Citation Nr: 1322523 Decision Date: 07/15/13 Archive Date: 07/24/13 DOCKET NO. 09-20 027 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for status post fracture of the right wrist secondary to the service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to a rating in excess of 20 percent for the residuals of a left ankle fracture, status post open reduction and internal fixation fibula. 3. Entitlement to a rating in excess of 30 percent for PTSD during the period prior to May 26, 2009. 4. Entitlement to a rating in excess of 50 percent for PTSD during the period from May 26, 2009 to September 25, 2012. 5. Entitlement to a rating in excess of 70 percent for PTSD during the period since September 26, 2012. 6. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD N. J. Nardone, Associate Counsel INTRODUCTION The Veteran had active military service from September 1998 to September 2001 and again from November 2003 to June 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2008 and May 2008 rating decisions by the Department of Veterans' Affairs (VA) Regional Office (RO) in Buffalo, New York. In pertinent part of the April 2008 decision, the RO granted a compensable rating of 20 percent for the left ankle disorder and an increased rating of 30 percent for PTSD. Both ratings were made effective October 30, 2007, the date of receipt of the Veteran's claim for increase. The May 2008 rating decision denied service connection for status post fracture of the right wrist. During the pendency of the appeal, by way of a June 2009 Supplemental Statement of the Case (SSOC), the RO granted an increased rating to 50 percent for PTSD effective May 26, 2009. In August 2012, the Board remanded these matters for additional development. [In the August 2012 remand, the Board inaccurately reported the effective date for the award of an increased rating to 50 percent for PTSD. The issues have been recharacterized herein as reflected on the title page and no reflect the correct date.] By way of a February 2013 decision, the RO awarded an increased rating to 70 percent for the Veteran's PTSD effective September 26, 2012. The case has been returned to the Board for further appellate consideration. Inasmuch as higher ratings for the service-connected PTSD are available, and inasmuch as a claimant is presumed to seek the maximum available benefit for a given disability, the claims for higher ratings, as reflected on the title page, remain viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). As will be discussed more fully herein, the evidence suggests that the Veteran is unable to retain employment due to his service-connected disabilities, including his PTSD and the service-connected residuals of a left ankle fracture, status post open reduction and internal fixation fibula. Entitlement to a TDIU is part of an increased rating claim when such claim is raised by the record. As such, the issue is now properly before the Board. See Rice v. Shinseki, 22 Vet. App. 447 (2009); see also VAOGCPREC 06-96, 61 Fed. Reg. 66749 (1996). The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to an increased rating in excess of 30 percent for PTSD for the period prior to May 26, 2009, entitlement to an increased rating in excess of 50 percent for PTSD during the period from May 26, 2009 to September 25, 2012, entitlement to an increased rating in excess of 70 percent for PTSD for the period since September 26, 2012, and entitlement to a TDIU 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 preponderance of the evidence indicates that status post fracture of the right wrist did not manifest in service and that arthritis of the right wrist did not manifest during the first post-service year, and that status post fracture of the right wrist is not due to an event occurring during active service or proximately due to a service-connected disability. 2. The Veteran's residuals of a left ankle fracture, status post open reduction and internal fixation fibula, result in painful motion with motion loss no more than marked in degree even when considering functional limitation on use; there is no ankylosis. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for status post fracture of the right wrist, to include as secondary to a service-connected disability, have not been met. 38 U.S.C.A. §§ 1110, 1112, 1154, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. The claim of entitlement to a rating greater than 20 percent for service-connected left ankle fracture, status post open reduction and internal fixation fibula, is denied. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321(b), 4.1-4.14, 4.16, 4.40, 4.45, 4.59, 4.71a, DC 5271 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). See also 73 Fed. Reg. 23,353-23,356 (April 30, 2008) (concerning revisions to 38 C.F.R. § 3.159). Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. The notification requirements are referred to as Type One, Type Two, and Type Three, respectively. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: 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). If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VA notice, followed by readjudication of the claim, as in a Statement of the Case (SOC) or Supplemental Statement of the Case (SSOC). Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran submitted his claims for service connection for status post fracture of the right wrist and an increased rating for the service-connected residuals of a left ankle fracture in October 2007. In a pre-adjudicatory letter sent to the Veteran in November 2007, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection on a secondary basis, and what information and evidence is needed to substantiate the increased rating claim at hand. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In this respect, the Veteran was advised of the types of evidence and/or information deemed necessary to substantiate the claims, the relative duties on the part of the Veteran and VA in developing his claims, and how VA determines disability ratings and effective dates of award. Moreover, VA examinations with medical opinions were obtained; and the Veteran was afforded the opportunity to submit additional evidence and argument, which he did. The Veteran was also afforded the opportunity to testify before the Board. The Veteran has had ample opportunity to respond/supplement the record and he has not alleged that notice in this case was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (holding that "where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream issues"). Neither the Veteran nor his representative has alleged any prejudicial or harmful error in the notice, and the Board finds, based the factors discussed above, that no prejudicial or harmful error in VA notice has been demonstrated in this case. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). VA also has a duty to assist a veteran in the development of the claims. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, all evidence necessary to decide these claims has been obtained. The Veteran's service medical treatment records have been included in the claims file and reviewed. VA has either obtained, or made sufficient efforts to obtain, records corresponding to all VA and private treatment described by the Veteran pertinent to the claims decided herein. VA has provided the Veteran with VA medical examinations in November and December 2007, May 2008, and April 2013, to determine the etiology of his status post fracture of the right wrist. The Veteran was last afforded VA examination of his left ankle in October 2012, with an addendum provided in November 2012. This examination report contains all findings necessary to decide the claim for an increased rating for the service-connected residuals of a left ankle fracture. A medical opinion is adequate when it is based upon consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991)). The Board finds that these actions were conducted by health care professionals, and the associated reports reflect review of the Veteran's prior medical history and records. The Board finds that the April 2013 examination report is sufficiently detailed with recorded history and clinical findings. In addition, it is not shown that the report was in any way incorrectly prepared or that the VA examiner failed to address the pertinent criteria for service connection. As a result, the Board finds that additional development by way of another examination or medical opinion would be redundant and unnecessary. See 38 C.F.R. § 3.326 and 38 C.F.R. § 3.327; Green v. Derwinski, supra. Therefore, the Board concludes that the appellant was afforded an adequate examination. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Finally, the Board remanded the claims decided herein in August 2012. A remand by the Board confers on the Veteran, as a matter of law, the right to compliance with the remand. Stegall v. West, 11 Vet. App. 268 (1998). The Board finds that the RO has substantially complied with the prior remand orders. The RO obtained medical examinations and opinions as requested by the Board. Additionally, the RO obtained VA and private treatment records identified by the Veteran, in addition to pertinent law enforcement records. Overall, the Board finds that the evidence of record is sufficient to decide the claims on appeal, and that there is no reasonable possibility that any further assistance would aid the Veteran in substantiating these claims. The Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Therefore, there is no duty to assist that was unmet, and the Board finds no prejudice to the Veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the veteran has been prejudiced thereby). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. The Merits of the Claims Having carefully considered the Veteran's contentions in light of the evidence of record and the applicable law, the Board finds that the preponderance of the evidence is against the claims for service connection for status post fracture of the right wrist and an increased rating in excess of 20 percent for the residuals of a left ankle fracture, status post open reduction and internal fixation fibula, and that these claims must be denied. A veteran prevails in a claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against a veteran's claim that the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet.App. 49 (1990). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence, and on what the evidence shows or fails to show with respect to the appealed claims. See Timberlake v. Gober, 14 Vet.App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet.App. 303 at 308 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (medical opinion not required to prove nexus between service-connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet.App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet.App. 303 (2007) (concerning varicose veins); see also Jandreau, supra (a dislocated shoulder); Charles v. Principi, 16 Vet.App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet.App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet.App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet.App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). Service Connection The Veteran contends that he has a status post fracture of the right wrist secondary to the service-connected PTSD. Specifically, he contends that his right wrist was injured in June 2007 when he fractured it in an altercation which occurred during a flashback. The Veteran is service-connected for PTSD. In order to establish service connection for a claimed disability, the facts, as shown by evidence, must demonstrate that a particular disease or injury resulting in a current disability was incurred during active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be: (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). Under 38 C.F.R. § 3.310(a), service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a non-service-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. See Sklar v. Brown, 5 Vet. App. 140 (1993). A medical examiner's review of the claims folder may heighten the probative value of an opinion, as the claims folder generally contains all documents associated with a veteran's disability claim, including not only medical examination reports and STRs, but also correspondence, raw medical data, financial information, RO rating decisions, Notices of Disagreement, materials pertaining to claims for conditions not currently at issue and Board decisions disposing of earlier claims. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008). However, an examiner's review of the claims folder is not required in each case. See Snuffer v. Gobber, 10 Vet. App. 400, 403 -04 (1997) (review of claims file not required where it would not change the objective and dispositive findings made during a medical examination); see also D'Aries v. Peake, 22 Vet. App. 97, 106 (2008) (holding that it is not necessary for a VA medical examiner to specify review of the claims folder where it is clear from the report that the examiner has done so and is familiar with the claimant's extensive medical history). A significant factor to be considered for any opinion is based on an accurate factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). The Board finds that while the Veteran has a current right wrist condition, the preponderance of the evidence indicates that his right wrist condition is not due to his service-connected PTSD. Initially, the Board notes that the Veteran does not contend, and the evidence does not show, that the claimed status post fracture of the right wrist is due to service on a direct basis. In this regard, the Board observes that the service treatment records are negative for any in-service complaints, findings, or treatment referable to the right wrist. Rather, the Veteran claims that he is entitled to service connection for the current right wrist condition as secondary to his service-connected PTSD because he asserts that he injured his right wrist in June 2007 during a flashback. The Board notes that VA treatment records dated in late 2006 show that the Veteran reported to treatment providers that he was having a lot of problems with flashbacks. His PTSD symptoms were found to be getting worse, as was his substance abuse. The Veteran began VA substance abuse treatment in March 2007. Private treatment records show that in June 2007, the Veteran underwent a mental health arrest by local police because he was reportedly intoxicated and unable to care for himself. Treatment reports from a hospital emergency department further reveal that the Veteran was in an altercation and was pushed to the ground, injuring his right wrist. The Veteran's affect/behavior upon admission was noted to be agitated and angry. X-rays showed that the Veteran had sustained fractures of the distal right radius and ulna. The June 2007 police report documenting the incident indicates that the Veteran and a few associates were at a motel when one of the individuals called the police to report that the Veteran and 2 other people were intoxicated and arguing. During the course of the argument, the Veteran reportedly got upset and punched a hole in the wall. The Veteran was arrested and his apparent condition was noted to include mental disability and alcohol impairment. The Mental Hygiene Form associated with the Veteran's arrest indicates that the Veteran's right wrist was possibly broken. The narrative portion of this form states that the Veteran confronted one of his associates and the associate pushed the Veteran in self defense. The Veteran then fell and hurt his right wrist. The Veteran was placed under mental health arrest due to his inability to care for himself because of his extreme level of intoxication. The report indicated that the Veteran was making threats to everyone at the scene and was very uncooperative. VA treatment records dated since the June 2007 incident reveal that the Veteran has provided a history of having experienced flashbacks in which he became violent, including one during the summer of 2007. He reported that he attacked one of his buddies, thinking that the man was an Iraqi. The Veteran indicated that he had been drinking at the time of the incident, and was taken to the hospital by police for psychiatric evaluation. In September 2007, the Veteran was admitted into a VA Psychosocial Residential Rehabilitation Treatment Program. The Veteran underwent a November 2007 VA PTSD examination, during which the claims file was reviewed. The examiner indicated that the Veteran reported that at that time he was receiving treatment for PTSD and substance abuse in the domiciliary care facility at a VA Medical Center, and had been there since September 2007. He had previously received a 30 day residential substance abuse/alcohol related treatment program in 1990 following a DWI. He was also subject to a mental hygiene arrest and remained at a hospital for eight hours in June 2007, during an incident in which he broke his arm during a flashback. Upon mental status examination, the diagnoses included PTSD, alcohol abuse, and cocaine abuse. It was noted that the Veteran continues to suffer from what was previously diagnosed as service-connected PTSD, as well as secondary alcohol and cocaine abuse. While the Veteran showed good insight into the reasons for his substance abuse as a form of self-medication, abatement of such substance abuse had proven more difficult. The examiner opined that although it cannot be determined whether the Veteran's wrist fracture was related to his flashbacks, there is no reason to question his account of that incident and causality. The Veteran underwent a VA joints examination in December 2007. At that time he reported that he had fractured his right wrist after an altercation in June 2007. He stated that during this altercation he fell backwards and put his hand out to catch his fall, breaking the right wrist. He stated that when the police responded he had flashbacks that he was in Iraq and began swinging at the officers. After a physical examination, the diagnosis was right wrist fracture, although the examiner did not provide an opinion on the etiology of such. The Veteran was provided another VA joints examination in May 2008 to evaluate his claimed right wrist condition. The Veteran indicated that in June 2008 he was involved in an altercation and fell backwards, fracturing his right wrist. He indicated that he was having flashbacks and fighting officers at the time. He subsequently underwent surgery in November 2007 with an open reduction, internal fixation of the right wrist with a bone graft. After performing a physical examination and reviewing the results of X-rays taken at that time, the examiner rendered a diagnosis of status post open reduction, internal fixation of the right wrist with residual decreased range of motion. The examiner did not opine on the etiology of the Veteran's diagnosed right wrist condition. The Veteran was afforded a VA wrist conditions examination in April 2013, during which the claims file was reviewed. The examiner recorded the Veteran's substance abuse history as reflected in prior VA treatment records. With regard to alcohol, the examiner noted that the Veteran's first usage was at age 16, and he had received a DWI in 1990. With regard to cocaine, the Veteran's first usage was at age 24. The Veteran had reported that after returning from Iraq his cocaine usage increased to 3 times a week. The examiner also noted in the examination report that medical notes form the time of the wrist fracture have no mention of war flashbacks. Further, the Veteran was severely intoxicated at the time and received a mental health arrest for intoxication. The examiner indicated that the Veteran has a diagnosis of right wrist fracture. The examiner related that in June 2007 the Veteran was intoxicated, got into an altercation, and was pushed to the ground injuring his right wrist. He sustained a right colles fracture. The Veteran had a mental health arrest at the time secondary to severe intoxication. The examiner observed that the Veteran states that he had a mental flashback at the time, but this was not in the medical notes from the time. After performing a physical examination, the examiner opined that the Veteran's claimed right wrist condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner also found that the claimed right wrist condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. The examiner's rationale for such opinions is that the Veteran's wrist fracture was a result of a fight the Veteran was in while severely intoxicated. The Veteran began drinking alcohol at age 16. There is medical evidence of alcohol abuse prior to the Veteran entering the military. The examiner noted that VA did send the Veteran to a substance abuse service prior to his altercation and wrist fracture. Further, the Veteran had a DWI in 1990 prior to any combat stressors that could cause PTSD. Based on the totality of the evidence of record, the Board finds that the preponderance of the competent and probative evidence is against finding a nexus between the Veteran's current status post fracture of the right wrist and service or his service-connected PTSD. As noted above, the Veteran does not contend that his current right wrist disorder is related to service or any incident therein. Moreover, a careful review of the Veteran's service treatment records reveals no complaints or findings pertaining to the right wrist during service. Further, the Board finds substantially probative the opinion expressed by the April 2013 VA examiner undertaken specifically to address the matter on appeal. This opinion was rendered after review of the Veteran's claims file, including his service medical treatment records, post-service medical evidence, the June 2007 hospital and arrest records, and lay statements; the opinion is clearly based on an accurate history. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (finding that a physician's access to the claims file and the thoroughness and detail of the opinion are important factors in assessing the probative value of a medical opinion). The April 2013 VA examiner opined that the Veteran's claimed right wrist condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness, or proximately due to or the result of the Veteran's service-connected condition. The examiner's express rationale was the fact that the Veteran's wrist fracture was a result of a fight the Veteran was in while severely intoxicated. The Veteran began drinking alcohol at age 16, and there is medical evidence of alcohol abuse prior to the Veteran entering the military. Further, the Veteran had a DWI in 1990 prior to any combat stressors that could cause PTSD. While the Board recognizes the absence of more lengthy explanation of the basis for the VA provider's stated findings, there are sufficient grounds to reach the determination that the examiner stated. This contrasts with the remarks made by the VA PTSD examiner in November 2007 who indicated that although it cannot be determined whether the Veteran's wrist fracture was related to his flashbacks, there is no reason to question his account of that incident and causality, as this examiner did not appear consider the Veteran's June 2007 hospital and arrest records pertaining to the right wrist injury prior to forming an opinion. Further, the Board notes that this examiner did not provide an etiological nexus to the Veteran's PTSD. With regard to the April 2013 VA examiner's conclusion that the Veteran's wrist fracture was a result of a fight the Veteran was in while severely intoxicated, and to the extent that the file reflects diagnosed substance abuse disorders and drug and alcohol use, Section 8052 of the Omnibus Budget Reconciliation Act (OBRA) of 1990, Pub. L. No. 101-508, § 8052, 104 Stat. 1388 , 1388- 91, prohibits, effective for claims filed, as in the instant case, after October 31, 1990, payment of compensation for a disability that is a result of a Veteran's own alcohol or drug abuse. Moreover, Section 8052 also amended 38 U.S.C.A. § 105(a) to provide that, with respect to claims filed after October 31, 1990, an injury or disease incurred during active service will not be deemed to have been incurred in line of duty if the injury or disease was a result of the person's own willful misconduct, including abuse of alcohol or drugs. See 38 U.S.C.A. § 105 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.1(m), 3.301(d) (2012). The Board notes that in Allen v. Principi, 237 F.3d. 1368 (Fed. Cir. 2001) the United States Court of Appeals for the Federal Circuit provided a limited exception, holding that a Veteran can receive compensation for an alcohol or drug abuse disability acquired as secondary to, or as a symptom of a service-connected disability. The Court made it clear that in order to grant service connection for alcohol or drug abuse secondary to a service-connected disability, there must be a causal relationship between the service-connected disability and the alcohol or drug abuse. The Court stated "clear medical evidence establishing that the alcohol or drug abuse disability is indeed caused by a Veteran's primary service connected disability and where the alcohol or drug abuse disability is not due to willful wrongdoing" is needed. Allen, 237 F.3d at 1377. In this case, the evidence does not show that a service-connected disorder caused the Veteran's alcohol dependence, nor has any such link been made by virtue of competent medical evidence or opinion. To the contrary, the April 2013 VA examiner found that there is medical evidence of alcohol abuse prior to the Veteran entering the military. As such, service connection is not warranted for any diagnosed alcohol related condition, or any injury due to the Veteran's abuse of alcohol. Further, with respect to presumptive service connection, the evidence does not show that any arthritis of the right wrist was manifested to a compensable degree within a year after the Veteran's discharge from service in 2005. Thus, the presumptive provisions of 38 C.F.R. § 3.309(a) are not for application. Accordingly, service connection is not warranted on a presumptive basis as a result of the Veteran's active service. The Board has considered the Veteran's statements asserting a nexus between his currently-diagnosed right wrist disorder and his service-connected PTSD. 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). The Board has considered the Veteran's contentions that he injured his wrist because he had a flashback due to PTSD, but finds them not credible. Caluza, 7 Vet. App. at 511-512. Other than his own unsupported statements, the evidence of record weights against finding any etiological relationship between the Veteran's current right wrist disability and flashbacks. The Board notes that there have been contradictions in the Veteran's statements during the course of the appeal. The Veteran's statements to treatment providers about having been involved in the June 2007 altercation due to flashbacks are in conflict with his statements during the December 2007 VA joints examination during which he reported that the flashbacks occurred when the police responded, after the altercation itself, when he began swinging at the officers. He provided a similar history during the May 2008 VA joints examination. The Board finds the contemporaneous medical and arrest records from the time of the June 2007 right wrist injury to be highly probative. The arrest records from the time of the injury indicate that the Veteran was placed under mental health arrest due to his inability to care for himself because of his extreme level of intoxication. In addition, these records indicated that the Veteran was making threats to everyone at the scene and was very uncooperative. The Veteran was found to be agitated and angry upon his admission to the hospital at that time. The Board finds it pertinent that the arrest and hospital records from the time of this incident omit any complaint regarding flashbacks. VA cannot ignore a veteran's testimony simply because the veteran is an interested party, but his personal interest may affect the credibility of the evidence. See Cartwright v. Derwinski, 2 Vet.App. 24, 25 (1991). Further, the treatment notes stating that the Veteran was involved in an altercation due to flashbacks wherein he fractured his wrist appear to be based only on the medical history provided by the Veteran. The U.S. Court of Appeals for Veterans Claims (Court) has held that medical history provided by a veteran and recorded by an examiner without additional enhancement or analysis is not competent medical evidence. LeShore v. Brown, 8 Vet.App. 406, 409 (1995). Although the Veteran has been diagnosed with status post fracture of the right wrist, the preponderance of the competent and credible evidence is against finding a nexus between such disorder and the service-connected PTSD. As the preponderance of the evidence is unfavorable on this claim, the benefit-of-the-doubt doctrine is not applicable and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert, 1 Vet. App. at 55. Increased Rating The Veteran seeks a higher schedular disability rating for his service-connected residuals of a left ankle fracture, status post open reduction and internal fixation fibula. He asserts that he is in constant pain due to such disability, and the left ankle gives out. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, separate ratings may also be assigned for separate periods of time based on the facts found. Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. Included within 38 C.F.R. § 4.71a are multiple Diagnostic Codes (DC's) that evaluate impairment resulting from ankle disorders, including DC 5270 (ankylosis), DC 5271 (limitation of ankle motion), DC 5272 (ankylosis of the subastragalar or tarsal joint), DC 5273 (malunion of the os calcis or astragulus), and DC 5274 (astragalectomy). Ankylosis refers to immobility and consolidation of a joint due to disease, injury, or surgical procedure). See Shipwash v. Brown, 8 Vet. App. 218, 221 (1995) (citing DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 91 (27th ed. 1988). See also 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, NOTE (5) (defining ankylosis as fixation of a joint in a particular position). The criteria of DC 5271 provide a 10 percent rating for moderate limitation of ankle motion. 38 C.F.R. § 4.71a, DC 5271. A 20 percent rating is warranted for marked limitation of ankle motion. Id. Normal ankle motion is measured from 0 to 20 degrees of dorsiflexion and 0 to 45 degrees of plantar flexion. 38 C.F.R. § 4.71a, Plate II. As the lay and medical evidence does not reflect a history of ankylosis, ankylosis of the subastragalar or tarsal joint, malunion of the os calcis or astragalus, or astragalectomy, the criteria of DCs 5270, 5272, 5273 and 5274 do not apply. VA regulations also instruct that evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Notably, the Court has held that pain alone does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The words "slight," "moderate," and "severe" as used in the various DC's are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6. Historically, the Veteran was originally granted service connection for residuals of a left ankle fracture, status post open reduction and internal fixation fibula, effective June 18, 2005, in a November 2005 rating decision. The service treatment records show that the Veteran sustained a left ankle fracture dislocation in April 2004, and underwent an open reduction, internal fixation, left lateral malleolus at that time. VA treatment records show that the Veteran underwent a VA orthopedic surgery consultation in May 2007. The Veteran reported that his symptoms did not seem to change with the type of footwear that he uses. The Veteran was taking medication two or three times a day on an as-needed basis for pain. Upon physical examination of the left ankle, the scar was well healed. The Veteran had no tenderness of the lateral aspect of his fibula. The plate was palpable underneath the skin; however, there was no evidence of skin breakdown. There was minimal swelling of the left ankle with no detectable effusion. The Veteran had no tenderness over any of the ligamentous complex. The examining physician indicated that the Veteran's range of motion of his ankle was excellent from about 20 degrees of dorsiflexion to 30 degrees of plantar flexion. The Veteran's subtaler range of motion was painless. He did have focal tenderness anteriorly in the ankle. This was moderate in terms of severity. The remainder of the Veteran's left leg was neurovascularly intact. His calf was soft and nontender. He was well perfused. He was able to wiggle all toes without difficulty. The Veteran walked with a normal gait and no evidence of limp. X-ray examination demonstrated no evidence of arthritic breakdown within the ankle, focal defects within the talus, or otherwise. The Veteran's fracture appeared to be well healed underneath the plate and screw construct applied to the lateral aspect of the distal fibula. The impression was left anterior ankle pain with unclear etiology, with no evidence of instability and minimal evidence of post-traumatic arthritis. The Veteran was provided a VA joints examination in December 2007, during which the claims file was reviewed. The Veteran's subjective complaints included left ankle pain which shoots up his leg, weakness, stiffness, swelling, and lack of endurance. He stated that his ankle seemed to give out on him. His condition did flare-up which occurred 2 to 3 times per week and lasted from 20 minutes up to a couple of hours. The left ankle increased in severity to a 3-4/10. Precipitating factors included walking. He reported that he was walking 3 to 5 miles a day, and stated that such exercise did worsen his symptoms. He also said that just being on his ankle might induce a flare-up. Alleviating factors included using it less and medication. Treatment included aspirin, which he would take as needed and gave response with no side effects. The Veteran denied any additional limitations in motion or functional impairment, although he stated that he would favor his left ankle due to increased pain. He denied using any assistive devices for the left ankle. He reported that the disability did effect his occupation, because it makes it difficult to walk and climb for long periods of time. He denied any affect of the disability on his activities of daily living. Upon physical examination of the left ankle, the examiner noted mild swelling. There was tenderness in the lateral aspect of that ankle over the lateral malleolus. Range of motion in the left ankle was dorsiflexion from 0 to 10 degrees out of 20 degrees, and plantar flexion from 0 to 30 degrees out of 45 degrees. The Veteran did have pain throughout the entire range of motion. Upon repetitive range of motion, the Veteran maintained the above-stated range of motion without any additional limitations or functional impairments. There was no varus angulation of the os calcis in relationship to the long axis of the tibia and fibula. There was good circulation and motor and sensory function in the distal foot. The diagnoses included left ankle fracture. The Veteran was provided another VA examination in October 2012 to evaluate his service-connected left ankle disability. The examiner noted that the Veteran was diagnosed with left ankle fracture with internal fixation. The Veteran reported experiencing intermittent pain which he rated as mild to moderate. He also indicated that flare-ups impact the function of the ankle, as he reportedly limps. Range of motion measurements showed left ankle plantar flexion to be to 45 degrees or greater, with no objective evidence of painful motion. Left ankle plantar dorsiflexion (extension) was to 20 degrees or greater, with no objective evidence of painful motion. After repetitive-use testing with 3 repetitions, the left ankle plantar flexion was to 45 degrees or greater and left ankle dorsiflexion was to 20 degrees or greater. The examiner found that the Veteran did not have additional limitation in range of motion of the left ankle following repetitive-use testing. The Veteran also did not have any functional loss and/or functional impairment of the ankle. He did have localized tenderness or pain on palpation of the joints/soft tissue of the left ankle. Muscle strength testing of the left ankle was measured as 5/5 for plantar flexion and 5/5 for dorsiflexion. On both the anterior drawer and talar tilt tests there was no laxity compared with the opposite side. The Veteran did not have ankylosis of the ankle, subtaler, and/or tarsal joints. The Veteran does not now have and nor has he ever had "shin splints," stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or a talectomy (astragalectomy). He has not had a total ankle joint replacement. The examiner indicated that the Veteran has had internal fixation surgery on the left ankle. The examiner reported that the Veteran does have pain as a residual sign and/or symptom due to the left ankle surgery. The examiner found that the Veteran did have scars related to his service-connected left ankle disability, although the scars were not painful and/or unstable, and the total of all related scars was not greater than 39 square centimeters. The Veteran did not have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to the service-connected left ankle disability. The Veteran did use an assistive device as a normal mode of locomotion, although occasional locomotion by other methods may be possible. Specifically, the Veteran occasionally used a left ankle brace. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis due to the ankle disability. The examiner noted that imaging studies of the ankle had been performed and there were abnormal findings of degenerative or traumatic arthritis of the left ankle. There were no other significant diagnostic test findings and/or results. The examiner indicated that the Veteran's ankle condition did impact his ability to work, as the Veteran complained of pain while using stairs. The examiner remarked that the left lateral ankle surgical scar was 9 by 1 centimeter. In a November 2012 addendum to the examination report, the October 2012 VA examiner noted that the claims file was reviewed in writing the examination report. VA treatment records dated during the course of this appeal reflect ongoing complaints of pain referable to the left ankle; however, except as discussed above, such records do not provide any specific range of motion measurements with regard to the left ankle. Applying the criteria to the facts of this case, the Board finds that the criteria for a rating greater than 20 percent for service-connected residuals of a left ankle fracture, status post open reduction and internal fixation fibula, have not been met for any time during the appeal period. In this respect, the Veteran is in receipt of the maximum evaluation assignable for limitation of motion of the ankle. See 38 C.F.R. § 4.71a, DC 5271. Further, the credible lay and medical evidence establishes that the Veteran's left ankle disability results subjective complaints of pain and motion loss no more than marked in degree even when considering functional limitation on use; there is no ankylosis. With respect to current left ankle range of motion, the Veteran's dorsiflexion was shown to be, at worse, to 10 degrees with pain, and his plantar flexion was shown to be, at worse, to 30 degrees with pain. Such findings were rendered in the December 2007 VA examination report. The VA C&P examination in October 2012 found dorsiflexion to 20 degrees or greater, with no objective evidence of painful motion, and plantar flexion to 45 degrees or greater, with no objective evidence of painful motion. This is considered normal ankle motion. 38 C.F.R. § 4.71a, Plate II. In December 2007 and October 2012, upon repetitive range of motion testing, the Veteran maintained the above-stated ranges of motion without any additional limitations or functional impairments. As the Veteran is receiving the maximum evaluation assignable for limitation of motion of the ankle, consideration of painful motion could not warrant a higher rating. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997) (implicitly holding that once a particular joint is evaluated at the maximum level in terms of limitation of motion, there can be no additional disability due to pain). As noted above, the Board also finds no additional DCs applicable to the left ankle claim. In this respect, there is no lay or medical evidence of ankylosis (DCs 5270 and 5272), malunion of the os calcis or astragalus (DC 5273) or astragalectomy (DC 5274). The October 2012 VA examiner indicated that the Veteran did not have ankylosis of the ankle, subtaler, and/or tarsal joints, and he does not now have, nor has he ever had, malunion of calcaneus (os calcis) or talus (astragalus), or a talectomy (astragalectomy). The Board has also considered the propriety of a separate rating for the Veteran's scar, which was noted by the October 2012 examiner. However, the evidence does not show the scar is deep, painful, or tender, or that it causes any functional impairment. The scar is also not shown to be adherent, and the total of all related scars was not greater than 39 square centimeters. Thus, a separate rating under 38 C.F.R. § 4.118 is not indicated. 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805 (2012). In so deciding, the Board finds that the Veteran's general complaints of left ankle pain with functional impairment on use are credible. However, the Board places greater probative weight to the specific clinical findings by trained clinicians than the Veteran's generalized allegations. There is no doubt of material fact to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b). Extraschedular consideration To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The provisions of 38 C.F.R. § 3.321(b) state as follows: Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: 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 as to render impractical the application of the regular schedular standards. In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. VA's General Counsel has stated that consideration of an extra-schedular rating under 3.321(b)(1) is only warranted where there is evidence that the disability picture presented by the Veteran would, in that average case, produce impairment of earning capacity beyond that reflected in the rating schedule or where evidence shows that the Veteran's service-connected disability affects employability in ways not contemplated by the rating schedule. See VAOPGCPREC 6-96 (Aug. 16, 1996). In Thun, the Court further explained that the actual wages earned by a particular veteran are not considered relevant in the calculation of the average impairment of earning capacity for a disability, and contemplate that veterans receiving benefits may experience a greater or lesser impairment of earning capacity than average for their disability. The Thun Court indicated that extraschedular consideration cannot be used to undo the approximate nature of the rating system created by Congress. The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. However, the Board is not precluded from raising this question, see Floyd v. Brown, 9 Vet. App. 88 (1996), and addressing referral where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In this case, the Veteran's left ankle disability is primarily manifested by pain on use absent significant limitation of motion. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's service-connected left ankle disability is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, as demonstrated above, evaluate disabilities involving the ankle based on ankylosis (DC 5270), limitation of motion (DC 5271), ankylosis of the subastragalar or tarsal joint in poor weight-bearing position (DC 5272), malunion of the os calcis or astragulus (DC 5273) and residuals of astragalectomy (DC 5274), all of which were considered in this case as well as consideration of motion and function limited by factors such as pain and weakness, pursuant to 38 C.F.R. §§ 4.40, 4.45, and 4.59. The rating schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] 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." 38 C.F.R. § 4.1. In this case, the problems and limitations reported by the Veteran in conjunction with his left ankle disability are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with the left ankle disability, no further consideration is required, and the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Lastly, the Board acknowledges that the October 2012 VA examiner indicated that the Veteran's ankle condition did impact his ability to work, as the Veteran complained of pain while using stairs. The Board observes that a TDIU claim is addressed by the Board in the Remand below. ORDER The claim of entitlement to service connection for status post fracture of the right wrist secondary to the service-connected PTSD, is denied. A disability rating for in excess of 20 percent for the service-connected residuals of a left ankle fracture, status post open reduction and internal fixation fibula, is denied. REMAND This appeal was previously before the Board in August 2012, at which time the Board remanded the issues of entitlement to an increased rating for the service-connected PTSD, for additional development. In the August 2012 remand, the Board found that the Veteran should be scheduled for new VA examination to determine the current severity of his PTSD. The Board directed, in pertinent part, that the RO/AMC was to schedule the Veteran for a VA examination in order to determine the current nature and severity of his service-connected PTSD. It was requested that the VA examiner indicate all present symptoms and manifestations attributable to the Veteran's service-connected PTSD, in accordance with the rating criteria specified at 38 C.F.R. § 4.130, Diagnostic Code 9411. The findings of the examiner were to address the degree and extent of social and occupational impairment attributable to the Veteran's PTSD, to include providing an opinion as to whether he is considered to be totally socially and occupationally impaired due to PTSD. The Board further directed that the RO/AMC should subsequently readjudicate the claims on appeal. If any benefit sought remained denied, the RO/AMC was requested to issue an appropriate SSOC. In September 2012, the Veteran underwent a VA PTSD examination. However, review of the examination report reflects that it does not fully comply with the Board's instructions in the August 2012 remand for the reasons explained below. RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the RO must obtain a supplemental opinion from the VA examiner who conducted the September 2012 examination. The September 2012 examination report indicates in the body of the report that the Veteran's service-connected PTSD causes occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. However, the examiner later remarked in the examination report that employment is not a feasible goal at this time for the Veteran, and stated that it is the examiner's opinion that the Veteran is totally socially and occupational impaired due to PTSD at this time. Therefore, the Board finds that the September 2012 VA examination report contains an internal inconsistency with regard to the degree and extent of social and occupational impairment attributable to the Veteran's PTSD. Accordingly, the RO should obtain a supplemental opinion from the VA examiner who provided the September 2012 VA examination concerning the Veteran's PTSD, and request that the examiner clarify the degree and extent of social and occupational impairment attributable to the Veteran's PTSD, to include providing an opinion as to whether he is considered to be totally socially and occupationally impaired due to PTSD. Additionally, the Board also notes that in the August 2012 remand, the Board directed that after completing the requested development, the RO/AMC was to readjudicate the claims on appeal. If any benefit sought remained denied, the RO/AMC was requested to issue an appropriate SSOC. However, while the AMC issued a SSOC in April 2013, it failed to readjudicate the Veteran's claim for entitlement to an increased rating in excess of 50 percent for the service-connected PTSD from May 26, 2009 to September 25, 2012. Thus, if the Veteran's claim for entitlement to an increased rating in excess of 50 percent for PTSD from May 26, 2009 to September 25, 2012 remains denied, the Veteran and his representative must be provided an appropriate SSOC and given an opportunity to respond. Moreover, the evidence suggests that the Veteran is unable to hold a job due to service-connected disabilities, to specifically include PTSD and the service-connected residuals of a left ankle fracture, status post open reduction and internal fixation fibula. Accordingly, the Veteran should be asked to complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. In addition, statutory and regulatory notice should be provided concerning the information and evidence necessary to substantiate a claim for TDIU. Moreover, an appropriate VA examination to determine the effects of the Veteran's service-connected disabilities on his ability to obtain and maintain employment consistent with his education and occupational experience has not been conducted. Such can be accomplished on remand. Lastly, the Board finds that the Veteran's claim for TDIU is impacted by the increased evaluation claims and, therefore, is inextricably intertwined with the claims for increased evaluations for PTSD. The TDIU claim cannot be reviewed while the pending claims for increased ratings remain unresolved. As these issues are "inextricably intertwined," the TDIU claim needs to be remanded pending adjudication of the Veteran's increased evaluation claims. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (noting that two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The RO must send the Veteran proper statutory and regulatory notice that advises the Veteran about what is needed to substantiate a claim for TDIU. In addition, the Veteran must complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, to obtain relevant employment information. 2. The RO must return the Veteran's claims file, including a copy of this Remand and a copy of the September 2012 VA PTSD examination report to the VA examiner who provided the September 2012 VA PTSD examination, and request clarification as to the degree and extent of social and occupational impairment attributable to the Veteran's PTSD, to include providing an opinion as to whether he is considered to be totally socially and occupationally impaired due to PTSD. The examiner should set forth the complete rationale for all conclusions reached. 3. If the examiner who performed the September 2012 VA PTSD examination is no longer available, the RO/AMC should schedule the Veteran for a VA examination in order to determine the current nature and severity of his service-connected PTSD. The claims file must be made available to the examiner, including a copy of this Remand and all records on Virtual VA, and the examiner should include in the examination report a discussion of the Veteran's medical history and assertions. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. It is requested that the VA examiner indicate all present symptoms and manifestations attributable to the Veteran's service-connected PTSD, in accordance with the rating criteria specified at 38 C.F.R. § 4.130, Diagnostic Code 9411. The findings of the examiner should address the degree and extent of social and occupational impairment attributable to the Veteran's PTSD, to include providing an opinion as to whether he is considered to be totally socially and occupationally impaired due to PTSD. The examiner should assign a Global Assessment of Functioning (GAF) score and explain the basis for this finding. The examiner should set forth all examination findings, along with the complete rationale for all conclusions reached. 4. The RO/AMC should schedule the Veteran for a VA examination to determine the effects of his service-connected disabilities on his ability to obtain and maintain employment consistent with his education and occupational experience. The claims file and all records on Virtual VA must be made available to the examiner, and the examiner must specify in the examination report that the claims file and Virtual VA records have been reviewed. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. The examiner must elicit from the Veteran and record for clinical purposes a full work and educational history. Based on the clinical examination, a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must provide an opinion as to whether the Veteran's service-connected disabilities preclude him from securing and following substantially gainful employment consistent with his education and occupational experience. This opinion must be provided without consideration of his nonservice-connected disabilities, or age. The examiner should set forth all examination findings, along with the complete rationale for all conclusions reached. 5. After the development requested has been completed, the RO must review the examination reports to ensure that they are in complete compliance with the directives of this Remand. If the reports are deficient in any manner, the RO must implement corrective procedures at once. 6. The RO/AMC should review the claims file to ensure that all the foregoing requested development is completed, and, thereafter, arrange for any additional development indicated. The RO/AMC should then readjudicate the claims on appeal, to include adjudication of the issue of entitlement to TDIU. If any benefit sought remains denied, the RO/AMC should issue an appropriate SSOC and provide the Veteran and his representative the requisite time period to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. No action is required of the appellant unless he is notified. 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). No action is required of the appellant until further notice. However, the Board takes this opportunity to advise the appellant that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claims, including reporting for any scheduled VA examination, is both critical and appreciated. The appellant is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. These claims 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). ______________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs