Citation Nr: 1310896 Decision Date: 04/02/13 Archive Date: 04/11/13 DOCKET NO. 07-15 703 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to August 8, 2011 (excluding periods of a temporary total rating). 2. Entitlement to a rating in excess of 70 percent for PTSD since August 8, 2011. 3. Entitlement to a rating in excess of 10 percent for right knee strain. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. R. Fletcher, Counsel INTRODUCTION The Veteran served on active duty from October 1975 to November 1978. This appeal is before the Department of Veterans Affairs (VA) Board of Veterans Appeals (Board) from an August 2006 rating decision of the VA Regional Office (RO) in St. Petersburg, Florida. Jurisdiction of the claims files was subsequently transferred to the New York, New York RO. The Veteran testified at a travel Board hearing in April 2010 before the undersigned Veterans Law Judge sitting at the New York RO. The transcript of this hearing is of record. This case was remanded for additional development in April 2011. In October 2012, the claim for PTSD was increased to 70 percent rating effective August 8, 2011; thereafter, the Veteran continued his appeal. The Veteran has been awarded temporary total disability rating for PTSD for the periods from July 25, 2006, to September 30, 2006, and from August 10, 2010, to September 30, 2010, for hospitalizations over 21 days. Because the temporary total disability ratings for PTSD are the maximum rating available for this disability, his appeal for a higher initial rating for PTSD is moot for these periods. The Board notes that, in addition to the paper claims files, there is a Virtual VA electronic claims file associated with the Veteran's claims. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims files or are irrelevant to the issues on appeal. FINDINGS OF FACT 1. Prior to August 8, 2011 (excluding periods of a temporary total rating), PTSD was manifested by no more than occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to symptoms of depressed mood, anxiety and chronic sleep impairment. Symptoms such as circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impaired judgment; impaired abstract thinking; or difficulty in establishing and maintaining effective work and social relationships, were not shown. 2. Since August 8, 2011, PTSD has been manifested by deficiencies in most areas, such as work, family relations, or mood, due to such symptoms as: near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name have not been shown. 3. The Veteran's right knee strain has been manifested by complaints of pain, X-ray evidence of osteoarthritis and flexion limited to no less than 35 degrees; neither instability, recurrent subluxation, nor limited extension was present. CONCLUSIONS OF LAW 1. The criteria for rating in excess of 30 percent for PTSD prior to August 8, 2011 (excluding periods of a temporary total rating), were not met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code (DC) 9411 (2012). 2. The criteria for a rating in excess of 70 percent for PTSD since August 8, 2011, have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.130, DC 9411 (2012). 3. The criteria for a rating in excess of 10 percent for right knee strain have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5003, 5257, 5260, 5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, the Board notes that it has reviewed all of the evidence in the Veteran's claims files, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, 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 the claims. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). PTSD Under the General Rating Formula for Mental Disorders, 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 warrants a 100 percent evaluation. 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 warrants a 70 percent evaluation. Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships warrants a 50 percent evaluation. Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) warrants a 30 percent evaluation. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). The Global Assessment of Functioning (GAF) Scale considers psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness and do not include impairment in functioning due to physical (or environmental) limitations. The relevant ranges are as follows: 60 - 51 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); 50 - 41 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); 40 - 31 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; child frequently beats up younger children, is defiant at home, and is failing at school). The symptoms listed in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation 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. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Veteran submitted his original claim for service connection for PTSD in January 2006. VA treatment records dated from December 2005 to June 2006 note that he was seen for various complaints, including anger, cocaine dependence, depression, anxiety and insomnia. He attended addiction, group and individual therapy sessions. A June 2006 VA PTSD examination report notes that the Veteran was involved in a motorcycle accident during service. He was broadsided by a jeep and was hospitalized. He ultimately had to have his big toe and part of another toe amputated. Currently, he complained of recurrent nightmares, anger and irritability. On examination, the Veteran was clean and neatly groomed. He was oriented times three. His speech, thought process and thought content were unremarkable. His attitude was cooperative and friendly and his affect was normal. His mood was anxious. He had no delusions. His judgment and insight were good; he understood the outcome of his behavior and that he had a problem. He exhibited no inappropriate, obsessive, or ritualistic behavior. He had no current panic attacks, homicidal thought, or suicidal thoughts. (He had two prior suicide attempts in 2001 and 2002, prior to the appeal period.) Memory was normal. Impulse control was fair; he occasionally had outbursts of anger. The examiner noted that the Veteran was receiving Social Security disability benefits for a herniated disc in his neck; however, he also was able to work part-time for the past 13 years, as permitted by law, as a mechanic. He reported that he kept his mechanic jobs for only a few months at a time because of his problems with substance abuse and anger management. Currently he was not working. He enjoyed fishing and attended Alcoholics Anonymous (AA) meetings two or three times per week. The Veteran reported that he was married from 1979 until his divorce in 2002. He had three adult children with his ex-wife. He also had a four year old son with an ex-girlfriend. He reported that his relationships with the mothers of his children were strained. His relationship with his adult children was improving since he stopped using drugs. He indicated that he had a new girlfriend and friends from AA. The examiner opined that the Veteran had no problem with activities of daily living. The examiner noted that the GAF score was 50. VA outpatient treatment records dated from October 2006 to August 2011 note the Veteran's ongoing treatment for PTSD and polysubstance abuse. His symptoms included irritability, depression and sleep impairment. Specifically, a July 2010 psychiatry consultation report notes his complaints of depression, insomnia, worsening memory and suicidal ideation without plans. He denied hallucinations, delusions, violent behavior and homicidal ideation. On examination, his grooming and hygiene were good. Psychomotor activity was good. No thought disorders were noted. No abnormal, involuntary movements were noted. GAF score was 55. During an April 2010 travel Board hearing the Veteran testified that he did see his three children, albeit infrequently. An August 2011 VA examination report notes his complaints of depressed mood, panic attacks more than once a week, chronic sleep impairment, difficulty understanding complex commands, suicidal ideation, obsessional rituals, impaired impulse control such as unprovoked irritability with periods of violence, and disturbances of motivation and mood. The examiner noted that the Veteran was living alone and had poor social support. His family relationships were strained. He reported that he had a "friend" who helped him with his finances. He had no delusions, hallucinations, inappropriate behavior, neglect of appearance or hygiene, disorientation to time or place, or gross impairment of thought process or communication. The diagnosis was PTSD with a GAF score of 36. The examiner noted that the Veteran had occupational and social impairment with deficiencies in most areas, but was competent to manage his VA affairs. In a September 2012 addendum, the VA examiner noted that he had reviewed the Veteran's claims file. VA outpatient treatment records dated from September 2011 to August 2012 note the Veteran's ongoing treatment for PTSD. HIs symptoms included irritability, depression and sleep impairment. Specifically, in November 2011, he complained of nightmares and depressed mood. He denied suicidal ideation. Additional evidence of record includes records from SSA, which show psychiatric treatment prior to the period at issue in this appeal, and treatment for other disabilities not herein at issue. Period Prior to August 8, 2011 (Excluding Periods of Temporary Total Ratings) For the period prior to August 8, 2011 (exclusive of the periods of a temporary total rating), the Veteran's PTSD was rated at 30 percent disabling. The evidence for this period shows 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, and chronic sleep impairment. The Veteran was divorced but did have a girlfriend during this period. He was receiving Social Security disability benefits, but still worked part-time as a mechanic. He also enjoyed hobbies such as fishing. He had friends from AA and was attempting to have a relationship with his children. At no time were symptoms such as circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory ; impaired judgment; impaired abstract thinking; or difficulty in establishing and maintaining effective work and social relationships, shown, as is required for a 50 percent rating. The Board has weighed and considered the GAF scores during the entire rating period. The GAF scores have varied between 50 and 55, which reflect moderate to serious symptoms or any moderate to serious impairment in social, occupational, or school functioning. However, the Veteran's symptoms noted on examination do not correlate to the examples for that score. However, the medical evidence of record does not reflect that he exhibited the symptoms identified in the DSM-IV as serious (GAF scores ranging from 41 to 50) (no friends, unable to keep a job, severe obsessional rituals) or moderate (GAF scores ranging from 51 to 60) (circumstantial speech, occasional panic attacks OR moderate difficulty in social, occupational, or school functioning) for the period at issue. Rather, his symptoms more closely correspond to GAF scores ranging from 61 to 70, reflecting 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 generally functioning pretty well, and has some meaningful interpersonal relationships. The GAF scores ranging from 61 to 70, reflecting mild to moderate symptomatology and functional impairment, are generally consistent with the objective findings and a 30 percent rating. For all the foregoing reasons, the Veteran's claim for an initial rating in excess of 30 percent for PTSD prior to August 8, 2011 (excluding temporary total ratings), is denied. Consideration has been given to assigning a staged rating; however, at no time during the period in question (exclusive of the temporary total ratings) has the disability warranted more than a 30 percent schedular rating. Since August 8, 2011 For the period beginning August 8, 2011, the Veteran's PTSD has been rated 70 percent. The evidence for this period shows that he has not been working and isolates himself socially. His depression has been near constant and he has poor sleep and outbursts of anger. The Board has considered whether the next higher (100 percent) rating might be warranted for the period. As noted above, for the period at issue, the Veteran has been alert and oriented, and he denied hallucinations and delusions. He had no inappropriate behavior, neglect of appearance or hygiene, or gross impairment of thought process or communication. Although some concentration problems and forgetfulness is noted in the record, there has been no evidence of total loss of memory. Further, the Veteran has not been a real danger to himself or others and has been functionally cogent. He has maintained at least some social contact with his children. There has been no evidence of bizarre behavior, or total disorientation. There is accordingly no reasonable basis on which the Board can find him to be totally disabled due to his PTSD for this period. A GAF score of 36 was listed on the August 2011 examination report, reflecting 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). The medical evidence of record does not reflect that the Veteran exhibited any of the symptoms identified in the DSM-IV as 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) (GAF scores ranging from 21 to 30) for the period at issue. Therefore, this alone cannot form the basis of a higher rating. As such, the appeal is denied. Right Knee Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40 and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. When, however, the limitation of motion of the specific joint involved is noncompensable under the appropriate diagnostic code, a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. The rating schedule provides for a 10 percent rating for slight recurrent subluxation or lateral instability of the knee, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. Under DC 5258, dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint warrants a 20 percent rating. 38 C.F.R. § 4.71a, DC 5258. Next, flexion of the leg limited to 60 degrees warrants a 0 percent rating, flexion limited to 45 degrees warrants a 10 percent rating, flexion limited to 30 degrees warrants a 20 percent rating, and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, DC 5260. Extension limited to 5 degrees warrants a 0 percent rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, DC 5261. Flexion of the knee to 140 degrees is considered full and extension to 0 degrees is considered full. See 38 C.F.R. § 4.71, Plate II. VA's General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9-98, (August, 1998). Moreover, the General Counsel has also held that separate ratings may be assigned for disability of the same joint under Codes 5260 (for limitation of flexion) and 5261 (for limitation of extension). VAOGCPREC 9-2004 (September, 2004). In January 2006, the Veteran submitted his original claim for service connection for right knee disability. He had previously been awarded service connection for amputation of the toes of the right foot. A June 2006 VA examination report notes the Veteran's complaints of pain in the right knee that was precipitated by walking. On examination, range of motion of the right knee was from 0 degrees of extension to 140 degrees of flexion. All ligaments were intact. Slight tenderness and weakness was noted by the examiner. The diagnosis was right knee strain secondary loss of right toes. VA outpatient treatment records dated from July 2006 to August 2011 note the Veteran's continual complaints of right knee pain. Examination revealed decreased right knee flexion with pain. The Veteran testified during an April 2010 travel Board hearing that he had problems bending his knee and that his knee occasionally gave out. An August 2011 VA examination report notes the Veteran's history of right toe amputation. He complained of progressively worsening pain and diminishing flexion in his right knee. He also complained of giving way, instability, stiffness, weakness, incoordination, locking, tenderness and swelling in the right knee. He denied any limitations with standing. He reported that he was unable to walk more than a few yards, and used corrective shoes and a brace. The examiner noted that there was no inflammatory arthritis in the right knee. Examination revealed tenderness about the medial and lateral aspects of the knee. There was no crepitation, clicking, snapping, grinding, instability, or abnormality of the right knee. Range of motion testing revealed flexion of 35 degrees and extension of 0 degrees. There was objective evidence of pain with active motion and repetitive motion, but no additional limitations with repetitive movement. There was no instability. X-ray studies of the right knee obtained in April 2010 were normal. An MRI study obtained in August 2010 showed a mild medial collateral ligament sprain and mild osteoarthritis. There was no ankylosis of the joint. For the period of the appeal, the Veteran's right knee disability is evaluated as 10 percent disabling. Based on a review of the evidence of record, the Board concludes that he is not entitled to an increased rating for this period. A close review of the record reveals no distinct period during which the criteria for the next higher (20 percent) rating were met. Specifically, for the period at issue, the Board finds the right knee disability has been manifested by complaints of pain, X-ray evidence of osteoarthritis and flexion limited to no less than 35 degrees, without evidence of lateral instability, recurrent subluxation, or limited extension, including as a result of pain or functional loss. The evidence does not show flexion limited to 30 degrees, including as a result of pain or functional loss. Therefore, entitlement to a rating in excess of 10 percent for this disability is denied. The Board has considered alternative rating criteria but has determined that none would result in a higher rating for the Veteran's knee disability. Throughout the period of appeal, there is no evidence of extension of the right knee being limited to 15 degrees as is required for a 20 percent rating under DC 5261. Likewise, there is no evidence of moderate recurrent subluxation or lateral instability so as to merit a 20 percent rating under DC 5257. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, pain, or flare-ups. DeLuca, supra; 38 C.F.R. § 4.59. Here, the VA examiner in August 2011 found no additional loss of knee motion due to pain, fatigue, weakness, or lack of endurance following repetitive use. Additionally, the medical evidence did not demonstrate any ankylosis (DC 5256), removal of semilunar cartilage (DC 5258), impairment of the tibia and fibula (DC 5262), or genu recurvatum (DC 5263). Therefore, these diagnostic codes are inapplicable in this case. See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of diagnostic code should be upheld so long as it is supported by explanation and evidence). Additionally, the Board has taken into consideration the Veteran's complaints. However, the percentage rating assigned represents as far as can practicably be determined, the average impairment in earning capacity resulting from the knee disability and its residual condition in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. In this case, his knee disability has no more than a slight impact on his ability to work. (He is receiving Social Security disability benefits for other disabilities.) In conclusion, a higher rating is not warranted With respect to both claims, the Board has also considered his statements that his disabilities are worse. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is not, however, competent to identify a specific level of disability of these disorders according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's PTSD and right knee disability have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which these disabilities are evaluated. Moreover, as the examiners have the requisite medical expertise to render medical opinions regarding the degree of impairment caused by the disabilities and had sufficient facts and data on which to base the conclusions, the Board affords the medical opinions great probative value. As such, the Board finds these records to be more probative than the Veteran's subjective evidence of complaints of increased symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest in the outcome of a proceeding may affect the credibility of testimony). In sum, after a careful review of the evidence of record, the Board finds that the benefit of the doubt rule is not applicable and the appeals are denied. The Board has also considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(a). In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). With respect to the claim for PTSD, the Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, DC 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD has manifested difficulty sleeping, anxiety, and depression. These symptoms are part of the schedular rating criteria. In addition, the level of occupational and social impairment is explicitly part of the schedular rating criteria. In addition, the GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Moreover, all the Veteran's psychiatric symptomatology is contemplated by the schedular rating criteria, which rates by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. With respect to the claim for a right knee disability, comparing the Veteran's disability level and symptomatology to the rating schedule, the degree of disability throughout the appeal period under consideration is contemplated by the rating schedule. His right knee limitation of extension and flexion corresponds to the schedular criteria for no more than a 10 percent rating, which also incorporates various orthopedic factors that limit motion or function of the knee. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. The rating also recognizes functional impairment. For these reasons, the Board finds that the assigned schedular rating is adequate to rate the Veteran's right knee disability, and no referral for an extraschedular rating is required. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with the disabilities, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, 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 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). 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). When VCAA notice is delinquent or erroneous, the "rule of prejudicial error" applies. See 38 U.S.C.A. § 7261(b)(2) (West 2002). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In this case, letters satisfying the notice requirements under 38 C.F.R. § 3.159(b)(1) were sent to the Veteran in March and June 2006, prior to the initial RO decision in August 2006 that is the subject of this appeal. The letters informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. Based on the above, the notice deficiencies do not affect the essential fairness of the adjudication. Therefore, the presumption of prejudice is rebutted. For this reason, no further development is required regarding the duty to notify. Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In this case, all appropriate development to obtain the Veteran's service treatment records and pertinent, post-service (VA, private and Social Security Administration) medical records has been completed. In addition, he has been afforded appropriate VA examinations and provided testimony at a hearing before the Board. Therefore, the available records and medical evidence have been obtained in order to make an adequate determinations as to these claims. Significantly, neither the Veteran 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 claims that has not been obtained. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim / claims. 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 A rating in excess of 30 percent for PTSD prior to August 8, 2011 (excluding periods of a temporary total rating), is denied. A rating in excess of 70 percent for PTSD since August 8, 2011, is denied. A rating in excess of 10 percent for right knee strain is denied. ____________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs