Citation Nr: 1316836 Decision Date: 05/22/13 Archive Date: 05/31/13 DOCKET NO. 09-03 442A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for a left shoulder disability, including as secondary to service connected disabilities. 2. Entitlement to service connection for a left knee disability, including as secondary to service connected disabilities. 3. Entitlement to a rating in excess of 10 percent for a low back disability. 4. Entitlement to an increase in the "staged" (50 percent prior to May 17, 2012, and 70 percent from that date) ratings for posttraumatic stress disorder (PTSD), with major depression. 5. Entitlement to a rating in excess of 50 percent for post traumatic vascular headaches, to include extraschedular consideration. REPRESENTATION Appellant represented by: Illinois Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD M. Young, Counsel INTRODUCTION The appellant is a Veteran who retired from active duty in April 2005 after 20 years of service beginning in April 1985 and was awarded a Combat Action Ribbon. These matters are before the Board of Veterans' Appeals (Board) on appeal from an April 2006 rating decision and July 2009 decision review officer (DRO) decision by the Chicago, Illinois Department of Veterans Affairs (VA) Regional Office (RO). The April 2006 rating decision, in pertinent part, denied service connection for left knee, neck, and left shoulder disabilities, and granted service connection for a back "condition", rated 10 percent, and depression, rated 50 percent, each effective May 1, 2005. An interim, September 2007, rating decision recharacterized the Veteran's service-connected psychiatric disability as PTSD with major depression, and continued the 50 percent rating. An interim December 2008 (notice letter dated in January 2009) DRO decision granted service connection for degenerative joint disease (DJD) of the cervical spine, rated 0 percent, effective May 1, 2005. A July 2009 DRO decision increased the rating for headaches to 50 percent effective May 1, 2005. In May 2010 the Veteran filed a notice of disagreement (NOD) expressing disagreement with that decision. In September 2011, a Travel Board hearing was held before the undersigned. A transcript of that hearing is associated with the claims file. In March 2012, the Board remanded these matters for additional development. A November 2012 rating decision increased the rating for PTSD with major depression to 70 percent, effective May 17, 2012. The issuer is characterized to reflect that "staged" ratings are assigned, and that both stages are on appeal. In his May 2010 NOD, the Veteran raised a matter of permanency of the 50 percent rating assigned for post traumatic vascular headaches. As this matter has not been addressed by the RO, and the Board does not have jurisdiction over it, it is referred to the RO for appropriate action. The issue of entitlement to a rating in excess of 50 percent for post traumatic vascular headaches, to include on an extraschedular basis, is being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if action on his part is required. FINDINGS OF FACT 1. The Veteran is not shown to have a left shoulder disability. 2. A chronic left knee disability was not manifested in service, and the preponderance of the evidence is against a finding that any current left knee disability is related to the Veteran's service, including as due to injury therein, or was caused or aggravated by a service-connected disability. 3. At no time during the evaluation period is the Veteran's low back disability shown to have been manifested by limitation of thoracolumbar spine forward flexion to 60 degrees or less; by limitation of combined range of motion to 120 degrees or less; or by muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; incapacitating episodes of disc disease and /or separately ratable neurological manifestations are not shown. 4. At no time prior to May 17, 2012 was the Veteran's PTSD manifested by symptoms productive of impairment greater than occupational and social impairment with reduced reliability and productivity; symptoms productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood were not shown. 5. At no time since May 17, 2012 is the Veteran's PTSD shown to have been manifested by symptoms greater than productive of occupational and social impairment with deficiencies in most areas; symptoms such 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; or any other totally disabling symptoms of equivalent nature and gravity are not shown. CONCLUSIONS OF LAW 1. Service connection for a left shoulder disability, including as secondary to service-connected disabilities is not warranted. 38 U.S.C.A. §§ 1110, 1131 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 2. Service connection for a left knee disability, including as secondary to service-connected disabilities is not warranted. 38 U.S.C.A. §§ 1110, 1131 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 3. A rating in excess of 10 percent is not warranted for the Veteran's low back disability. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.21, 4.71a, Diagnostic Code (Code) 5237 (2012). 4. Ratings for PTSD with depression in excess of 50 percent prior to May 17, 2012, and/or in excess of 70 percent from that date are not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.21, 4.126, 4.130, Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claims. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Regarding the service connection claims, the Veteran was advised of VA's duties to notify and assist in the development of such claims prior to their initial adjudication. A November 2004 letter explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence he was responsible for providing. A March 2006 letter informed the Veteran of disability rating and effective date criteria. Regarding the increased rating claims, as a rating decision on appeal granted service connection and assigned disability ratings and effective dates for the awards, statutory notice had served its purpose, and its application was no longer required. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). December 2008 (low back disability) and March 2010 (PTSD with depression) statements of the case (SOCs) provided notice on the "downstream" issue of entitlement to an increased initial rating; and November 2012 and February 2013 supplemental SOCs (SSOCs) readjudicated the matters after the Veteran and his representative had opportunity to respond. 38 U.S.C.A. § 7105; see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). He has had ample opportunity to respond/supplement the record and has not alleged that notice in this case was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) ("[W]here a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream issues"). The Veteran's service treatment records (STRs) and pertinent postservice VA and private treatment records have been secured. His Virtual VA record (VA's electronic data storage system) has been reviewed. Pursuant to March 2012 Board remand, the RO obtained private mental health records and private treatment records from the Veteran's chiropractor. He was afforded VA examinations in November 2004, August 2007, November 2009, May 2012, June 2012, and January 2013 (with February 2013 addendum). The examination reports are adequate to assess the Veteran's disabilities as the examiners expressed familiarity with the history of the disabilities, and conducted thorough examinations of the Veteran, noting all findings necessary for proper determinations in the matters. See Barr v. Nicholson, 21 Vet. App. 303 (2007). At the September 2011 Travel Board hearing before the undersigned, the Veteran was advised of what is still needed to substantiate his claims; his testimony reflects that he is aware of what remains necessary. He has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis Initially, the Board notes that it has reviewed all of the evidence in the Veteran's claims file and in Virtual VA, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Service Connection Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection also may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for a claimed disability, there must be: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Briefly, the legal requirements for a successful secondary service connection claim are: (1) evidence of a current disability for which secondary service connection is sought; (2) a disability which is service connected; and (3) competent evidence of a nexus between the two. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Left Shoulder Disability The Veteran filed a pre-service-discharge claim of service connection for bilateral shoulder pain. A December 1998 Report of Medical Examination shows his musculoskeletal system was normal on clinical evaluation. A December 1998 Report of Medical History, notes that he did not have or had ever had painful or "trick" shoulder. A December 1999 STR shows he complained of shoulder tightness; there was no diagnosis pertaining to the shoulders. A March 2002 Report of Medical Examination shows a normal musculoskeletal system on clinical evaluation, and the corresponding Report of Medical History notes he did not have and had never had painful or "trick" shoulder. A January 2004 record notes the Veteran reported that his shoulder felt "pretty good." Examination showed he had hypertonicity of the bilateral levator scapulae/upper trapezius, right greater than left. On November 2004 pre-service-discharge VA examination, the Veteran reported experiencing pain in his right shoulder after martial arts training, and playing hockey and basketball. He noted pain with pushups and with heavy lifting (he lifted weights). He reported that the pain was chiefly around the right scapular area. He stated that he continued to lift weights and had a frequent knot in the muscles around the right scapular area and occasionally the left. The examiner noted that the shoulders had no objective findings, and there was no disability noted. Service connection for a right shoulder disability was granted in the April 2006 rating decision. The Veteran continues to assert that service connection is warranted for a left shoulder disability, including as secondary to service connected disabilities. A May 2006 private treatment report (from Dr. Schultz), notes the Veteran's complaints of a constant dull ache in the neck and across the shoulder blades. There was no diagnosis of a shoulder disability. In his April 2007 NOD the Veteran noted that his left shoulder was injured in service in 1997, in the event resulting in his neck injury. He stated that he was assigned to a small boat Company and injured his neck during a night recovery coming onto the stern ramp of the ship. As the boat pulled up to the ship to enter they were slammed into the hull of the ship. He was seen at the aid station and by other marines assigned to his boat. He was also seen by a chiropractor prior to his discharge from service, and had continued to be seen ("at least twice a month if not more") as his left shoulder had never improved. At his September 2011 Travel Board hearing the Veteran stated that the pain in his cervical spine travels to his shoulder. He did not have any problems with dislocation of the left shoulder. On June 2012 VA shoulders examination, the examiner indicated that the Veteran did not have a shoulder disability. The Veteran complained of bilateral posterior shoulder pain. He reported a history of symptoms beginning after serving in combat (1990-1991) when he sustained multiple injuries from an explosion of antitank rounds (friendly fire). He reported chronic symptoms; pain radiated to the posterior aspect of the bilateral shoulders (trapezial) also intrascapularly intermittently on a daily basis. He described the pain as sharp. He denied anterior/superior shoulder pain. He had no difficulty pushing a door open, he experienced occasional pain when working overhead, he denied mechanical symptoms and instability. He had not had a recent injury or surgery. On examination, left shoulder flexion and abduction were to 165 degrees; external and internal rotation was to 90 degrees. There was no objective evidence of painful motion. There was no deformity, muscle atrophy, soft tissue swelling or inflammation, or effusion. There was no tenderness of the biceps tendon (with a negative speed test) or of the acromioclavicular joint (with negative cross body adduction). X-rays of the left shoulder showed no appreciable degenerative changes of the acromioclavicular joint or glenohumeral joint. The impression was normal shoulder examination. The examiner opined that a left shoulder disability was less likely than not (less than 50 percent probability) incurred in or caused by an injury, event or illness in service. (as the Veteran did not have such disability). The threshold requirement for establishing service connection for a claimed disability is that there must be competent evidence of such disability. Here, there is no objective evidence that the Veteran has a left shoulder disability. The Board acknowledges the Veteran's complaints of left shoulder pain. However, the United States Court of Appeals for Veterans Claims (Court) has held that pain alone, without a diagnosed or identifiable underlying malady or condition, is not in and of itself a compensable disability. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). While the evidence shows that in service the Veteran complained of bilateral shoulder discomfort and had hypertonicity of the levator scapulae/upper trapezius, bilaterally, the record reflects that any such left shoulder symptoms resolved without residuals. In summary, it is not shown that the Veteran has a chronic left shoulder disability. He has not satisfied the threshold legal requirement for establishing service connection for such disability/presented a valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). Consequently, the preponderance of the evidence is against this claim. In such a situation, the benefit of the doubt doctrine does not apply; the appeal in this matter must be denied. Left Knee Disability The Veteran's theory of entitlement to service connection for a left knee disability is primarily one of secondary service connection. In his April 2007 NOD he noted that his left knee disability was secondary to his right knee surgery. In a February 2009 substantive appeal, he claimed that his left knee symptoms were secondary to his right knee surgery and his back disability. On June 2012 VA examination he reported that left knee symptoms started approximately five years prior. Service connection has been established for a right knee disability and for a back disability, each rated 10 percent from May 1, 2005. As the Veteran has also advanced a contention that his left knee disability may have begun during service and persisted, the Board will also address a direct (i.e., to service) causation theory of entitlement to service connection. The Veteran's STRs show that in June 1992 he was seen for physical therapy for chronic knee pain/swelling after running. He had a provisional diagnosis of overuse syndrome - patella, medial collateral. In July 1992 he attended "Knee School" and an evaluation of his knees revealed positive Lachman's and anterior drawer bilaterally. An August 1992 health record shows he was seen with complaints of chronic right knee pain. He reported he suddenly felt like his right knee was giving out after physical training. On examination, left knee lateral laxity was noted. The assessment was chronic knee pain, no acute disease and chronic laxity. In a September 1992 orthopedic medical record it was noted that the left knee had laxity. It was further noted that he had bilateral knee pain; and that the left knee was injured in a football game a month earlier. X-rays showed both knees were within normal limits. There was no diagnosis pertaining to the left knee. On clinical evaluation for re-enlistment in July 1993 the Veteran's lower extremities and other musculoskeletal were normal. In his medical history report, he noted he did not have or ever had "Trick" or locked knee. A December 1998 Report of Medical Examination notes abnormality of the right knee, but not the left. The Veteran reported that he did not have or had ever had a "trick" or locked knee. A March 2002 examination found no lower extremity abnormalities; the Veteran reported in corresponding medical history that he did not have and had never had a "trick" or locked knee. On November 2004 pre-service-discharge VA examination, there was no evaluation/assessment made regarding the left knee. On January 2013 VA examination, the Veteran complained of bilateral knee pain. He reported that left knee symptoms began approximately five years prior; there was no injury or obvious precipitating event. He stated he experienced intermittent knee pain on a daily basis. He described the pain as being largely inferior and an aching sensation with an intensity of 3/10. He reported increased pain with kneeling and squatting and with using stairs. He denied stiffness, and swelling. He had equivocal mechanical symptoms without locking. There were no instability symptoms. He had taken medications for the claimed left knee disability. His activities of daily living were not compromised. He had no difficulties at work. He stated that his symptoms fluctuate but are relatively consistent and he does not experience flare-ups. On examination range of motion was normal and there was no objective evidence of painful motion. The diagnosis was left knee patellar tendinosis. X-rays of the left knee showed patellar tendinosis. It was noted that patellar tendinosis is a degenerative condition which is not uncommon in the general population. Other possible, but less likely, etiology for the left anterior knee pain would be low grade patellofemoral syndrome. The examiner opined that it is less likely as not that the Veteran's present left knee disability (patellar tendinosis) was caused or incurred by military service. The rationale was that the condition is a common degenerative/repetitive motion injury of the patellar tendon. The Veteran's symptoms began approximately five years prior, which would be more than a year following separation from service. He had a service-connected right knee disability. The examiner commented that under certain conditions any [knee] condition can cause "strain" of the contralateral knee. For example degenerative changes of one knee causing a significant limp for a protracted period can cause degenerative changes of the contralateral knee; however, the Veteran had no such limp and accordingly [the left knee disability was unrelated to the right knee disability]. In a February 2013 addendum to the January 2013 VA knees examination report, the examiner opined that it is less likely than not that the Veteran's left knee condition is secondary to his service-connected back and cervical spine disabilities. The rationale was that a low back or cervical spine condition in general cannot cause a knee condition. An exception would be significant paralysis of the l2/:3/L4 nerve roots causing significant quadriceps weakness (or profound cervical myelopathy) and in turn degenerative changes of the knee or at worst severe compromise in ability to ambulate. That was not the case in the Veteran's situation. The Veteran had left knee symptoms of pain and laxity during service. However, what he must still show to establish service connection for a left knee disability is that his current left knee disability is related to the complaint in service (or is otherwise related to his service). Regarding the left knee laxity noted in service in August 1992, subsequent medical reports, including a pre-discharge VA examination, are silent for any complaints, findings, treatment or diagnosis relating to the left knee. This reflects that left knee symptoms in service were acute and resolved, with no residual pathology. Postservice treatment records provide no indication that a left knee disability may somehow be directly related to the Veteran's service. Furthermore, the Board notes there is no competent evidence in the record that shows or suggests that the Veteran's claimed left knee disability is related to his service. The only competent (medical) evidence that addresses the matter of a nexus between the Veteran's current left knee disability and his service is the opinion of the January 2013 examiner, which is against the claim. The examiner opined that it is less likely as not that the Veteran's present left knee patellar tendinosis was caused or incurred by military service. Because this opinion is by a medical professional (who has medical expertise and is competent to offer it) and is accompanied by explanation of rationale (with citation to supporting factual data) it is probative evidence in this matter; and because there is no competent evidence to the contrary, it is persuasive. The preponderance of the evidence is also against the Veteran's alleged secondary service connection theory of entitlement to the benefit sought. On January 2013 VA examination (the report of which the Board finds adequate and probative), and the February 2013 addendum, the examiner opined that the Veteran's left knee complaints are unrelated to his service-connected right knee, back, and cervical spine disabilities. The examiner noted the history of the claimed disability, and thoroughly explained the rationale for the opinion. The Board finds this evidence highly probative in the matter at hand. Because there is no competent (medical opinion/treatise) evidence (with opinion supported by an explanation) to the contrary the Board finds the January 2013 (and February 2013 addendum) VA examiner's opinion to be persuasive. Regarding the Veteran's own opinion that his left knee disability is due to his service-connected right knee and back disabilities, he is a layperson, lacks medical expertise, and does not cite to supporting medical opinion or medical literature evidence. Therefore, his opinion on this question of causality (which is medical in nature and beyond lay observation) has little probative value. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Any current left knee disability is not shown to be related to the Veteran's service or to a service-connected disability. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for a left knee disability. Accordingly, the appeal in the matter must be denied. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. With the initial rating assigned following a grant of service connection, separate (staged) ratings may be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. When an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue, including the degree of disability, shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. When all of the evidence is assembled, 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Low Back Disability The Veteran's service connected low back disability, has been rated by the RO under Code 5237 (for lumbosacral strain under the General Rating Formula for Diseases and Injuries of the Spine (General Formula)). 38 C.F.R. § 4.71a, Code 5237. Given that intervertebral disc syndrome is not, rating the disability alternatively under Code 5243 (for intervertebral disc syndrome (IVDS)), to include based on incapacitating episodes, would be inappropriate. 38 C.F.R. § 4.71a. Under the General Formula a 10 percent rating is warranted when (1) forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; (2) the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; (3) there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or (4) there is vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted when (1) forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; (2) the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or (3) there is 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 rating is warranted when (1) forward flexion of the thoracolumbar spine is limited to 30 degrees or less, or (2) when there is favorable ankylosis of the entire thoracolumbar spine. These criteria apply 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. 38 C.F.R. § 4.71a. There are several notes following the General Formula criteria, which provide: (1) Associated objective neurological abnormalities including, but not limited to, bowel or bladder impairment are to be rated separately under an appropriate diagnostic code. (2) For purposes of VA compensation, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateroflexion is 0 to 30 degrees, and left and right lateral rotation is 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateroflexion, and left and right rotation. The normal combined range of the thoracolumbar spine is to 240 degrees. (3) In exceptional cases, an examiner may state that, because of age, body habitus, neurological 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 the regulation. 38 C.F.R. § 4.71a. On November 2004 pre-service-discharge VA examination, the Veteran reported that he had three sick call visits in 2004 due to left sacroiliac and mid thoracic spine pain after he fell off a snowboard. He had physical therapy. He stated that the pain was chiefly in the mid thoracic area; and did not radiate. Physical examination showed he stood with a normal mild lumbar lordosis and thoracic kyphosis. His back moved easily. The lumbar spine flexed to 90 degrees, extended to 30 degrees, and laterally bended 30 degrees in each direction without pain and without weakness. Straight leg raising was negative bilaterally. His lower extremity reflexes were positive and equal with no motor weakness. His thoracic spine easily rotated 30 degrees in each direction without pain and without weakness. X-rays of the thoracic and lumbar spine were negative and normal. There was no evidence of any lack of endurance or lack of coordination. The diagnosis was back pain in the thoracic and lumbar area following an injury with no objective findings on examination and no disability noted. In May 2006 private chiropractic clinic notes, lumbar spine flexion was noted to be to 76 degrees, extension o 30 degrees; right and left lateral flexion to 30 degrees each, right rotation to 25 degrees and left rotation to 30 degrees. An October 2006 letter from (the Veteran's private chiropractor), notes that the Veteran had constant lower back pain. In his April 2007 NOD, the Veteran asserted that the 10 percent rating assigned for his low back disability does not reflect the degree of pain or the treatment required to allow him to maintain his employment and quality of life. He stated that he had to see a doctor on an almost weekly basis to keep pain and back motion at a tolerable level. His stated his lower back pain was moderate to severe. A July 2008 VA primary care nurse practitioner's note shows an assessment of low back pain with radiculopathy. A September 2009 VA pain clinic note shows the Veteran complained of mid and lower back pain. He presented a history of chronic lower back pain radiating to the groin and down his left leg to his thigh since 1991. He stated that his pain was unchanged since, and that he had seen a chiropractor since that time to help control his pain. The pain is in his lower back, his upper back, and his shoulders. He described it as aching, stabbing, burning, and sharp in the lower back, radiating down the right lower extremity all the way to his toes. It ranged from 3-8[on a scale of] 10, and was worse with labor/activity and better with rest and after chiropractic manipulation. The pain affects his functional abilities and daily personal interaction. He denied any urinary or bowel incontinence. The assessment was chronic back pain, myofascial pain and tender points. A September 2009 VA pain clinic procedure note shows a diagnosis of chronic back pain; the Veteran received right lumbar paraspinal and rhomboid muscle trigger point injections. It was noted that there were no complications from the procedure. He was discharged home in satisfactory condition. On November 2009 VA (cervical) spine examination, the Veteran's posture was erect. His gait was normal and brisk, with reciprocal heel to toe. (He was observed walking up the hallway to "C&P clinic" with two people). There was no unusual shoe wear pattern. At the September 2011 Travel Board hearing the Veteran testified that due to his back he experiences discomfort when driving. He stated that he uses heated seats in the car and has a special chair at the office and at home. The pain radiates throughout the body, as far as his ankles and up into his shoulders. At times he noticed redness or discoloration of his back. He could not tie his shoelaces. Chart notes from [the Veteran's private chiropractor) from August 2009 to April 2012 note the Veteran's lower back pain and discomfort. The diagnoses were lumbar intervertebral disc displacement without myelopathy, lumbar sprain/strain, and thoracic sprain/strain. On January 2013 VA spine examination of the Veteran mechanical back pain syndrome was diagnosed. He reported that he experienced intermittent (relatively constant) low back pain on a daily basis. He described the pain as an ache to a sharp pain with a pain intensity that reaches 5/10. The pain may be exacerbated by prolonged sitting. He had increased pain with lifting and straining. He reported radiation of pain to the left buttock/thigh-not below the knee. He had intermittent stiffness. He denied bowel or bladder incontinence. He did not take medication for the low back disability or wear a back brace, and had not had a recent injury or surgery. He had increased pain after walking one half mile or standing 20 minutes. He stated that his activities of daily living had not been compromised. He stated that he is employed as a claims representative for VA and has difficulty lifting at work, but overall his job performance is not compromised. The Veteran reported that flare-ups did not impact the function of his thoracolumbar spine. Forward flexion of the thoracolumbar spine was to 80 degrees with painful motion beginning at 70 degrees; extension was to 30 degrees; lateral flexion was to 25 degrees, symmetric; and lateral rotation was to 25 degrees, symmetric. He was able to perform repetitive-use testing with three repetitions. He did not have additional limitation in range of motion of the back following repetitive-use testing. He did have functional loss and/or functional impairment of the thoracolumbar spine, manifested by less movement than normal, and pain on movement. He had localized tenderness or pain to palpation for joints and/or soft tissue of the back. He did not have guarding or muscle spasm of the back. His muscle strength overall was normal. He did not have muscle atrophy. His reflexes were normal. He had a normal sensory examination. Lasegue and straight leg raising were negative. Sensation preserved to light touch in the L1 through S1 dermatomes. There was no radicular pain or any other signs or symptoms due to radiculopathy. There was no intervertebral disc syndrome (IVDS). He did not use any assistive devices. X-rays of the lumbosacral spine showed no significant facet joint degenerative changes. The Veteran reported that his low back disability impacts his ability to work because he has some difficulty lifting at work but overall his job performance is not compromised. The impression was mechanical low back pain syndrome. The examiner noted that the Veteran's symptoms may be attributed to the diagnosis. Likely pain generators were multiple, with degenerative disease predominating. The Veteran was neurologically intact as to the lumbosacral spine. He had four lumbar vertebrae (a congenital variant)(there was some controversy whether that condition can cause low back pain with the general consensus that, in and of itself, it does not). While the Veteran has reported chronic back pain, at no time is there evidence of thoracolumbar spine forward flexion being limited to 60 degrees or less, or combined range of thoracolumbar spine motion limited to 120 degrees or less; 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, even when taking into account additional loss of motion after repetitive use due to pain. In this regard, it should be noted that on range of motion testing in November 2004 forward flexion of the Veteran's back was to 90 degrees and the combined range of thoracolumbar spine motion was 240 degrees. In May 2006 forward flexion was to 76 degrees, and the combined range of thoracolumbar spine motion was 221 degrees. In January 2013 forward flexion was to 80 degrees, and the combined range of thoracolumbar spine motion was 210 degrees. As the symptoms and associated impairment of function of the low back throughout the evaluation period fall squarely within the parameters of the criteria for the 10 percent rating assigned, and never meet (or approximate) the criteria for the next higher (20 percent) rating under the General Formula, a rating in excess of 10 percent under the General Formula criteria is clearly not warranted throughout the appeals period. Neurological manifestations of a low back disability are to be separately rated (under the appropriate Code) and such rating is to then be combined with the rating under the General Formula, discussed above. A July 2008 VA treatment report notes an assessment of low back pain with radiculopathy and in September 2009, the Veteran presented a history of low back pain radiating to the groin and down his left leg to his thigh. He also described radiating pain to his right lower extremity all the way to his toes. However, on January 2013 VA examination, there was no evidence of radiculopathy, and other neurological manifestations were not noted or alleged. Therefore, a separate compensable rating for neurological manifestations of the low back is not warranted. The record does not reflect any distinct period of time when the symptoms of the Veteran's low back disability exceeded those encompassed by the 10 percent rating assigned, and therefore a "staged" increased rating is not warranted. The preponderance of the evidence is against this claim; therefore, the appeal in the matter must be denied. PTSD with Major Depression Under 38 C.F.R. § 4.130, Code 9411 (for PTSD under the General Rating Formula for Mental Disorders (General Formula)), a 50 percent rating 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; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Code 9411. A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating requires total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. 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 (1996). A score of 41-50 is assigned where there are "[s]erious 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)." A score of 51-60 is appropriate where there are "[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers)." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV) 47 (4th ed.1994). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). 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. However, 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 on the basis of social impairment. 38 C.F.R. § 4.126(b). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability there from and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The record shows psychiatric diagnoses other than PTSD. Where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). As noted above, the April 2006 rating decision granted the Veteran service connection for depression, rated 50 percent, effective May 1, 2005. In April 2007, he filed a claim for service connection for PTSD. An interim, September 2007, rating decision recognized PTSD as service connected, and recharacterized the Veteran's service-connected psychiatric disability as PTSD with major depression, continuing the 50 percent rating. An interim, November 2012 rating decision increased the rating to 70 percent, effective May 17, 2012. Consequently, for consideration is entitlement to a rating in excess of 50 percent prior to May 17, 2012 (since service) and to a rating in excess of 70 from that date. On November 2004 pre-service-discharge VA psychiatric examination, the Veteran was fully alert, although he appeared fatigued, which he attributed to his difficulty sleeping. He was oriented in all spheres. His dress was casual, but appropriate; he was neat and clean, and his grooming was good. He made appropriate eye contact, with the exception of times when he became tearful (which was frequent). During those episodes, he averted his eyes in what he later explained was shame. He was articulate, though elegantly simple and with no hint of over-elaboration. He was highly expressive despite his discomfort with emotions he felt were unmanly and unworthy of a Marine. His speech was slowed in rate, owing to his choking affect, reduced in volume, but normal in rhythm. The examiner noted motor retardation, in that the Veteran barely moved in his chair, gripping the arms of the chair tightly throughout the evaluation. His mood was highly dysthymic and undeniably anxious. His affect was limited in range to expressions of sadness, hopelessness, and little hope for his post-discharge and post-divorce future or options. He denied hallucinations and delusions. There was no evidence of a psychotic process during the examination. Despite his unquestionable depressed state, he denied any current or historical suicidal ideation or intent. He was not deemed a danger to self, but passively and likely unknowingly self-destructive and inattentive to his basic need (excessive use of alcohol, inability to sleep, and lack of appetite). He denied any homicidal intent or plan. He had no reported cognitive or memory deficits. His intellectual capacity was within normal range of human intelligence. His insight was limited by the severity of his depression. His judgment was sufficiently adequate to allow him to function on a day-to-day basis, but negatively impacted by his depressive interpretation of the world around him. The examiner noted that the Veteran unquestionably met the full criteria for a diagnosis of major depressive disorder without psychotic features which was moderately severe in intensity. World events, physical problems, and deteriorating interpersonal circumstances had conspired to exacerbate a depression for which he was briefly treated. He was undeniably impaired in multiple domains as a result of his depression and has been advised to seek professional assistance before his upcoming retirement from the military. The diagnosis under Axis I was major depressive disorder without psychotic features, moderately severe. His GAF was 49. A February 2007 VA mental health report notes the Veteran was still having problems with sleep. He stated that he was doing okay at work. He was less irritable; his sex drive had decreased. He continued to have "weird, bad" dreams. He slept an average of 5 to 6 hours and dreamed about 4 to 5 times per week. He had been "sluggish" and his motivation was mediocre. His focus and concentration were fine. He had gained about 25 pounds in 6 months. He experienced decreased enjoyment. He stated "I want alone time." He admitted that certain things make him hopeless and feeling tearful at times. He denied suicidal or homicidal ideation, paranoia, and manic symptoms. He stated "I can still see faces of people I know." He admitted to having hypervigilance. He stated that he goes into public place because he has to, and is always on guard. Regarding alcohol, he stated he has a 6-pack a day; he denied drug use. He was working full-time for VA. On mental status examination, the Veteran was alert and oriented times 3. The examiner noted that he was casually dressed, well groomed, cooperative, had good eye contact, and no psychomotor retardation or agitation. His speech was normal volume, fluent, and coherent. His mood was irritable and his affect was congruent to his mood. He had logical and sequential thought process. He denied suicidal/homicidal ideation, auditory/visual hallucinations and delusions. His memory was intact and his judgment and insight were fair. The diagnosis under Axis I was major depressive disorder and PTSD. His GAF was 55. A February 2007 VA social work report, notes the Veteran was seen for individual psychotherapy for treatment of depression. He reported that he was getting along better with his wife and his anger was more under control. He stated that medication was helping him keep his anger in check. He was having some financial strains which he was working on. He felt like he was dragging today and was having some difficulty concentrating. He thought it was due to just getting over the flu. On August 2007 VA PTSD examination it was noted that there was no previous hospitalization or outpatient care for PTSD. The Veteran reported that his psychiatric symptoms were frequent, moderate to severe, and chronic. Substance use he acknowledged amounted to a 6 to 12-pack of beer weeknights and somewhat more on weekends. He stated that drinking calmed his nerves and helped him get to sleep. He complained of difficulty sleeping on a nightly basis. He had continuing agitation, irritability, and depression with occasional feelings of hopelessness. There was chronic anger with occasional verbal abusiveness. He noted a suspiciousness of others, being easily startled and frequent nightmares. He indicated impaired concentration because of the intrusive combat memories, avoidance of public places, and preferring to be by himself rather than socializing with others. He stated that his brother was his only friend. On mental status examination, the examiner noted that the Veteran's thought process was logical and sequential with cognitive functioning grossly intact. Judgment and insight were fair. There was no psychotic thought disorganization. The Veteran was alert, friendly and cooperative. He was dressed casually and neatly groomed. There were no delusions or hallucinations. Eye contact was good. There were no suicidal or homicidal ideations. Personal hygiene was adequate. Orientation was good times 4. Short- and long-term memory was within normal limits. Obsessive or ritualistic behaviors were not noted. Rate and flow of speech was within normal limits and was relevant. Panic attacks were not noted. Mood was distressed and was relevant. Panic attacks were not noted. Mood was distressed and irritable. Affect was anxious. Impulse control was considered fair. Sleep impairment was noted to be frequent and severe. The examiner noted that the Veteran meets the DSM-IV criteria for PTSD. The Veteran noted a traumatic experience in Liberia where his smaller unit was called to replace a larger unit guarding the embassy against rebel troops. He indicated that his life was in danger every moment of that time and he saw many others get hit and killed. He had intrusive memories of that situation. Nightmares of that experience continue to impair his sleep. The diagnoses under Axis I were major depressive disorder and PTSD. His GAF was 55. The examiner further noted that the Veteran's PTSD symptoms have been chronic since his discharge from the military. The original diagnosis of major depressive disorder was appropriate, but did not take into account PTSD. A mental health attending note, included PTSD, in addition to the major depressive disorder. The designated GAF of 55 is supported by a review of symptoms in the context of PTSD interview. The Veteran's psychosocial functioning, quality of life, family role of functioning, performance in employment were fair. There was moderate to severe impairment of psychological social and occupational functioning. The Veteran is employed as a Veteran's service officer. Discussions with other Veterans may at times trigger traumatic memories. There is reduced reliability and productivity due to PTSD signs and symptoms. A July 2009 VA mental health clinic consultation report (electronic file), noted the Veteran was seen in intake for help with depressive symptoms. He had been experiencing increased irritability, poor sleep, 40-pound weight gain, decreased sexual desire, decreased energy, interest, and motivation, and fatigue. He also suffered from chronic pain, especially lower back and headache pain. He drank [alcoholic beverage] 5 out of 7 days a week, 12-18 beers at a time. His drinking had escalated over the last 6 years. He reported significant marital strain and feared that his wife will leave him. He reported a trial of several different antidepressants, however, the only one he felt was helpful was Wellbutrin. He denied any suicidal or homicidal ideations, or any history of suicide attempts. He denied any psychotic symptoms. His Axis I diagnosis was PTSD. An April 2010 VA mental health treatment plan notes the Veteran had poor coping skills, poor impulse control, poor insight into his illness, and poor physical health. He still had nightmares and flashbacks. He stated, "I want to stop thinking about being attacked." It was noted that symptoms were in remission and no further treatment was required. He was relocating and would continue care at another facility. He had been non-compliant with clinic requirements; he had not received treatment in a year. However the current treatment plan was developed with his participation. At the September 2011 Travel Board hearing, the Veteran testified that he receives private treatment for PTSD from Dr. Ripley. When asked if his PTSD interfered with his work (as a Veterans service officer) he stated that he had taken time off because of it on a couple of occasions, (three or four times a year). The Veteran's wife testified that when the Veteran comes home in the evening, he usually has a few beers and goes to his room, where he stays most of the night; he does come out of his room to eat. When there is a disruption in the house he is verbally abusive. She stated that she and the children are able to avoid him because he stays in his room and they have the rest of the house. She stated that she has counseling with Dr. Ripley and the children see a psychiatrist as needed. They were in counseling in the summertime. A March 2012 mental health attending note notes that the Veteran was last seen in April 2010. He switched care because of a conflict of interest as he worked for the State of Illinois as a Veteran service representative. It was noted that he was under the care of a private sector therapist. He reported increased irritability, depression, poor sleep, and feeling numb toward family. He and his wife separated for period of time, but were now reunited. He reported having a depressed mood. He denied suicidal ideation, intent or plan, and no previous attempt. He had a history of alcohol use 2-3 times a week (14-15 beers). His last drink was the previous night. He denied use of illicit drugs. On mental status examination, he was alert and oriented times 3. His appearance was calm; he was neatly dressed and groomed. His speech was a normal rate, tone and volume. He denied suicidal and homicidal ideations. His mood was irritable and his affect was congruent. Memory and concentration were grossly intact. His judgment was fair and his insight was poor. His diagnosis under Axis I was PTSD, alcohol dependence, and rule out major depressive disorder. His GAF score was 55. It was noted that he was not a candidate for inpatient treatment but was in need of outpatient psychiatric services. The examiner noted that he reviewed VA recommended limits for alcohol consumption and recommended that the Veteran abstain, or drink at or under the recommended limit. He also recommended treatment, "AA." On May 17, 2012 VA PTSD examination, the diagnosis was PTSD, with a GAF score of 46 assigned. It was noted that he did not have more than one mental disorder diagnosed. His level of occupational and social impairment with regard to all mental diagnoses was an occasional decrease in work efficiency and intermittent periods of inability to perform occupational task, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. He lived with his wife and three children. He was isolated and has no friends. He worked as a Veterans service officer. He received VA treatment and medication for PTSD, with some improvement. He engaged in heavy drinking as self-medication for PTSD until 2011 and had abstained since. The examiner noted that the Veteran's PTSD symptoms were depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and including work or worklike setting. There were no other symptoms attributable to PTSD. The examiner noted that the Veteran's PTSD is the cause of his depression and is directly related to his combat experiences in Kuwait. Prior to May 17, 2012 On review of the record the Board finds that prior to May 17, 2012, the Veteran never manifested symptoms of PTSD that met or approximated the criteria for the next higher (70 percent) rating, i.e., had symptoms of PTSD that caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. In particular, the evidence as described above reflects that prior to May 17, 2012, the PTSD was characterized by avoidant and isolative behavior, intrusive thoughts, nightmares, sleep disturbances, and other like symptoms of anger, depression, anxiety, and irritability/angry outbursts. While the Veteran and his wife describe him as isolative, the evidence shows that during the period prior to May 17, 2012 he was employed full-time as a Veterans service representative for the State of Illinois (a position requiring public contact). A February 2007 VA mental health report notes that he was doing okay at work. A February 2007 VA social work report notes that he reported that he was getting along better with his wife and his anger was more under control. On mental status examination in August 2007, the examiner described his cognitive functioning as "grossly intact." At the September 2011 hearing he testified that he had only taken time off work on a couple of occasions related to his PTSD. A March 2012 mental health attending report noted his memory and concentration were grossly intact. This contradicts any suggestions of deficiencies in most areas, such as work, family relations, judgment, or thinking due to PTSD symptoms. Presumably, if he had exhibited deficiencies in most areas, he would not have been to maintain a full-time job in a responsible position such as a Veterans service representative for the State of Illinois, (he missed very little time from work due to PTSD symptoms). The evidence does not show that the Veteran had suicidal ideation; on examination/evaluation he denied suicidal ideation, intent or plan. Neither were symptoms of obsessional rituals, which interfere with routine activities shown. On August 2007 VA examination he reported having a suspiciousness of others, avoiding public places, and being easily startled. Such behavior does not rise to the level of obsessional rituals which interfere with routine activities. His speech was not noted to be intermittently illogical, obscure, or irrelevant at any time. In August 2007 his speech was within normal limits and relevant. In March 2012 his speech was a normal rate, tone and volume. The evidence also does not show impairment rising to the level of near-continuous panic or depression affecting the ability to function independently, appropriately and effectively. From February 2007 to March 2012 the Veteran endorsed depressive symptoms, difficulty sleeping and anxiety; however, as noted, he continued to work full-time in a responsible position and work on his marital relationship. While an April 2010 mental health treatment plan notes the Veteran had poor impulse control, there was no evidence of unprovoked irritability with periods of violence. While he reported having poor coping skills, and having nightmares and flashbacks, the provider noted that his symptoms were in remission and no further treatment was required. It was also noted that the Veteran had not been compliant with clinic requirement and had not received treatment in a year (suggesting maintenance of functioning without treatment). There is no evidence of spatial disorientation; the Veteran was oriented on all occasions observed. There were no occasions when his appearance was compromised. On November 2004 pre-service-discharge VA psychiatric examination he was dressed appropriately, neat and clean with good grooming. The February 2007 examiner noted he was casually dressed, and well groomed. On August 2007 VA PTSD examination he was casually dressed and neatly groomed. On March 2012 VA mental health clinic visit, his appearance was calm; he was observed as neatly dressed and groomed. The evidence does not show neglect of personal appearance and hygiene. There is no evidence of difficulty in adapting to stressful circumstances (including work or a worklike setting). The Veteran has shown ability to adapt to circumstances, especially at work. In February 2007 he complained of having problems with sleep, but stated that he was doing okay at work. His focus and concentration were fine. In addition, in February 2007 he indicated that he was having some financial strains, which he stated he was working on. The evidence shows he has maintained full-time employment, in responsible positions, throughout the period prior to May 17, 2012, despite his mental and physical disabilities, many of which are service-connected. There is no evidence of inability to establish and maintain effective relationships. The Veteran reported that his only friend is his brother. In 2007 he stated that he was getting along better with his wife. In 2009 he reported significant marital strain. In 2012 he reported that he and his wife had separated but were reunited. Based upon the foregoing, the Veteran's disability picture does not reflect that prior to May 17, 2012 his PTSD caused the deficiencies in most areas (such as work, family relations, judgment and thinking) that would warrant a 70 percent rating. The Board has also considered the GAF scores assigned prior to May 17, 2012, which range from 49 to 60. Despite the seriousness of PTSD symptoms suggested by the assignment of a GAF score of 49, which signifies 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), the Board has conducted a thorough review of the record and finds that it fails to show that the Veteran's PTSD symptoms at any point during this portion of the appeal period, more nearly approximated the criteria for a 70 percent rating. Accordingly, the Board finds that prior to May 17, 2012 the criteria for a 70 percent schedular rating were not met or approximated, and that a schedular rating in excess of 50 percent for PTSD with depression was not warranted. From May 17, 2012 From May 17, 2012 (the date of a VA examination when symptoms found warranting an increased rating were first shown in the record) the Veteran's PTSD has been rated 70 percent. On close review of the record the Board finds that a still higher rating is not warranted at any point since that date. The evidence since May 17, 2012, shows that the Veteran continues to be somewhat socially isolative and reports increased difficulty in getting along with his spouse and family. Such findings suggest that the Veteran's PTSD symptoms have increased in severity (compared to symptoms manifested during the period for which a 50 percent rating was assigned); however, they do not demonstrate that his PSTD has become so severe that he warrants an increased (100 percent) rating for the disability. Significantly, the Veteran still works full-time as a Veterans service officer; and despite his reports at-times of strained marriage and preference for solitude, he remains married, and maintains contact with his wife and children. This clearly does not reflect total occupational and social impairment. Notably, the May 2012 VA examiner found that the Veteran's PTSD signs and symptoms were depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and including work or worklike setting; and indicated there were no other symptoms attributable to his PTSD. The Board finds that, even with consideration given to Mauerhan v. Principi, 16 Vet. App. 436 (2002), at no time during this part of the appeal period has the disability picture shown by the record more nearly approximated the criteria for a 100 percent rating for PTSD. In particular, it is not shown that PTSD has ever resulted in gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Although the Veteran and his spouse report that he tends to isolate himself and has no friends, the evidence shows that he is employed as a Veterans service officer and misses very little time from work due to his PTSD symptoms. Such employment is evidence of interaction with others. In conclusion, the Veteran's overall disability picture from May 17, 2012, does not include symptoms and impairment exceeding the schedular criteria for a 70 percent rating. The preponderance of the evidence is against the claim for a rating in excess of 70 percent; the benefit of the doubt rule does not apply. The Board has also considered whether referral for extraschedular consideration is indicated for the service-connected low back disability and PTSD with depression. Inasmuch as all symptoms and associated impairment of the Veteran's low back disability and PTSD are fully encompassed by the criteria for the schedular ratings assigned, the schedular criteria are not inadequate, and referral for extraschedular consideration is not necessary. See Thun v. Peake, 22 Vet. App. 111 (2008). The Board notes that the evidence shows that the Veteran has been gainfully employed throughout the appeal period. The matter of a total disability rating based on individual unemployability due to service-connected disability is not raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER Service connection for a left shoulder disability, including as secondary to service connected disabilities is denied. Service connection for a left knee disability, including as secondary to service connected disabilities is denied. A rating in excess of 10 percent for a low back disability is denied. Ratings for PTSD with depression in excess of 50 percent prior to May 17, 2012 and/or in excess of 70 percent from that date are denied. REMAND In May 2010, the Veteran submitted a written statement expressing disagreement with the July 2009 DRO decision that assigned a 50 percent (maximum under Code 8100) rating effective May 1, 2005 for his post traumatic vascular headaches. Such statement constituted a timely NOD with that determination. The filing of a timely NOD initiates the appeal process. As an SOC has not been issued regarding entitlement to a rating in excess of 50 percent for post traumatic vascular headaches, (to include extraschedular consideration, as sought) the Board is required to remand the matter for such action. See Manlincon, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following: The RO should issue a SOC in the matter of entitlement to a rating in excess of 50 percent for post traumatic vascular headaches (to include on an extraschedular basis). The Veteran should be advised of the time period afforded for submission of a substantive appeal, and that this matter will only be before the Board if he timely perfects an appeal by submitting a substantive appeal after the SOC is issued. If that occurs, the matter should be returned to the Board for appellate consideration. 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 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). ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs