Citation Nr: 1300949 Decision Date: 01/10/13 Archive Date: 01/16/13 DOCKET NO. 10-30 820 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an evaluation in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to an evaluation in excess of 10 percent for service-connected residuals of a shell fragment wound (SFW) of the right calf and knee (right leg disorder). 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD J. W. Loeb INTRODUCTION The Veteran served on active duty from November 1965 to December 1968. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2007 rating decision of the Department of Veterans Affairs (VA) regional office in Columbia, South Carolina (RO). A December 2011 rating decision granted 50 percent for PTSD, effective January 19, 2007; this decision also granted service connection for a residual scar of the right tibia, associated with the service-connected SFW, and assigned a 10 percent rating effective January 19, 2007. A February 2012 rating decision granted service connection for arthritis of the right knee, associated with the service-connected SFW, and assigned a 10 percent rating effective January 19, 2007. The Veteran and his wife testified at a videoconference hearing with the undersigned Veterans Law Judge in May 2012, and a transcript of the hearing is of record. The issue of entitlement to TDIU is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. FINDINGS OF FACT 1. All known and available service medical records have been obtained; the Veteran has been advised under the facts and circumstances of this case as to the evidence which would substantiate his claims for increased evaluations for service-connected PTSD and right leg disability; and he has otherwise been assisted in the development of his claims. 2. The evidence shows occupational and social impairment with reduced reliability and productivity; his psychiatric symptomatology does not more nearly approximate occupational and social impairment comparable to deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to psychiatric symptomatology. 3. The Veteran's residuals of a GSW of the right leg do not cause more than moderate limitation of function. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 50 percent for service-connected PTSD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for the assignment of an evaluation in excess of 10 percent for service-connected right leg disability have not been met. 38 U.S.C.A. § 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.73, Diagnostic Code 5311 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App"). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction. The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts). Duty to Notify and Assist The Board has considered the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 and Supp. 2012). The regulations implementing VCAA have been enacted. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. See also Quartuccio v. Principi, 16 Vet. App. 183 (2002). After having carefully reviewed the record on appeal, the Board has concluded that the notice requirements of VCAA have been satisfied. The notice and assistance provisions of VCAA should be provided to a claimant prior to any adjudication of the claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the RO sent the Veteran a letter in February 2007, prior to adjudication, which informed him of the requirements needed to establish entitlement to an increased rating. In compliance with the duty to notify, the Veteran was informed in the February 2007 letter about disability ratings and effective dates. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In accordance with the requirements of VCAA, the February 2007 letter informed the Veteran what evidence and information he was responsible for and the evidence that was considered VA's responsibility. Additional private evidence was subsequently added to the claims files after the letter. VA has a duty to assist the claimant in obtaining evidence necessary to substantiate a claim. VCAA also requires VA to provide a medical examination when such an examination is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159. Evaluation of the Veteran's right leg and a psychiatric evaluation were obtained in March 2011. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA evaluations obtained in this case are adequate, as they include a discussion of the Veteran's relevant right leg and psychiatric symptomatology. There is adequate medical evidence of record, which include VA treatment records in Virtual VA, to make a determination on the increased rating issues in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination relevant to the increased rating issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Board concludes that all available evidence has been obtained and that there is sufficient medical evidence on file on which to make a decision on the issues decided herein. The Veteran has been given ample opportunity to present evidence and argument in support of his claims, including at his May 2012 videoconference hearing. The Board additionally finds that general due process considerations have been complied with by VA, and the Veteran has had a meaningful opportunity to participate in the development of the claims. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); 38 C.F.R. § 3.103 (2007). The Board has reviewed the record in regard to whether the Veteran was afforded his due process rights in the development of evidence through testimony. At the May 2012 videoconference hearing, the Veteran was afforded an extensive opportunity to present testimony, evidence, and argument. The transcript reveals an appropriate colloquy between the Veteran and the Veterans Law Judge, in accordance with Stuckey v. West, 13 Vet. App. 163 (1999) and Constantino v. West, 12 Vet. App. 517 (1999) (relative to the duty of hearing officers to suggest the submission of favorable evidence). Analysis of the Claims Increased Rating Claims Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Schedule). 38 C.F.R. Part 4 (2012). The percentage ratings contained in the 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 the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2012). Separate diagnostic codes identify the various disabilities. In considering the severity of a disability it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Nevertheless, where entitlement to compensation has already been established and an increase in the disability rating is at issue the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. 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 (2012). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. See Butts v. Brown, 5 Vet. App. 532 (1993). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 at 308 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Pertinent to a claim for an increased rating, lay testimony is competent when it describes symptoms, which supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see Proscelle v. Derwinski, 2 Vet. App. 629 (1992) (holding that, in general, for the need for a VA examination to arise, a claimant would only need submit his competent testimony that symptoms, reasonably construed as related to the service-connected disability, have increased in severity since the last evaluation.). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). PTSD The Veteran has contended, including at his May 2012 videoconference hearing, that his service-connected PTSD is more severe than currently evaluated. A claim for service connection for PTSD was granted by rating decision in April 1988, and a 30 percent rating was assigned effective November 13, 1984. The Veteran filed a claim for increase in January 2007. A 50 percent rating was granted for PTSD by rating decision in December 2011, effective January 19, 2007. The Veteran continued his appeal on this issue. Under the rating schedule, a 30 percent evaluation is assignable for psychiatric disability when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 50 percent evaluation is assignable for psychiatric disability 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 (for example, retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is assignable for psychiatric disability 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 worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation for psychiatric disability is assignable with 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; memory loss for names of close relatives, own occupation, or own name. Id. The global assessment of functioning (GAF) score reflects 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). A GAF score of 31 to 40 involves some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A GAF score of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 51 to 60 is defined as moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF of 61 to 70 is defined as 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, has some meaningful interpersonal relationships. A GAF of 71 to 80 is assigned when symptoms, if present, are transient and are expected reactions to psychosocial stressors (e.g., difficulty concentrating after family argument), with no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). See QUICK REFERENCE TO THE DIAGNOSTIC CRITERIA FROM DSM-IV, 46-7 (1994). A letter received from the Veteran's granddaughter in March 2007 refers to the Veteran's psychiatric problems, including insomnia and hyperarousal. According to a July 2007 private psychological evaluation, the Veteran complained of depression, insomnia, crying spells, and nightmares and intrusive thoughts of Vietnam. He was well oriented. The diagnoses were adjustment disorder with mixed emotional features and PTSD. The GAF score was 55. The Veteran complained on VA psychiatric evaluation in August 2007 of insomnia, hyperarousal, difficulty with energy and concentration, discomfort in crowds, depression, anxiety, and weekly panic attacks. He was not taking any medication for his PTSD. He had been married for over 20 years, and he and his wife were raising his sister-in-law's grandchildren. He denied any conflict with family or neighbors; he had made some friends in church but did not socialize on a regular basis. On mental status evaluation, he was well groomed. His speech was relevant and coherent but somewhat rambling. His mood was described as depressed and anxious; he had limited coping skills and difficulty with managing stress. He was alert and oriented; he did not have any impulse control problem; he did not have homicidal or suicidal ideation. PTSD was diagnosed, and the GAF score was 55. The Veteran's symptoms were considered moderate to serious. A September 2007 decision from the Social Security Administration (SSA) granted disability benefits effective February 8, 2007, with a primary diagnosis of hypertension and a secondary diagnosis of affective disorders. VA treatment records reveal diagnoses of PTSD, with a GAF score of 50, in March 2009, December 2009, and May 2010. A VA psychiatric evaluation for compensation purposes was conducted in March 2011. The Veteran reported nightmares of Vietnam 2-3 times a week, intrusive thoughts of Vietnam on a daily basis, and flashbacks approximately once a week. He indicated that his symptoms were getting worse. He avoided crowds, loud noises, and situations that reminded him of his military service. He had lost interest in his usual activities. He kept himself isolated from others; he had numbness and difficulty experiencing positive emotions; he only slept about three hours a night; he had irritability and outbursts of anger; and he had difficulty concentrating. He reported hypervigilance, an exaggerated startle response, and depression. He was taking medications that helped calm him down, although he said that he did not always take his medications. He reported that he last worked in 2006, when he became physically unable to do the job anymore. On mental status evaluation in March 2011, the Veteran was described as adequately groomed. He was alert and oriented, with no memory problem. His speech was somewhat pressured but goal directed. His affect was congruent to content; his mood was anxious. There was no evidence of any thought or perceptual disturbance; his communication was logical and directed. He was not experiencing suicidal or homicidal ideation. His insight and judgment were considered adequate. His fund of information and level of intelligence were in the average range. PTSD was diagnosed, and the GAF score was 48. The examiner noted that the Veteran continued to experience significant symptoms of PTSD. The Veteran testified at his videoconference hearing in May 2012 that he had to quit work because of his PTSD and right leg disabilities and that his PTSD made it difficult to deal with others, including his family. The Veteran's wife also testified as to his psychiatric problems, such as his inability to tolerate noise. A Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002); however, as the Court held in Mauerhan, without the examples noted in the rating criteria, differentiating a 50 percent evaluation from a 70 percent evaluation would be extremely ambiguous. The Board is to consider all symptoms of a Veteran's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. If the evidence demonstrates that a Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating should be assigned. Id. In determining that the preponderance of the evidence is against a rating in excess of 50 percent, the Board has considered the Veteran's complaints regardless of whether they are listed in the rating criteria. In sum, the Veteran has reported nightmares 2-3 times a week, intrusive thoughts on a daily basis, avoidance of crowds, loud noises, and situations that reminded him of his military service, loss of interest in his usual activities, depression, poor sleep, hypervigilance, exaggerated startle response, irritability, outbursts of anger, and difficulty concentrating. He has been married over 20 years, and he and his wife are raising his sister-in-law's grandchildren. Also, he had made some friends at church, but did not otherwise socialize on a regular basis. It was clinically assessed that he had limited coping skills and difficulty managing stress. On VA examination in August 2007, the examiner considered his symptoms as moderate to serious, and assigned a GAF score of 55 which is consistent with such assessment. On VA examination in August 2007, he reported he had been unable to work due to physical limitations. Despite some evidence of symptomatology indicative of a 70 percent rating, such as difficulty in adapting to stressful circumstances, the evidence during the appeal period does not show most of the symptomatology indicative of a 70 percent rating, such as suicidal ideation, obsessional rituals which interfere with routine activities, illogical or irrelevant speech, near-continuous panic or depression affecting the ability to function appropriately and effectively, spatial disorientation, and neglect of personal appearance and hygiene. In fact, when seen in August 2007, his panic attacks were noted to be weekly, rather than continuous, and he did not have an impulse control problem. He was well groomed, well oriented, and did not have suicidal or homicidal ideation in August 2007 or March 2011. His speech was relevant and coherent in August 2007 and goal directed in March 2011. His symptoms more nearly fit with a 50 percent rating, and do not approach or approximate the magnitude of the symptoms listed in the criteria for a 70 percent rating under DC 9411. Moreover, he does not have symptoms of equal or greater severity. Despite the Veteran's preference to avoid others, he maintained a relationship with his family during the rating period on appeal. The record reflects that he remains married to, and lives with, his wife and sister-in-law's grandchildren. Despite his PTSD symptoms, he is able to maintain these social relationships. The Veteran's ability to live with his wife and family members, maintain grooming and hygiene, maintain family relationships, maintain friendships in church, not have suicidal or homicidal ideation, is alert and oriented with no memory problem, and maintains goal-directed speech and adequate insight and judgment, is indicative that his impairment is not so significant as to warrant a 70 percent rating. In this case, the Veteran and his wife are competent to report his psychiatric symptoms, as indicated above. His complaints have been considered; however, the evidence does not show the severity required for a higher schedular rating based on the applicable symptomatology under the rating codes for psychiatric disorder, as discussed above. Right Leg Disability The Veteran has contended, including at his May 2012 videoconference hearing, that his service-connected right leg disability is more severe than currently evaluated. A claim for service connection for a right leg disability was granted by rating decision in August 1985, and a 10 percent rating was assigned effective November 13, 1984. A claim for increase was received by VA in January 2007, which was denied by rating decision in October 2007; the Veteran timely appealed. As noted above, a December 2011 rating decision granted service connection for a residual scar of the right tibia, 10 percent disabling; and a February 2012 rating decision granted service connection for arthritis of the right knee, 10 percent disabling. The applicable provisions of the rating schedule at 38 C.F.R. § 4.73, Diagnostic Codes 5301 to 5323 prescribe the evaluation of disabilities manifested by muscle injuries based upon the classifications of slight, moderate, moderately severe, or severe. 38 C.F.R. § 4.56(d)(1)-(4) (2012). The corresponding level of severity of a service-connected muscle injury is determined to a significant extent by the presence or absence of cardinal signs and symptoms of muscle disability, which consist of loss of power, lowered threshold of fatigue, weakness, pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c). Under Diagnostic Codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe as follows: (1) Slight disability of muscles--(i) Type of injury. Simple wound of muscle without debridement or infection. (ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section. (iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue. (2) Moderate disability of muscles--(i) Type of injury. Through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. (ii) History and complaint. Service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. (iii) Objective findings. Entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. (3) Moderately severe disability of muscles--(i) Type of injury. Through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. (4) Severe disability of muscles--(i) Type of injury. Through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56 (d) (2012) Diagnostic Code 5311 pertains to Muscle Group XI, which includes the posterior and lateral crural muscles, and muscles of the calf. This muscle group concerns the functions of propulsion, plantar flexion of the foot, stabilization of the arch, flexion of the toes, and flexion of the knee. The muscles affected consist of the: (1) Triceps surae (gastrocnemius and soleus); (2) tibialis posterior; (3) peroneus longus; (4) peroneus brevis; (5) flexor hallucis longus; (6) flexor digitorum longus; (7) popliteus; (8) plantaris. Under Diagnostic Code 5311, a noncompensable rating is assigned for a slight disability; a 10 percent rating is warranted for a moderate disability; a 20 percent rating is warranted for a moderately severe disability; and a 30 percent rating is assigned for a severe disability. 38 C.F.R. § 4.73, Diagnostic Code 5311 (2012). The Veteran's service treatment records reveal that he incurred a fragment injury to his right leg; there is no record of hospitalization. His lower extremities were normal on medical evaluation for separation in November 1968. VA treatment records for February 1985 reveal complaints of loss of motion and pain in the right lower extremity. On VA orthopedic evaluation in May 1985, the Veteran said that his right leg bothered him if he was sitting on the floor or squatting; standing might cause some numbness in the right leg. Examination did not reveal any swelling of the knee or atrophy of the calf. He walked well and was able to do a full squat. He used a cane in his right hand to walk. There was a slight increase in sensitivity to pinprick in the right leg compared to the left. He said that cold weather aggravated his right leg. X-rays showed a normal appearing right knee and proximal leg. The impression was shrapnel fragment wounds of the right calf and knee with minimal degenerative changes of the knee and no instability. According to a letter received from the Veteran's granddaughter in March 2007, he complained of problems with his right leg and he limped. It was noted on VA compensation and pension evaluation in July 2007 that the Veteran's right leg wounds were not tender; there was no muscle, artery, nerve, bone or joint damage. Range of motion of the right knee was from 0 to 125 degrees with complaints of pain. The Veteran was reported to have excellent muscle strength. The diagnosis was SFW of the right calf and knee. X-rays of the right knee were reported to show arthritis. According to a September 2007 medical report from Affinity Medical Center, related to the Veteran's application for SSA benefits, range of motion of the knees was from 0 to 120 degrees. The diagnoses included a history of chronic pain in the right leg secondary to SFW in service, history of gouty arthritis, and a history of arthritis in all big joints. It was reported that the Veteran's ability to do lifting or carrying was somewhat impaired due to neck pain and arthritis, but his ability to do other activities, such as walking without assistance was not impaired. VA treatment records for November 2008 reveal complaints of chronic right knee pain. On physical examination, there was full range of motion of the right leg, with pain at the extremes. There was no joint line tenderness, no swelling, and good stability. Knee osteoarthritis, with chronic pain, was diagnosed. According to a March 2009 private medical assessment, most of the Veteran's activities were affected by impairment due to low back and right lower extremity pain. When seen by VA in March 2009, the Veteran complained of right knee pain. Range of motion was from 0 to 110 degrees. There was mild effusion and no instability; McMurray's sign was negative. The Veteran complained on VA orthopedic evaluation in March 2011 of difficulty walking on the right leg due to right knee pain and of increased fatigability. It was reported that he had normal muscle function. Right knee range of motion was from 0 to 130 degrees. There was no additional impairment following repetitive testing. It was noted that the Veteran had retired from work in 2007 because of right leg and knee pain. The effect on his daily activities was moderate for sports and mild for chores, shopping, exercise, recreation, and traveling; there was no effect on eating, bathing, dressing, going to the bathroom, and grooming. Shrapnel wound of the right calf and knee was diagnosed. The Veteran testified at his videoconference hearing in May 2012 that his right leg ached, that his right leg gave out due to weakness, and that he used a cane to walk 5-6 times a week. His wife testified that he has right leg pain and swelling of the ankles and that it hurt him to walk. To warrant an evaluation in excess of 10 percent for right leg disability under Diagnostic Code 5311, there would need to be evidence of more than moderate impairment of the lower leg, indicative of moderately severe impairment. However, the Board notes that VA examinations in July 2007 and March 2011 do not show any significant functional impairment due to this disability. Range of motion of the right leg from 0 to at least 110 degrees. There was no loss of muscle function. Moreover, there was no additional impairment following repetitive testing; and the effect on his daily activities was no more than mild for everything but sports, which was moderately impaired, in March 2011. There is no service department record or other evidence showing hospitalization for a prolonged period for treatment of the right leg wound, which is indicative of a moderately severe wound. In fact, his lower extremities were normal on medical evaluation for separation in November 1968. There is also no objective findings involving loss of deep fascia, muscle substance, or normal firm resistance of muscles of the right lower extremity. When examined in May 1985, there was no swelling of the knee or atrophy of the calf. He walked well and was able to do a full squat. Additionally, tests of strength and endurance of the right leg did not demonstrate positive evidence of impairment. Consequently, a rating in excess of 10 percent is not warranted for the Veteran's service-connected right leg disability under Diagnostic Code 5311. As there is no medical evidence of a clear change in severity of the Veteran's right leg disability during the appeal period, a staged rating for this disorder is not warranted under Hart, supra. As noted above, the Veteran and his wife are competent to report his right leg symptoms, such as pain. His complaints have been considered; however, the evidence does not show the severity required for a higher schedular rating based on the applicable symptomatology under the rating code for a muscle injury, as discussed above. Additional Considerations Ordinarily, the Schedule will apply unless there are exceptional or unusual factors, which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular rating is warranted upon a finding that "the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2012). The schedular evaluations in this case are not inadequate. Ratings in excess of those assigned are provided for certain manifestations of the service-connected disorder at issue, but the medical evidence reflects that those manifestations are not present in this case. See 38 C.F.R. § 4.1 (2012). While the severity of the Veteran's PTSD and right leg symptomatology is indicated by the assigned ratings, the medical findings during the appeal period in question do not indicate that the Veteran's PTSD and/or right leg disability causes "marked" interference with employment. His GAF scores of 48 to 55 are indicative of moderate to serious symptoms. Although the Veteran indicated that he quit working because of his PTSD and right leg disability, he was granted SSA disability effective in February 2007 primarily due to hypertension. Moreover, when examined by VA in March 2011, muscle function in the right lower extremity was normal; and, except for sports, his right leg disability caused no more than mild impairment of daily activities. There is also no evidence of frequent periods of hospitalization due to PTSD or right leg disability. Consequently, the Board finds that the criteria for referral for the assignment of an extraschedular evaluation for PTSD and right leg disability during the period in question pursuant to 38 C.F.R. § 3.321(b)(1) are not met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). In reaching the above findings, the Board has applied the benefit-of-the-doubt doctrine. The preponderance of the evidence is against the claim for higher initial ratings for service-connected PTSD both prior to May 5, 2009 and beginning on that date. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER A rating in excess of 50 percent for PTSD is denied. A rating in excess of 10 percent for right leg disability is denied. REMAND The Court of Appeals for Veterans Claims (Court) has held that a request for TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim, or, if the disability upon which entitlement to TDIU is based has already been found to be service connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Here, the record includes the contention at the Veteran's May 2012 videoconference hearing that his service-connected PTSD and right leg disabilities caused him to stop working (hearing transcript page 7). Accordingly, the Veteran should be provided with appropriate notice as to how to substantiate a claim for TDIU. It would be fundamentally unfair to the Veteran to decide a claim which has not been developed and adjudicated by the RO. See Bernard v. Brown, 4 Vet. App. 384 (1993). In order to comply with precedential Court opinion, this issue, therefore, is remanded for further development. Therefore, the case is remanded for the following actions: 1. The AMC/RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his TDIU claim. Based on his response, the AMC/RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. All attempts to secure this evidence must be documented in the claims file by the AMC/RO. If, after making reasonable efforts to obtain named records the AMC/RO is unable to secure same, the AMC/RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the AMC/RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 2. The Veteran will be requested to submit an up-to-date VA Form 21-8940, Veterans Application For Increased Compensation Based On Unemployability, which will be added to the claims files. 3. The Veteran must be afforded an appropriate VA examination to determine the effects of his service-connected disabilities on his ability to obtain and maintain employment consistent with his education and occupational experience. The claims files and all records on Virtual VA must be made available to the examiner, and the examiner must specify in the examination report that the claims files and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records that were reviewed. All necessary special studies or tests are to be accomplished. The examiner must elicit from the Veteran and record for clinical purposes a full work and educational history. Based on the clinical examination, a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must provide an opinion as to the following: Whether it is at least as likely as not that the Veteran's service-connected disabilities preclude him from securing and following substantially gainful employment consistent with his education and occupational experience. This opinion must be provided without consideration of his nonservice-connected disabilities, or his age. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report prepared must be typed. 4. The AMC/RO must notify the Veteran that it is his responsibility to report for the examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for the aforementioned examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 5. Thereafter, the AMC/RO must review the claims files and ensure that the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. 6. Following completion of all indicated development, the AMC/RO must adjudicate the claim for entitlement to TDIU, to include consideration of all of the evidence of record, including all evidence that has been added to the record since its last adjudicative action. If the benefit sought on appeal remains denied, the Veteran will be provided a Supplemental Statement of the Case, which should include all pertinent law and regulations. The Veteran will then be given an appropriate opportunity to respond thereto. Thereafter, the case must be returned to the Board for the purpose of appellate disposition. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). The RO and the Veteran are advised that the Board is obligated by law to ensure that the RO complies with its directives, as well as those of the appellate courts. It has been held that compliance by the Board or the RO is neither optional nor discretionary. Where the remand orders of the Board or the Courts are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs