Citation Nr: 1313478 Decision Date: 04/23/13 Archive Date: 05/03/13 DOCKET NO. 10-48 089 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a rating in excess of 30 percent for degenerative disc disease of the cervical spine. 3. Entitlement to a compensable rating for degenerative disc disease of the lumbar spine. 4. Entitlement to a rating in excess of 10 percent for chondromalacia of the right knee. 5. Entitlement to a rating in excess of 10 percent for chondromalacia of the left knee. 6. Entitlement to an increased rating for left ankle sprain (claimed as fracture of left foot) rated as 0 percent since September 17, 2009, and 10 percent disabling prior thereto, to include whether a reduction was proper. ATTORNEY FOR THE BOARD T.S. Willie, Counsel INTRODUCTION The Veteran served on active duty from November 1961 to February 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. Jurisdiction rests with the Winston-Salem, North Carolina RO. FINDINGS OF FACT 1. PTSD is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. Degenerative disc disease of the cervical spine is manifested by flexion limited to 15 degrees. Unfavorable ankylosis of the entire cervical spine is not shown by the record. 3. Degenerative disc disease of the lumbar spine is manifested by forward flexion of the thoracolumbar spine greater than 85 degrees and a combined range of motion of the thoracolumbar spine greater than 235 degrees. There is also no showing of muscle spasm, guarding, localized tenderness, or, vertebral body fracture with loss of 50 percent or more of the height. 4. Chondromalacia of the right knee is manifested by slight impairment of the knee. Limitation of right knee motion is not shown. 5. Chondromalacia of the left knee is manifested by slight impairment of the knee. Limitation of motion of the left knee is now shown. 6. In the February 2010 rating decision, the RO reduced the rating for the Veteran's service-connected left ankle sprain, without observance of applicable regulation; the rating reduction is therefore void ab initio. There is no significant limitation of motion or instability shown. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 and Supp. 2012); 38 C.F.R. § 4.130; Diagnostic Code (DC) 9411 (2012). 2. The criteria for a rating higher than 30 percent disabling for degenerative disc disease of the cervical spine have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 3. The criteria for a compensable rating for degenerative disc disease of the lumbar spine have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 4. The criteria for an evaluation higher than 10 percent disabling for chondromalacia of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 5. The criteria for an evaluation higher than 10 percent disabling for chondromalacia of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 6. The February 2009 rating decision reducing the Veteran's rating for his service-connected left ankle sprain from 10 percent to 0 percent without compliance with VA regulations renders the reduction void ab initio. The criteria for a rating in excess of 10 percent have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. § 3.344, Part 4, Diagnostic Codes 5271, 5284. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met with regard to the issues decided herein. There is no issue as to providing an appropriate application or the completeness of the application. By correspondence dated in June 2009, VA advised the Veteran of the information and evidence needed to substantiate the claims. The letter provided notice of what part of that evidence is to be provided by the claimant, and notice of what part VA will attempt to obtain. The Veteran was also provided information regarding the assignment of disability ratings and effective dates. The appeal was most recently readjudicated in the September 2010 statement of the case. VA has also satisfied its duty to assist. The claims folder contains service treatment records, VA medical records, VA examinations and available private treatment records. In sum, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. 38 C.F.R. § 3.159(c). ANALYSIS Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation 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. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. The basis of disability evaluation 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. 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). 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. PTSD The Veteran's PTSD is evaluated pursuant 38 C.F.R. § 4.130 Diagnostic Code 9411, and is subject to the criteria listed under the General Rating Formula for Mental Disorders. The General Rating Formula provides a 30 percent evaluation when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment or abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for 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 work like setting); inability to establish and maintain effective relationships. A 100 percent evaluation is indicated where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. 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. 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. In assessing the evidence of record, it is important to note that the GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A score of 31 to 40 is assigned where there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). Id. A score of 41-50 is assigned where there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. A score of 51-60 is assigned where there are 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, conflict with peers or co- workers). Id. A score of 61-70 is indicated where there are some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Id. The Veteran appeals the assignment of a 30 percent rating for PTSD. Based on the evidence presented, the Board finds that a rating higher than 30 percent for PTSD is not warranted as the Veteran's symptoms are more characteristic of a disability picture that is contemplated by a 30 percent rating than that contemplated by a 50 percent rating or higher under Diagnostic Code 9411. A majority of the type of criteria contemplated for a 50 percent rating under Code 9411 have not been demonstrated. In this regard, in the June 2009 evaluation by Dr. Jabbour, it was stated that the Veteran was married with one child. He worked as a part time real estate agent. Examination revealed his speech and thought processes were within normal limits. He was cooperative and related very well. He was alert, oriented, and able to register and recall. His remote and recent memory was intact, and his insight and judgment was good. He denied auditory or visual hallucinations, and suicidal or homicidal ideation. There was no evidence of psychosis or delusions. A GAF score of 40 was assigned. The Veteran was afforded a VA examination in September 2009. During this examination, the Veteran denied suicide attempts and panic attacks. He related that he continued to work part time because of stress. He lived with his wife and related that they were doing better now but had separated in the past. He took care of personal activities, worked or did chores around the house most days and went to church two or three times a week. He attended the service only and did not socialize afterwards. He reported that he socialized no more than two or three times a month, and even then with close family members. According the Veteran, he was uncomfortable in crowds and public places but could eat at restaurants once he got himself in a position where he felt secure. His symptoms included irritability, fatigue from lack of sleep, difficulty focusing and getting along with others. Examination revealed he was alert, oriented and cooperative. There was no gross sign of thought disorder, hallucinations , delusions, obsessions, compulsions or phobias, except some mild social phobia. Insight and judgment appeared adequate, and intellectual capacity appeared to be grossly intact. He complained of some difficulty with focusing, attention and concentration. The VA examiner found that the Veteran appeared to have mild to moderate impairment in occupational realm and moderate to occasionally severe impairment in the social, recreational and familial areas. A GAF score of 58 was assigned. Based on the evidence presented, the Board finds against the claim. In this regard, the evidence shows that the Veteran presented well during his VA and private examinations. He was alert, oriented, and with normal speech and thought processes. He also denied hallucinations and suicidal/homicidal ideations. Despite some past marital discord, the Board notes that the Veteran remains married. He socializes two to three times a month, attends church and at times can eat out at restaurants. He also works part time. The evidence is devoid of a showing of thought disorder, hallucinations, delusions, obsessions and/or compulsions. In light of the above evidence, the Board finds that a rating higher than 30 percent disabling is not warranted. The Veteran has been competent and credible when reporting his symptoms. The Board acknowledges his reports to include concentration difficulty, irritability, fatigue, difficulty focusing , social avoidance and getting along with others. The above, however, have been considered and contemplated in the 30 percent evaluation. Although the Veteran has reported having occupational difficulties, social isolation and avoidance, such findings do not warrant a 50 percent evaluation when all the other manifestations are considered. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Furthermore, although an examiner's classification of the level of a psychiatric impairment, by words or by a GAF score, is to be considered but is not determinative of the percentage disability rating to be assigned (38 C.F.R. § 4.126), it is notable that for the period considered in this appeal the Veteran's more probative GAF score was 58 which is indicative of moderate symptoms. In the view of the Board, the GAF score is consistent with the Veteran's PTSD symptomatology and the assignment of a 30 percent rating. The Board recognizes that a GAF score of 40 was assigned by Dr. Jabbour in June 2009. Although this score reflects some impairment in reality testing or communication, the score is wildly inconsistent with the objective evidence of record to include the findings of Dr. Jabbour in the June 2009 evaluation. To that end, during the examination the Veteran's speech and thought processes were within normal limits and he related very well. He was also alert, oriented, and able to register and recall. His memory was intact, insight and judgment good, and he denied auditory or visual hallucinations, suicidal thoughts and homicidal thoughts. There also was no evidence of psychosis or delusions. During the September 2009 VA examination a GAF score of 58 was assigned in which similar psychological symptoms were reported. The Board acknowledges the GAF scores assigned by Dr. Jabbour. The Board, however, affords the opinion and the GAF score rendered by the VA examiner as more probative. The probative value of medical evidence is based on the medical expert's personal observation of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 471 (1993). It is not error for the BVA to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases. Owens v. Brown, 7 Vet. App. 429 (1995). Here, the Board finds that the opinion of the VA examiner was rendered after review of the record (containing pertinent information), examination and interview of the Veteran and consideration of the nature and extent of his PTSD. The opinion and GAF score is also consistent with the objective evidence of record. In sum, the Veteran's symptoms are more characteristic of a disability picture that is contemplated by a 30 percent rating and no more. Stated differently, the medical and lay evidence as well as the GAF scores establish that there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The manifestations, however, even when accepted as credible, do not establish occupational and social impairment with reduced reliability and productivity. Neither the lay or credible medical evidence shows these symptoms have been persistent or rises to the level required for a 50 percent evaluation. Accordingly, the claim is denied. CERVICAL AND LUMBAR SPINE Under the general rating formula for diseases and injuries of the spine, a 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 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 30 percent rating is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine is 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine; and 100 percent for unfavorable ankylosis of the entire spine. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. 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 cervical spine is 340 degrees and 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. Note (3): In exceptional cases, an examiner may state that because of age, body habits, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire 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 neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The Veteran appeals the denial of a rating higher than 30 percent disabling for degenerative disc disease of the cervical spine. He also appeals the denial of a rating higher than 0 percent disabling for degenerative disc disease of the lumbar spine. His disabilities are rated under Diagnostic Code 5242. The 30 percent rating contemplates periarticular pathology productive of painful motion. 38 C.F.R. § 4.59. Consideration is also given to additional limitation on repetition related to pain, fatigue, incoordination, weakness or lack of endurance. DeLuca, supra, 8 Vet. App. 202. Based on the evidence presented, the Board finds against the claims. In this regard, the September 2009 VA examination revealed complaints of cervical disk disease with radiculopathy. The Veteran had some atrophy, radiation from the neck into the shoulders, and numbness and tingling of the hands. His low back pain was to a lesser degree without radiation. It was stated that the Veteran worked as a real estate agent but was inactive because of the economy. He had no incapacitating episodes in the past 12 months from either the cervical or lumbar spine. Range of motion of the cervical spine was forward flexion to 15 degrees, extension 15 degrees, lateral flexion 10 degrees bilaterally and rotation 20 degrees bilaterally. Any effort to go further was painful and he was unable to do any significant repetitive movement because of restriction in the neck movement. Any attempt at repetitive movement did not alter his range of motion. Range of motion of the lumbar spine revealed forward flexion to 90 degrees, extension to 30 degrees, lateral flexion to 30 degrees bilaterally and rotation to 40 degrees bilaterally. He was able to do repetitive movement of the lumbar spine without any alteration of range of motion or any undue pain. Neurological testing revealed normal reflexes of the upper extremities and there were absent reflexes in the lower extremities involving the knees and ankles. Motor was normal to include the hands, arms and shoulder muscles. Motor function of the legs was also normal in the feet and ankles. In light of the evidence above, the Board finds that a rating higher than 30 percent disabling for degenerative disc disease of the cervical spine is not warranted. In this regard, the evidence does not show unfavorable ankylosis of the entire cervical spine. At most, the evidence shows flexion to 15 degrees and extension to 15 degrees. These findings are consistent with the 30 percent evaluation but not higher. The Board accepts that the Veteran has functional impairment, pain, and pain on motion. See DeLuca, supra. However, neither the lay nor medical evidence reflects the functional equivalent of the criteria required for a higher evaluation, i.e. unfavorable ankylosis of the entire cervical spine. While atrophy and some upper extremity radiation are reported, motor strength and neurological testing of the upper extremities revealed essentially no abnormality. There are no findings warranting a separate compensable rating based on additional functional impairment. The Board further finds that a rating higher than 0 percent for degenerative disc disease of the lumbar spine is not warranted. In this regard, the Board finds that there is no basis for a higher rating based on forward flexion of the thoracolumbar spine. At most, the evidence shows forward flexion of the lumbar spine limited to 90 degrees which, according to the examiner, was done quickly and easily. Repetitive movement of the lumbar spine was without any alteration of range of motion or any undue pain. Neither the lay nor medical evidence suggests the functional equivalent of forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees. Also, the September 2009 examination revealed flexion to 90 degrees, extension to 30 degrees, bilateral lateral bending to 30 degrees and bilateral rotation to 40 degrees. The Veteran's ranges of motion added together are 260 degrees. The combined ranges of motion totaling 260 degrees is well above that which would support a 10 percent rating, i.e. combined range of motion not greater than 235 degrees. Furthermore, the evidence is devoid of a showing of muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. As such, a higher rating is not warranted on this basis. With regard to neurologic abnormalities, the Board notes that the Veteran reported radiation from the neck into the shoulders and numbness and tingling of the hands. Cervical radiculopathy bilateral was diagnosed. For claims in which symptoms of a neurologic defect have been claimed or found, 38 C.F.R. § 4.120 dictates that neurological conditions and convulsive disorders are to be rated in proportion to the impairment of motor, sensory or mental function. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a , disability from neurological disorders is rated from 10 percent to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, or severe incomplete paralysis, or complete paralysis of the peripheral nerves. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123; 38 C.F.R. § 4.124. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. While the evidence demonstrates complaints of tingling and numbness of the hands, it does not demonstrate significant upper extremity neurological impairment resulting therefrom. In this regard, the September 2009 VA examination revealed normal reflexes of the upper extremities. Sensation was also intact with some diminished sensation of the fingers. Furthermore, motor strength to include the hands, arms and shoulder muscles were normal. The Veteran is competent to report his symptoms, such as numbness and tingling, the objective findings however regarding strength, sensation, and even reflexes are largely normal. The Board concludes that the findings of skilled professionals are more probative than the Veteran's lay statements and a separate compensable evaluation for bilateral upper extremity radiculopathy is not warranted. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Also, there is no evidence of any neurologic manifestations associated with the lumbar spine which require separate compensable rating. In this regard, neurological examinations reveal normal motor function in the feet and ankles, and normal sensation in the lower extremities. Accordingly, a separate compensable rating for neurological abnormalities associated with the lumbar spine is also not warranted. In reaching these determinations, the Board has considered the guidance established in section 4.120, 4.123 and 4.124. However, when rated by analogy, separate compensable evaluations are not warranted. The Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the appellant or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, the Board finds no other provision upon which to assign a higher rating. Accordingly, the claims are denied. KNEES The Veteran appeals the denial of a rating higher than 10 percent for chondromalacia of the right and left knee. His disability is rated under Diagnostic Code 5257. Diagnostic Code 5257 provides that an evaluation of 10 percent is assigned for slight recurrent subluxation or lateral instability, an evaluation of 20 percent is assigned when the impairment is moderate, and an evaluation of 30 percent is assigned when the impairment is severe. Included within 38 C.F.R. § 4.71a are multiple DCs that evaluate impairment resulting from service-connected knee disorders, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). Diagnostic code 5258 applies to dislocated semi lunar cartilage with frequent episodes of locking, pain, and effusion into the joint. A 20 percent rating applies for this disability. Diagnostic code 5259 applies to removal of symptomatic semi lunar cartilage. A 10 percent rating applies for this disability. Diagnostic Code 5260 pertains to limited flexion of the knee. A 10 percent rating applies when flexion is limited to 45 degrees. A 20 percent rating applies when flexion is limited to 30 degrees. A 30 percent rating applies when flexion is limited to 15 degrees. Diagnostic Code 5261 pertains to limitation of extension of the knee. A 10 percent evaluation is assigned for extension that is limited to 10 degrees. A 20 percent evaluation is assigned for extension that is limited to 15 degrees. A 30 percent evaluation is assigned for extension that is limited to 20 degrees. A 40 percent evaluation is assigned for extension that is limited to30 degrees. A 50 percent evaluation is assigned for extension that is limited to 45 degrees or greater. The VA General Counsel held that a Veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 (which provides for a 10 percent rating for a noncompensable limitation of motion or painful motion of an affected joint) and 5257, provided that a separate rating must be based upon additional disability. VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). Also, separate rating may be assigned for limitation of flexion and limitation of extension of the same knee. Specifically, where a Veteran has both a compensable limitation of flexion and a compensable limitation of extension of the same knee, the limitations must be rated separately to adequately compensate for functional loss associated with the disability. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). Based on the evidence of record, the Board finds that the chondromalacia of the left and right knee is no more than 10 percent disabling. In this regard, in the September 2009 VA examination the knees appeared normal. Both knees extended to 0 degrees and flexed to 132 degrees. The knees were stable in lateral and medial movement. There was no drawer sign, McMurray sign and/or crepitation. Repetitive movement of the knees was done without alteration in range of motion or pain. Normal knee examination was diagnosed. These findings are against a finding of moderate knee impairment. Rather, examination revealed normal knee. The Board has considered whether a separate compensable evaluation is warranted based on limitation of flexion and extension. 38 C.F.R. § 4.71a, Diagnostic Codes 5260-5261. It is shown, however, that the Veteran retains full extension and flexion is only limited to 132 degrees. As such, a separate rating is not warranted for limitation of flexion and/or extension. Furthermore, the evidence is devoid of a showing of ankylosis (DC 5256), dislocated semilunar cartilage (DC 5258), symptomatic removal of semilunar cartilage (DC 5259), impairment of the tibia and fibula (DC 5262), and/or genu recurvatum (DC 5253). As such, these codes are inapplicable. The Board acknowledges the Veteran's assertions that his disability is more severe than evaluated to include his reports of knee pain. The Veteran is competent to report such symptoms. See Layno v. Brown, 6 Vet. App. 465 (1994). The Board has also considered the pleadings and reports, and finds that the Veteran is credible in reporting the severity of his disability. The more credible and probative evidence, however, is devoid of a showing that he has left and right knee instability much less moderate impairment of the knee. Neither the lay nor medical evidence reflects the functional equivalent of symptoms required for a higher evaluation, i.e., the functional equivalent of moderate knee impairment. The Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the appellant or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, the Board finds no other provision upon which to assign a higher rating. Accordingly, the claims are denied. LEFT ANKLE The Veteran appeals the reduction in the disability rating for left ankle sprain, from 10 percent to 0 percent, effective September 17, 2009. Historically, the RO granted service connection for left ankle sprain in August 1994. The disability was evaluated as 10 percent disabling under DC 5284, effective March 1, 1994. This decision was not appealed and became final. See 38 U.S.C.A. § 7105. The Veteran submitted his request for an increased rating in June 2009. He was provided a VA examination in September 2009. In the September 2009 VA examination, dorsiflexion of the ankles was to 20 degrees and plantarflexion was to 45 degrees bilaterally. The Veteran was able to do repetitive movement without any alteration in range of motion. There was some edema about the posterior aspect of the ankles bilaterally. There was no pain on palpation of the ankles and repetitive movement of the ankles was done without any alteration in range of motion. Ankle sprain, remote without any residual, normal examination was diagnosed. In a February 2010 rating decision, the RO reduced the Veteran's evaluation for his left ankle disability from 10 percent to 0 percent, under DC 5284 and assigned an effective date of September 17, 2009. Where action by the rating agency would result in the reduction or discontinuance of compensation payments, section 3.105(e) requires that a rating initially proposing the reduction or discontinuance be prepared setting out all material facts and reasons for the proposed action. The regulation requires that the beneficiary of the compensation payments be notified at his or her latest address of record of the contemplated action, furnished detailed reasons therefore, and be given 60 days from the date of the notice for the presentation of additional evidence to show that the compensation payments should be continued at their present level. See 38 C.F.R. § 3.105(e). Furthermore, section 3.105 (i) requires that the Veteran be informed that he or she may request a predetermination hearing provided that the request is received by VA within 30 days from the date of the notice of the proposed rating reduction. See 38 C.F.R. § 3.105 (i)(1) . Section 3.105 directs that unless otherwise provided by the subsection 3.105(i), final rating action will be taken and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires. See 38 C.F.R. § 3.105(e) . As an initial matter, RO correctly noted in the February 2010 rating decision that the Veteran's compensation payments were not reduced as a result of the rating reduction. Therefore, the provisions at 38 C.F.R. § 3.105(e) are inapplicable. In this regard, the Veteran's combined rating remained at 80 percent before and after the effective date of the reduction (i.e., September 17, 2009) and the 'amount of compensation payable' was not reduced. See generally VAOPGCPREC 71-91 (Nov. 7, 1991) (38 C.F.R. § 3.105(e) does not apply to a proposed reduction in evaluation of individual disabilities where there is no reduction in the amount of compensation payable). The Board notes however, that the RO failed to comply with the provisions found in 38 C.F.R. § 3.344. In this regard, the Board notes that the Veteran's 10 percent rating had been in effect for at least 15 years and his rating was reduced based on one VA examination. A rating that has been in effect for 5 years or more may not be reduced on the basis of only one examination, in cases where the disability is the result of a disease subject to periodic or episodic improvement. 38 C.F.R. § 3.344. Here, the RO simply implemented a rating reduction for the Veteran's service-connected left ankle disability, from 10 percent to 0 percent, based on the results of a single examination. As the RO improperly reduced the Veteran's evaluation in this case without following the regulations, the reduction is void ab initio. The 10 percent rating is restored effective the date of the reduction, i.e., September 17, 2009. The record otherwise does reflect that the rating was assigned for the claimed fracture of the foot. The recent examination findings, the single recent exam, did reveal essentially no functional impairment. Virtually complete motion was found and there was no suggestion of instability. As such, there is no basis to assign a rating over the 10 percent rating that is restored as a result of this decision. Extraschedular Consideration The Board has considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) ; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). There are no exceptional or unusual factors with regard to the Veteran's disability. The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluation for that service-connected disability is inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical.") Here, the rating criteria reasonably describe the Veteran's disability levels and symptomatology to include pain and psychiatric symptoms, and provide for consideration of greater disability and symptoms than currently shown by the evidence. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extra-schedular consideration is not warranted. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b). (CONTINUED ON NEXT PAGE) ORDER An initial rating higher than 30 percent disabling for PTSD is denied. A rating in excess of 30 percent for degenerative disc disease of the cervical spine is denied. A compensable rating for degenerative disc disease of the lumbar spine is denied. A rating in excess of 10 percent for chondromalacia of the right knee is denied. A rating in excess of 10 percent for chondromalacia of the left knee is denied. Entitlement to restoration of the 10 percent rating for left ankle sprain (claimed as fracture of left foot) is granted. A rating in excess of 10 percent for a left ankle sprain is denied. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs