Citation Nr: 1322235 Decision Date: 07/11/13 Archive Date: 07/18/13 DOCKET NO. 06-35 963 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an increased evaluation in excess of 10 percent for patellofemoral pain syndrome of the left knee, (exclusive of the period from August 23, 2004 to September 30, 2004, during which a temporary total evaluation was assigned pursuant to 38 C.F.R. § 4.30). 2. Entitlement to an increased evaluation in excess of 10 percent for limited flexion of the left knee. 3. Entitlement to an increased evaluation in excess of 10 percent for low back strain. 4. Entitlement to an increased (compensable) evaluation for status post Bartholin's gland excision prior to July 11, 2007, and an evaluation in excess of 10 percent beginning July 11, 2007. 5. Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Bruce, Counsel INTRODUCTION The Veteran had active service from October 1997 to July 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2005 rating decision of the Department of Veteran's Affairs (VA) Regional Office (RO) in Waco, Texas. In a July 2007 rating decision, the RO increased the rating of the service-connected status post Bartholin's gland excision from noncompensable (0 percent) to 10 percent disabling, effective July 11, 2007. Subsequently, in January 2013, the RO assigned the 10 percent rating back to July 19, 2001. Because a rating higher than 10 percent is available, and because a claimant is presumed to be seeking the maximum available rating for a service-connected disability, the claim for a higher rating, as reflected on the title page, remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran testified before the undersigned Acting Veterans Law Judge in a hearing at the RO in October 2009. A transcript of the hearing has been associated with the claims file. The Board remanded the claims on appeal for further development in January 2011. The development having been accomplished, the issues return for appellate review. The Board has re-characterized the issue of entitlement to service connection for PTSD to include the broader issue of entitlement to service connection for an acquired psychiatric disability, to include PTSD, pursuant to the recent case of Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that, when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). The issues of entitlement to an increased (compensable) evaluation for status post Bartholin's gland excision prior to July 11, 2007, and an evaluation in excess of 10 percent beginning July 11, 2007, 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. The Veteran's for patellofemoral pain syndrome of the left knee is manifested by slight medial lateral instability, no current objective evidence of subluxation; no ankylosis; no impairment of the tibia and fibula; flexion limited to 45 degrees or less, extension limited to 15 degrees; no semilunar, dislocated cartilage with frequent episodes of "locking," pain and effusion into the joint; no removal of semilunar cartilage; and no evidence of genu recurvatum. 2. The Veteran's limited flexion of the left knee is manifested by flexion limited to 90 degrees, no current objective evidence of subluxation or instability; no ankylosis; no impairment of the tibia and fibula; no compensable limitation of extension; no semilunar, dislocated cartilage with frequent episodes of "locking," pain and effusion into the joint; no removal of semilunar cartilage; and no evidence of genu recurvatum. 3. The Veteran's low back strain is manifested by forward flexion limited to, at worst, 70 degrees, and combined range of motion at worst, limited to 185 degrees, with no evidence of muscle spasm or guarding severe enough to result in an abnormal gait, or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 4. The competent and credible evidence fails to demonstrate that the Veteran has an acquired psychiatric disorder, to include PTSD, that is related to his active duty service to include any verified stressors. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for patellofemoral pain syndrome of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). 2. The criteria for a rating in excess of 10 percent for limited flexion of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). 3. The criteria for a rating in excess of 10 percent for a low back strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). 4. An acquired psychiatric disorder, to include PTSD, was not incurred in or aggravated by active military duty. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of (1) the information and evidence not of record that is necessary to substantiate a claim, (2) which information and evidence VA will obtain, and (3) which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159 (2011); see also 73 Fed. Reg. 23,353-6 (April 30, 2008) (codified at 38 C.F.R. § 3.159 (May 30, 2008)). See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). After careful review of the claims file, the Board finds that the letters dated in April 2005 and April 2006 fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). In this regard, these letters advised the Veteran what information and evidence was needed to substantiate the claim decided herein. These letters also requested that the Veteran provide enough information for the RO to request records from any sources of information and evidence identified by the Veteran, as well as what information and evidence would be obtained by VA, namely, records like medical records, employment records, and records from other Federal agencies. The United States Court of Appeals for Veterans Claims (Court) in Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006), held that the VCAA notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The April 2006 letter provided this information. The Board observes that the April 2005 letter was sent to the Veteran prior to the November 2005 rating decision. The VCAA notice with respect to the elements addressed in this letter was therefore timely. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). VCAA notice in accordance with Dingess, however, was sent after the initial adjudication of the Veteran's claim. Nevertheless, the Board finds this error nonprejudicial to the veteran. See Mayfield v. Nicholson, 19 Vet.App. 103 (2005). In this regard, the notice provided in the April 2006 letter fully complied with the requirements of 38 U.S.C.A. § 5103(a) (2009), 38 C.F.R. § 3.159(b) (2012), and Dingess, supra, and after the notice was provided the case was readjudicated and an October 2006 statement of the case was provided to the Veteran. See Pelegrini II, supra; Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (a (supplemental) statement of the case that complies with all applicable due process and notification requirements constitutes a readjudication decision). Therefore the Board concludes that the requirements of the notice provisions of the VCAA have been met, and there is no outstanding duty to inform the Veteran that any additional information or evidence in needed. The Board finds that VA has also fulfilled its duty to assist the Veteran in making reasonable efforts to identify and obtain relevant records in support of the Veteran's claims and providing a VA examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(4)(i) (2012). In this regard, the Veteran's service treatment records, service personnel records, private treatment records, and VA treatment records are associated with the claims folder. In January 2011, the Board remanded the case to the agency of original jurisdiction (AOJ) for additional development. A remand by the Board confers on the appellant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that the above stated issues were previously remanded in order for the RO/AMC to attempt to obtain the Veteran's service personnel records, information regarding the Veteran's claimed stressors, VA and private treatment records, and VA examinations for each issue. As will be further explained below a VA examination for status post Bartholin's gland excision was not obtained and as such another remand is required. With regard to the remaining issues, however, the personnel records having been obtained, stressor information having been developed and VA examinations having been provided, the issues now return to the Board for review. The Board recognizes a duty to provide a VA examination when the record lacks evidence to decide the Veteran's claim and there is evidence of (1) a current disability (including persistent or recurrent symptoms of disability), (2) an in- service event, injury, or disease, and (3) some indication that the claimed disability may be associated with the established event, injury, or disease. 38 C.F.R. § 3.159(c)(4)(i) (2012); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). VA examinations were provided in October 2004, October 2005, July 2007, and December 2012 with regard to the knee and back claims and in December 2012 with regard to the PTSD claim. 38 C.F.R. § 3.159(c)(4). To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Additionally, an examination for rating purposes should contain sufficient detail and reflect the whole recorded history of a Veteran's disability, reconciling the various reports into a consistent picture. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); 38 C.F.R. § 4.2 (2012). The Board finds that the VA examinations, including opinions, obtained in this case are more than adequate, as they collectively are predicated on a full reading of the VA medical records in the Veteran's claims file. They consider all of the pertinent evidence of record and the statements of the Veteran, and provide a complete rationale for any opinions stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c) (4) (2012). Under the circumstances of this case, "the record has been fully developed," and "it is difficult to discern what additional guidance VA could have provided to the Veteran regarding what further evidence he should submit to substantiate his claim." Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Furthermore, as discussed above, the Board finds that there has been substantial compliance with its January 2011 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand). See also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Therefore, the Board is satisfied that VA has complied with the duty to assist requirements of the VCAA and the implementing regulations and the record is ready for appellate review. Analysis I. Increased Ratings Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. However, if VA's adjudication of an increased rating claim is lengthy, a claimant may experience multiple distinct degrees of disability that would result in different levels of compensation from the time the increased rating claim was filed until a final decision on that claim is made. Thus, VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased-rating claim has been pending. Cf. McClain v. Nicholson, 21 Vet. App. 319, 323 (2007) (Board finding that Veteran had disability "at some point during the processing of his claim," satisfied service connection requirement for manifestation of current disability); Moore v. Nicholson, 21 Vet. App. 211, 216-17 (2007). In Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court found no basis for drawing a distinction between initial ratings and increased rating claims for applying staged ratings. Accordingly, it was held that ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See also, Hart v. Mansfield, 21 Vet. App. 505 (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C.A. § 1155). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a Veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). With regard to the claims for patellofemoral pain syndrome of the left knee, limited flexion of the left knee, and a low back strain, under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant on motion. Disability of the musculoskeletal system is the inability to perform normal working movement with normal excursion, strength, speed, coordination, and endurance, and that weakness is as important as limitation of motion, and that a part that becomes disabled on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, through atrophy, for example. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. §§ 4.45 and 4.59 also contemplate inquiry into whether there is limitation of motion, weakness, excess fatigability, incoordination, and impaired ability to execute skilled movements smoothly, and pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing, and weight-bearing are also related considerations. The Court has held that diagnostic codes predicated on limitation of motion require consideration of a higher rating based on functional loss due to pain on use or due to flare-ups. 38 C.F.R. §§ 4.40, 4.45, 4.59; Johnson v. Brown, 9 Vet. App. 7 (1997); and DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). Left Knee The Veteran's left knee disability is currently rated as 10 percent disabling under Diagnostic code 5257 for patellofemoral pain syndrome and 10 percent disabling under Diagnositic Code 5260 for limitation of flexion. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 and 5260. Diagnostic Code 5257 provides for a 10 percent evaluation where there is slight recurrent subluxation or lateral instability, a 20 percent evaluation is assigned where there is moderate recurrent subluxation or lateral instability, and a 30 percent evaluation where there is severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). Diagnostic Code 5260 provides for a zero percent evaluation where flexion of the leg is only limited to 60 degrees. For a 10 percent evaluation, flexion must be limited to 45 degrees. A 20 percent evaluation is warranted where flexion is limited to 30 degrees. A 30 percent evaluation may be assigned where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Knee disabilities, generally, are rated under Diagnostic Codes (DC) 5256 through 5263. When determining the proper rating for a knee disability it is necessary to consider each applicable Diagnostic Code. Diagnostic Code 5261 provides for a zero percent evaluation where extension of the leg is limited to five degrees. A 10 percent evaluation requires extension limited to 10 degrees. A 20 percent evaluation is warranted where extension is limited to 15 degrees. A 30 percent evaluation may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent evaluation, extension must be limited to 30 degrees. And finally, where extension is limited to 45 degrees, a 50 percent evaluation may be assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Additionally, the Board must consider whether the Veteran is entitled to separate ratings under Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg). VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 (2004). Specifically, where a Veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Id. However, as the evidence fails to demonstrate compensable limitation of flexion, the Board finds that VAOPGCPREC 9-04 is inapplicable in the instant case. The Veteran was afforded a VA examination in October 2004. The Veteran noted she had surgery done in August 2004 for a medial meniscal tear and that her knee was basically no better. She stated that her knee popped, locked, and did not straighten out completely after she had been sitting for a while. She further stated that her knee ached when the weather changed, when she got up in the morning, and when walking, standing, or getting up from sitting. Upon examination the Veteran exhibited limited range of motion with flexion to only 120 degrees, with pain, and extension to 0 degrees, but with pain as well. The examiner noted that the Veteran did have increased impairment because of pain, fatigue, weakness, or lack of endurance upon repetitive motion. Primarily the Veteran experienced pain which caused a 10 percent decrease range of motion in the left knee. The McMurray's sign was negative. The knee was not swollen. The patella and collateral and cruciate ligaments were stable. The examiner noted some short term minor flare-ups, but no incapacitating episodes. The examiner noted that the Veteran had a debridement of the medial meniscus. X-rays taken in September 2003 revealed a normal left knee. The examiner diagnosed the Veteran with patellofemoral pain syndrome with status post debridement of the meniscus. The Veteran was afforded another VA examination in October 2005. The examiner initially noted the Veteran's August 2004 medial meniscal debridement. The Veteran reported daily pain in her knee that was worse when walking long distances and standing. She reported instability when walking upstairs. She further reported that if she sat for long periods of time her left knee would lock and she would have to manipulate it to get it moving again. She reported no incoordination, excess fatigability, or weakened movement. Additionally there was no increased pain with repetitive motion or flare-ups. Upon examination the Veteran had limited range of motion with flexion to 90 degrees and extension to 0 degrees without pain. She had a subpatellar click with intact cruciate and collateral ligaments and negative McMurray's and Lachmans tests. A November 2003 MRI showed a medial meniscal tear and a thin anterior cruciate ligament. She was diagnosed with arthroscopic debridement of the medial meniscus of the left knee with continued pain and mechanical symptoms. The Veteran was afforded another VA knee examination in July 2007. The examiner noted initially that at the time of the August 2004 arthroscopic surgery, the articular cartilage of the knee was found to be normal, but she had a small radial tear of the anterior horn medial meniscus which was resected. The Veteran complained of intermittent swelling, giving way, and locking of the knee. Walking and standing was limited to 3-5 minutes due to pain in her knee. The examiner noted that the Veteran was moderately obese, but that she walked with a normal gait and used no assistive devices. Upon examination the examiner noted no effusion, but tenderness with movement of the patella and along the medial joint line. The Veteran's range of motion for both active and passive motion was pain free from 0 to 90 degrees. She complained of pain from 90 degrees to 130 degrees with no guarding or grimacing. The Veteran could not flex beyond 130 degrees due to her large calf and thigh mass. The knee was stable to varus and valgus stress. Anterior drawer and Lachman's tests were negative. There was no complaint of pain with repetitive motion but she reported it was uncomfortable and fatiguing. The examiner noted no loss of motion, weakness, noticeable fatigability or incoordination. The Veteran was diagnosed with patellofemoral syndrome left knee with partial resection of the anterior horn of the medial meniscus. Her condition was noted to be worsened by obesity. X-rays taken in association with the examination revealed no evidence of fracture, dislocation, arthritic change, effusion, or other abnormality of either knee. The Veteran was afforded a VA examination in December 2012 for her left knee condition. The Veteran was diagnosed with left knee medial meniscal tear and repair with residuals. The Veteran reported that she had chronic pain deep in the left knee that occasionally led to falls, approximately ten times a year. The Veteran underwent medial meniscal debridement in 2004, but was unimproved by the procedure. She stated she did not have flare-ups that impact the function of the knee. Upon examination the Veteran exhibited limitations in range of motion of the left knee including flexion to 130 degrees with pain beginning at 120 degrees, extension to 0 degrees with no objective evidence of painful motion. Upon repetitive testing the Veteran exhibited flexion to 130 degrees and extension to 0 degrees. There was no additional limitation in range of motion of the left knee upon repetitive testing. Additional functional loss included less movement than normal, pain on movement, and interference with sitting, standing, and weight-bearing for the left knee. The Veteran reported pain to palpation, but normal muscle strength, anterior stability, and posterior stability. She exhibited medial-lateral instability of 1+ on the left side. There was no evidence or history of recurrent patellar subluxation or dislocation. The Veteran did not report any shin splints. It was noted the Veteran had a meniscal tear with frequent episodes of joint locking. The examiner noted the Veteran had left knee arthroscopic surgery in August 2004. There was no use of assistive devices. X-rays associated with the examination noted no arthritis, patellar subluxation, or any other significant diagnostic findings. The Veteran's knee did impact her ability to work in that she is unable to engage in prolonged standing, squatting, and walking. However, she is able to engage in sedentary sitting employment. With consideration of all of the above, the Board finds that the Veteran's left knee disabilities do not meet the criteria for a rating in excess of 10 percent, under Diagnostic Code 5257 or Diagnostic Code 5260. See 38 C.F.R. § 4.71a, Diagnostic Code 5257, 5260 (2012). In this regard, the Board notes that the evidence of record does not indicate that the Veteran has moderate subluxation or lateral instability. While she did exhibit some medial lateral instability it did not reach the moderate level, there was no evidence of subpatellar subluxation. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). With regard to flexion, a higher rating would mean flexion limited to 30 degrees. At worst, the Veteran's flexion was limited to 90 degrees. Consideration has been given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, the Board finds no basis upon which to assign a 20 percent evaluation for the Veteran's service-connected patella femoral syndrome and limitation of flexion of the left knee because the competent evidence fails to reveal any additional functional impairment associated with such disability to warrant consideration of alternate rating codes, other than the codes already considered herein. In this regard, the Board notes there is no medical evidence of flexion limited to 30 degrees or less, extension limited to 15 degrees or less, malunion or nonunion of the tibia and fibula, semilunar, dislocated cartilage with frequent episodes of "locking," pain and effusion into the joint, or ankylosis associated with the service-connected left knee disabilities that would support a higher evaluation under the criteria set forth in Diagnostic Codes 5256, 5258, 5261 or 5262. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5261, 5262 (2012). In addition, there has not been any removal of semilunar cartilage and no evidence of genu recurvatum; therefore Diagnostic Codes 5259 and 5263 are also not applicable. 38 C.F.R. § 4.71a, Diagnostic Codes 5259, 5263 (2012). The Board acknowledges the Veteran's statements regarding the severity of her left knee disability. The Veteran contends that her left knee is far more disabled than the currently assigned 10 percent for patellofemoral syndrome and 10 percent for limitation of flexion that she is currently assigned. The Board further notes that the Veteran is competent to attest to the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006). In this regard, the Board acknowledges the Veteran's statements that her service-connected left knee is worse than the assigned ratings. However, the Board places significantly more weight on the objective clinical findings reported on examination than the Veteran's statements as the Veteran is not shown to have the requisite training to determine the severity level of her service-connected left knee disabilities. See Smith v. Derwinski, 1 Vet. App. 235, 237 (1991) (determining the credibility of evidence is a function for the Board). Furthermore, the opinions and observations of the Veteran cannot meet the burden imposed by the rating criteria under 38 C.F.R. § 4.71a with respect to determining the severity of her service-connected left knee disabilities. See Moray v. Brown, 2 Vet. App. 211, 214 (1993); 38 C.F.R. § 3.159(a)(1) and (2) (2012). Lumbar Spine Diagnostic Codes 5237 through 5243 are applicable to the spine. Of particular interest in this instance is Diagnostic Code 5237 which governs ratings of lumbosacral or cervical strain. The current General Rating Formula for Diseases and Injuries of the Spine provides that with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. An evaluation of 20 percent is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. An evaluation of 40 percent is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. An evaluation of 50 percent requires unfavorable ankylosis of the entire thoracolumbar spine. An evaluation of 100 percent requires unfavorable ankylosis of the entire spine. There are several notes set out after the diagnostic criteria, a summary of which is as follows: First, associated objective neurologic abnormalities are to be rated separately under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). Second, for purposes of VA compensation, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion of 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is to 240 degrees. Further, the normal ranges of motion for each component of spinal motion are the maximum that can be used for calculation of the combined range of motion. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (2). Third, in exceptional cases, an examiner may state that, because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in the regulation. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (3). Fourth, each range of motion should be rounded to the nearest 5 degrees. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (4). Fifth, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). Sixth, disabilities of the thoracolumbar and cervical spine segments are to be evaluated separately, except when there is unfavorable ankylosis or both segments. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (6). The evaluation criteria are meant to encompass and take into account the presence of pain, stiffness, or aching, which are generally present when there is a disability of the spine. Therefore, an evaluation based on pain alone would not be appropriate, unless there is specific nerve root pain, for example, that could be evaluated under the neurologic sections of the rating schedule. See 68 Fed. Reg. 51, 455 (Aug. 27, 2003). Additionally, the Board notes that Diagnostic Code 5243 governs ratings of intervertebral disc syndrome, either on the total duration of incapacitating episodes over the past 12 months, or by combining under 38 C.F.R. § 4.25 (combined rating tables) separate evaluations of its chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities, which ever method results in the higher evaluation. A maximum 60 percent rating is warranted when rating based on incapacitating episodes, and such is assigned when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. A 40 percent rating is assigned for incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months. A 20 percent rating is assigned for incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months, and a 10 percent rating is assigned with the incapacitating episodes having a total duration of at least 1 week, but less than 2 weeks, during the past 12 months. Note 1 provides that for the purposes of evaluations under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. "Chronic orthopedic and neurological manifestations" means orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. Note 2 provides that when evaluating on the basis of chronic manifestations, evaluate orthopedic disabilities using evaluation criteria for the most appropriate orthopedic diagnostic code or codes. Evaluate neurological disabilities separately using evaluation criteria for the post appropriate neurological diagnostic code or codes. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2002). The Veteran was afforded a VA examination in October 2004. She reported low back pain in the midline area. She reported an increase in pain with weather changes, laying down too long, standing too long (as little as 10 minutes at times), walking more than one and half blocks, carrying something, or sitting for 20-30 minutes. She stated she did not use assistive devices. The Veteran also noted that her back interfered with her employment because she was working as a dental technician and her back limited her ability to lean over. She also reported that she had to get help to clean the house. Upon examination it was noted the Veteran stood without abnormal curvatures. She exhibited flexion to 70 degrees with pain, but can flex further to 80 degrees. She had 20 degrees of side tilt in either direction and 15 degrees of extension. There was pain with both left side tilt and extension. She could rotate 60 degrees in either direction with mild discomfort. The Veteran did have impaired function as a result of pain, fatigue, weakness, or lack of endurance following repetitive use. Straight leg raising was negative with normal sensory findings and reflexes. The examiner noted that pain likely caused the Veteran to lose an additional 10 degrees of motion. She reported flare-ups of short duration. There was no muscle spasm, weakness, or tenderness. Neurological examination did not show motor or sensory deficit. There was no atrophy, abnormal tone, or loss of strength. X-rays associated with the examination did not reveal any abnormalities. An MRI of the lumbar spine conducted in May 2003 did not show any abnormality. She was diagnosed with low back strain. The Veteran was afforded a VA examination in October 2005. She reported pain at a level of 7/10 particularly at night limiting sleep. She noted the pain radiates into her legs. She stated she did not use a brace and had no incapacitating episodes in the previous year. She reported no incoordination, excess fatigability, or weakened movements. Upon examination it was noted she had pain on palpation of the paraspinal lumbar musculature, but no spasm. She exhibited flexion to 70 degrees with pain, extension to 30 degrees with pain, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right and left lateral rotation to 30 degrees. She was diagnosed with chronic lumbosacral strain. The Veteran was afforded another examination in July 2007. She complained of chronic low back pain located mostly in the midline in the lower lumbar region with some radiation up the spine and into the lower buttock area when standing or walking as little as five minutes. She did not report wearing a back brace. She stated she had flare-ups in the past that required self imposed bed rest. She reported bed rest for 10-15 days in the previous year. There was no doctor prescribed bed rest. Her bowel and bladder were intact. She did have increased limitations with repetitive use as evidenced by decreased walking and standing times. Upon examination the Veteran had a normal gait. She exhibited mild tenderness to palpation in the midline L4 to S1, and over both SI joints. She exhibited active and passive flexion to 90 degrees with some midline low back pain, extension to 20 degrees with some low back pain in the midline and left buttocks, lateral bend 20 degrees left and right with some left buttocks pain with maximum lateral bend right. Rotation was 20 degrees right and left with low back pain with maximum rotation to the left. Repetitive motion was done through three cycles and she complained of increased low back pain. The Veteran was diagnosed with chronic lumbar strain with occasional flare-ups. X-rays associated with the examination revealed no evidence of compression fracture and intervertebral spaces were maintained. The Veteran was afforded a VA examination in December 2012. She was diagnosed with chronic lumbar strain. She reported chronic pain in the mid thoracic paraspinal musculature and chronic pain in the lower lumbar musculature. She further noted increased pain with bending, lifting, standing, or sitting in one place over five minutes. It was noted that she currently worked in a clerical position and was able to handle her position. She did not report any flare-ups. Upon examination the Veteran exhibited flexion to 90 degrees or greater with pain beginning at 50 degrees, extension to 25 degrees with pain beginning at 20 degrees, right and left lateral flexion to 25 degrees with pain beginning at 20 degrees, right and left lateral rotation to 25 degrees with pain beginning at 25 degrees. The Veteran was able to perform repetitive use testing with three repetitions. Upon repetitive use testing the Veteran exhibited flexion to at least 90 degrees, extension to 25 degrees, right and left lateral flexion to 25 degrees, right and left lateral rotation to 25 degrees. There was no additional limitation of motion upon repetitive use testing. Additional functional loss or impairment included less movement than normal, pain on movement, and interference with sitting, standing, and/or weight-bearing. There was bilateral muscular tenderness at the mid thoracic and lower lumbar musculature. The Veteran had normal muscle strength, normal reflexes, and normal sensory findings. The straight leg raising test was negative and there was no evidence of radiculopathy. There was no evidence of intervetebral disc syndrome or incapacitating episodes. The Veteran did not report using any assistive devices. X-rays associated with the VA examination revealed no arthritis, vertebral fracture, or any other significant diagnostic test findings. The examiner noted that the Veteran's lumbar spine disorder did impact her ability to work in that she would be unable to engage in manual labor, prolonged standing, bending, and lifting. She is able to engage in sedentary sitting employment. The Board notes that there is no competent medical evidence of record which reflects that the Veteran's low back strain should be rated higher than the currently assigned 10 percent rating. In this regard the Board notes that at worst the Veteran has forward flexion to 70 degrees and combined range of motion of 185 degrees. The next higher rating of 20 percent would require forward flexion greater than 30 degrees, but not greater than 60 degrees, or a combined range of not greater than 120 degrees. There was no evidence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. As such, the Veteran is not entitled to an increased rating in excess of 10 percent for his low back strain. See 38 C.F.R. §4.71a, Diagnostic Code 5237. Consideration has been given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, the Board finds no basis upon which to assign a 20 percent evaluation for the Veteran's service-connected low back strain because the competent evidence fails to reveal any additional functional impairment associated with such disability to warrant consideration of alternate rating codes, other than the codes already considered herein. The Board acknowledges the Veteran's statements regarding the severity of her low back strain. The Veteran contends that her low back is far more disabled than the currently assigned 10 percent rating indicates. The Board further notes that the Veteran is competent to attest to the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006). In this regard, the Board acknowledges the Veteran's statements that her service-connected low back is worse than the assigned ratings. However, the Board places significantly more weight on the objective clinical findings reported on examination than the Veteran's statements as the Veteran is not shown to have the requisite training to determine the severity level of her service-connected low back disability. See Smith v. Derwinski, 1 Vet. App. 235, 237 (1991) (determining the credibility of evidence is a function for the Board). Furthermore, the opinions and observations of the Veteran cannot meet the burden imposed by the rating criteria under 38 C.F.R. § 4.71a with respect to determining the severity of her service-connected low back disability. See Moray v. Brown, 2 Vet. App. 211, 214 (1993); 38 C.F.R. § 3.159(a)(1) and (2) (2012). Extraschedular In evaluating the Veteran's claims for higher ratings, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disabilities is inadequate. A comparison between the level of severity and symptomatology of the Veteran's knee and spine disabilities with the established criteria found in the rating schedule for those disabilities shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology, as discussed above. The Board further observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the Veteran has required frequent hospitalizations for her claims. There is no persuasive evidence in the record to indicate that any of the service-connected disabilities on appeal would, by itself, cause any impairment with employment over and above that which is already contemplated in the assigned schedular rating. The Board therefore has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. Further, 38 C.F.R. § 4.1 specifically sets out that "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." Factors such as requiring periodic medical attention are clearly contemplated in the Schedule and provided for in the evaluations assigned herein. What the evidence does not demonstrate in this case is that the manifestations of the Veteran's service-connected disabilities have resulted in unusual disability or impairment that has rendered the criteria and/or degrees of disability contemplated in the Schedule impractical or inadequate. Accordingly, consideration of 38 C.F.R. § 3.321(b)(1) is not warranted in this case. The Board has considered the applicability of the benefit of the doubt doctrine. A preponderance of the evidence is against assignment of a higher rating than is currently assigned for patellofemoral syndrome of the left knee, limitation of flexion of the left knee, or low back strain, for the entire appeal period. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Service Connection-Acquired Psychiatric with PTSD Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2011). As a general matter, service connection for a disability on the basis of the merits of such a claim requires (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. See Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995). That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2012). Service connection may also 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. 38 C.F.R. § 3.303(d) (2012). Generally, service connection for PTSD requires medical evidence establishing a diagnosis of the disorder, credible supporting evidence that the claimed in-service stressor(s) occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor(s). 38 C.F.R. § 3.304(f) (2012). With regard to the second PTSD element as set forth in 38 C.F.R. § 3.304(f), evidence of an in-service stressor, the evidence necessary to establish that the claimed stressor actually varies depending on the circumstances of the stressor and the nature of a Veteran's service. The DSM-IV provides two requirements as to the sufficiency of a stressor: (1) A person must have been "exposed to a traumatic event" in which "the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others" and (2) "the person's response [must have] involved intense fear, helplessness, or horror." DSM-IV at 427-28. These criteria are no longer based solely on usual experience and response but are individualized (geared to the specific individual's actual experience and response). Hence, under the DSM-IV, the mental illness of PTSD would be treated the same as a physical illness for purposes of VA disability compensation in terms of a predisposition toward development of that condition. Cohen v. Brown, 10 Vet. App. 128, 141 (1997). In Zarycki v. Brown, 6 Vet. App. 91 (1993), the Court held that the presence of a recognizable stressor is the essential prerequisite to support the diagnosis of PTSD. The Board also notes that effective July 13, 2010, VA amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances the evidentiary standard for establishing the required in-service stressor. See 75 Fed. Reg. 39843 (July 13, 2010). Service connection is generally warranted only if there is competent evidence of a causal relationship between any present disability and service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303(d). The Board acknowledges that lay evidence may be sufficient to establish a causal relationship between a current disability and service. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Specifically, lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Additionally, lay persons can provide an eye-witness account of a Veteran's visible symptoms. See, e.g., Caldwell v. Derwinski, 1 Vet. App. 466, 469 (1991) (competent lay evidence concerning manifestations of a disease may form the basis for an award of service connection where a claimant develops a chronic disease within a presumptive period but has no in-service diagnosis of such disease). In weighing lay evidence, the Board must render a finding with regard to both competency and credibility. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Initially, the Board finds, as an initial matter, that the Veteran's correspondence and her VA treatment records show that the scope of this claim is not limited to a claim of service connection for PTSD alone, but should be construed to also encompass a claim of service connection for any other psychiatric disorder. For instance, her VA treatment records show diagnoses of major depressive disorder as well as anxiety disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). With specific regard to the issue of service connection for PTSD, the Veteran is contending that she has PTSD due to various in-service stressors. The Veteran has described several stressful events during her active duty. At her October 2009 Board hearing, she testified that she served in Sarajevo, Bosnia, in August 2000, as a field dental technician attached to a medical unit involved in front-line treatment. In performing her duties, she was involved in the treatment of several children who had stepped on a landmine. She was also involved in treating a Turkish soldier who had attempted suicide by firing his M-16 into his chest. (During a January 2005 VA consultation, she indicated that she actually witnessed these two events, but was not involved in their treatment.) Also, at a March 2005 VA PTSD evaluation, the Veteran reported providing medical treatment to a soldier who was wounded by a hand grenade thrown into his vehicle, and another soldier who had battery acid thrown in his face. Additionally, she indicated, her medical unit traveled in convoys to provide treatment, and she was always fearful of being shot at while traveling. She had shots fired around her, but was never hit. Finally, the Veteran has described being the victim of sexual harassment by a civilian Department of Defense employee while serving in Bosnia. The Veteran's claimed stressors have not been verified. See 75 Fed. Reg. 39843 (Jul. 13, 2010) (codified at 38 C.F.R. § 3.304(f)(3)). The Veteran's DD 214 shows that she was a dental specialist and had 6 months, 21 days of foreign service. She received the Armed Forces Expeditionary Medal and the N.A.T.O. medal. Her DD 214 does not show that fear of hostile military action is consistent with the places, types, and circumstances of her service. As requested in the previous remand, the RO attempted to obtain any missing service personnel records and issued a November 2012 Formal Finding with regard to the Veteran's stressors. The Formal Finding noted that the Fort Hood FOIA office, the National Archives, Modern Military Branch, as well as the 502nd, Medical Company, all provided negative responses with regard to the Veteran's alleged stressors. The Veteran was afforded a VA examination in December 2012 for her PTSD. The examiner determined that the Veteran did not meet the criteria for an Axis I diagnosis of PTSD, but rather diagnosed the Veteran with an anxiety disorder on Axis I. After a thorough examination of the Veteran, to include consideration of her alleged stressors, the examiner determined that while the Veteran did experience, witness, or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others to which the Veteran's response involved intense fear, helplessness, or horror, the Veteran did not otherwise meet the criteria for an Axis I diagnosis of PTSD. The examiner determined that the Veteran's reported events were not directly related to combat and not due to fear of hostile military or terrorist activity. Additionally, the examiner noted that the Veteran's anxiety disorder, not otherwise specified (NOS) was not related to or caused by her military service. The examiner noted on Axis IV that the Veteran's psychosocial and environmental problems contributing to the Veteran's anxiety disorder were chronic health issues. The Board notes that the post-service medical records include a diagnosis of PTSD. A VA Nurse Practitioner in January 2005 determined that the Veteran met the criteria for a PTSD diagnosis due to non-combat trauma. Similarly, at the March 2005 VA PTSD evaluation, during which the Veteran described fear of hostile military action, a VA therapist diagnosed PTSD. However in August 2007, a VA psychologist determined that the Veteran did not meet the criteria for a PTSD diagnosis at that time and most recently the December 2012 VA psychologist also found that the Veteran did not meet the criteria for an Axis I diagnosis of PTSD. Based on the evidence of record, the Board finds that service connection for an acquired psychiatric condition, to include PTSD is not warranted. Although the Veteran is currently diagnosed with anxiety disorder, the evidence does not demonstrate that this disorder was incurred in or is otherwise related to service. There is no indication of any diagnosis or treatment for a psychiatric condition in service, and the Veteran's enlistment and separation examinations were normal. The March 2012 VA examiner offered a negative opinion on etiology with regard to service connection for anxiety disorder. Finally the Veteran does not meet the DSM-IV criteria for a PTSD diagnosis as required by 38 C.F.R. § 4.125(a). The Board notes that there are conflicting diagnoses with regard to the issue of PTSD; however, the Board notes that after a careful review of the above medical evidence, in its role as a finder of fact, the Board finds that the December 2012 VA examiner's opinion is the most persuasive medical evidence addressing the diagnosis of the Veteran's claimed PTSD. The report reveals that the examiner conducted a thorough examination of the Veteran and provided a full and complete rationale for his opinion. In addition, the opinion is highly probative because it reconciles all of the medical evidence of record. As held by the Court, "the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches." Guerrieri v. Brown, 4 Vet. App. 467, 470 (1993). The credibility and weight to be attached to these opinions is within the province of the Board. Id. See also Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when VA gives an adequate statement of reasons and bases). As the December 2012 examiner's opinion is based upon an evaluation of the Veteran, a review of the claims folder, and a thorough analysis of all the DSM-IV criteria, the Board finds that it is entitled to the most weight regarding the diagnosis of the Veteran's claimed PTSD. The Board further acknowledges, as noted above, that lay evidence may be sufficient to establish a causal relationship between a current disability and service. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In weighing lay evidence, the Board must render a finding with regard to both competency and credibility. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Also, as noted above, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. To the extent that the Veteran's lay statements are offered as evidence of continuity of symptomatology, the Board acknowledges that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. See Buchanan, supra. As noted, in adjudicating her claims, the Board must evaluate the Veteran's credibility. See Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). As noted, competency of evidence differs from weight and credibility. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, supra; see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Here, the Board does not find that the Veteran is competent to render diagnoses of in-service or post-service psychiatric disorders. While the Veteran is certainly competent to report observable symptoms, she has not been shown to be competent to identify specific disorders based solely on observation. Further, while the Veteran has asserted that her psychiatric disorder is the result of her experiences in service, she has not demonstrated the medical knowledge required to establish such an etiological nexus. See Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992); see also 38 C.F.R. § 3.159 (a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). Therefore, although the statements of the Veteran offered in support of her claim have been given full consideration by the Board, they are not considered competent medical evidence and do not serve to establish a medical nexus between the claimed disorders and the Veteran's period of service. The preponderance of the evidence is against a grant of service connection for an acquired psychiatric disorder to include PTSD as the Veteran does not currently meet the criteria for PTSD under the DSM-IV and no competent and credible medical nexus has been established to relate her currently diagnosed anxiety disorder to her active duty service. As a preponderance of the evidence is against the award of service connection, the benefit of the doubt doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). ORDER An increased evaluation in excess of 10 percent for patellofemoral pain syndrome of the left knee is denied. An increased evaluation in excess of 10 percent for limited flexion of the left knee is denied. An increased evaluation in excess of 10 percent for low back strain is denied. Service connection for an acquired psychiatric disorder, to include PTSD is denied. REMAND Upon review, the Veteran's claim of entitlement to an increased evaluation for status post Bartholin's gland excision, must be remanded. In the January 2011 remand the Board requested that the Veteran be afforded a VA examination to evaluate the severity of the service-connected status post Bartholin's gland excision disability because the most recent examination was in April 2007. A remand by the Board confers on the appellant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268 (1998). Unfortunately, an examination was never afforded. The Veteran testified during her October 2009 Board hearing that her symptoms had worsened and become more severely disabling since the most recent examination. As such, the Board has no discretion and must remand this claim to afford the Veteran an opportunity to undergo a contemporaneous VA examination to assess the current nature, extent and severity of her service-connected status post Bartholin's gland excision disability. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect.); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43,186 (1995). The AMC/RO should also ensure that the VA examination expresses all medical findings in terms conforming to the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204 (1994). Accordingly, the case is REMANDED for the following action: 1. The RO should send the Veteran a letter asking that she provide the names, addresses, and approximate dates of treatment for all health care providers who may have additional records pertinent to the remanded claim. 2. The RO should then schedule the Veteran for an appropriate VA examination to determine the nature and severity of the service-connected gynecological disability. The entire claims file, including a copy of this remand, must be made available to each examiner for review. Accordingly, the examiner is asked to review the pertinent evidence, including the Veteran's lay assertions, and undertake any indicated studies. Then, based on the results of the examination, the examiner is asked to provide an assessment of the current nature and severity of the Veteran's service-connected gynecological disability. The examiner, in a printed (typewritten) report, should set forth all examination findings, along with a complete rationale for all opinions and conclusions reached. Also, specific references to the Veteran's claims file, including all pertinent medical records, and the Veteran's lay assertions should be provided, as appropriate. 3. After completing all requested action, plus any additional notification and/or development warranted by the record, the RO should readjudicate the remanded claim in light of all pertinent evidence and legal authority. If any benefit sought on appeal remains denied, the RO should furnish to the Veteran and her representative, if any, an appropriate Supplemental Statement of the Case (SSOC) that includes clear reasons and bases for all determinations, and affords the appropriate time period to respond. The appellant has the right to submit additional evidence and argument on the matter or matters 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). ______________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs