "just did not care about anyone, anything, or anywhere." She described the Veteran as uncaring; quick to anger; irritable with coworkers, family and friends; afraid of loud noises; and cautious and nervous when in a crowd. She noted that he talked in his sleep, kicked legs, hit with fists, and attacked her during sleep, but that he never remembered anything in the morning and had difficulty concentrating or remembering. She indicated that his symptoms worsened without medication and that she had to sleep away from him. In a January 2005 private treatment report, B.E., M.D. noted the Veteran's history of leg kicks and dream enactment behavior. Dr. E. stated that the Veteran's PTSD had significantly affected his behavior at night and emotional stability during the day and that this impairment was permanent as it required medication to control symptoms. In a May 2005 letter, the Veteran's private psychiatrist, R.G., M.D., noted the Veteran's history of chronic depression since his discharge from service with recurrent episodes of severe depression. Symptoms of depression included excessive anxiety, especially in public places; irritability; increased anger; low self esteem; feelings of apathy and hopelessness; frequent flashbacks of his military service; and nightmares. The Veteran reported that he dealt with his depression by immersing himself in work for long hours and when he returned home, he would spend the majority of his time isolated. He stated that he had worked as a methods analyst for over 24 years and that his job involved little social interaction with coworkers. Dr. G. found that social impairment was evidenced by the Veteran's long history of marital problems and avoidance of social situations due to his severe anxiety and paranoid ideation that would be frequently associated with episodes of angry outbursts. It was noted that the Veteran had heightened startle response to loud noises especially sounds similar to gunfire that had frequently resulted in him seeking a place to hide or take cover. The Veteran reported that in 1996 he began to have sleep difficulty characterized by increased physical activity that progressed to a point where he was physically attacking his wife in his sleep, which was diagnosed as sleep disorder breathing in addition to lower extremity movement and dream enactment associated with PTSD. The diagnoses were recurrent major depressive disorder, dysthymia, and PTSD. A July 2005 private treatment report notes that the Veteran's wife sent a note concerning the Veteran's recent behavior due to PTSD exacerbation following the death of his mother. His wife reported a violent episode during his sleep and increasing depression and isolation since the funeral. The Veteran denied suicidal ideation. Psychotic symptoms were absent. On mental status examination, the Veteran's affect was brighter with decreased anxiety except when discussing his military history and details about the funeral. He was more reactive. A December 2005 treatment report notes the Veteran's statement that his mood remained stable but that he had increased nightmares for the previous two weeks and that his wife was sleeping in another room. In a December 2005 letter, Dr. G explained that diagnoses of the Veteran's PTSD, major depression, dysthymia, and other psychiatric conditions were based on a psychiatric evaluation and extensive clinical history. Dr. G. opined that the Veteran's clinical history revealed episodes of severe depression and PTSD that would meet the disability criteria for a higher level of 50 to 60 percent and had occurred over an approximately 36 year period. Specifically, he noted that the disability was identified by 1) estrangement from family; 2) marital problems throughout their marriage associated with his anger issues and violent nightmares with physical aggression towards his wife that necessitated her sleeping in another room; 3) episodes of severe depression associated with apathy, thoughts of death, and vague suicidal ideation. Dr. G. also stated that the Veteran had been able to function quite well at his occupation because of the solitary nature of his duties. In a December 2005 letter, M.D. stated that he observed that the Veteran experienced inability to sleep at night due to nightmares resulting in violent movement, anger management issues, and bouts of depression. The Veteran underwent a VA psychiatric examination in May 2006. With regard to his PTSD symptoms, he reported "I don't like people. I don't like crowds. I get suicidal thoughts. I don't sleep with my wife. I have forgetfulness. I lose time and I get very angry." As to employment, he reported working as a methods analyst for the past 31 years and that he had not missed any work because of PTSD or other illness. As for family relationship, he stated that he had been married to his present wife for 41 years and that they had continued to have marital problems. He denied having any hobbies or any leisure pursuits other than his job. He stated that although he had not made any suicide attempts he had thoughts about suicide, but denied any thoughts about homicide. On examination, the Veteran had normal eye contact. There was little spontaneous speech but answers to questions were logical, relevant and coherent, without any loose thought associations, tangentiality, or circumstantiality. He denied grandiose or paranoid delusions. There was no history of hallucinations, fights, or problems with impulse control other than occasional anger and destructiveness to his own personal property. He reported panic attacks when getting in a tight spot and problems going to sleep at night. The Veteran's mood was mildly depressed at the examination. He was fully oriented and had fair memory. The diagnosis was PTSD and a GAF score of 58 was listed. A September 2006 private treatment report notes the Veteran's report of doing well. He related that he occasionally experienced low mood lasting about two days. Examination revealed no serious mental status abnormalities. The Veteran exhibited neither depression nor mood elevation. His speech was normal in rate, volume, and articulation and his language skills were intact. His memory, judgment, and insight were intact and he was fully oriented. He denied suicidal and self injurious ideas or intentions, hallucinations, and delusions and his behavior was generally appropriate. His thinking was basically logical and thoughts content was appropriate. There were no signs of cognitive difficulty, anxiety, or hyperactivity. In a May 2007 letter, Dr. G. stated that the Veteran's clinical history was significant for recurrent episodes of severe depression and PTSD for several years after his service discharge. Dr. G. noted that the Veteran's impairment in social functioning was characterized by his severe anxiety, avoidance of public places, and limited social interaction with family and friends, as well as the strained relationship with his wife. He indicated that there were multiple instances in the past where the Veteran was physically aggressive towards his wife during his nightmares, which resulted in them frequently sleeping in separate rooms. He noted the Veteran's report of episodes of severe depression with irritability, agitation, and vague paranoid ideation in public places. Dr. G. found that the Veteran had not exhibited a significant impairment in his occupation due to the solitary nature of his job and limited interaction with his coworkers. A June 2007 VA psychiatric examination was conducted. The VA examiner stated that the Veteran's claims file was reviewed. The Veteran stated that he was not bothered greatly by his PTSD symptoms until the 1990's when he attended a Veteran's meeting and exchanged stories concerning wartime experiences. He stated "I would just like to stay home. I don't like people. At work nobody bothers me." He reported nightmares two to three times a week. He stated that he had no real social life and he had a rocky marital relationship. The examiner noted that the Veteran was able to engage in a normal range and variety of activities of daily living without interruption to his typical daily routine. On mental status examination, the Veteran was very serious and showed logical and coherent thought process and average social skills. He was well groomed, cooperative, intelligent, fully oriented, and overall mentally intact. He exhibited flat and blunt affect, good reasoning and fund of general information, good comprehension and concentration, intact memory, and clear sensorium, with no psychomotor slowing or agitation. Psychological symptoms included anxiety, panic attacks, depression, insomnia, crying spells, anhedonia, nightmares, racing thoughts, and suicidal ideas in the past. He denied any specific anger control problems, hallucinations, delusions, or homicidal ideation. The diagnoses were delayed PTSD and major depressive disorder, with a GAF score of 55. The examiner stated that the Veteran had a very stable work history and even a stable marriage although he tended to ignore having a civil relationship with his wife. In an October 2007 letter, Dr. G. stated that the Veteran continued to have frequent exacerbations of his anxiety and depression characterized by frequent anxiety/panic attacks, especially in social situations. He noted that there was a significant amount of social impairment, such as very limited social interactions with family and friends, avoiding public places, and positioning himself so that he could view the entire place and identify an escape route. Dr. G. also stated that there had been a significant strain on the Veteran's marriage due to his PTSD symptoms, especially during episodes of nightmares and flashbacks and that the Veteran remained depressed despite a marked improvement of symptoms with treatment. He also indicated that there were problems with motivation and cognitive symptoms such as impairment in concentration and memory. In regards to occupational functioning, Dr. G. stated that the Veteran had been fortunate to have a job that was very solitary in nature. He noted that during exacerbations of depression and anxiety, there were increased irritability, agitation, and episodes of aggression. He also related that the Veteran frequently reported having vague suicidal thoughts. The Veteran underwent another VA psychiatric examination in August 2008. The examiner indicated that the claims file was reviewed. The Veteran reported frequent nightmares and flashbacks, depression, and lack of motivation. His wife stated that the Veteran had not been social even with people he had known all of his life. In regards to occupational adjustment, the examiner found that the Veteran was able to handle his job without any major outburst or conflicts but that his PTSD had more impact on his social life than on occupational functioning. The Veteran reported that he had not socialized since 1991 and had no friends now. He did not have any contact with family or anyone. On mental status examination, the Veteran was casually dressed, well groomed, verbal, generally cooperative, and his social skills were fair to poor. He exhibited logical, coherent, and relevant thought process; blunted affect; fair reasoning and judgment; and orientation to time, place, person and situation. He and his wife reported a decline in concentration over the previous two or three years, as well as in short-term memory. Psychological symptoms included general anxiety, nightmares, disturbed sleep, panic-like symptoms, anger, irritability, and mild paranoid tendencies. No true psychotic symptoms, such as hallucinations or delusions were shown. The Veteran denied homicidal ideation but endorsed depression, guilt, insomnia, and periodic suicidal ruminations. In regards to occupational and social functioning, the Veteran described no more than occasional declines in work efficiency and intermittent periods of inability to perform occupational tasks. He stated that he had no friends or family that he saw. He stated that he had been married to his wife for many years but they had problems. The diagnoses were PTSD and major depressive disorder and a GAF score of 55 was noted. In a December 2009 letter, Dr. G. stated that the Veteran continued to be symptomatic with frequent exacerbations of his anxiety and depression characterized by frequent anxiety/panic attacks, especially in social situations. He noted that there was a significant amount of social impairment, such as very limited social interactions with family and friends, avoiding public places, and positioning himself so that he could view the entire place and identify an escape route. Dr. G. also stated that there had been a significant strain on the Veteran's marriage due to his PTSD symptoms, especially during episodes of nightmares and flashbacks and that the Veteran remained depressed despite a marked improvement of symptoms with treatment. He indicated that there were also problems with motivation and cognitive symptoms such as impairment in concentration and memory. During exacerbations of depression and anxiety, there were increased irritability, agitation, and episodes of verbal aggression. He reported having frequent suicidal thoughts. Most recently, the Veteran underwent a September 2010 VA psychiatric examination. The VA examiner noted that the claims file was reviewed. The Veteran reported that "[s]uicidal thoughts are in my head all day and all night. My memory is getting worse. Things that used to be very simple, taking apart stuff, sometimes I don't know how to put it back together." The Veteran's wife stated that she had to keep track of her husband's appointments and that he would frequently forget where he placed things. The Veteran described anxiety attacks occurring approximately two times a week in response to being enclosed in a small area. He reported nightly distressing dreams and violent behaviors in sleep. He also reported irritability, outbursts of anger, difficulty concentrating, and hypervigilance. He stated that he became a workaholic as a way of coping with his PTSD symptoms over the years, noting that in the past, he put in 20 hour days at times. He related that he had very little interaction with other employees or supervisors. As to social functioning, the examiner noted that the Veteran had been married for 47 years and never had children, and that he mostly stayed at home. On mental status examination, the Veteran was casually dressed with good eye contact, grooming, and hygiene. His psychomotor activity was normal. He was cooperative, although somewhat guarded; his movement was stiff; he was cautious in his conversation; and his affect was flat. He exhibited clear, logical, linear, coherent, and goal directed thought process; thought content notable for intrusive memories; appropriate behavior with no delusions or hallucinations; depressed mood; and flat affect. He denied homicidal ideation but admitted to daily suicidal thoughts in the previous three to four years. He was fully oriented and showed poor concentration, intact remote memory, somewhat deficient short-term memory, and fair judgment and insight. The examiner noted that the Veteran's thought process showed no evidence of abnormalities that would interfere with either social or occupational functioning. His speech and communication were normal. The examiner found that the Veteran's behavior would interfere with social functioning to a severe degree and occupational functioning to at least a moderate degree. Other psychiatric symptoms included depressed mood, suicidal thoughts, sleep problems, anger, irritability, and psychomotor retardation. The diagnoses were chronic and severe PTSD and recurrent severe major depression. A GAF score of 40 to 45 was assigned. The VA examiner stated that the Veteran's PTSD was considered severe due to a variety of factors, to include daily suicidal thoughts, panic symptoms, daily nightmares so intense that his wife could hear him from another room, and inability to sexually function with his wife for the past 15 years not due to the effects of any sort of medical disorder. The examiner stated "[i]t is possible that past reviewers of this [Veteran's] life and symptoms have concluded he is functioning on a somewhat higher level because of his long and stable work career. However, it is common for many Veterans with severe [PTSD] to become workaholics and avoid thoughts and feelings associated with their trauma by investing themselves excessively in their work, often to the detriment of all other areas of a normal life. In this way, the [V]eteran's history of putting in long hours at the office...is a symptom of [PTSD] as much as it is a measure of daily functioning." After reviewing the evidence of record since the initial grant of service connection, the Board concludes that the Veteran's PTSD is most appropriately rated as 70 percent disabling, and no more. In making this determination, the Board finds that the medical evidence of record does not support an initial evaluation in excess of 70 percent. The GAF scores during the period on appeal ranged from 40 to 65, which contemplate moderate symptoms, such as circumstantial speech, occasional panic attacks, or moderate difficulty in social, occupational or school functioning, for example, having few friends or having conflicts with peers or co-workers; and serious symptoms, such as suicidal ideation, severe obsessional rituals, frequent shoplifting, or any serious impairment in social or occupational functioning, for example, no friends, unable to keep a job. DSM-IV at 46-47. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. The other evidence of record demonstrates that since the initial grant of service connection, the Veteran has reported symptoms of severe depression, sleep problems with nightmares and violent dream enactment, panic attacks, flashbacks, anger outbursts, anxiety, irritability, hypervigilance, hyper-startle response, avoidance of crowds, social isolation, numbing of general responsiveness, mildly impaired memory, and difficulty concentrating. The evidence shows that there has been significant impairment in social and occupational functioning, with deficiencies in most areas, such as work, family relations, judgment, or mood. Although the Veteran reported having worked for most of the time since his service discharge, the record reflects that the Veteran became a workaholic and worked long hours as a way to avoid thoughts and feelings associated with his trauma, often to the detriment of all other areas of a normal life. The record also reflects that he was emotionally distant from his wife and family and virtually had no social life. In considering this disability as a whole, the Board concludes that the Veteran's PTSD is most analogous to the symptoms warranting a 70 percent rating for PTSD. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). The evidence does not reflect that the Veteran's PTSD has been manifested by symptoms of such severity to warrant a higher disability rating in excess of 70 percent at any time since the initial grant of service connection. Objectively, the Veteran has been well groomed, appropriately dressed, alert, fully oriented, cooperative, and with good eye contact. He has exhibited depressed mood, flat and blunted affect, normal speech, logical and coherent thought process, adequate intellectual functioning, good judgment, and fair insight. No evidence of homicidal ideations, delusions, paranoia, or psychosis was found. The medical evidence does not demonstrate delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; the intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place; or memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Although significant impairment has been shown adapting to stressful circumstances as well as the inability to establish and maintain effective relationships, total social and occupational impairment has not been shown. Accordingly, the Board finds that the objective evidence of record does not support an evaluation in excess of 70 percent. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2010). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2010). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria under the Rating Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is adequate, and no referral is required. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the currently assigned 70 percent disability rating for PTSD inadequate. As noted above, the Veteran's service-connected PTSD is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411, the criteria of which is found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. Since the initial grant of service connection effective July 15, 2004, the Veteran's PTSD has been manifested by severe depression, sleep problems with nightmares and violent dream enactment, panic attacks, flashbacks, anger outbursts, anxiety, irritability, hypervigilance, hyper-startle response, avoidance of crowds, social isolation, numbing of general responsiveness, mildly impaired memory, and difficulty concentrating. Objectively, the Veteran has been well groomed, appropriately dressed, alert, fully oriented, cooperative, and with good eye contact. He has exhibited depressed mood, flat and blunted affect, normal speech, logical and coherent thought process, adequate intellectual functioning, good judgment, and fair insight. No evidence of homicidal ideations, delusions, paranoia, or psychosis was found. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the currently assigned 70 percent disability rating for his service-connected PTSD. A rating in excess of 70 percent is provided for certain manifestations of service-connected PTSD but the medical evidence of record reflects that those manifestations are not present in this case. The medical evidence does not demonstrate total occupational and social impairment due to gross impairment in thought processes or communication; delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; the intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place; or memory loss for names of close relatives, own occupation, or own name. Therefore, the currently assigned schedular evaluation is adequate and no referral is required. 38 C.F.R § 4.130, Diagnostic Code 9411; Thun, 22 Vet. App. at 115. Staged ratings have been considered. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD, the evidence shows no distinct periods of time since service connection became effective, during which the Veteran's PTSD varied to such an extent that a rating greater than or less than 70 percent would be warranted. Thus, staged ratings are not in order. See Fenderson, 12 Vet. App. at 126. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim for an initial evaluation in excess of 70 percent for PTSD, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Traumatic Arthritis of the Left Knee Service connection for the Veteran's traumatic arthritis of the left knee was granted by a September 1982 rating decision and a 10 percent evaluation was assigned under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5010, effective August 12, 1982. In August 2007, the Veteran filed the present claim for an increased evaluation for the left knee disability and in a February 2008 rating decision, the RO continued the 10 percent based on limitation of flexion of the left knee pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5260-5010 (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned, the additional code is shown after the hyphen). In July 2010, the Board remanded the Veteran's increased rating claims for further evidentiary development. Subsequently, in a July 2011 rating decision, the RO assigned a separate 30 percent disability evaluation for limitation of extension of the left knee pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5261, effective January 8, 2009. See VAOPGCPREC 9-04, 69 Fed. Reg. 59990 (2004) (holding that separate ratings may be assigned under Diagnostic Code 5260 and Diagnostic Code 5261, where a Veteran has both a limitation of flexion and limitation of extension of the same leg). Diagnostic Code 5010 states that traumatic arthritis is to be rated as degenerative arthritis under Diagnostic Code 5003, which in turn, states that the severity of degenerative arthritis, established by x-ray findings, is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected, which in this case would be Diagnostic Codes 5260 and 5261. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under limitation of motion, a 10 percent rating will be assigned for each affected major joint or group of minor joints. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Painful motion of a major joint or groups of minor joints caused by arthritis, established by x-ray, is deemed to be limited motion and entitled to the minimum 10 percent rating even though there is no actual limitation of motion. Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). As discussed above, separate ratings may be assigned for limitation of flexion and limitation of extension of the same joint. VAOPGCPREC 9-04, 69 Fed. Reg. 59990 (2004). In addition, VA General Counsel has also held that compensating a claimant for separate functional impairment under Diagnostic Code 5257 and 5003 does not constitute pyramiding. See VAOPGCPREC 23-97; 62 Fed. Reg. 63604 (1997). Specifically, VA General Counsel found that a Veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating must be based upon additional disability. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5257 (2010). Under Diagnostic Code 5257, a 10 percent disability evaluation is assigned for slight recurrent subluxation or lateral instability. A 20 percent disability evaluation is contemplated when such impairment is moderate. A 30 percent disability evaluation is contemplated when such impairment is severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under Diagnostic Code 5260, a 10 percent disability rating will be assigned for limitation of flexion of the knee to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2010). A 20 percent disability evaluation is warranted when flexion is limited to 30 degrees. Id. A 30 percent disability evaluation is warranted when flexion is limited to 15 degrees. Id. Under Diagnostic Code 5261, a 10 percent rating will be assigned for extension of the knee limited to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2010). A 20 percent disability evaluation is warranted when extension is limited to 15 degrees. Id. A 30 percent disability evaluation is warranted when extension is limited to 20 degrees. Id. Normal range of motion for the knee is defined as follows: flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71, Plate II (2010). A December 2007 VA joints examination was conducted. The examiner noted the Veteran's history of gunshot wound through the left knee while in service. The Veteran reported daily pain with flare-ups in cold weather. He denied incoordination, falling, locking, excess fatigue, or lack of endurance. He was able to drive a car. He stated that he did normal activities around the home but had to stop training, riding, or jumping horses due to knee pain. He used no brace or assistive device. He indicated that he occasionally took pain medication and stated that the pain did not interfere with his work. A December 2004 X-ray of the left knee revealed degenerative joint disease with narrowing of the joint space. On physical examination, the Veteran walked with a slight limp. There was a healed scar on the medial aspect of the knee and tenderness in the joint line and on the medial patella. The Veteran could flex his left leg from 0 to 100 degrees limited by pain. There was no change in the range of motion, weakness, coordination, fatigue, endurance, or pain level, with three repetitive motions. There was subpatellar clicking. Lachman's sign and McMurrary's sign were negative. The cruciates and collaterals appeared to be intact. The impressions were gunshot wound to the left knee; surgical removal of bullet; traumatic arthritis of the left knee; decreased range of motion of the left knee; and chronic pain of the left knee secondary to traumatic arthritis. Another VA joint examination was conducted in January 2009. The Veteran complained of constant soreness and swelling in his left knee and noted the onset of giving way and falling. He reported limited motion with pain, but with no periods of flare-ups. He used a cane to assist with stability when ambulating. He stated that he took two to three days off at work in the previous year due to his knee. His activities of daily living were affected in that he could not take long walks or train horses due to knee pain. The Veteran was able to shower, shave, or dress himself. The examiner stated that there was no prosthesis implanted within the left knee joint. Physical examination revealed a limping gait, with the use of a cane. Left knee active range of motion was from 25 to 80 degrees with pain throughout. Passively, the range of motion was from 10 to 90 degrees with pain throughout. There was tenderness diffusely about the knee, with no effusion. Mild medial laxity was shown when valgus stress was applied to the knee. Lachman's sign was negative. The examiner stated that there was a well healed surgical wound which was unchanged since the previous VA examination. The examiner noted that there was no additional limitation following repetitive use other than increased pain without further loss of motion. There was also no effect of incoordination, fatigue, weakness, or lack of endurance on the joint function. X-ray revealed degenerative changes about the knee. The diagnosis was degenerative joint disease of the left knee secondary to a gunshot wound in 1967. In a February 2009 addendum, the examiner explained that the range of motion testing performed during the January 2009 VA examination showed that the Veteran's left knee lacked 25 degrees of active full extension, full extension being to neutral or 0 degrees, and that his active knee flexion was only 80 degrees from neutral 0 degrees. The passive left knee motion, expressed as from 10 to 90 degrees, indicated that the Veteran's left knee lacked 10 degrees of full extension and that his passive knee flexion was only 90 degrees. In a January 2010 private treatment record, the Veteran reported increasing pain and dysfunction with prolonged ambulation and activity. On physical examination, the left knee range of motion was from 5 to 120 degrees. The anterior and posterior drawer test was negative and there was 1+ medial laxity and 1+ dorsal pedal pulse. Motor strength was 5 out of 5. There was also significant patellofemoral crepitus with positive patellar grind. Left knee radiographics demonstrated evidence of post traumatic osteoarthrosis, with varus deformity and significant patellofemoral osteoarthrosis, with bone-on-bone articulation of the patella and the lateral trochlear groove. The assessment was left knee post traumatic osteoarthrosis secondary to gunshot wound. An April 2010 private treatment record reflects that the Veteran was seen for a cortisone injection for increasing knee pain. Most recently, the Veteran was afforded a VA joints examination in September 2010. The Veteran complained of continued daily pain in the left knee, which increased with activity. He also complained of swelling, stiffness, and episodes of giving way causing him to fall. He denied any locking, heat, or redness. He stated that he took pain medication and had undergone injections to help lubricate the joint, which he stated did not provide much relief. He noted that he used an anterior cruciate ligament sports brace and ambulated with a cane on a daily basis. He could walk approximately 100 yards and stand 10 to 15 minutes before needing to rest. The examiner stated that the Veteran's activities of daily living were not limited as he was able to take care of all basic daily living activities despite the knee pain. Recreational activities were affected by the disability in that he was unable to do any activity that required prolonged walking. He could no longer ride horses and had difficulty going for prolonged shopping trips. The Veteran's occupational activities were not limited as he had a sedentary job and was able to perform work duties although he needed to take frequent breaks when he occasionally had to walk around. The Veteran reported flare-ups approximately two to three times per week causing him to seek self-imposed bed rest for approximately three to four hours. His private orthopedic surgeon recommended total knee replacement but the Veteran was trying to delay this as long as possible. On physical examination, the gait was antalgic with the aid of a knee brace and cane. Active range of motion was from -25 degrees to 80 degrees with complaints of pain throughout. Passive range of motion was -10 degrees to 80 degrees with pain throughout. There was no additional loss of motion due to pain, fatigue, weakness, lack of endurance, or incoordination shown on repetitive motion testing. The Veteran did not complain of increased pain on repetitive motion testing. There were mild swelling, tenderness to palpation globally about the knee, palpable crepitus on range of motion testing, and very mild laxity to valgus stress, however, no laxity with varus stress. Lachman's sign was negative and McMurrary's test was positive for pain without meniscal clunk. Anterior and posterior drawer was of limited use since the Veteran was unable to flex beyond 80 degrees. The examiner stated that it was very difficult to examine the Veteran due to muscular guarding and complaints of pain. There was well healed surgical scar, which was unchanged since the previous VA examination. The VA examiner also noted that there was very slight instability in the left knee based on the examination. The Veteran had complaints of instability which the examiner categorized as moderate with episodes of giving way and falling. He was noted to use an anterior cruciate ligament brace which he stated helped stabilize his knee and reduced his episodes of falling. The impression on X-ray of the left knee was tricompartmental degenerative joint disease, with narrowing of medial joint compartment and irregular osteophytic projection from the posterior tibial plateau, with no evidence of acute injury or effusion. Throughout the entire period on appeal, the Veteran's left knee disability has been assigned a 10 percent evaluation. In order to obtain an evaluation in excess of 10 percent pursuant to limitation of flexion, the evidence of record must demonstrate knee flexion limited to at least 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. On December 2007 VA examination, the Veteran was able to flex left knee to 100 degrees, and during the January 2009 VA examination, he was able to flex his left knee to 80 degrees. In January 2010, the Veteran's left knee showed a range of flexion to 120 degrees. On September 2010 VA examination, the Veteran was able to flex his left knee to 80 degrees. In sum, the Veteran's left knee disability is manifested by limitation in motion consisting of flexion to no less than 80 degrees at any time during the appeal. The findings as to the limitation of left knee flexion results in a noncompensable evaluation throughout the pendency of this appeal. Id. However, according to Diagnostic Code 5003, as the limitation of motion of left knee joint was shown by painful motion, a rating of 10 percent is for application of left knee based on limitation of flexion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Consequently, the Board finds that an evaluation in excess of 10 percent for the Veteran's left knee disability is not warranted based on limitation of knee flexion. The Board has also considered whether there is any additional functional loss not contemplated in the current 10 percent evaluation. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2010); see also DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Factors involved in evaluating and rating disabilities of the joints include: weakness, fatigability, lack of coordination, restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. The Veteran has consistently reported daily knee pain that increased with prolonged walking or activities. The Veteran also reported that he could not stand or walk for an extended period of time. Although the medical evidence shows pain in the left knee with repetitive motion, repetitive use caused no additional limitation of motion in the left knee that would warrant an evaluation in excess of the current 10 percent. The medical evidence of record demonstrates that there was no incoordination, locking, clicking or snapping, effusion, flare-ups, instability, or other tendon or bursae abnormality. Specifically, on the December 2007 VA examination, the Veteran denied incoordination, falling, locking, excess fatigue, or lack of endurance. To that effect, the December 2007 VA examiner noted that there was no change in the range of motion, weakness, coordination, fatigue, endurance, or pain level on repetitive motion. The January 2009 VA examiner also stated that there were no additional limitation of motion or effect of incoordination, fatigue, weakness, or lack of endurance on the left knee joint function, following repetitive use, other than increased pain. Finally, on the September 2010 VA examination, the VA examiner found no additional loss of motion due to pain, fatigue, weakness, lack of endurance, or incoordination on repetitive motion testing and the Veteran did not complain of increased pain. The degree of limitation shown based on painful motion is already contemplated in the 10 percent and 30 percent ratings currently assigned for limitation of flexion and extension, respectively. 38 C.F.R. § 5003. As such, the Board finds that there is no additional functional loss not contemplated in the currently assigned disability ratings. 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 206. Accordingly, an increased evaluation on this basis is not warranted. The Board has also considered whether an increased evaluation is warranted based on limitation of extension. The evidence of record shows limitation of motion no less than 25 degrees of left knee extension throughout the entire appeal period. This is contemplated by the current 30 percent evaluation, which is the maximum evaluation provided for this disability. The Court has held that, once a Veteran is receiving the maximum rating available for limitation of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 do not allow for a higher evaluation. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Finally, the Board has considered whether the Veteran is entitled to a separate compensable rating under Diagnostic Code 5257. On the January 2009 VA examination, the Veteran noted the onset of giving way and falling. Mild medial laxity was shown on valgus stress testing. In addition, during the September 2010 VA examination, the Veteran complained of episodes of giving way causing him to fall. Although, the VA examiner found very slight instability in the left knee based on clinical examination, it was noted that the Veteran had "complaints of instability that this examiner would categorize as moderate with episodes of giving way and falling." The Veteran's statements are competent evidence of observable symptomatology associated with his left knee disability, and the Board has no reason to doubt the credibility such statements. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Further, the Board finds significant the September 2010 examiner's characterization of the Veteran's complaints of left knee instability as moderate with episodes of giving way and falling. Based on the foregoing evidence, the Board finds that the medical evidence of record reveals impairment of the left knee with no more than moderate recurrent subluxation or lateral instability. Therefore, the Veteran is entitled to a separate 20 percent disability rating for his left knee instability under 38 C.F.R. § 4.71a, Diagnostic Code 5257. Consideration has also been given to increased evaluations under other potentially applicable diagnostic codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). However, there is no evidence of dislocated semilunar cartilage, with frequent episodes of locking, pain, and effusion; left knee ankylosis; or malunion or nonunion of the tibia and fibula. 38 C.F.R. § 4.71A, Diagnostic Codes 5256, 5258, 5262 (2010). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disability ratings for traumatic arthritis of the left knee inadequate. The Veteran's left knee disability is evaluated pursuant to 38 C.F.R. § 4.71a, the criteria for which are found to specifically contemplate the level of disability and symptomatology. Manifestations of traumatic arthritis of the left knee include daily pain and limitation of motion to, at most, 80 degrees of forward flexion and 25 degrees of extension, with no worse than moderate lateral instability. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the current disability ratings assigned for his service-connected traumatic arthritis of the left knee. Ratings in excess of those currently assigned are provided for certain manifestations of the service-connected knee disorder, but the medical evidence of record did not demonstrate that such manifestations were present in this case. The criteria for the currently assigned disability ratings more than reasonably describe the Veteran's service-connected left knee disability level and symptomatology and, therefore, the schedular evaluations are adequate and no referral is required. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260-5010, 5261, 5257; see also VAOPGCPREC 6-96; 61 Fed. Reg. 66749 (1996). As the current evaluations represent the greatest degree of impairment shown during the period on appeal, there is no basis for a staged rating. 38 U.S.C.A. § 5110 (West 2002); see Hart, 21 Vet. App. at 505. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim for increased evaluations, the doctrine is not for application. Gilbert, 1 Vet. App. at 54; see also Massey v. Brown, 7 Vet. App. 204, 208 (1994) (finding the Board may only consider the specific factors as are enumerated in the applicable rating criteria). ORDER An initial evaluation in excess of 70 percent for PTSD is denied. An increased evaluation in excess of 10 percent for traumatic arthritis of the left knee with limitation of flexion is denied. An increased evaluation in excess of 30 percent for limitation of extension of the left knee is denied. A separate 20 percent disability evaluation for impairment of the left knee with moderate recurrent subluxation or lateral instability is granted, subject to the regulations governing the award of monetary benefits. ______________________________________________ J. K. BARONE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs