Citation Nr: 1317010 Decision Date: 05/23/13 Archive Date: 05/31/13 DOCKET NO. 07-30 239 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to an initial evaluation for posttraumatic stress disorder (PTSD) in excess of 10 percent prior to December 2, 2010 and in excess of 30 percent thereafter. 2. Entitlement to an increased evaluation for fracture, right tibia and fibula, residuals of a gunshot wound with right knee arthritis, currently assigned separate 10 percent disability ratings for limitation of flexion of the leg and for instability. REPRESENTATION Veteran represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD T. Blake, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1964 to August 1967. This case comes before the Board of Veterans' Appeals (Board) on appeal from February 2006 and December 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania and Boston, Massachusetts. In February 2006, the RO, in pertinent part, continued the noncompensable (0 percent) evaluation for fracture, right tibia and fibula, residuals of a gunshot wound. In December 2008, the RO granted, in pertinent part, service connection for PTSD assigned at 10 percent disabling, effective September 24, 2007. The Veteran testified before the undersigned Veterans Law Judge in May 2010 and a transcript of the hearing is of record. In August 2010, the Board, in pertinent part, remanded the claims on appeal for additional development and adjudicative action. In a March 2012 rating decision, the RO assigned separate 10 percent disability ratings for fracture, right tibia and fibula, residuals of a gunshot wound with right knee arthritis for limitation of flexion of the leg and for instability, effective October 14, 2005 (the date of claim). The Veteran was advised of the March 2012 rating decision, but did not express agreement with the decision or withdraw the appeal. In AB v. Brown, 6 Vet. App. 35 (1993), the United States Court of Appeals for Veterans Claims (Court) held that, on a claim for an initial or increased rating, a veteran will generally be presumed to be seeking the maximum benefit allowed by law and regulation, and it follows that such a claim remains in controversy, even if partially granted, where less than the maximum benefit available is awarded. Because the assigned 10 percent disability ratings are not the maximum benefits available for this service-connected disability, this appeal continues for the entire increased rating period. The case was returned to the Board for further appellate review. In a September 2012 decision, the Board, in pertinent part, remanded the claim for an increased evaluation for fracture, right tibia and fibula, residuals of a gunshot wound with right knee arthritis for the RO to readjudicate. In February 2013, the RO readjudicated the issue in a supplemental statement of the case (SSOC) and this claim has been returned to the Board for further appellate review. In the September 2012 decision, the Board also increased the disability rating for PTSD to 30 percent disabling prior to December 2, 2010 and denied an evaluation in excess of 30 percent for the entire initial rating period on the merits. The Veteran appealed the Board's decision for this issue to the Court. By order dated March 2013, the Court granted a Joint Motion for Remand (JMR), partially vacated the September 2012 Board decision for this issue, and remanded the case for compliance with the terms of the JMR. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. The issue of entitlement to an increased evaluation for fracture, right tibia and fibula, residuals of a gunshot wound with right knee arthritis, currently assigned separate 10 percent disability ratings for limitation of flexion of the leg and for instability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. The issue of entitlement to service connection for diabetes mellitus, type II, has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. All relevant evidence necessary to decide the Veteran's appeal regarding the issue of an initial evaluation for PTSD in excess of 10 percent prior to December 2, 2010 and in excess of 30 percent thereafter has been obtained. 2. For the entire initial rating period, the service-connected PTSD is characterized by 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: frequent irritability, hypervigilance, exaggerated startle response, chronic sleep impairment, and difficulty concentrating. 3. For the entire initial rating period, the service-connected PTSD is not characterized by occupational and social impairment with reduced reliability and productivity due to such symptoms as: circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; or impaired abstract thinking. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation of 30 percent, but no greater, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for an initial evaluation in excess of 30 percent for PTSD have not been met for any period on appeal. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability Rating Legal Criteria and Analysis for PTSD Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity. See U.S.C.A. § 1155 (West 2002). Separate diagnostic codes identify the various disabilities. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012). When entitlement to compensation has been established and a higher initial evaluation is at issue, the level of disability at the time entitlement arose is of primary concern. Consideration must also be given to a longitudinal picture of a veteran's disability to determine if the assignment of separate ratings for separate periods of time, a practice known as "staged" ratings, is warranted. See Fenderson v. West, 12 Vet. App. 119 (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 a manifestation of the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2012). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim for PTSD on appeal. Pursuant to the March 2013 JMR, the Court held that the Board erred by not addressing the December 2010 VA examination (1) Axis I diagnosis of "PTSD, moderate" and GAF score of 60 in determining the level of occupational and social impairment, (2) the examiner's opinion that the Veteran suffered from "reduced reliability and productivity due to PTSD symptoms," which is consistent with the language contained in the criteria for a 50 percent rating, and (3) the examiner's notation that the Veteran's current social functioning is more severe than reflected in the previous July 2008 VA examination and due to the change in severity, the examiner reduced the GAF score from 70 to 60. Moreover, the Board should (1) discuss the specific findings contained in the December 2010 VA examination report and (2) consider the applicability of staged ratings to the Veteran's PTSD claim. Pursuant to the rating criteria for mental disorders, the Veteran's service-connected PTSD is rated at 10 percent disabling prior to December 2, 2010 and at 30 percent disabling thereafter under Diagnostic Code 9411. A 10 percent disability evaluation is assigned under the general rating formula for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 38 C.F.R. § 4.130. A 30 percent disability evaluation is assigned for occupational and social impairment with evidence of 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, or recent events). Id. A 50 percent disability evaluation is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment in short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability evaluation 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. Id. A 100 percent disability evaluation is assigned for 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; 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 a veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2012). 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. Id. The rating agency shall also consider the extent of social impairment, but not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Moreover, 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 evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). The Global Assessment of Functioning (GAF) Scale reflects the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the DSM-IV; see also Carpenter v. Brown, 8 Vet. App. 240, 242-44 (1995). Higher scores correspond to better functioning of the individual. Id. A score of 21 to 30 indicates that behavior is considerably influenced by hallucinations or delusions or there is serious impairment in communication or judgment or the ability to function in almost all areas is seriously impaired. Id. A score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). Id. A score of 41 to 50 is defined as 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 to 60 is defined as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. A score of 61 to 70 is defined as 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. After a full review of the record and consideration of whether the assignment of separate (staged) ratings for separate periods of time is warranted, the Board finds that entitlement to an initial 30 percent evaluation is warranted for the entire initial rating period and a preponderance of the evidence is against an initial evaluation in excess of 30 percent for any period on appeal. The Veteran was afforded a VA examination in July 2008. He reported that following his military service, he had difficulty adjusting to civilian life. He described himself as agitated and irritable and reported that he drank extensively and used marijuana. He reported that he has experienced nightmares since his return, which occur approximately four times per month. He described himself as talkative, moody, irritable, and grumpy. He has hypervigilance and an exaggerated startle reflex and loud sounds bother him. He stated that he has to keep himself busy to avoid getting agitated. He described some mild concentration problems, as well as some financial problems because of impulsivity. He reported playing golf from time to time as a hobby. The Veteran was described by the examiner as rather aloof, with a tendency to soliloquize and control the conversation, and he needed to be redirected towards the exam. He was loquacious and verbal and appeared to be of average intelligence. His speech was somewhat pressured, but within normal limits. His motor activity was tense. He was oriented to time, place, and person. His memory appeared within normal limits, and he had full range of affective expression. Depending on the stimulus, the Veteran experiences high levels of anxiety, irritability, and inner psychic agitation. The Veteran's judgment was fair and there was no evidence of any dissociative states, thought disorders, delusions, disorganized thinking, or hallucinations. He denied any major depressive symptoms. He reported some passive suicidal ideations when he is having financial difficulties, but denied any other homicidal or suicidal ideations. The Veteran complained of feelings of detachment and estrangement from others. He has irritability and outbursts of anger at least weekly. He used numbing and avoidance as coping mechanisms. The examiner concluded that the Veteran was capable of performing all activities of daily living and that his social functioning was well within normal limits. He also concluded that the Veteran's employment functioning was not affected by his PTSD symptoms. The Veteran was diagnosed with mild PTSD and assigned a GAF score of 70. At his May 2010 hearing, the Veteran testified that he experiences irritability and road rage. He stated that his wife has told him he has a drinking problem. He estimated that he got approximately three hours of sleep a night. He also reported having problems with his supervisors. The Veteran was afforded a second VA examination in December 2010. At that time, the Veteran complained of frequent irritability, difficulty concentrating, hypervigilance, exaggerated startle response, difficulty sleeping, and nightmares six to seven times per month. He reported some compulsive checking, including security related issues (windows, doors, etc.). The Veteran reported that he was getting along with his spouse, although "I have my short fuse moments." He admitted that he was often verbally aggressive, although not physically. He stated that his wife has complained that he drinks too much, which the Veteran appeared to concede. His leisure activities include golfing and making his own wine. He reported missing four weeks of work in the last twelve months, but attributed the lost time to medical treatment for multiple physical problems. The only problem he described related to his occupational functioning was decreased concentration, providing highly probative evidence against his own claim. The Veteran was described as cooperative with the examiner. His speech was rapid, but his mood was good and his affect normal. His attention, memory, and orientation were intact. Thought content and thought processes were unremarkable. There was no evidence of delusions or hallucinations. The Veteran denied homicidal or suicidal ideations, as well as panic attacks or episodes of violence. His impulse control was judged to be good. The examiner concluded that the Veteran was able to maintain minimal personal hygiene and perform activities of daily living. The examiner diagnosed the Veteran with moderate PTSD and alcohol abuse and assigned a GAF score of 60. The examiner noted that the Veteran's alcohol abuse worsens his health situation, adds to his sleep difficulties, and makes it more difficult to control his temper. The Board finds that there is sufficient evidence to conclude that the Veteran's PTSD symptoms are more than mild and transient for the entire initial rating period on appeal. He has consistently testified to struggling with frequent irritability, which has by his account has affected both his relationship with his spouse and his relationship with his supervisors. He has repeatedly complained of problems concentrating, as well as chronic sleep impairment and recurring nightmares. He has also reported that impulsivity causes him financial problems, which in turn have occasionally caused passive suicidal ideation. It does not appear that the Veteran has any close relationships other than his family. Moreover, both VA examiners noted the Veteran's irritability, anxiety, and hypervigilance which addresses some degree of suspiciousness. The December 2010 VA examination report and May 2010 Board hearing transcript further noted sleep impairment. Accordingly, the Board finds that the Veteran's symptoms are more appropriately rated under the criteria for a 30 percent disability rating for the entire initial rating period on appeal. This takes into consideration the Veteran's credible statements regarding the nature and extent of his problem with this disability. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the Board also finds that a preponderance of the evidence is against an initial evaluation in excess of 30 percent for any period on appeal. The Board acknowledges the change in Axis I diagnoses and GAF scores from mild PTSD and a score of 70 in July 2008 to moderate PTSD and a score of 60 in December 2010. The December 2010 VA examiner opined that the Veteran suffered from "reduced reliability and productivity due to PTSD symptoms" and that the Veteran's social functioning is more severe than as reflected in the July 2008 VA examination report. The July 2008 VA examiner noted the Veteran's reported passive suicidal ideation associated with financial difficulties, and the Veteran testified at the May 2010 hearing that he has problems with his supervisors. Moreover, the Veteran informed the December 2010 VA examiner of his compulsive checking to include security related issues and that he gets along with his spouse although he has short fuse moments and is often verbally aggressive. Nevertheless, while the Veteran's PTSD has resulted in a change of impairment in occupational and social functioning, overall, the record reflects that this degree of impairment is of a mild to moderate nature throughout the entire initial rating period, in light of the noted changes therein, with some evidence that does not support the 30 percent evaluation, including some of the Veteran's own statements regarding the nature and extent of his own disorder. In any event, his compulsive checking is currently contemplated in the assigned 30 percent disability rating for hypervigilance and suspiciousness. Although the Veteran has reported some difficulty concentrating and occasional interpersonal conflict with his supervisors, he has not reported missing any work because of his PTSD, and he works alone which allows him to avoid interacting with others. Such findings are not indicative of occupational and social impairment with reduced reliability and productivity or deficiency in most areas of life due to his psychiatric symptoms, despite the December 2010 VA examiner's opinion, which is found to be clearly outweighed by the evidence as a whole (including some of the Veteran's own statements citing the problems he has with his PTSD). With regard to social impairment, despite having few close relationships, he has been married to his current spouse for over thirty years and has described a number of hobbies, including golf and making his own wine. The evidence of record also does not show that his symptoms have led to legal problems or required hospitalization. Therefore, based on the lay and medical evidence, including the GAF scores and specifically documented frequency, severity, and duration of the psychiatric symptomatology discussed above, the Board finds that an initial evaluation in excess of 30 percent is not warranted for any period. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (holding that a veteran may only qualify for a given disability rating under 38 C.F.R. § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration). With respect to the entire initial rating period on appeal, the Board is aware that the symptoms listed under the next-higher ratings are essentially examples of the type and degree of symptoms for those ratings, and that the Veteran need not demonstrate those exact symptoms to warrant a higher initial rating. See Mauerhan, 16 Vet. App. at 436. Moreover, entitlement to a 50, 70, or 100 percent evaluation for any period requires sufficient symptoms of the requirements, or others of similar severity, frequency, or duration, that cause the specific type of occupational and social impairment. See Vazquez-Claudio, 713 F.3d at 118. In this case, the Board has considered the next higher ratings for any period but finds that the period on appeal is rated appropriately. Specifically, the Board notes that the VA examination reports do not, overall, indicate findings of the following psychiatric symptoms to support a clinical picture of occupational and social impairment with reduced reliability and productivity or deficiencies in most areas: impaired speech; panic attacks; impaired memory; impaired judgment; disturbances of motivation and mood; active suicidal or homicidal ideation; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; or inability to perform activities of daily living. It is important for the Veteran to understand that this disability rating is being assigned based on the current degree of occupational and social impairment his specific PTSD causes, and not all evidence supports the current finding. In statements to VA, such as his July 2009 substantive appeal, the Veteran has complained that veterans of the conflicts in Iraq and Afghanistan have received higher disability ratings for PTSD for circumstances the Veteran considers less traumatic than his own combat experience in Vietnam. Such an argument only provides evidence against his claim as does not suggest how his disability impacts him, he argues only that he should receive additional compensation based on what he believes is in an inequality of result. However, VA disability compensation is not intended to compensate or somehow make whole a veteran for the trauma that caused his or her disability, assuming such a thing is even possible. Rather, it is intended to help a veteran who has difficulty working due to a service connected disability by compensating him or her to the degree the disability effects employability. See 38 C.F.R. § 4.1. It is based on how it impacts the Veteran, not based on the stressor. Thus, the Veteran should not view the assignment of 30 percent disability rating as slight to his highly meritorious service or a determination by the Board or VA that his service is somehow considered less worthy. The assignment of a 30 percent evaluation reflects the fact that despite the psychological trauma he has experienced (a generally 30% reduction in the ability to function in the work force, which would very generally take into consideration the problems he himself has cited), the Veteran's symptoms of PTSD have had only a mild to moderate impact on his occupation and he has been very successful in performing the duties of his employment, despite his psychiatric disability, but with some problems. Without taking into consideration these problems, there would be no basis to assign the current rating. In this regard, it is important for the Veteran to understand that if he did not have problems with his PTSD, there would be no basis for the current 30% finding (which require the Veteran have problems with his PTSD), let alone a higher rating. A review of the problems he has cited generally provides evidence in support of the current evaluation, clearly indicating an ability to function, with problems that the VA would not dispute (and in fact take into full consideration when the 30 percent evaluation is awarded). The Board has also considered all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4, with respect to the claim as required by the Court. See Schafrath, 1 Vet. App. at 594. However, after careful review of the available diagnostic codes and the lay and medical evidence of record, the Board finds there are no other diagnostic codes that provide a basis to assign a rating higher than the currently assigned 30 percent evaluation for the service-connected PTSD on appeal for any period. While the Veteran frequently complains that he should be considered "100 percent disabled," at his May 2010 hearing, however, when questioned by the undersigned Veterans Law Judge, he clearly indicated that he was not claiming the issue of a total disability rating based on individual unemployability (TDIU). Furthermore, the record reflects that the Veteran has been employed throughout the entire period on appeal. His statement appears to be related to his concern that other Veteran's receive compensation at higher levels for less traumatic events. Again, the evlaution is not based on the nature of the trama. Accordingly, the Board will not further consider the issue of TDIU at this time. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Lastly, the Board has considered whether referral for an extra-schedular evaluation is warranted for PTSD. In exceptional cases an extra-schedular rating may be provided. 38 C.F.R. § 3.321 (2012). 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 evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. The Board finds that the schedular rating criteria reasonably reflect the Veteran's disability levels and symptomatology. The Veteran's reported difficulties are not so exceptional or unusual a disability picture as to render impractical application of regular schedular standards. Therefore, no referral for extra-schedular consideration is required and no further analysis is in order. Therefore, fully considering the lay and medical evidence of record, the Board finds that an initial evaluation for PTSD in excess of 30 percent is not warranted for any period. 38 C.F.R. §§ 4.3, 4.7. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. The Board finds that the VCAA notice requirements have been satisfied by a July 2008 letter. In this letter, VA informed the Veteran that in order to substantiate a claim for service connection, the evidence needed to show he had a current disability, a disease or injury in service, and evidence of a nexus between the post service disability and the disease or injury in service, which was usually shown by medical records and medical opinions. As to informing the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf, VA informed the Veteran it had to obtain any records held by any federal agency. This letter also informed the Veteran that on his behalf VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. Finally, the letter told the Veteran that he could obtain private records himself and submit them to VA. The VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the July 2008 letter included the type of evidence necessary to establish a disability rating and effective date. Regarding the duty to assist, VA must make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the initial rating claim for PTSD on appeal, the evidence of record includes statements from the Veteran and July 2008 and December 2010 VA examination reports. The VA examiners reviewed the Veteran's claims file and medical history, recorded pertinent examination findings, and provided conclusions with supportive rationale. The Board notes that the VA examination reports are probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In May 2010, the Veteran testified at a Board hearing held before the undersigned Veterans Law Judge. Any deficiencies in development were addressed in the subsequent Board remands. See Bryant v. Shinseki, 23 Vet. App. 488 (2010) (holding that the Veterans Law Judge who conducts a hearing fulfill the duty to fully explain the issues and the duty to suggest the submission of evidence that may have been overlooked). Pursuant to the Board's August 2010 remand instructions for this claim on appeal, the RO arranged for a VA examination in December 2010. That examination report reflects that the examiner considered the evidence of record and the reported history of the Veteran, conducted a thorough examination of the Veteran, noting all findings necessary for proper adjudication of the matter, and explained the rationale for the opinion offered. Hence, the Board concludes that the December 2010 examination was adequate and substantially complied with the August 2010 remand instructions. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes); see also Dyment v. West, 13 Vet. App. 141 (1999) (a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where there is substantial compliance with the Board's remand instructions). For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claim on appeal. The evidence of record provides sufficient information to adequately evaluate the claim, all obtainable evidence identified by the Veteran relative to the claim has been obtained and associated with the claims file, and the Board is not aware of the existence of any additional relevant evidence which was not obtained. Therefore, no further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). ORDER An initial 30 percent evaluation for PTSD is granted. An initial evaluation in excess of 30 percent for PTSD is denied for every period on appeal. REMAND A remand is required in this case to ensure there is a complete record upon which to decide the issue of an increased evaluation for fracture, right tibia and fibula, residuals of a gunshot wound with right knee arthritis. VA has a duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a) (West 2002); 38 C.F.R. § 3.159(c), (d) (2012); Ascherl v. Brown, 4 Vet. App. 371, 377 (1993). In August 2010, the Board remanded this claim on appeal for the RO/AMC to schedule the Veteran for a VA examination to determine, in pertinent part, whether there is involvement of any muscle groups with the service-connected fracture, right tibia and fibula, residuals of a gunshot wound with right knee arthritis. In October 2010, the Veteran underwent a VA joints examination. Following the clinical evaluation and review of the claims file, the examiner failed to address whether the requested service-connected disability encompasses the involvement of any muscle groups. The Board notes this requested information is necessary to properly adjudicate the claim on its merits under the applicable schedular rating criteria. As a result, the Board finds that an additional VA medical opinion is necessary to ensure there is a complete record upon which to decide this claim on appeal. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Stefl v. Nicholson, 21 Vet. App 120 (2007). The RO/AMC should arrange for the Veteran's claims file to be reviewed by the VA physician who conducted the October 2010 VA joints examination for fracture, right tibia and fibula, residuals of a gunshot wound with right knee arthritis and prepared the medical opinion (or a suitable substitute if that VA physician is unavailable) for the purpose of preparing an addendum opinion. Accordingly, the issue of entitlement to an increased evaluation for fracture, right tibia and fibula, residuals of a gunshot wound with right knee arthritis is REMANDED for the following actions: 1. Furnish the Veteran's entire claims file to the VA physician who conducted the October 2010 VA joints examination and prepared the medical opinion (or a suitable substitute if that VA physician is unavailable). The VA physician must review all pertinent evidence of record and prepare an addendum opinion as to whether there is involvement of any muscle groups with the service-connected fracture, right tibia and fibula, residuals of a gunshot wound with right knee arthritis. A rationale should be given for all opinions and conclusions expressed. If an opinion cannot be rendered without resorting to speculation, the VA physician should explain why it would be speculative to respond. If an additional clinical evaluation is necessary to render the requested information, then that opportunity should be made available. 2. Thereafter, the issue of entitlement to an increased evaluation for fracture, right tibia and fibula, residuals of a gunshot wound with right knee arthritis, currently assigned separate 10 percent disability ratings for limitation of flexion of the leg and for instability, should be readjudicated. If the benefit sought on appeal is not granted, the Veteran and his representative should be provided with a supplemental statement of the case (SSOC) and afforded the appropriate time period within which to respond thereto. The Veteran and representative have 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 remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012). Department of Veterans Affairs