Citation Nr: 1301606 Decision Date: 01/15/13 Archive Date: 01/23/13 DOCKET NO. 09-25 278 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for residuals of a right knee injury. 2. Entitlement to service connection for residuals of a right foot injury. 3. Entitlement to an initial disability rating in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD) prior to February 1, 2008. 4. Entitlement to an initial disability rating in excess of 50 percent for service-connected PTSD from February 1, 2008. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD E. D. Anderson, Counsel INTRODUCTION The Veteran served on active duty from February 1985 to January 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2006 and December 2007 rating decisions by the Chicago, Illinois, Regional Office (RO) of the Department of Veterans Affairs (VA). In an April 2009 rating decision the RO granted entitlement to an increased 50 percent rating for PTSD effective from February 1, 2008. Because this increase does not represent a grant of the maximum benefits allowable for this disorder, the Veteran's claim remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In August 2011, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge. A copy of the transcript of that hearing is of record. At that time, the Veteran clarified that he was seeking service connection, in pertinent part, for a right foot disability and a right knee disability. In January 2012, the Board dismissed the issue of entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU) as the Veteran stated at an August 2011 personal hearing that he wished to withdraw this issue from appellate review indicating that he was gainfully employed; the Board also remanded the issue of entitlement to a higher initial disability rating for PTSD to the RO via the Appeals Management Center (AMC) in Washington, D.C. to afford the Veteran VA examinations. The action specified in the January 2012 Remand is completed, the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). The issues of entitlement to service connection for a right knee disability and a right foot disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's PTSD has been characterized for the entire period on appeal by occupational and social impairment with deficiencies in most areas. 2. The Veteran's PTSD does not result in total occupational and social impairment. CONCLUSION OF LAW The criteria for a disability rating of 70 percent but no greater for service-connected PTSD have been met for the entire period on appeal. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has reviewed all of the evidence in the claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to these claims. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2010); 38 C.F.R., Part 4 (2012). Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.7 provides that, where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding the Veteran's increased evaluation claim, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 22 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. In Fenderson, the U.S. Court of Appeals for Veterans Claims (Court) held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then-current severity of the disorder. In that decision, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126. Hart appears to extend Fenderson to all increased rating claims. As noted above, the Veteran is seeking a higher disability rating for his service-connected PTSD. The Veteran's PTSD is rated under the General Rating Formula for Mental Disorders, found at 38 C.F.R. § 4.130 (2012). A 30 percent evaluation is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss(such as forgetting names, directions, recent events). Id. A 50 percent evaluation is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficult establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where 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; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. It is further noted that the nomenclature employed in the portion of VA's Schedule for Rating Disabilities ("the Schedule") that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "the DSM-IV"). 38 C.F.R. § 4.130 (2012). The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. GAF scores ranging between 61 and 70 are assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th. ed., 1994). GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. GAF scores ranging between 41 and 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. GAF scores ranging between 31 and 40 are assigned when there is 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). Id. GAF Scores between 21 and 30 are assigned when behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). Id. Symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a) (2012). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2012). VA Psychiatry Assessment Notes from February 2006 show that the Veteran reported an eighteen year history of emotional problems and substance abuse related to his military sexual assault. Although he was currently employed as a dockworker, he had a history of poor attendance and violent behavior at work. He reported that he had missed sixty days of work in the past year due to his emotional problems. He described symptoms of anxiety, irritability, poor sleep, isolation, and inability to embrace any male, including close family members. The Veteran was assigned a GAF score of 40. In March 2006, the Veteran was afforded an Initial PTSD Evaluation. At this evaluation, the Veteran reported that his PTSD caused severe impairment in his sexual and intimate emotional life in his marriage, with his first marriage ending because of his mental illness. His PTSD also affected his employment. He reported that his current employment status was shaky because he required frequent time off due to his psychiatric problems, as well as because of interpersonal difficulties with his co-workers secondary to his PTSD. He reported that he had been forced to leave other jobs in the past because of similar problems. The Veteran was diagnosed with PTSD and assigned a GAF score of 40. A December 2006 VA Psychiatry Progress Note documents that the Veteran was frustrated and angry that he lost his job. In December 2006, the Veteran requested leave from his employer under the Family and Medical Leave Act of 1993 due to his PTSD. The form was completed by the Veteran's VA psychologist, Dr. J.Y., who reported that the Veteran suffered from "severe PTSD symptoms, including sleep disorders, social isolation, hyperarousal, hypervigilance, bouts of depression, social isolation, avoidance of reminders, [and] social incapacity." Dr. J.Y further noted that the Veteran's "condition is chronic and will continue over an extended period of time, causing episodic incapacity and requiring regular treatment." He estimated that the Veteran's incapacitating episodes would last from a day to two weeks and would occur ten to fifteen times per year. It appears that the Veteran's request for leave under the Family and Medical Leave Act has been periodically renewed. In February 2007, the Veteran's spouse submitted a statement in which she testified that the Veteran suffers from nightmares, flashbacks, anxiety, depression, panic attacks, and angry outbursts. She reported that the Veteran's nightmares occurred two to three times per week and were sometimes violent and that he had flashbacks every day. She also testified that the Veteran was too anxious to drive and that he frequently became involved in altercations at work. Finally, she indicated that the Veteran had expressed suicidal ideations and expressed her belief that the Veteran would benefit from hospitalization if he could afford it. In a March 2007 statement, the Veteran reported that he had lost his job on several occasions because of his PTSD and currently only worked on a part-time basis. He complained that even though he was receiving treatment for his PTSD from the VA twice a week, his symptoms were getting worse and he was suicidal. He also complained that he so anxious that it was hard for him to leave his home. The Veteran was afforded a VA examination of his PTSD in October 2007. At that time, the Veteran complained of a long history of frequent intrusive nightmares and flashbacks pertaining to his military sexual trauma, sleep problems, difficulties with focus and concentration, anxiety, isolation, and marital problems. The Veteran was alert and well-oriented, but anxious and depressed. He denied suicidal or homicidal ideations or psychotic thought disorder. His judgment was intact, but his insight was judged to be limited. He was diagnosed with chronic, moderate PTSD and assigned a GAF score of 57. A November 2007 Psychiatry Progress Note assigned the Veteran a GAF score of 43. A February 2008 Mental Health Treatment Plan Note assigned the Veteran a GAF score of 35 In November 2008, the Veteran was afforded another VA examination. The Veteran continued to complain of symptoms such as hypervigilance, hyper-anxiety, nightmares, headaches, restlessness, and difficulty dealing with people. He also described frequent panic attacks and acute anxiety attacks. He complained that things were getting worse for him. He reported that he worked in a warehouse, was on his third marriage, and had four children. On examination, the Veteran was alert and well-oriented. However, he was very hyper and anxious and unable to maintain attention span. His affect was limited in range and depressed. His mood was anxious. He denied suicidal or homicidal ideations, plans, or impulses. The Veteran was again diagnosed with PTSD and assigned a GAF score of 48. In a November 2008 statement, the Veteran testified that his symptoms were so severe, he was rarely able to leave his home. He was only able to work part-time. He had panic attacks on at least a daily basis, sometimes twice a day, and experienced severe anxiety in confined spaces or around other people. He was unable to sleep without medication and when he did sleep, he had nightmares. He was unable to get along with others, and was estranged from his family. In a January 2009 letter, the Veteran reported that he was working sixteen to twenty four hours a week, and that even that was too much for him. The Veteran stated that he was unable to drive and believed he was unable to work as well. In June 2009, the Veteran submitted another statement, complaining that his condition continued to worsen, that he suffered from continuous depression and increasing panic attacks, that he isolated himself from his family, that he felt like he was "losing my mind", that he was having memory and concentration problems, and that he was suicidal. Also of record are numerous letters from the Veteran's employer reprimanding him for tardiness and absenteeism. At his August 2011 videoconference hearing, the Veteran described increasing anxiety and depression, as well as nightmares and problems controlling anger. A September 2011 VA Psychology Progress Note records that the Veteran "continues to be almost totally disabled by PTSD symptoms caused by exposure to military sexual trauma. He experiences severe occupational and social impairment." The Veteran's treating psychologist, Dr. J.Y., noted that the Veteran was unable to trust others and could not tolerate even mild mistreatment by others. He frequently experienced self loathing for being abused and for being helpless to stop the abuse. He also occasionally experienced suicidal and homicidal ideations. Dr. J.Y stated that the Veteran was able to work, but then followed up by stating that the Veteran could not tolerate the social circumstances of work. In a March 2012 addendum, Dr. J.Y. explained that he had treated the Veteran for six years and that his observations of the Veteran had been gathered from numerous intensive interviews and phone calls over this period. He offered the following observations regarding the Veteran's PTSD: I have spoken to this patient at the height of social and occupational crises many, many times in these last 6 years. He is extremely sensitive and overreactive to interpersonal harassment in his social and family life, and in his life on the job. Unfortunately, he has experienced more harassment than a normal person would experience, partly because of the unusual progress of his life with severe PTSD and partly out of really bad random events. In summary, this patient has to exert massive and exhausting effort to cope with interpersonal stress, and, as a consequence of these required efforts, has had to conduct a life which requires an absolute minimal amount of social contact and minimal exposure to random interpersonal stress. He is chronically subject to wondering whether he should end his life to avoid further misery, and thinks occasionally about exacting revenge for his sexual traumatization in the military by harming whatever tormentor he has to be involved with. In other words, he is chronically suicidal and potentially homicidal. I do not believe he is likely to act on these thoughts in the course of his normal life, but maintaining this degree of safety requires massive avoidance of people and exhausting of his impulses when he has to sustain contact with others. In January 2012, the Veteran was afforded his most recent VA psychiatric evaluation. At that time, the Veteran reported that he was currently separated from his third wife and living with his parents. The Veteran described symptoms of anxiety, hypervigilance, recurrent recollections of traumatic events, difficulty falling and staying asleep, and transient suicidal ideations. He reported missing only a few hours of work. The Veteran appeared to be tense and guarded. His mood was anxious and depressed. He avoided eye contact. He spoke rapidly, but his answers were coherent and relevant. He was oriented to person, place, and time, and there was no evidence of overt psychotic symptomatology. His memory was intact and was competent to manage his benefits. The Veteran was diagnosed with PTSD and assigned a GAF score of 60. In March 2012, the Veteran submitted a statement from his spouse. She reported that the Veteran was "debilitated" by anxiety, depression, and suspiciousness. She had witnessed panic attacks and violent outbursts, as well as obsessive rituals in which the Veteran paced around the houses making sure all the doors and windows were locked. She had also heard the Veteran express suicidal and homicidal ideations. In March 2012, the Veteran also submitted a statement from E.W., his union steward. E.W. testified that he represented the Veteran on numerous occasions when he had gotten into trouble at work. He reported that the Veteran had a lot of anger issues, which led to violence. The Veteran did not work well with others, and according to E.W., could not be touched, looked at, or even talked to. E.W. also stated that he had observed the Veteran become so debilitated from panic attacks or depressed that he was unable to work. Finally, the Veteran also submitted statement from W.S., a friend. W.S. reported that he had observed the Veteran experience daily depression and panic attacks. He noted that the Veteran was hypervigilant and had talked about suicide. He also stated that the Veteran could become violent if he believed he was being threatened and opined that the Veteran could be dangerous. Based on all of the above evidence, the Board finds that the Veteran's disability evaluation should be increased to 70 percent, but no greater, for the entire period on appeal as there is evidence of occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood, due to such symptoms as chronic suicidal ideation; obsessional rituals which interfere with routine activities; near-continuous panic and depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Throughout the period on appeal, the Veteran has complained of constant anxiety and depression with at least daily panic attacks and agoraphobia; recurrent nightmares and flashbacks; difficulty sleeping; hypervigilance; frequent altercations with co-workers which have habitually jeopardized his employment; marital problems; and chronic suicidal and homicidal ideations. The Board finds these statements to be competent and credible. These complaints have been corroborated by the reports of the Veteran's VA psychologist, Dr. J.Y., who assigned GAF scores in the 30s and 40s throughout the period on appeal, indicating severe impairment. Lay statements from the Veteran's friends and family also paint a picture of an individual who is frequently debilitated by his psychiatric problems. While the VA examiners who have examined the Veteran have assigned higher GAF scores, suggesting a less severe degree of impairment, the Board has given equal weight to the opinion of the Veteran's treating psychologist. In cases such as this, where there are conflicting statements or opinions from medical professionals, it is within the Board's province to weigh the probative value of those opinions. In Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993), the U.S. Court of Appeals for Veterans Claims (Court) stated: The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicators; . . . So long as the Board provides an adequate reason or basis for doing so, the Board does not err by favoring one competent medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). Greater weight may be placed on one examiner's opinion over another depending on factors such as reasoning employed by the examiners and whether or not, and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). Additionally, the thoroughness and detail of a medical opinion are among the factors for assessing the probative value of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, the Board gives equal weight to Dr. J.Y. as to the various VA examiners because of Dr. J.Y.'s lengthy history of treatment of the Veteran; his comprehensive explanation for why he believes the Veteran is severely disabled by his PTSD; and the consistency of these findings with the descriptions of the Veteran's PTSD symptoms provided by his family and friends, those who are able to observe the Veteran's symptoms on a daily basis. However, while the Board finds that the Veteran's PTSD is severely disabling and that a 70 percent disability rating should be awarded for the period on appeal, the Board concludes that the Veteran's PTSD does not result in total occupational and social impairment, due to such symptoms as, for example: 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. All the available evidence shows that the Veteran is mentally competent. He is well-oriented to person, place, and time, and is free from delusions and hallucinations. His memory and thought processes are grossly intact. Despite his interpersonal difficulties, he is able to communicate lucidly. He is able to perform activities of daily living, including maintaining minimal personal hygiene. Furthermore, while the Veteran reports chronic suicidal and homicidal ideations, it appears he is without intent or plan. Thus, the Board finds that the Veteran's level of impairment, while severe, is not total. The Board has also considered whether the Veteran's disability warrants referral for extraschedular consideration. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2012). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. In this case, it does not appear that the Veteran has an "exceptional or unusual" disability; he merely disagrees with the assigned evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected disorder that are unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations for that service-connected disability are adequate. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is not required. See Thun, supra. For all the above reasons, entitlement to a 70 percent disability rating, but no greater, is granted for the entire period on appeal. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2011). The Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the Veteran is challenging the initial evaluation assigned following the grant of service connection. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. VA also has a duty to assist the veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's service treatment records, as well as VA treatment records. The Veteran submitted lay statements from friend, family, and colleagues, and was provided an opportunity to set forth his contentions during the August 2011 videoconference hearing before the undersigned Veterans Law Judge. The appellant was afforded a VA medical examination in October 2007, November 2008, and January 2012. These examinations are based upon review of the claims folder, and thoroughly discuss the nature and severity of the Veteran's disability as well as the functional impairments resulting therefrom. These examination reports are adequate for rating purposes. See 38 C.F.R. § 4.2. Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Entitlement to a 70 percent disability rating, but no greater, for service-connected PTSD is granted for the entire period on appeal subject to the laws and regulations governing the payment of monetary benefits. REMAND The Veteran is also seeking entitlement to service connection for a right knee disability and a right foot disability. The Veteran has proposed two theories of entitlement for these disabilities. In a September 2005 statement, the Veteran argued that the physical demands of his military duties, such a carrying extremely heavy gear over long distances and running up to five miles daily, placed strain on his knees, causing or aggravating his current disability. He also claimed that he injured his right foot when he twisted it while on a twenty mile hike. The Veteran's form DD-214 shows that his military occupational specialty was a Rifleman in the United States Marine Corps. Accordingly, the Board finds that the Veteran's accounts are consistent with the nature of his service. Additionally, the Veteran has testified at his August 2011 videoconference hearing that he was involved in an altercation with another Marine who was threatening him and he was pushed down a hill, injuring his right knee and fracturing his foot. The Veteran testified that the perpetrator of this attack was the same as the perpetrator of his sexual assault in service. The Board notes that the Veteran has been granted entitlement to service connection for PTSD based on this assault, which is presumed to have occurred. As part of the Board's January 2012 remand, the Veteran was afforded VA examination of his joints. The examiner diagnosed the Veteran with the following current disabilities: a high riding patella of the right knee, right foot hammertoes of the second through fourth digits, and bilateral knee crepitation consistent with patellofemoral disease. The examiner opined that the high riding patella of the right knee is a congenital defect and not related to service. He offered no opinion regarding the etiology of the Veteran's right foot hammertoes. However, the Board notes that the Veteran is seeking service connection for a right foot disability. While the Veteran has claimed that he fractured his right foot, and thus, the examiner focused on finding residual evidence of a fracture, the Veteran has also complained of symptoms such as pain and swelling that could be caused by a number of foot disabilities, including hammertoe. A decision by the Court, in Clemons v. Shinseki, 23 Vet. App. 1 (2009) clarified the scope of a claim on appeal by holding that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. Accordingly, on remand, the examiner is asked to offer an opinion concerning whether the Veteran's right hammertoes (and any other disabilities of the right foot) had its onset in service or is otherwise related to the Veteran's active military service. In reaching this decision, the examiner is asked to consider both of the Veteran's theories of entitlement. That is, the examiner should consider both whether the Veteran's right foot disability is the result of an injury sustained during an assault in service and whether it is consistent with the physical demands of the Veteran's service. The examiner also stated that the Veteran's patellofemoral disease does not mean the Veteran suffered any particular trauma and is most likely normal wear and tear for a man of the Veteran's age. However, it appears that in reaching this conclusion, he considered only the Veteran's second theory of entitlement- that is, he only considered whether the Veteran had an injury to his knee or knees in service from a fall caused by an assault, but did not consider whether the physical demands of the Veteran's service otherwise caused his right knee disorder beyond the normal aging process. On remand, the examiner is asked to consider both theories of entitlement in a supplemental opinion. Accordingly, the case is REMANDED for the following action: 1. Ensure that all current VA treatment records are associated with the Veteran's claims file. 2. Once this is done, the RO should refer the case to the January 2012 VA examiner for a supplemental opinion regarding the issue of service connection for disabilities of the right knee and right foot. If that examiner is unavailable, the case should be referred to another suitable examiner for review. If either the January 2012 VA examiner or any new VA examiner indicates that additional examination of the Veteran is necessary, such examination should be afforded the Veteran. The VA examiner is asked to render an opinion as to whether it is at least as likely as not (fifty percent or greater) that the Veteran's right knee (including patellofemoral disease) and/or right foot (including hammertoes) disabilities had its onset in service or is otherwise related to the Veteran's military service. In reaching his or her conclusions, the examiner should consider both whether the Veteran's claimed disabilities are consistent with a traumatic injury, and whether the physical demands of the Veteran's active military service caused the right foot and/or right knee disabilities. The Veteran's claim folder and a copy of this REMAND should be furnished to the examiner, who should indicate in the examination report that he or she has reviewed the claims file. All findings should be described in detail and all necessary diagnostic testing performed. 3. When the development requested has been completed, and the RO has ensured compliance with the requested action, this case should again be reviewed by the RO on the basis of the additional evidence. If the benefit sought is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs