Citation Nr: 1311513 Decision Date: 04/08/13 Archive Date: 04/19/13 DOCKET NO. 10-10 219 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a chest disability (claimed as chest pain) to include as secondary to a service connected back disability and/or a service connected respiratory disability. 2. Entitlement to service connection for insomnia, and other sleep disorders. 3. Entitlement to an initial disability rating in excess of 10 percent for a back disability (thoracolumbar spine scoliosis and degenerative disc disease.) 4. Entitlement to an initial disability rating in excess of 10 percent for obstructive pulmonary disease (claimed as respiratory condition). 5. Entitlement to an initial disability rating in excess of 20 percent for duodenal ulcers (claimed as acid reflux). 6. Entitlement to an initial disability rating in excess of 30 percent for post traumatic stress disorder (PTSD) with obsessive-compulsive disorder (OCD). 7. Entitlement to an initial disability rating in excess of 10 percent for left knee patellofemoral syndrome. 8. Entitlement to an initial disability rating in excess of 10 percent for right knee patellofemoral syndrome. REPRESENTATION Appellant represented by: Wounded Warrior Project ATTORNEY FOR THE BOARD H.J. Baucom, Associate Counsel INTRODUCTION The Veteran had active service from December 2001 to November 2008. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a December 2008 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Winston-Salem, North Carolina, which granted service connection and assigned the following ratings: a back disability with a 10 percent rating, obstructive pulmonary disease with a 10 percent rating, duodenal ulcer with a 10 percent rating, obsessive compulsive disorder with insomnia with a 10 percent rating, noncompensable left knee disability and noncompensable right knee disability. The rating decision also denied service connection for chest pain. During the pendency of the appeal a November 2011 rating decision from the RO in Roanoke, Virginia, expanded the obsessive compulsive disorder to include PTSD and increased the initial rating to 30 percent, increased the initial rating for duodenal ulcer to 20 percent, increased the initial rating for the left knee to 10 percent and increased the initial rating for the right knee to 10 percent. As these are not complete grants of benefits, the issues remain on appeal. In July 2012 the Veteran was informed that he had been scheduled for a Board hearing at the RO in Roanoke, Virginia in August 2012. He failed to report as scheduled. The Veteran responded that he was not able to appear for the hearing in Roanoke. He stated that he thought hearings were held at the McGuire VA hospital in Chesterfield, Virginia and he would like to be scheduled for a hearing there as he cannot travel to the RO. Board hearings are not held at VA hospitals. As the Veteran did not ask to reschedule the hearing at the RO or Central Office in Washington DC, as has otherwise not presented good cause for his failure to report to the hearing, the case will be decided on the record. 38 C.F.R. § 20.704(d). The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. The issue of service connection for insomnia, and other sleep disorders, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A chest disability (claimed as chest pain) was not first shown during service or within the first post-service year, and the medical evidence of record does not show that a current chest disability (claimed as chest pain), if any, is otherwise related to any disease or injury in service. 2. The back disability is manifested by painful, limited motion, with functional loss of forward flexion and scoliosis. There is no unfavorable ankylosis or objective findings of neurological abnormalities. 3. The service connected obstructive lung disease is manifested by FEV-1 of 76 percent predicted and FEV-1/FVC of 78 percent at the worst. FEV-1 of 56 to 70 percent predicted or FEV-1/FVC of 56 to 70 percent has not been demonstrated at any time during the period on appeal. 4. The Veteran's duodenal ulcer is manifested by frequent acid reflux and occasional hematemesis. There are no manifestations of anemia or weight loss and no recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. 5. The Veteran's overall psychiatric disability picture encompasses occupational and social impairment with occasional decrease in work efficiency. 6. The left knee patellofemoral syndrome is manifested by a torn meniscus with no evidence of locking, pain and effusion. There is no limitation of motion and no documented arthritis. 7. The right knee patellofemoral syndrome is manifested by limitation of motion of 135 degrees of flexion at the worst. There is no documented arthritis. CONCLUSIONS OF LAW 1. The criteria for service connection for a chest disability (claimed as chest pain) have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107, 7104 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. The criteria for the assignment of a 40 percent initial rating, but no more, for a back disability have been met. 38 U.S.C.A. §§ 1155, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5242. 3. The criteria for the assignment of an initial rating greater than 10 percent for obstructive lung disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.96, 4.97, Diagnostic Code 6604 (2012). 4. The criteria for an initial rating greater than 20 percent for duodenal ulcer are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.1-4.7, 4.114, Diagnostic Code 7305 (2012). 5. The criteria for an initial 30 percent rating, but no greater, for PTSD and OCD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.130, Diagnostic Code 9411 (2012). 6. The criteria for an initial rating in excess of 10 percent for left knee patellofemoral syndrome have not been met. 38 U.S.C.A. §§ 1155, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5010, 5019, 5256, 5257, 5260, 5261, 5262, 5263 (2012). 7. The criteria for an initial rating in excess of 10 percent for right knee patellofemoral syndrome have not been met. 38 U.S.C.A. §§ 1155, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5010, 5019, 5256, 5257, 5260, 5261, 5262, 5263 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance 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. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). A letter was provided to the Veteran prior to discharge satisfying the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). This letter also the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's service treatment records and VA medical treatment records have been obtained; he did not identify any additional private or VA treatment records pertinent to the appeal. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Board has reviewed the Veteran's "Virtual VA" file. The Veteran has not indicated, and the record does not contain evidence, that he is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159 (c) (2). A VA examinations were conducted in June 2008, April 2010 and February 2012; the Veteran has not argued, and the record does not reflect, these examinations were inadequate for rating purposes. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The examinations were adequate as the examiners diagnosed the Veteran's disabilities and evaluated the Veteran's current disability level and provided findings to allow for proper application of the rating criteria. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). Service Connection Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). To establish service connection, there must be a competent diagnosis of a current disability; medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. The Veteran reports that his chest pain is related to his back pain and it has been bothering him since service. At the June 2008 pre-discharge examination the Veteran reported experiencing chest pain once a week for about 10 to 30 minutes. He stated that he gets chest pain and shortness of breath when he gets back pain. The Veteran reported pain and discomfort over his chest area, stabbing pain which feels like a heart attack but the physician told him it was due to his back. The examiner noted there was no specific diagnosis for the chest pain. The Veteran denied congestive heart failure, a history of rheumatic heart disease, and heart attack. Heart examination was normal with no congestive heart failure, cardiomegaly or cor pulmonale. X-rays of the chest were negative. The examiner concluded that there was no diagnosis because there was no pathology to render a diagnosis. Although the Veteran complained of chest pain there was no objective evidence with a normal EKG and normal chest x-ray. While the Veteran may suffer from occasional chest pain, and there is no reason to doubt the Veteran's credibility regarding such chest pain, the fact remains that there are no medical findings of a disability for which service connection may be established. The most current medical evidence or record consists of the June 2008 pre-discharge exam which concluded there was no diagnosed condition related to chest pain. Pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted, unless there is a medical nexus linking the veteran's pain to an incident in service. See Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). A claim based on "pain alone" fails when there is no sufficient factual showing that the pain derived from an in-service disease or injury. Such pain cannot be compensable in the absence of proof of an in-service disease or injury to which the current pain can be connected by medical evidence. Disability compensation for veterans derives from two statutes, sections 1110 and 1131. Both provide for compensation, beginning with the following words; "For disability resulting from personal injury suffered or disease contracted in line of duty..." Thus, in order for a veteran to qualify for compensation under those statutes, the veteran must prove the existence of current disability and that a disability has resulted from a disease or injury that occurred in the line of duty. See Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Absent evidence of an actual diagnosed disabling condition of the heart or chest, the Veteran's claim of service connection must fail. It is essential that there be a current disability in order to establish service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). The Veteran's factual recitation as to his symptoms is accepted as true. However, as a layperson, lacking in medical training and expertise, the Veteran cannot provide a diagnosis for his condition and his views are of no probative value. And, even if his opinion was entitled to be accorded some probative value, it is far outweighed by the lack of in-service and post-service medical evidence. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In sum, there is no objective evidence of a current chest disability or chest pain diagnosis. The preponderance of the evidence is against the claim of service connection for a chest disability (chest pain); there is no doubt to be resolved; and service connection is not warranted. 38 U.S.C.A. § 5107(b), Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Increased ratings In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). 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 importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found, however. This practice is known as "staged" ratings." Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the evidence for and against a claim is in equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. 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 required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. The Schedule provides for consideration of additional functional impairment due to pain, weakness, fatigue, incoordination, and lack of endurance when assigning evaluations. 38 C.F.R. § 4.40, 4.45, 4.59; see DeLuca v. Brown, 8 Vet. App. 202 (1995), Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Back disability The Veteran was assigned an initial rating of 10 percent disabling for a back disability (thoracolumbar spine scoliosis and degenerative disc disease.) The General Rating Formula for Disease and Injuries of the Spine requires that a back disability be evaluated under whichever method results in the higher evaluation, when all disabilities are combined, under 38 C.F.R. § 4.25, and the spine is to be evaluated with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Under the General Rating Formula, a 20 percent evaluation contemplates forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation would be assigned where forward flexion of the lumbar was spine limited to 30 degrees or less or favorable ankylosis of the thoracolumbar spine. A 50 percent evaluation would be assigned if the medical evidence shows unfavorable ankylosis of the entire thoracolumbar spine; and a 100 percent evaluation would be assigned for unfavorable ankylosis of the entire spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Notes (1) following the General Rating Formula stipulates that any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately, under an appropriate diagnostic code. Note (2) reflects that for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. Note (4) indicates that range of motion measurements should be rounded to the nearest five degrees. Note (5) stipulates that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire thoracolumbar spine is fixed in flexion or extension and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurological symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. See 38 C.F.R. § 4.71a, Diagnostic Code 5235 through 5242, effective September 26, 2003. The Veteran began to have severe back pain during service. X-rays taken in March and April 2007 revealed mild degenerative changes, as well as scoliosis. The Veteran was recommended for a Medical Evaluation Board and the Physical Evaluation Board found him unfit for service based upon his back disability. At the June 2008 pre-discharge examination the Veteran reported having pain in his back for the last six years constantly. He reported the pain is 10/10 brought on by physical activity, stress or by itself. The Veteran reported that walking, climbing stairs, driving a car, taking out the trash, and pushing a lawnmower caused back pain. Upon physical examination the Veteran's posture and gait were normal and he did not require any device for ambulation. Range of motion testing revealed flexion to 90 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees, and right and left lateral rotation to 30 degrees. No pain was noted in the range of motion testing chart however the examiner's diagnosis of thoracolumbar scoliosis and degenerative disc disease of the lumbar spine found there was painful range of motion of the lumbar spine and increased pain with repetitive range of motion. There was increase in pain but no fatigue, weakness, lack of endurance or incoordination after repetitive motion of the back. There was no radiation of pain on movement, muscle spasm or tenderness. Straight leg raising test was negative bilaterally. The Veteran was noted to have scoliosis. The Veteran did not have intervertebral disk disease at the time. There was no evidence of erectile, bowel or bladder dysfunction. Neurological examination was normal. In November 2009 the Veteran was seen at a VA pain management center at which time he reported prior back treatment of nerve block, epidural steroids, physical therapy and TENS unit. Upon physical examination motor strength was good, straight leg testing was negative, and there was intact sensory of the bilateral lower extremities. The preliminary diagnosis included lumbar radiculopathy. A November 2009 MRI revealed levoconvex curvature of the lumbar spine with a prominent rotary component and disc protrusions at L4-5 and L5-S1 with mass effect upon the left L5 and right S1 nerve roots. In November 2010 the Veteran had a steroid injection in his back. At a February 2012 VA examination the Veteran reported current symptoms of back pain, sciatica, numbness, burning and discomfort. Range of motion testing found forward flexion to 85 degrees, extension to 30, right and left lateral flexion to 30 degrees and right and left lateral rotation to 30 degrees. All testing revealed objective evidence of painful motion beginning at 0 degrees. The examiner noted no additional limitation in range of motion testing after repetitive motion but did note functional loss and/or functional impairment of the spine due to pain on movement. The Veteran had localized tenderness. Muscle strength, reflex and sensory examinations were all normal. The examiner did not find the Veteran to have radiculopathy or intervetebral disc syndrome. The Board finds that a higher initial rating of 40 percent rating is warranted. The examiner specifically found that the Veteran had functional loss and impairment due to pain on movement. He has pain beginning at 0 degrees in every range of motion. It is not the pain, but the functional impairment caused by pain, that reduces the range of motion such that it more nearly approximates the criteria for the next higher rating of 40 percent. Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). A rating in excess of 40 percent, however, is not warranted as there is no evidence of unfavorable ankylosis of any part of the spine. Intervertebral disc syndrome (Diagnostic Code 5243) may be rated under the General Rating Formula above, or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever provides for the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. A 20 percent rating is assigned for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is assigned for incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks during the past 12 months. A 60 percent rating is assigned for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note 1 provides that for the purposes of evaluations under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. The Veteran is not currently diagnosed with intervetebral disc syndrome however, as there is no evidence of any incapacitating episodes requiring bedrest prescribed by a physician, a higher evaluation under Diagnostic Code 5243 is not warranted. Note 1 under The General Rating Formula provides for separate evaluations for any associated objective neurologic abnormalities. 38 C.F.R. § 4.71a. The Veteran has reported pain radiating down his legs however there are no objective findings of neurologic abnormalities despite multiple examinations. Without evidence of any objective neurologic abnormalities, a separate evaluation for such is not warranted. Obstructive pulmonary disease The Veteran's respiratory condition is initially rated at 10 percent under Diagnostic Code 6604 for chronic obstructive pulmonary disease. Diagnostic Code 6604 provides ratings for chronic obstructive pulmonary disease. Forced Expiratory Volume in one second (FEV-1) of 71- to 80-percent predicted value, or; the ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of 71 to 80 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) is 66- to 80-percent predicted, is rated 10 percent disabling. FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56- to 65-percent predicted, is rated 30 percent disabling. FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit), is rated 60 percent disabling. FEV-1 less than 40 percent of predicted value, or; FEV-1/FVC of less than 40 percent, or; DLCO (SB) of less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy, is rated 100 percent disabling. 38 C.F.R. § 4.97. When evaluating based on pulmonary function tests (PFTs), use post-bronchodilator results in applying the evaluation criteria in the rating schedule unless the post-bronchodilator results were poorer than the pre-bronchodilator results. In those cases use the pre-bronchodilator values for rating purposes. 38 C.F.R. § 4.96. At a June 2008 VA pre-discharge examination the Veteran reported that he gets shortness of breath with his back pain which causes chest pain. A pulmonary function test was conducted which found the flow rate (FEV1/Forced Vital Capacity) to be 76 percent, and the FEV-1/FVC to be 78 percent, both after the use of the bronchodilator. The Veteran gave a good effort, and the interpretation of the results was mild restriction with mild obstruction with no significant improvement with the bronchodilator. Chest x-rays did not reveal any abnormalities of the chest or lung area. The lung examination was normal without any wheezing, rales, or rhonchi. There was no evidence showing that the Veteran required continuous medication for this condition. In February 2012 a pulmonary function test was conducted in conjunction with a VA examination with FEV-1 of 83 percent, and FEV-1/FVC of 93 percent, both post bronchodilator. The Veteran reported the use of intermittent inhalation bronchodilator but not oral bronchodilator. The examiner noted there to be partial impairment of physical activities of employment due to COPD as the Veteran reported he is "unable to function when flare-ups occur." While the Veteran's subjective complaints of difficulty breathing have been considered, an initial rating higher than 10 percent is not warranted as the evidence does not demonstrate pulmonary function tests with FEV-1 of 56 to 70 percent predicted; or FEV-1/FVC of 56 to 70 percent; or DLCO (SB) 56 to 65 percent predicted. Duodenal ulcers The Veteran's duodenal ulcer is rated under 38 C.F.R. § 4.114, Diagnostic Code 7305. Diagnostic Code 7305 provides the rating criteria for duodenal ulcers. A moderate duodenal ulcer with recurring episodes of severe symptoms 2 or 3 times a year averaging 10 days in duration or with continuous moderate manifestations warrants a 20 percent rating; a 40 percent rating is assigned for moderately severe ulcer disease manifested by symptoms less than "severe" but with impairment of health manifested by anemia and weight loss, or recurrent incapacitating episodes averaging 10 days or more in duration at least 4 or more times a year; and a 60 percent rating is assigned for severe symptoms manifested by pain which is only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis(vomiting of blood) or melena(black tarry stools), with manifestations of anemia and weight loss productive of definite impairment of health. The Veteran reported frequent heartburn on his exit examination and VA treatment records show continuous treatment for frequent heartburn. At the June 2008 pre-discharge examination the Veteran reported symptoms of difficulty swallowing, pain behind the stomach, heartburn, pain behind the breastbone, reflux, regurgitation and chest pain. Examination was within normal limits. A June 2008 upper GI found several mucosal ulcerations within the duodenal bulb measuring up to three millimeters in diameter. These cause mild spasms through this region. There was a normal swallowing function noted fluoroscopically, and there are no esophageal mass lesions, constricting lesions, or areas of mucosal ulceration. There is no hiatal hernia or gastroesophageal reflux noted. The body of the stomach is normal, and the C-loop and proximal small bowel have a normal mucosal pattern. The Veteran has reported severe acid reflux where he coughs up blood with bad attacks and that he takes medication two to three times per day. The Veteran is competent to report his symptomatology and his reports are credible. However a higher initial rating for duodenal ulcers is not warranted unless the ulcer disease symptoms, either severe or moderately severe, cause an impairment of health as manifested by anemia and weight loss. The Veteran has moderately severe symptoms of acid reflux with hematemesis however there is no evidence of anemia or weight loss. There is no evidence of recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. As such, a higher rating is not warranted. Psychiatric disability The Veteran's PTSD with OCD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Psychiatric disabilities are evaluated under a general rating formula for mental disorders. All psychiatric disabilities are evaluated together regardless of the diagnoses. Under the general rating formula, a 30 percent rating is warranted 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, mild memory loss (such as forgetting names, directions, recent events). A disability rating of 50 percent rating is warranted 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 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 effective work and social relationships. A disability rating of 70 percent is warranted when the psychiatric disorder results in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, 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 an 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. A total schedular rating of 100 percent is assigned when the condition results in 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 mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The symptoms recited in the criteria in the rating schedule 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. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. The Global Assessment of Functioning (GAF) scale reflects the psychological, social and occupational functioning under a hypothetical continuum of mental illness. See American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV); see also Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). A GAF score between 31 and 40 is indicative of some impairment in reality resting or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A GAF score between 41 and 50 is indicative of 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. A GAF score between 51 and 60 is indicative of 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 coworkers). Id. A GAF score between 61 and 70 is indicative of mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, but generally functioning pretty well, has some meaningful interpersonal relationships. Id. The evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Rather, all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV, are to be considered. See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, then the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Federal Circuit has embraced the CAVC's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). At the July 2008 mental health examination the Veteran appeared to have a lot of anxiety and tension. He reported poor sleep with problems falling asleep, staying asleep, and nightmares about once a month. At the time he reported getting along well with his spouse and child. He was able to do chores and go out. Upon examination the Veteran was neatly groomed and dressed and his behavior was normal and cooperative. Speech and thought content was normal with no suicidal or homicidal ideation. The Veteran had some anxiety and OCD. He denied panic attacks. The Veteran was oriented and his concentration, memory, judgment, and insight were good. He reported that his OCD interfered with his life some. The examiner diagnosed OCD and insomnia with a GAF score of 65. In August 2009 the Veteran reported poor energy and insomnia. In October 2009 he reported irritability, insomnia, and nightmares. His judgment and insight were noted as fair and he was diagnosed with post traumatic stress disorder with a GAF score of 60. In November 2009 the Veteran reported difficulty with anger management, and he was noted to be irritable and anxious. At the April 2010 VA PTSD examination the Veteran reported being divorced with three children but he currently lives with his girlfriend with whom he has a good relationship. He also has a good relationship with his peers and his girlfriend's family. The Veteran reported enjoying riding his motorcycle, target shooting, spending time at the beach, and being outdoors in general. The Veteran reported that he was employed full time and that he had several social relationships. His OCD symptoms reduced the efficiency of the Veteran's functioning in his everyday life although he stated that his OCD symptoms are not as bad as they were when he was in the military. Upon examination the Veteran was neatly groomed. He had restless psychomotor activity, normal speech, and was cooperative with appropriate affect. The Veteran's mood was irritable. He denied delusions, hallucinations, panic attacks, inappropriate behavior, and suicidal or homicidal ideation. The Veteran had normal judgment and insight. He reported difficulty falling asleep, and stated that he felt fatigued throughout the day. The Veteran had good impulse control, with a mildly impaired remote memory. He reported difficulty concentrating, hypervigilance, and an exaggerated startle response. The Veteran reported that he did not feel as emotionally attached to others and is chronically fatigued. The examiner diagnosed PTSD and OCD with a GAF score of 71. The examiner concluded that the prognosis was good as the Veteran currently is working fulltime and has established a personal relationship with a woman and her family, noting that this was in spite of not currently being treated for PTSD or OCD. The Veteran's psychiatric disability warrants a higher 30 percent initial rating as his overall disability picture encompasses symptoms of occupational and social impairment with occasional decrease in work efficiency. He has some mild impaired memory and disturbances of mood. The Veteran is emotionally detached, irritable, and hypervigilant with sleep impairment. A higher 50, 70, or 100 percent rating is not warranted as the overall disability picture does not encompass symptoms of occupational and social impairment with reduced reliability and productivity. Notably the Veteran is now married, is responsible for his children, maintains social contact with others, and is employed fulltime as referenced in his August 2012 letter. Left and Right Knee Patellofemoral Syndrome 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. At the June 2008 pre-discharge examination the Veteran reported weakness, stiffness and stabbing pain in his knees. He reported experiencing pain in his knees intermittently two times a day which lasts for minutes or hours. The Veteran reported not being able to run or do impact activities when his knees hurt. Upon physical examination the Veteran's knees were normal in appearance. There was bilateral crepitus. Range of motion was within normal limits without pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. There was no ankylosis. Range of motion was flexion to 140 degrees, and extension to 0 degrees, on the right and left. Varus and valgus are negative bilaterally. Drawers and McMurray's are negative bilaterally. At the February 2012 VA examination the Veteran reported flare ups of pain. Range of motion testing showed right knee flexion to 135 degrees and extension to 0 degrees with no objective evidence of painful motion. Left knee flexion was 140 degrees and 0 degrees extension with no objective evidence of painful motion. After repetitive testing left and right knee flexion was 140 degrees. No additional limitation of range of motion of the knee was noted after repetitive testing. The examiner did note functional loss of bilateral crepitus and positive McMurray on the left. The examiner found no subluxation or instability. The examiner did note a meniscal tear (semilunar cartilage) in the left knee with no meniscectomy. There was no arthritis documented as x-rays of the left and right knee were negative. The left and right knee patellofemoral syndrome disabilities are rated at 10 percent under Diagnostic Code 5260- 5019. Diagnostic Code 5019 is bursitis which instructs to rate the disability on the limitation of motion, as arthritis degenerative. The regulations define normal range of motion for the leg as zero degrees of extension and 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate I. Diagnostic Code 5260 is for actual or functional limitation of flexion. Under Diagnostic Code 5260, limitation of flexion of the knee warrants a zero percent rating when flexion is limited to 60 degrees; a 10 percent rating when limited to 45 degrees; a 20 percent rating when limited to 30 degrees; and a 30 percent rating when limited to 15 degrees. The only limitation of motion of flexion of the knee was on the right side to 135 degrees which is noncompensable. As there is no actual or functional limitation of flexion limited to 45 degrees or less on either side a compensable rating under Diagnostic Code 5260 for the left or right knee is not warranted. Diagnostic Code 5261 is for actual or functional limitation of extension. Under Diagnostic Code 5261, limitation of extension of the leg warrants a zero percent rating when extension is limited to 5 degrees; a 10 percent when extension is limited to 10 degrees; 20 percent when limited to 15 degrees; 30 percent when limited to 20 degrees; 40 percent when limited to 30 degrees; and 50 percent when limited to 45 degrees. As there is no actual or functional limitation of extension on the left or right knee, a compensable rating under Diagnostic Code 5261 is not warranted. When there is limitation of motion of the knee that is noncompensable under Diagnostic Code 5260 and Diagnostic Code 5261 and there is objective evidence of arthritis, as confirmed by an x-ray, or the rating code instructs to rate the disability as arthritis, a maximum 10 percent rating may be assigned under Diagnostic Code 5003 for noncompensable limitation of motion which is what has been assigned for the left and right knee patellofemoral syndrome. The February 2012 VA examiner noted torn meniscus (semilunar cartilage) in the left knee. Diagnostic Code 5258 provides a rating for dislocated semilunar cartilage with locking, pain and effusion. There is objective evidence of dislocated semilunar cartilage however as there is no evidence of locking, pain and effusion a separate rating for the left knee under Diagnostic Code 5258 is not warranted. As there was no removal of semilunar cartilage which is symptomatic therefore Diagnostic Code 5259 is not for application. There is no ankylosis, impairment of the tibia and fibula or genu recurvatum therefore Diagnostic Codes 5256, 5262 and 5263 are not for application Additional ratings for the left and right knee patellofemoral syndrome under any of the potentially applicable diagnostic codes are not warranted. Extraschedular Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, a determination must be made as to whether the schedular criteria reasonably describe a veteran's disability level and symptomatology. Id. At 115. If the schedular rating criteria do reasonably describe a veteran's disability level and symptomatology, referral for extraschedular consideration is not required and the analysis stops. Id. If the schedular rating criteria do not reasonably describe a veteran's level of disability and symptomatology, a determination must be made as to whether an exceptional disability picture includes other related factors, such as marked interference with employment and frequent periods of hospitalization. Id. At 116. If an exceptional disability picture including such factors as marked interference with employment and frequent periods of hospitalization exists, the matter must be referred 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. Ratings in excess of that assigned are provided for certain manifestations of the service-connected disabilities discussed above but for the reasons and bases discussed above, those manifestations are not present in this case. The evidence demonstrates that the schedular criteria reasonably describes the Veteran's disability level and referral for consideration of an extraschedular evaluation is not warranted here. ORDER Service connection for a chest disability (claimed as chest pain) to include as secondary to a service connected back disability and/or a service connected respiratory disability is denied. An initial disability rating of 40 percent for a back disability (thoracolumbar spine scoliosis and degenerative disc disease) is granted subject to laws and regulations governing the payment of monetary benefits. An initial disability rating in excess of 10 percent for obstructive pulmonary disease (claimed as respiratory condition) is denied. An initial disability rating in excess of 20 percent for duodenal ulcers (claimed as acid reflux) is denied An initial disability rating of 30 percent only for post traumatic stress disorder (PTSD) with obsessive-compulsive disorder (OCD), is granted subject to laws and regulations governing the payment of monetary benefits. An initial disability rating in excess of 10 percent for patellofemoral syndrome, left knee is denied. An initial disability rating in excess of 10 percent for patellofemoral syndrome, right knee is denied REMAND A remand for examination and separate adjudication of the claim for service connection for a sleep disorder, to include insomnia is required. The Veteran contends that his insomnia began in service separate and apart from his psychiatric disorders. The July 2008 mental health VA examiner noted that the Veteran had sleep problems which might be due to the obsessive compulsive disorder and back problems but might also be a separate sleep problem. The Veteran was diagnosed with insomnia. At more recent VA examinations the Veteran has reported an increase in sleep difficulties such as trouble falling asleep, staying asleep, and being chronically fatigued. A remand for a medical opinion as to the etiology of the Veteran's insomnia and sleep disorders, and to determine whether it is a separate disability. Accordingly, this matter is REMANDED for the following action: 1. Schedule a VA examination to determine the etiology of the Veteran's insomnia, or any other sleep disorders. Conduct all testing as indicated. The examiner is to note that the Veteran is competent to report symptomatology he has experienced in service and post service. The examiner is to diagnose all current sleep disorders and provide an opinion as to the etiology of the Veteran's insomnia, and any other sleep disorders. The examiner shall provide an opinion as to whether the Veteran's insomnia, as diagnosed in July 2008 in service, is related to his psychiatric disabilities or his back disabilities or whether is a separate disability. The entire claims file (i.e. both the paper claims file and any medical records contained in Virtual VA) should be made available to and be reviewed by the examiner in conjunction with the examination. If the examiner does not have access to Virtual VA, any treatment records contained in Virtual VA file must be printed and associated with the paper claims file so they can be available to the examiner for review. 2. Thereafter, the RO/AMC must review the claims file to ensure that all of the foregoing requested development is completed, and arrange for any additional development indicated. Then adjudicate the claim for insomnia, and any other sleep disorder. If the benefit sought remains denied, issue an appropriate supplemental statement of the case and provide the Veteran and his representative the requisite period of time to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter 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). ______________________________________________ MATTHEW D. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs