Citation Nr: 1319454 Decision Date: 06/17/13 Archive Date: 06/27/13 DOCKET NO. 07-13 323 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to an initial disability rating in excess of 50 percent for the service-connected posttraumatic stress disorder (PTSD), prior to May 5, 2008. 2. Entitlement to a disability rating in excess of 70 percent for the service-connected PTSD since May 5, 2008. 3. Entitlement to service connection for a right knee disability. 4. Entitlement to service connection for a left knee disability. 5. Entitlement to an initial disability rating in excess of 10 percent for the service-connected scar, base of the left thumb, status post release of extensor tendon for tenosynovitis (De Quervain's disease). 6. Entitlement to an initial compensable disability rating for the service-connected scar, back of the right hand. 7. Entitlement to an initial compensable disability rating for the service-connected scar, ring finger of the left hand. 8. Entitlement to an initial compensable rating for the service-connected bilateral hearing loss. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD L. B. Cryan, Counsel INTRODUCTION The Veteran served on active duty from February 1967 to January 1971. His DD Form 214 reveals that he received the Basic Parachute Insignia, among other medals. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. In that decision, the RO granted service connection for PTSD and bilateral hearing loss, as well as for a scar at the base of the left thumb, status post release of extensor tendon for tenosynovitis (left thumb scar); a right hand scar; and a left ring finger scar. An initial 30 percent disability rating was assigned for the PTSD, and initial noncompensable ratings were assigned for the bilateral hearing loss, and all three scars. All of the ratings were effective from May 9, 2005. The RO also denied claims of service connection for right and left knee disabilities. In an April 2006 rating decision, the RO confirmed and continued the initial 30 percent rating assigned for the PTSD, and, increased the initial noncompensable disability rating for the service-connected left thumb scar to 10 percent, effective from May 9, 2005. The Veteran submitted a Notice of Disagreement with the denial of service connection for right and left knee disabilities, and the initial disability ratings assigned for the service-connected PTSD, hearing loss, and scars of the left thumb, right hand, and left ring finger. This appeal ensued. In April 2007, the Veteran testified at a personal hearing before a Decision Review Officer (DRO) at the RO. In a June 2010 rating decision, the RO confirmed and continued the denial of the claims of service connection for a right knee disability and a left knee disability; however, in that same rating decision, the RO increased the initial disability rating for the service-connected PTSD to 50 percent, effective from May 9, 2005; and, further increased the rating to 70 percent, effective from May 5, 2008. As this increase does not constitute a complete grant of benefits, the issue remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). In June 2010, after the RO issued the June 2010 rating decision, the Veteran withdrew the issues on appeal of entitlement to initial compensable disability ratings for the service-connected hearing loss, right hand scar, and left ring finger scar. In addition, the Veteran withdrew the issue of entitlement to an initial disability rating in excess of 10 percent for the service-connected left thumb scar. Before the case was certified to the Board on appeal, the RO issued additional rating decisions in October 2011 and August 2012. In the October 2011 rating decision, the RO granted entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), effective from February 2010. In the August 2012 rating decision, the RO granted service connection for prostate cancer and assigned a 100 percent scheduler disability rating effective from January 26, 2012. To the Board's knowledge, the Veteran has not disagreed with these decisions. Finally, in the August 2012 rating decision, it was noted that the issue of service connection for bilateral peripheral neuropathy had been deferred. In a September 2012 duty-to-assist letter, the RO notified the Veteran that it was still working on his claim of service connection for peripheral neuropathy due to Agent Orange exposure. Also, in a January 2013 VA Form 9, the Veteran raised new claims of service connection for: (1) erectile dysfunction; and (2) a psychiatric disorder other than PTSD, both claimed as secondary to the service-connected prostate cancer. All three of these issues have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issues of entitlement to service connection for a right knee disability and a left knee disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. In a written statement received at the RO in June 2010, and prior to the promulgation of a decision in the appeal, the Veteran requested to withdraw from appellate status the issues of entitlement to initial compensable disability ratings for the service-connected scar of the back of the right hand, scar of the left ring finger, and bilateral hearing loss, as well as the issue of entitlement to an initial disability rating in excess of 10 percent for the service-connected scar of the left thumb. 2. Throughout the appeal, and since the effective date of service connection, the Veteran's service-connected psychiatric disorder, as likely as not, has been manifested by symptoms of severe anxiety, depression and mood fluctuations affecting the ability to function appropriately and effectively; difficulty in adapting to stressful circumstances due to significant isolation from most people other than family members, irritability and a lack of impulse control with suicidal and homicidal impulses, rages, obsessive compulsive behavior, lack of patience, severe distrust of others and constant vigilance in public, all of which results in an overall disability picture that more nearly approximates that of deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. 3. At no time during the appeal period has total occupational and social impairment been demonstrated due to the service-connected PTSD; the record has not demonstrated symptoms on par with those contemplated in the maximum, 100 percent criteria, such as gross impairment in thought processes or communication; persistent delusions or hallucinations, 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. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal by the Veteran, with regard to the issue of entitlement to a disability rating in excess of 10 percent for the service-connected scar, base of the left thumb, status post release of extensor tendon for tenosynovitis (De Quervain's disease), have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2012). 2. The criteria for withdrawal of a substantive appeal by the Veteran, with regard to the issue of entitlement to an initial compensable disability rating for the service-connected scar, back of the right hand, have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2012). 3. The criteria for withdrawal of a substantive appeal by the Veteran, with regard to the issue of entitlement to an initial compensable disability rating for the service-connected scar, left ring finger, have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2012). 4. Resolving all doubt in the Veteran's favor, the criteria for the assignment of a 70 percent disability rating have been more nearly approximated since the effective date of service connection. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.16, 4.130, Diagnostic Code 9411 (2012). 5. The criteria for a rating in excess of 70 percent for PTSD are not met at any time during the appellate period. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.16, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Withdrawal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002). A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.202 (2012). Withdrawal may be made by the appellant or by his authorized representative. 38 C.F.R. § 20.204 (2012). In June 2010 correspondence to the RO, the Veteran requested to withdraw from appellate status the issues on appeal of entitlement to initial compensable disability ratings for the service-connected hearing loss, right hand scar, and left ring finger scar; and, the issue of entitlement to an initial disability rating in excess of 10 percent for the service-connected left thumb scar. As the Veteran has withdrawn his appeal as to these issues prior to the promulgation of a Board decision, there remain no allegations of errors of fact or law for appellate consideration with regard to those issues. Accordingly, the Board does not have jurisdiction to review the issues of entitlement to initial compensable disability ratings for the service-connected hearing loss, right hand scar, and left ring finger scar; and, the issue of entitlement to an initial disability rating in excess of 10 percent for the service-connected left thumb scar, and they are therefore dismissed. II. Duties to Notify and Assist Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The 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 v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). With regard to the claim of entitlement to a higher disability rating for the service-connected PTSD, initially rated as 50 percent disabling from May 9, 2005, and rated as 70 percent disabling from May 5, 2008, notice of the underlying service connection claim was provided to the Veteran in June and August 2005, prior to the initial adjudication of the claim of service connection for PTSD. Those letters did not specifically address all five elements of a service connection claim, but the claim of service connection for PTSD was thereafter granted pursuant to a March 2006 rating decision. That same month, the RO issued another letter notifying the Veteran of all five elements of a service connection claim. As the underlying claim of service connection was granted, any defect in the June and August 2005 letters is harmless error. With regard to the increased rating claim, here, the Veteran is challenging the initial rating assigned following the grant of service connection. In cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Thus, because the notice that was provided before service connection was granted was sufficient, VA's duty to notify in this case has been satisfied. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Moreover, the claims file reflects that the RO sent a subsequent duty-to-assist letter to the Veteran in March 2006 in compliance with the holding in Dingess, notifying the Veteran of all five elements of a service connection claim, on the same day as the notice of the favorable rating decision regarding the grant of service connection for PTSD was sent. Thus, the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). The Veteran has not alleged any prejudice with regard to notices provided to him with respect to the claims on appeal. VA has obtained service treatment records, assisted the Veteran in obtaining evidence to the extent possible, including VA and private treatment records, and records from the Social Security Administration (SSA) used by them in connection with his SSA disability claim; and the Veteran was afforded an opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file and the Veteran has not contended otherwise. In July 2010 correspondence, the Veteran indicated that he had no more information or evidence to submit in support of his claim for higher ratings for the PTSD. VA has afforded the Veteran physical examinations in conjunction with his claim. First, an examination was provided to assess whether the Veteran had PTSD related to service, and then additional examinations were provided to assess the extent and severity of the PTSD throughout the appeal period. All necessary opinions were obtained in this regard. Furthermore, the most recent VA PTSD examination of February 2010 is adequate as the examiner reviewed the history of the condition, conducted a mental status examination, and provided sufficient information so the Board's determination is an informed one. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). In short, VA has substantially complied with the notice and assistance requirements, and the Veteran is not prejudiced by a decision on the claim with regard to the proper ratings assigned for the service-connected PTSD. In addition to the paper claims file, there is a Virtual VA (VVA) electronic claims file associated with the Veteran's claim. The documents in the VVA file have been reviewed, and all relevant records are either duplicative of the evidence in the paper claims file or are separately identified and summarized below. III. Increased Ratings - PTSD The Veteran seeks a higher rating for the service-connected PTSD, rated as 50 percent disabling since May 9, 2005, the effective date of service connection, and rated as 70 percent disabling since May 5, 2008. He asserts that his PTSD symptoms are productive of near-continuous agitation; significant social isolation from most people other than family members, impaired impulse control due to a lack of patience, intense anger and rage, obsessive compulsive behavior, suicidal and homicidal impulses, hyper vigilance and severe distrust of others, all of which result in deficiencies in most areas. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity resulting from a disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When there is a question as to which of two evaluations should 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. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3. The Veteran's service-connected PTSD was assigned an initial 50 percent rating, effective from May 9, 2005. An increased rating to 70 percent was assigned during the course of this appeal, effective from May 5, 2008. As the award is not a complete grant of benefits, the issue remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). In cases such as this, where the Veteran appeals the initial rating assigned for a service-connected disability, consideration must be given to "staged" ratings, i.e., disability ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. See 38 C.F.R. § 4.126. Under 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders, diagnostic Code 9411 governs ratings for PTSD. Regardless of which diagnostic code is used to rate the psychiatric disability, the outcome is the same because all mental disorders are rated pursuant to the Schedule for Rating Formula for Mental Disorders at 38 C.F.R. § 4.130. Under Diagnostic Code 9411, a 30 percent evaluation is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted when the veteran exhibits occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The next higher, 70 percent, evaluation is warranted for a mental disorder where the veteran exhibits 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. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent rating is warranted where the veteran exhibits total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The only criteria for a total disability rating for any disability rated in accordance with the VA General Rating Formula for Mental Disorders are total occupational and social impairment. Sellers v. Principi, 372 F.3d 1318, 1324 (Fed. Cir. 2004). The "such symptoms as" language of the diagnostic codes for mental disorders in 38 C.F.R. § 4.130 means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, as the Court also pointed out in that case, "[w]ithout those examples, differentiating a 30% evaluation from a 50% evaluation would be extremely ambiguous." Id. The Court went on to state that the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Id. Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. Put another way, the severity represented by those examples may not be ignored. Global Assessment of Functioning (GAF) scores, which reflect the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health, are also useful indicators of the severity of a mental disorder. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). GAF scores ranging between 61 to 70 reflect 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 indicate that the individual is functioning pretty well, and has some meaningful interpersonal relationships. Scores between 51 to 60 are indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores between 41 to 50 reflect 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). Scores between 31 to 40 indicate some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). The Veteran was afforded VA psychiatric examinations in April 2006, June 2007 and February 2010. In addition, there are private and VA mental health records showing ongoing treatment for PTSD throughout the appeal period. The results from those reports are consistent, and show that the Veteran's PTSD symptoms, as likely as not, have resulted in an overall disability picture that more nearly approximates that of deficiencies in most areas since the effective date of service connection. The first evidence of PTSD comes from a private mental health provider, S.P., who reported in May 2005 and September 2005 that he had been seeing the Veteran in individual therapy since May of that year. Dr. S.P. noted PTSD symptoms of depression and mood fluctuations with suicide and homicidal impulses. According to S.P., the Veteran became alcohol dependent and drank excessively for years. He would get into fights and scare his family members with extreme behaviors. He experienced nightmares, flashbacks and intrusive memories. According to S.P., the Veteran avoided many social events and fireworks. He got easily angry and was overly controlling with his family. The Veteran gets into rages when he witnesses war protesters or feels wronged. According to S.P., the Veteran presented with severe distrust of others and constant vigilance in public. He did not confide in his family and did not consider himself to have any friends. The Veteran worked compulsively but he complained of interactions with his peers and superiors. At times he lost his temper and screamed at strangers. S.P. initially viewed the Veteran as higher functioning, but noted that he had a tendency to withhold aspects of his life because of pride. Diagnostic impression in May 2005 was PTSD and major depressive disorder with a GAF of 65. Diagnostic impression in September 2005 and again in July 2006 was PTSD, bipolar II disorder, alcohol dependence in sustained full remission, with a GAF was 50. In the July 2006 report, S.P. noted that the Veteran continued to struggle with high levels of social distrust and emotional reactivity. According to S.P., the Veteran appeared to get some temporary relief from the therapy, but had increasing depressive and agitations symptoms as the end of the treatment approached. He appeared to have difficulties developing an inner focus of control with his emotional turmoil. Although the Veteran was resistant to the use of psychotropic mediations, S.P. noted that the Veteran had reportedly agreed to use them when he resumed treatment through VA. At a VA examination in April 2006, the Veteran reported that he could not function. In addition to a continuation of the symptoms described by S.P, as noted above, the Veteran added that he had sleep disturbance and a lack of sleep with disturbing dreams or nightmares, and night sweats, every night. The Veteran reported an increase in irritability and anxiousness and intrusive thoughts daily. He reported continued hypervigilance, avoidance, and problems with anger, which manifests itself verbally, not physically. The Veteran denied flashbacks. The Veteran reported suicidal ideation, noting that he tried to hang himself five or six years earlier. However, that occurred while he was still drinking and he reportedly has not had any suicide attempts since that occurrence. He did indicate, however, that although he did not have any intent to hurt himself currently, he sometimes felt that it would be better off if he were not around. Although the Veteran is socially isolated, and wishes to be left alone, he does report a 38-year marriage with no plans of separation. He described his wife as, "She's great." The Veteran had a daughter and a son, ages 36 and 34, respectively. The daughter and his grandchildren live with the Veteran. Although the Veteran describes irritability in his relationship with his children, the relationship still remains positive. The Veteran worked at the counter of a car rental agency (which was later determined to be his wife's business). He became irritable and angry in the work setting with regard to customers, supervisors and co-workers. His bad temper has resulted in blow-ups with co-workers on a monthly basis and verbal warnings from his supervisors. The examiner concluded that the Veteran's mental health symptoms negatively impacted his work performance. With regard to activities of daily living (ADLs), the Veteran manages his own personal hygiene and grooming. His appearance at the examination was very casual but acceptable. The Veteran's wife prepares his meals, but he does participate in doing chores and errands. With regard to recreational activities, the Veteran did not enjoy doing much anymore. He watched television and had one friend who lived in California. He avoided people and reportedly hid when anyone rang his door bell. Overall, the examiner noted inappropriate behavior for the Veteran related to anger and irritability, which was verbal in manifestation, frequent in occurrence and moderate to serious in degree, and was occurring both in the work setting and in his interpersonal relationships at home. A mental status examination revealed satisfactory immediate and recent memories. Remote memory was good. He was oriented to time, place, and person, but reported not knowing the specific reason for the examination. Speech was normal as to rate and volume, emotional in tone and throughout the examination, that emotion being anxiety. Thought process production was spontaneous and abundant. Continuity of thought contained some rambling. The Veteran could be goal directed and relevant when refocused by the examiner. There was no homicidal or suicidal ideation. There were no delusions, ideas of reference or feelings of unreality. The Veteran's abstract ability and concentration were both intact. Mood was anxious and range of affect was broad. He was alert, responsive and cooperative. Judgment was intact. Insight was fair. GAF was 50. A November 2006 VA mental health note reveals that the Veteran had recently relocated and was seeking VA mental health treatment. He reportedly worked for 30 years as a manager for a phone company but chose to retire since he knew his anger would result in him getting fired. The report notes that the Veteran became more miserable when he stopped drinking about 5 years earlier. Symptoms of nightmares, night sweats, anger mismanagement, poor sleep, and pervasive survivor's guilt, with strong negative feelings about himself, and a depressive mood. He agreed to take Zoloft, and admitted that it has prevented over reaction to angry feelings. The examiner noted a diagnosis of PTSD with significant PTSD symptoms. He was advised to continue individual counseling. VA mental health records dating from December 2006 through March 2007 show that the Veteran began to attend group therapy. A March 2007 mental health interdisciplinary treatment plan shows that the Veteran reported a nearly identical social history as previously reported, noting the closeness with his immediate family members, but severe isolation from the public. The Veteran reported the severity of his impaired impulse control with rage, anger and irritability. He also reported being easily distracted with impairment of short term memory. On mental status examination, the Veteran was neat in appearance, alert and oriented times three with good eye contact. Affect/mood was down and irritable. The Veteran denied current suicidal and homicidal ideation; denied psychosis, paranoia, mania/hypermania, panic/and phobias. The Veteran's thoughts appeared logical and organized. Speech was clear/coherent with normal rate and volume. There were no abnormal movements. Insight and judgment were intact. The examiner noted the Veteran's complaints of poor short term memory, concentration and focus, but also noted that the Veteran was cooperative, pleasant and redirectable. An April 2007 mental health report shows that the Veteran started a new medication (sertraline) in May 2006, which was subsequently increased in August 2006. The Veteran reported that it helped with his anger and irritability; yet, he was still unable to manage social interaction in an occupational setting, and he had difficulty going to a family wedding and had to leave early due to irritability and an inability to manage anger, anxiety and paranoia. GAF was 50. An April 2007 group therapy note indicates that the Veteran was attentive and interactive during that session. At the Veteran's personal hearing in April 2007, he testified that he has not been able to hold a full-time job since his retirement from the phone company in 1998. He reported that when he was working with the phone company, he was moved from location to location. He originally believed these moves were equivalent to promotions, but he later found out it was because he was difficult to work with due to his hot temper, and the inability to get along with others. The Veteran reportedly attempted to obtain other jobs, but was unable to tolerate working with others. The Veteran's daughter testified that the Veteran only socializes with the immediate family, and if anyone outside the family comes to the house, the Veteran goes to his room and shuts the door. The Veteran's daughter indicated that he refused to attend her son's basketball games because he could not be around other people. The Veteran's daughter also testified that she had to remind him to bathe and to get his hair cut. At a VA examination in June 2007, the examiner noted a review of the claims file. The Veteran reported feeling very lonely. The examiner, who performed the earlier examination in April 2006 noted that the Veteran's treating psychiatrist, Dr. P, indicated GAF scores of 50 in August 2006, 60 in January 2007 and 50 in April 2007. The examiner specifically noted that based on the medical records reviewed, there had not been any remissions in the Veteran's PTSD since the last rating examination [in April 2006]. The examiner indicated that the Veteran's presentation at the present examination was vague as to content, but the examination report provided some development with regard to the severity of the PTSD. The Veteran continued to report nightmares and restless sleep, but he was able to sleep a few hours longer than what was reported in April 2006 (5-7 hours now versus four to five hours in April 2006. Similarly, the Veteran continued to report nightmares, but only three to four nights per week, and not daily as was reported in April 2006. Consistent with the April 2006 examination report, the Veteran continued to report intrusive thoughts on a daily basis, with an increase in the level of anger and irritability as well as anxiousness; however, with medication, his temper had improved. The Veteran reported that with the treatment, "I feel like somebody put the brakes on me." Likewise, the Veteran indicated that when he got anger, he would, in essence, internalize the anger and end up with a headache. The Veteran also demonstrated an anger of things he is unable to control (an intellectual irritability). According to the examiner, the Veteran continued to report hypervigilent behaviors at about the same level as previously reported and manifests itself by primarily avoiding social interaction. The Veteran also reported exaggerated startle for unexpected noise. He continued to report some suicidal ideation since the last rating examination, particularly when he is worried about his financial situation, but he has not taken any action on those thoughts and did not indicate any intention for self harm. The Veteran's wife, who was present at the examination, noted that the Veteran had no social life and was always alone. The Veteran indicated his desire to work; however, he indicated that he was only able to help his wife with her rental car business on a part time basis because of an inability to control his anger outbursts and inability to get along with customers and co-workers. The examiner also noted, however, that the Veteran was not working much because of his physical health problems and the Veteran did not report lost time from work due solely to PTSD. With regard to ADLs, the Veteran continued to manage his own personal hygiene and grooming, and his appearance was clean and casual. The Veteran watched television and did some limited activities with his grandson, but overall, he denied any social activity outside the immediate family. The Veteran's wife did the cooking and most of the chores and errands. The Veteran's inappropriate behavior continued to be the anger and irritability, which was managed most by avoidance and medication, and drinking alcohol. (Alcohol dependence was no longer in remission and the Veteran resumed drinking since the last examination). The Veteran reported drinking three shots of alcohol a day to reduce stress. A mental status examination revealed immediate and recent memories were satisfactory. His remote memory was good. He was oriented in all spheres. Speech was normal as to rate and volume, emotional in delivery. Thought process production was spontaneous and adequate. Continuity of thought was relevant and goal directed. There were no suicidal or homicidal ideations, no delusions, and no ideas of reference or feelings of unreality. The Veteran's abstractibility and concentration were both intact. His mood was mildly dysphoric and his range of affect was restricted. He was alert and responsive. His judgment was adequate, and his insight was fair. GAF was 50. In an August 2007 statement, the Veteran's primary therapist indicated that the Veteran continued to experience ongoing depression due to his inability to support his family, difficulty defusing anger, and pervasive survivor's guilt. He avoided experiencing emotions, thus had a limited range of affect, and isolated to avoid possible outbursts or excessive anxiety. His symptoms, according to the therapist, have affected most areas of his life, including straining his family, which was his primary support system. A December 2007 mental health treatment note reveals that the Veteran's symptoms and mood remained essentially unchanged. Although medications helped to control anger outbursts, the Veteran continued to struggle and his impulse control was only fair. Judgment was adequate. Thinking, memory and cognition were within normal limits/grossly intact. GAF was 50. A May 2008 VA psychiatric report notes that the Veteran initially showed improvement with medication, but was now showing signs of increased symptoms again, including increased irritability, nightmares, amotivation, anhedonia, and an inability to control anger.. Mental status examination showed no significant changes from previous examinations, but the Veteran's GAF was lower, at 45. Also in May 2008, the Veteran presented to the ER after drinking a pint of tequila. He called his PTSD buddy to help him because he wanted to take a gun to himself and wanted to hurt others. He was admitted with a diagnosis of suicidal and homicidal ideation and a GAF of 35. During the Veteran's 4-day admission, he was found to have met the criteria for consideration as a candidate for the mental health intensive case management (MHICM) team. Although he did not meet all the required criteria, it was noted that the Veteran had a diagnosis of severe and persistent mental illness; and, that he had severe functional impairment such that he is neither currently capable of successful and table self-maintenance in a community living situation nor able to participate in necessary treatments without intensive support. In September 2008, the Veteran's GAF was 45, and the findings on his mental status examination were similar to the findings on mental status examinations prior to the Veteran's May 2008 intoxication and 4-day hospital admission. VA mental health records from January 2009 through January 2010 show that the Veteran continued to seek treatment for his PTSD symptoms, and his GAF remained at 45. The Veteran's continued to show symptoms of avoidance, irritability, anxiety, worry, with nightmares and intrusive thoughts. He avoided contact with others and continued to struggle with depressed mood and situational conflicts. His avoidance was thought to be of a moderately severe degree that markedly affected functioning. At a VA examination in February 2010, the examiner indicated a review of the claims file, including the previous VA examination; and, the Veteran's medical record. The Veteran was interviewed, and he reported a continuity of symptoms without periods of symptom remission. The examiner specifically indicated that a review of the record was consistent with the Veteran's reports, as the record confirmed significant PTSD problems with no remissions. The Veteran described regular periods of anger and short temperedness, which included shoving people, mainly family, on a number of occasions. He described verbal outbursts, mainly directed toward family members, two to three times per week and it is usually directed at a family member because he has very little social support and did not go out much. The Veteran described an incident when his son was badgering him to tell stories about the war and the Veteran took a gun, cocked it and put it in his son's belly. The Veteran described feeling invaded and pushed into a corner, and that is why he responded defensively. The Veteran reported that he is unable to tolerate smaller insignificant items that most individuals can brush off. The Veteran's sleep continued to be restless, erratic and poor, with night sweats and nightmares. The Veteran continued to experience severe isolation as a form of avoidance. When he attempts to go somewhere, he becomes tense and anxious. Although there is no plan, the Veteran reported suicidal thoughts every few weeks. The Veteran continued to use alcohol as a coping mechanism. Findings on the mental status examination were the same as previously noted. Specifically, the Veteran was fully oriented and grooming and hygiene were appropriate. Speech was normal in terms of rate, volume and production. He was goal directed and clear in his thinking. There was no homicidal or suicidal thinking. There was no evidence of a psychotic disorder. Concentration and attention were well-preserved. There were no memory difficulties. Judgment and insight were adequate. GAF was 42, and the Veteran was competent to manage his funds and benefits. The examiner concluded that there had been no remittance in the Veteran's PTSD symptoms since he was last seen (in June 2007). Despite continued treatment with medications, he continued to suffer significant problems in most areas of his life. Anger and irritability had affected him on the job and he had not held any significant work since prior to the last VA examination. The examiner also concluded that the Veteran was socially isolative. His family tolerated his anger and frustration and walked on egg shells around him. He was using alcohol in excess to deal with his symptoms. He avoided people so as to not have confrontations and to avoid his anxieties. The examiner felt that things had worsened for him since his last examination. Given his symptom presentation, the examiner opined that being able to sustain any manner of prolonged employment would be unlikely at the current time, given the major impairments he has in the various areas. As noted above, the Veteran's service-connected PTSD is currently rated at 50 percent prior to May 2008 and at 70 percent thereafter. Based on a review of the record, and resolving all doubt in the Veteran's favor, the Board finds that his PTSD symptoms have resulted in deficiencies in most areas warranting the 70 percent rating, since the effective date of service connection. Beginning with a description of his symptoms by S.P. in May and September 2005, and continuing through VA examinations of April 2006, June 2007 and February 2010, the Veteran has always showed severely impaired impulse control, anger, and irritability, both occupationally and socially. The Veteran has always had suicidal and homicidal impulses, although he does not have any plan. The Veteran has always remained isolated from the community and prefers to be alone. His mood has always been depressed and anxious. These examination reports and outpatient mental health reports show that despite some improvement in the Veteran's impaired impulse control with the use of psychotropic medications, the Veteran remains severely occupationally impaired such that he is unable to perform any work that involves any social interaction. The Veteran also continues to have anger and irritability despite the medication. The record shows that the Veteran's alcohol use was in remission at the beginning of the appeal period, but he started drinking again around the time of his 4-day VA hospital admission in May 2008. Although the Veteran's anger control symptoms appeared to have worsened somewhat in conjunction with his increased drinking, the Veteran reported, at least twice, that the drinking helps him cope with stress and anxiety. Overall, the level of severity of the Veteran's PTSD symptoms have remained fairly consistent throughout the period covered by this appeal. Notably, the June 2010 examiner specifically opined that the Veteran has not had a period of remission from these symptoms according to the record. The record does reflect various points in time where the Veteran has experienced temporary exacerbations, such as when he was admitted for four days to a VA hospital in May 2008 with suicidal and homicidal ideations after drinking a pint of tequila. However, this was an isolated event, and does not appear to represent the Veteran's overall day to day functioning. Similarly, the record also shows that the Veteran's use of psychotropic medications temporarily helped the Veteran control his temper and anger somewhat; however, there is no indication that the Veteran's anger, isolative behavior, or avoidance changed during that time period such that overall improvement was apparent during the time period that the Veteran's anger management temporarily improved on medication. Further, the Veteran's primary therapist and the most recent VA examiner noted deficiencies in most areas, such as work, family, and mood due to the continuous and severe symptoms noted above. The Veteran has always noted that he is verbally abusive to his family members. Further, despite the Veteran's adequate grooming and hygiene during VA examinations, the Veteran's daughter testified that she has to remind him to bathe and have his hair cut. In a subsequent examination, the Veteran clarified that he just does not see the need in showering regularly and it took too much effort. Thus, the Veteran is clearly capable of maintaining acceptable grooming and hygiene, but the fact that he must be reminded to do so supports that notion that the Veteran continues to have a deficiency in the area of mood, in addition to work and family, as he maintains a lack of self worth, severe depression and a lack of motivation. There is essentially no medical or lay evidence to contradict the opinions of the VA examiners or the VA mental health providers who treat the Veteran's PTSD through therapy and period examinations. Based on the above evidence, there has been occupational and social impairment with deficiencies in most areas since the effective date of service connection. Although the GAF scores prior to May 2008 ranged between 50 and 60; but, were lower, between 42 and 45 during and after May 2008, the consistency with which the Veteran reported his symptoms and the consistency with which the examiners described the Veteran's mental status examination before and after May 2008 were nearly identical, providing doubt as to whether separate ratings should be assigned for those two periods. When there is a question as to which of two evaluations should 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. Significantly, as the symptoms since May 2008 are relatively similar to those prior to May 2008, the higher, 70 percent rating must be assigned for the appeal period prior to May 5, 2008. In light of the foregoing, the criteria for the assignment of a 70 percent rating, but no higher, have been more nearly approximated since the effective date of service connection. In essence, the evidence shows deficiencies in most areas, and more than just reduced reliability and productivity. Since the effective date of service connection, the Veteran has had very little productivity. Thus, an increased evaluation, specifically from 50 percent to 70 percent, from May 2005 to May 2008 is warranted. Moreover, the assignment of staged ratings has been considered pursuant to Fenderson v. West, 12 Vet. App. 119 (1999); however, at no time since service has the service-connected disability been more disabling than as currently rated. Significantly, while the evidence suggests that the Veteran's PTSD symptoms may have worsened somewhat since May 2008, as shown by the decrease in GAF scores, they have never risen to a level such that a 100 percent rating is warranted at any time. At no time since the effective date of service connection, has the Veteran exhibited total occupational and social impairment sufficient to warrant the maximum (100 percent) rating. The Veteran has been found unemployable primarily due to the service-connected PTSD, but that unemployability is based on his difficulty dealing with co-workers and supervisors, as reported by Veteran. While that may limit most, or all forms of feasible employment, the Veteran's judgment and thinking are not significantly impaired. The Veteran is not shown to be cognitively deficient. Certainly he has social impairment, as demonstrated by his isolative behavior, lack of friends, and anxiety or fear of being around people other than family members. However, the Veteran has remained married to his wife for over 40 years, continues to live with his daughter with whom he remains close, and has always been able to attend doctor's appointments and mental health counseling sessions, despite his anxiety. In other words, the evidence shows that the Veteran has significant social impairment, but not total social impairment. The Veteran does not have a psychosis, is not delusional, and does not have impairment in thought process. Although the Veteran prefers not to bathe, he has consistently maintained appropriate dress and adequate hygiene at all VA examinations. Although the Veteran had an acute exacerbation of symptoms in May 2008 when he was hospitalized for four days with homicidal and suicidal ideation, there is no demonstrable difference in the level of anxiety, irritability, hostility, anger, depression, chronic sleep impairment or impulse control before or after that admission. At no time during the appeal period has the Veteran ever experienced disassociation from reality. There have never been hallucinations or delusions, and the Veteran has no problem with his long-term memory. At every examination, the Veteran has been fully oriented, and his behavior has been appropriate. As total social impairment is not demonstrated, the criteria are not met for the assignment of a 100 percent schedular rating at any time during the course of this appeal. The Board has also considered whether the record raises the matter of an extraschedular rating under 38 C.F.R. § 3.321(b)(1). 38 C.F.R. § 3.321(b)(1) applies when the rating schedule is inadequate to compensate for the average impairment of earning capacity for a particular disability. The threshold factor for extraschedular 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. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, the Veteran's symptoms are significant social impairment with severe anxiety, isolation and avoidance, impaired impulse control and depression. These are specifically contemplated by the schedule. Thus, the Veteran's disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. ORDER An initial disability rating of 70 percent, but no higher, for the service-connected PTSD is granted, effective from May 9, 2005, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 70 percent for PTSD is denied. REMAND The Veteran seeks service connection for bilateral knee disabilities. The Veteran asserts that overuse of his knees in service, via parachute jumping, has resulted in his current knee disabilities. The service treatment records (STRs) are negative for any injury to, or complaints of pain in, the right knee. In December 1970, the Veteran was treated for trauma to the left knee times two days. He complained of pain around the patella while walking. There was no tenderness to the touch. The Veteran had good extension, and appeared to have good flexion, but with more pain. He was returned to duty with an ace wrap and provided with pain medication. The remainder of the STRs are negative with regard to the left knee. The Veteran did not report left knee pain or injury at the time of discharge in 1971. The records shows that the Veteran underwent left knee surgery in August 1997 for grade IV chondromalacia femoral trochlear and lateral tibial plateau; and, suprapatellar plica. The surgical procedure consisted of a left knee arthroplasty, chondroplasty, and excision of the suprapatellar plica. The surgical report noted a long history of left knee pain. In September 1997, the Veteran underwent a right knee arthroscopy and chondroplasty for right knee grade III chondromalacia femoral trochlea; and, grade II-III chondromalacia patella and medial femoral condyle. A May 2006 x-ray report indicated arthritic changes in the knees, but not diagnostic for rheumatoid arthritis. A May 2006 private treatment record indicates that the Veteran's knee pain may or may not be related to his Rheumatoid arthritis. The examiner noted a very complicated history of connective tissue disease. A May 2006 VA clinic note shows that the Veteran reported having arthritis in multiple joints since 1975, including the knees. At the Veteran's April 2007 personal hearing, he testified that his knees began hurting during service, but he was too proud to complain about it at that time. A May 2007 VA cardiology workup/surgical history and physical evaluation reveals that the Veteran underwent a prior bilateral knee arthroscopy in 1992, approximately 5 years before the documented 1997 procedures. Private treatment records from April 2001 indicate that the Veteran had rheumatoid arthritis. A July 2006 VA rheumatology consult revealed that the Veteran had pain in multiple joints, including the knees. At a VA examination in February 2010, the examiner was not initially provided with the claims file, and conducted the interview and physical examination without medical documentation of the Veteran's prior knee history, including his multiple surgical procedures. The examiner appeared to have access to the Veteran's VA medical records because he noted a diagnosis of degenerative joint disease (DJD), right and left knees, per an October 2008 x-ray study. The Veteran reported to the examiner that he retired in 1998 because of his knees. The Veteran reported that he initially injured his knees in the 1970's when he fell down some stairs and was treated with an Ace bandage. He also reported that he used his knees a lot while doing parachute jumps. The Veteran reported that he had knee pain at the time of discharge from service, and denied injury since that time. The examiner also acknowledged the Veteran's self-reported history of four arthoscopies of each knee since service, all of them done privately. Physical examination shows that the Veteran ambulated with a limp on the left using a Canadian crutch in the left hand. The diagnosis was DJD of both knees, with moderate functional impairment on the right and moderately severe functional impairment on the right. Initially, the examiner was unable to provide a nexus opinion because the claims file was not available for review. However, in a February 2010 addendum to the February 2010 VA examination report, the examiner noted a review of the file, including the STR. The examiner indicated that he was unable to find anything in the STRs regarding the Veteran's right/left knees or parachute jumping. The examiner therefore concluded that it was less likely as not that the current condition of the Veteran's knees required surgical intervention in 1997 began in service from parachute jumping. The February 2010 examination was clearly inadequate because the examiner's opinion was based on inaccurate information. The examiner's opinion was based on a finding that there was nothing in the STRs regarding the Veteran's right/left knees or his parachute jumping. However, the STRs clearly document a left knee injury, and the Veteran's DD Form 214 shows that the Veteran was awarded the Basic Parchute Insignia in service. In light of the inadequacy of the June 2010 opinion, the RO scheduled another VA examination in June 2012. The report reveals that the examiner is the same physician who conducted the June 2010 examination and provided that opinion. Unfortunately, the June 2012 opinion is also inadequate. The Veteran was not present for examination and the report only contained a medical opinion. In essence, the examiner indicated a review of the claims file and indicated that the claimed condition [of the knee(s) was less likely than not incurred in or caused by the claimed in-service injury. The examiner's rationale was stated as follows: The note in STR of 12/22/70 states "trauma to left knee 2 days - pain while walking" - this does not constitute trauma by any manner of means and I do not therefore consider left knee condition due to service. There was no "injury" to left knee in 12/70. Therefore right knee condition is not due to left knee condition, and wouldn't be anyway since there is nothing in the orthopedic literature I am aware of that relates a problem in a paired major joint directly affecting the contralateral same joint. Also - there is no evidence biomechanical or otherwise that the right knee condition would aggravate the left knee condition beyond is natural progression. First, the record reflects that June 2012 correspondence from the RO notified the Veteran that a VAMC would be contacting him soon to schedule him for a VA examination; and, the correspondence also provided the Veteran with notification of the consequences of his failure to report. Thus, it is clear that the RO intended to have the Veteran's knees re-examined in conjunction with a medical nexus opinion. Second, the examiner's opinion is based on a lack of evidence in the STRs with regard to parachuting; thus, the examiner never addresses whether the Veteran's parachute jumping in service, as likely as not, resulted in bilateral arthritis of the knees at some point after service. Significantly, service connection may be granted for any disease diagnosed after discharge, when all the evidence including that pertinent to service, establishes that the disease was incurred in service. The examiner completely disregarded the fact that VA essentially conceded parachute jumping in-service based on information obtained from the DD Form 214, despite a lack of corroborating evidence. Thus, his opinion is based on a negative finding of parachuting, when this fact has already been conceded. Because VA has conceded parachute jumping in service, the VA examiner must base his or her opinion on this finding. This was not accomplished in the June 2012 opinion. Third, the examiner refused to consider the Veteran's left knee injury in service as a "trauma" which is how it was described in the STRs. While the Veteran's in-service treatment for left knee pain may, or may not, have resulted from a "trauma" the fact remains that the Veteran's STRs document some sort of left knee injury, however slight or insignificant it may have been. Although the examiner explained that a left knee injury in service would not result in bilateral knee disabilities, it is of particular note, that the June 2010 VA examination of the knees revealed that the left knee had more functional impairment than the right. Because the examiner did not consider the December 1970 event to be an injury, the opinion is inadequate. Finally, the examiner did not consider the Veteran's lay testimony that he had knee pain at the end of service, but did not report it; and, the examiner did not consider the possibility of rheumatoid arthritis as was noted in the VA and private treatment records summarized above. Given the inadequacy of the June 2012 opinion, another VA examination is necessary to address the likely etiology of the bilateral knee arthritis. This opinion must be based on an examination of the Veteran and VA's finding of in-service parachute jumping and injury to the left knee in December 1970, no matter how slight. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file all outstanding VA medical and personnel records in connection with the Veteran's claim. 2. With appropriate authorization from the Veteran, obtain and associate any private treatments identified by him with regard to his bilateral knee arthritis and rheumatoid arthritis that have not been previously obtained and associated with the claims file. 3. After completion of #1 and #2 above, schedule the Veteran for an orthopedic examination to determine the current nature and likely etiology of the Veteran's current bilateral knee disability. If possible, have the Veteran examined by a doctor other than the one who examined the Veteran's knees in June 2010 and who provided the July 2012 opinion. The claims folder and a copy of this remand must be made available to the examiner. The examiner should note in the examination report that the claims folder has been reviewed. Any appropriate evaluations, studies, and testing deemed necessary by the examiner should be conducted at this time, and included in the examination report. The examiner is asked to address the following: a. The examiner is asked to obtain a full recorded medical history of the Veteran's knee disabilities, including when, and how many, knee surgeries the Veteran has undergone, as there is some discrepancy in the record. b. The examiner is asked to address the private and VA treatment records that refer to rheumatoid arthritis and express an opinion as to whether the Veteran has rheumatoid arthritis, and if so, whether it involves the knees. c. The examiner is asked to opine as to when the Veteran's currently diagnosed DJD of both knees was first manifested (i.e., prior to service, in service, or after service). In this regard, the examiner should opine as to whether the Veteran's in-service complaints of left knee pain and his competent and credible post-service reports of having knee pain at the time of service discharge would be compatible with symptoms usually seen in parachute jumpers. The examiner should also consider the Veteran's service treatment records and the Veteran's statements reported throughout the appeal and during his April 2007 personal hearing about the onset of his knee pain. d. If the examiner determines that the right and left knee disabilities were first manifested after service, the examiner should indicate whether the condition is at least as likely as not (i.e., 50 percent or greater possibility) related to the Veteran's period of active service, to include the parachute jumping (which has already been confirmed) and/or the December 1970 documented left knee pain. The examiner must provide a complete explanation for any stated opinion. In responding to this question, the examiner should consider the Veteran's competent and credible comments regarding continuity of symptoms since discharge from service. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 4. Following the above, ensure that the examination report is complete and responsive and, if not, return the report(s) as inadequate. Then readjudicate the Veteran's claims after undertaking any other development deemed warranted. If any benefit on appeal remains denied, a Supplemental Statement of the Case should be issued, and the Veteran and his representative should be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs