Citation Nr: 1324080 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 09-50 162 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a higher disability evaluation for lumbar spine degenerative disc disease (low back disability), currently evaluated as 40 percent disabling since May 7, 2010. 2. Entitlement to a higher initial disability evaluation for left knee suprapatellar effusion (left knee disability), rated 10 percent disabling. 3. Entitlement to an evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD), prior to September 9, 2011 4. Entitlement a higher evaluation for PTSD, currently evaluated as 50 percent disabling. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs ATTORNEY FOR THE BOARD Jarrette A. Marley, Associate Counsel INTRODUCTION The Veteran had active service from April 1993 to April 1995, November 2000 to April 2008, including service in Iraq from March to July 2003 and from July 2004 to May 2005, and service in Kuwait from August 2006 to August 2007. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision by the St. Petersburg, Florida Department of Veterans Affairs (VA) Regional Office (RO). In July 2011, the Board granted an increased 20 percent rating for the low back disability from April 2, 2008, to May 6, 2010, and granted a further increased 40 percent rating from May 7, 2010, but remanded entitlement to an evaluation higher than 40 percent during the latter period. The issue is characterized accordingly. The Board's July 2011 decision included a remand of the issues listed above for further development. In a January 2013 rating decision, the Veteran was granted an increased 50 percent rating for his PTSD, effective September 9, 2011. The issue has been characterized accordingly for consideration of both periods. The Board also notes that entitlement to service connection for a right thumb disability and for a right wrist disability were remanded by the Board in July 2011. In a January 2013 rating decision, the Veteran was granted service connection for a right wrist sprain and for residuals of a right thumb collateral ligament strain. Accordingly, those matters are no longer before the Board. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. At no time since May 7, 2010 is the Veteran's service-connected lumbar spine degenerative disc disease shown to have been manifested by unfavorable ankylosis of the entire thoracolumbar spine; separately ratable neurological symptoms (other than the already separately rated bilateral lower extremity neuropathy and erectile dysfunction) or incapacitating episodes are not shown. 2. The Veteran's left knee disability is manifested by x-ray evidence of degenerative joint disease with range of motion from 0 degrees extension to no worse than 90 degrees flexion, with pain on active motion. 3. Throughout the appeal, resolving all reasonable doubt in the Veteran's favor, the Veteran's left knee has been manifested by no more than slight instability. 4. Throughout the appeal period, resolving all reasonable doubt in the Veteran's favor, the Veteran's PTSD has been manifested by occupational and social impairment with reduced reliability and productivity; occupational and social impairment with deficiencies in most areas has not been shown. CONCLUSIONS OF LAW 1. A rating in excess of 40 percent for lumbar spine degenerative disc disease since May 7, 2010 is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5237, 5243 (2012). 2. The criteria for a rating in excess of 10 percent for left knee degenerative joint disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260, 5261 (2012). 3. The criteria for a separate 10 percent disability rating for left knee instability have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.71a, Diagnostic Code 5257 (2012). 4. Throughout the appeal period, the criteria for a 50 percent rating, but no higher, is warranted for the Veteran's PTSD. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The Veteran's left knee disability, PTSD, and low back disability arise from his disagreement with the initial evaluation following the grant of service connection. Once service connection is granted, the claim is substantiated, and additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). As to VA's duty to assist, all pertinent records from all relevant sources identified by the Veteran, and for which he authorized VA to request, have been obtained. VA has associated with the claims file the service treatment records and post-service treatment records. Regarding his low back disability claim, he was afforded a VA examination in August 2011. Regarding his left knee disability claim, he was afforded VA examinations in August 2008 (with a January 2009 addendum report) and August 2011. Regarding his PTSD claim, he was afforded VA examinations in November 2008 and September 2011. The Board finds that the examinations for the disabilities, cumulatively, are adequate for rating purposes as the examiners conducted thorough examinations, and noted all clinical findings needed for proper determinations in these matters. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). Further, all development requested in the July 2011 remand has been complied with. As the Veteran has not identified any additional evidence pertinent to his claims, and as there are no additional records to obtain, the Board concludes that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. §§ 5103(a), 5103A, or 38 C.F.R. § 3.159, and that the Veteran will not be prejudiced by the Board's adjudication of his claims. Analysis Initially, the Board notes that it has reviewed all of the evidence in the Veteran's claims file and in Virtual VA (i.e., VA's electronic data storage system), with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The percentage ratings in VA's Schedule for Rating Disabilities (Rating Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). Low Back Disability As noted above in the Introduction, the Board in its July 2011 decision granted an increased 20 percent rating for the low back disability from April 2, 2008 through May 6, 2010, and granted a further increased 40 percent rating from May 7, 2010. Consequently, the focus is on those criteria that would afford him a rating in excess of 40 percent. The Veteran's service-connected low back disability is rated under Diagnostic Code (Code) 5243 (for intervertebral disc syndrome). It may be rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), and under the based on incapacitating episodes, whichever is more favorable to the Veteran. 38 C.F.R. § 4.71, Code 5243. Under the General Rating Formula, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine limited to 30 degrees or less; or where there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. And a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. There are several notes following the General Rating Formula criteria, which provide: (1) Associated objective neurological abnormalities are to be rated separately under an appropriate diagnostic code. (2) For purposes of VA compensation, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateroflexion is 0 to 30 degrees, and left and right lateral rotation is 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateroflexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. (3) In exceptional cases, an examiner may state that, because of age, range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in the regulation. 38 C.F.R. § 4.71a. 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. 38 C.F.R. § 4.71a, Note 1 following the Formula for Rating Based on Incapacitating Episodes. As there is no evidence, or allegation, that the Veteran has had an incapacitating episode (bed rest prescribed by a physician), rating based on such episodes would be inappropriate). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Court in Mitchell explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). In a May 7, 2010 Paul J. Yocon, D.C., private treatment report, it was noted that the Veteran's current low back symptoms are pain with spasm extending from the lumbosacral area to the thoracolumbar region. Flexion and extension of the lumbar spine causes significant increase in symptoms. His pain is constant in varying degrees. His current treatment consists of muscle relaxants, ibuprofen, and Tylenol, which offer poor pain control. On physical examination, lumbar flexion was to 20 degrees with marked pain, and his lumbar extension was to 10 degrees, also with substantial pain. He could not rotate or laterally flex his lumbar spine in either flexion or extension positions due to substantial pain. There was moderate to substantial deep musculature hypertonicity throughout the lumbar spine that was most remarkable at the lumbosacral region and for localized lumbosacral pain. The diagnosis was post-traumatic low back syndrome with associated degenerative joint disease, chronic discopathy, and probable central canal stenosis. The private physician opined his disability would require orthopedic and/or neurosurgery as well as minimally invasive pain management procedures (e.g., nerve blocks). VA treatment records include an October 2010 primary care report noting the Veteran was no longer being treated by a private medical doctor. He denied taking any prescription medication in over a year, and he was not even taking over-the-counter medication for pain. On physical examination, there was no costovertebral angle tenderness, negative straight leg raise, and no spasm of the back. The impression was chronic low back pain. He was prescribed Naprosyn 500mg twice a day. A June 2011 primary care report noted the Veteran's complaint of chronic lower back pain. On August 2011 VA examination, the Veteran reported persistent low back pain with intermittent episodes of radiating pain into his right leg. He also reported random episodes of increased severity of low back pain that occurs approximately on a yearly basis. He avoids lifting/carrying heavy objects due to his back pain. His treatment includes Motrin, pain medication, physical therapy and trigger point injections. He indicated his low back disability symptoms include stiffness and spasms. He denied having any incapacitating episodes. On physical examination, the Veteran's gait was normal. There was no evidence of abnormal spinal curvatures, including thoracolumbar spine ankylosis. There was no evidence of spasm, atrophy, guarding, pain with motion or weakness of the thoracolumbar spine; there was evidence of tenderness. Range of motion studies revealed the following: flexion from 0 to 90 degrees; extension from 0 to 25 degrees; bilateral lateral flexion from 0 to 30 degrees; and bilateral lateral rotation from 0 to 30 degrees. There was no objective evidence of pain following repetitive motion, and there was no evidence additional limitations after three repetitions of range of motion. Reflex examination findings were normal (2+). Sensory examination findings were normal for the bilateral upper and lower extremities. Motor examination was normal (5/5) for the upper and lower extremities. The Veteran's muscle tone was normal and there was no evidence of muscle atrophy. The diagnosis was degenerative disc disease. The examiner noted that his disability can be aggravated by physical activity and manual labor, and is often exacerbated by bending/twisting and lifting/carrying objects. He is predisposed to episodes of increased intensity and dysfunction. These episodes are most likely precipitated by physical activity, including lifting/carrying heavy objects and bending/twisting activities. VA treatment records include an October 2011 primary care report that found on physical examination of the lumbar spine no paraspinous muscle, negative straight leg raises, bilaterally, and mild tenderness over the left sciatic notch area. The assessment was chronic lower back pain with possible sciatica. A December 2011 primary care report noted the Veteran's complaint of chronic, aching lower back pain (5 to 6 on a scale to 10). The pain is triggered by lifting, standing, sitting, walking, and stress. The pain is relieved by medication. The lower back pain effects his sleep, appetite, daily activities, physical activity, mood, emotions, social life, and walking. Based on the evidence above, the Board finds no distinct period of time since May 7, 2010 when symptoms of the Veteran's low back disability were of (or approximated) such nature and gravity as to warrant a rating in excess of 40 percent. Thoracolumbar forward flexion has been no less than 20 degrees, and extension has been no less than 10 degrees (even with consideration of range of motion with pain and after repetitive range of motion testing), and there is no evidence of ankylosis. The August 2011 VA examiner specifically noted that there was no evidence of ankylosis of the thoracolumbar spine. The Board notes further that VA regulations also provide that in addition to orthopedic considerations, any associated objective neurologic abnormalities, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. In this case, the Veteran has already been awarded separate 10 percent ratings for right and left lower extremity neuropathy (by the July 2011 Board decision). There is no evidence that such rating is inadequate. Notably, the August 2011 VA examiner found reflex, sensory, and motor examination of the Veteran's extremities were normal. He has also been granted special monthly compensation for erectile dysfunction. There is no evidence of any additional neurologic disability related to the Veteran's service-connected low back disability. As the criteria for the 40 percent rating currently assigned encompasses the greatest degree of severity of the Veteran's low back disability for the period since May 7, 2010, the Board finds that "staged" ratings are not warranted. The preponderance of the evidence is against this claim; accordingly, the benefit of the doubt doctrine does not apply. The claim must be denied. Left Knee Disability The Veteran's service-connected left knee disability is rated under Diagnostic Codes 5014-5261 (for osteomalacia and limitation of extension). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Court in Mitchell explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). In a February 2009 rating decision, the Veteran was granted service connection for left knee suprapatellar effusion, and assigned a 10 percent disability rating effective from April 3, 2008. The Veteran reports that his left knee disability is manifested by symptoms of chronic pain, giving way, stiffness, crepitus, locking and weakness. The evidence shows that his left knee symptoms include instability and degenerative changes. Therefore, the Board finds that it is more appropriate to rate the Veteran's left knee disability under Diagnostic Codes 5257 and 5003. See Butts v. Brown, 5 Vet. App. 532 (1993) (choice of diagnostic code should be upheld if it is supported by explanation of evidence). Under Diagnostic Code 5257, slight recurrent subluxation or lateral instability warrants a 10 percent evaluation. A 20 percent evaluation requires moderate recurrent subluxation or lateral instability, and a 30 percent evaluation is warranted for severe subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The words "slight," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. The diagnostic codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 and 5261. Normal range of motion of the knee is extension to zero degrees and flexion to 140 degrees. See 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5260, a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; and a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. In VAOPGCPREC 23-97, the General Counsel held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257 and that evaluation of a knee disability under both of these codes would not amount to pyramiding under 38 C.F.R. § 4.14 (2007). VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63,604 (1997); see also Esteban v. Brown, 6 Vet. App. 259 (1994). However, a separate finding must be based on additional disability. As noted above, the Veteran is currently in receipt of a 10 percent disability rating. Following a review of the record, the Board finds that there is sufficient evidence as to warrant the assignment of a separate 10 percent disability rating for left knee instability throughout the appeal period. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. On August 2008 VA examination, the Veteran complained of bilateral knee pain since 2001, worsened by physical activity, including running. The Veteran reported he was unable to walk a quarter of a mile. He related he has left knee pain, stiffness, weakness, and giving way. He denied any episodes of dislocation or subluxation, locking, effusion, flare-ups or inflammation. On physical examination, the Veteran's gait was manifested by waddling, but there was no evidence of abnormal weight bearing. The Board notes that range of motion studies are unclear as to which knee the range of motion findings are applicable based on the examination report. Notably, on forward flexion, although it indicates the range of motion is on the right side, it indicates the joint involved is the left knee. Flexion was found to be to 140 degrees, with pain beginning at 120 degrees. On extension, it is indicated both the right and left knee were involved, and extension was to 0 degrees. There was no loss of motion on flexion or extension on repetitive use. The examiner also noted there was evidence of left knee crepitus, tenderness and clicking/snapping. There was no evidence of left knee grinding, instability, or patellar or meniscus abnormality. X-rays revealed no degenerative changes but there was increased fluid in the suprapatellar recess. It was noted that a MRI in 2003 showed mild patellar tendinitis. A January 2009 VA examination addendum provided a diagnosis of left knee suprapatellar effusion. In a May 7, 2010 Paul J. Yocon, D.C., private treatment report, it was noted that the Veteran has constant pain of the left knee in varying degrees, and the knee occasionally locks. It was further noted that the examination of the knee was essentially identical to the right knee - flexion to 90 degrees with crepitus. The examination was consistent with degenerative joint disease traumatically induced. There was a strong suspicion regarding internal damage, and the physician noted that the degenerative disease does not answer the issue of the locking of the knee. It was indicated that the Veteran would be a candidate for an early total joint replacement of the left knee. The diagnosis was post-traumatic residual degenerative joint disease of the left knee with retro patellar pain, and probable internal damage. On August 2011 VA examination, the Veteran reported experiencing left knee crepitus, stiffness and pain involving the anterior aspect of his knee. The pain is made worse with prolonged standing/sitting, kneeling/bending, running and other physical activity. He also indicated he has episodes where his knee buckles. He denied catching/locking. His treatment includes non-steroidal anti-inflammatory drugs, pain medication, therapy, and a brace. He also reported experiencing giving way. He denied episodes of dislocation or subluxation, locking, effusion, or flare-ups of joint disease. It was noted that there were no limitations on standing or walking. On physical examination, the Veteran's gait was normal. There was no evidence of abnormal weight-bearing. There was no evidence of grinding, instability, or patellar or meniscus abnormality. There was evidence of left knee crepitation. Range of motion studies revealed flexion to 135 degrees and extension to 0 degrees. There was no evidence of pain following repetitive motion or additional limitations after repetitive range of motion. There was also no evidence of joint ankylosis. The diagnosis was left knee patellofemoral syndrome. For an increase based on limitation of motion, the evidence must minimally establish that the Veteran's left knee disability is manifested by flexion limited to 30 degrees (Diagnostic Code 5260), and/or by extension limited to 15 degrees (Diagnostic Code 5261). Following a review of the record, the Board finds that an increase based upon limitation of motion of the left knee is not met. At no point during the appeal period is the Veteran's left knee flexion shown to be less than 90 degrees, or extension shown to be other than normal (i.e., to zero degrees) (even with consideration of pain on range of motion testing, and after repetitive range of motion testing). Such findings do not meet the criteria for an increased rating under either Diagnostic Code 5260 or Diagnostic Code 5261. Notably, there is no other evidence of record during the appeal period providing range of motion findings so as to warrant consideration under Diagnostic Codes 5260 and 5261. In considering the applicability of other diagnostic codes, the Board notes that the Veteran is entitled to a separate 10 percent disability rating for slight instability of the left knee throughout the appeal period. The evidence shows that the Veteran has complained of left knee instability/giving way throughout the appeal period. While such has not been objectively found on physical examination, the Board does not question the Veteran's credibility as to the instability he reports in his left knee. As instability is something as to which the Veteran is personally able to report and experience, the Board also finds him competent to report his instability. Moreover, his account is consistent with the medical finding of probable internal left knee damage. Therefore, the Board finds that it is appropriate to assign a separate 10 percent disability rating, but no more, for the Veteran's left knee instability throughout the appeal period. In an effort to afford the Veteran the highest possible disability rating for his left knee disability, the Board has considered the disability under all other potentially appropriate diagnostic codes. The Veteran has never demonstrated or been diagnosed with ankylosis of the left knee, dislocated semilunar cartilage, symptomatic removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum (hyperextended knee). Therefore, 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 are not applicable. In sum, the Board finds that the preponderance of the evidence is against a disability rating greater than 10 percent limitation of motion (as compensable limitation of motion has not been shown, but there is evidence of arthritis) and a separate rating of 10 percent for left knee instability. PTSD PTSD is rated under 38 C.F.R. § 4.130, Code 9411 (the General Rating Formula for Mental Disorders (General Formula)), which provides for a 30 percent rating for occupational and social impariemnt with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex command; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. To warrant a 70 percent rating, the evidence must show occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when the evidence shows total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When determining the appropriate disability evaluation to assign, however, the Board's "primary consideration" is the Veteran's symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of all psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996). A score of 31 to 40 reflects some impairment in reality testing or communication or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood. A score of 41 to 50 is assigned where there are "[s]erious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV) 47 (4th ed. 1994). A score of 51 to 60 is appropriate where there are "[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers)." Id. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In addition to his PTSD, the evidence of record shows the Veteran has additional Axis I diagnoses, including depressive disorder not otherwise specified and adjustment disorder with depressed mood. When it is not possible to separate the effects of the service-connected condition from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected condition. Mittleider v. West, 11 Vet. App. 181 (1998). In this case, the effects of the Veteran's PTSD have not been adequately separated from the other Axis I diagnoses. Accordingly, the Board will attribute those signs and symptoms to the Veteran's service-connected PTSD for the limited purpose of this appeal. Historically, a February 2009 rating decision granted service connection for PTSD, rated 30 percent disabling, effective April 3, 2008. An interim, January 2013 rating decision, granted an increased 50 percent rating for the Veteran's service-connected PTSD, effective September 9, 2011. On August 2008 VA general examination, the Veteran reported he has difficulty sleeping with possible insomnia, flashbacks, and nightmares related to his service. On November 2008 VA examination, the Veteran reported experiencing anger, paranoia, and an exaggerated startle response. He also related he is easily aggravated by his wife and kids, always arguing and not sleeping well. He reported he prefers to stay away from people, staying in his room all the time, although he does help take his youngest daughter to school and pick her up. While he has nightmares, they have diminished in frequency and intensity over time, indicating he does not get them too often. He also indicated he has intrusive thoughts of his active service. It was found the Veteran's psychiatric symptoms were of mild to moderate severity. His treatment consists of individual therapy and medications. On mental status examination, the Veteran was casually dressed, showed regular psychomotor activity, and his eye contact was decreased. His affect was constricted to blunted. He was somewhat irritated for no particular reason. His mood was reported as frustrated with current unemployment and easily angered. There was no evidence of impairment of thought process or communication. The Veteran denied visual hallucinations, although he reported hearing "noises" but no actual voices. There was no evidence of inappropriate behavior. He denied any suicidal or homicidal thoughts, plans, or intent. It was noted he was able to maintain minimal personal hygiene. He was fully oriented to person, time and place. The Veteran reported that his memory was pretty good depending on what he is trying to remember. He denied having any obsessive or ritualistic behavior that interfered with routine activities. He had a normal rate and flow of speech. There was no evidence of irrelevant, illogical, or obscure speech patterns. The Veteran denied having panic attacks except when in tunnels, elevators and confined spaces. He indicated he has been feeling more depressed lately, having lost interest in most things. He denied any impairment of impulse control. He reported he used to drink alcohol heavily, although he currently does not drink heavily. The diagnosis was PTSD. A GAF score of 60 was assigned. VA treatment records include a February 2009 psychiatry report noting the Veteran was casually attired and well-groomed. He also maintained good eye contact. His affect was full and his mood was appropriate. His speech was normal in rate, volume and tone. His thought processes were logical, relevant and goal-directed. His insight was adequate, and his judgment and impulse control appeared intact. The Veteran's memory for recent and remote events was intact, and his concentration was noted to be adequate. He denied suicidal or homicidal ideation. The diagnosis was PTSD. A GAF score of 60 was assigned. In a March 2009 Wende J. Anderson, Psy. D. private treatment report, the Veteran reported a history of considerable arguing with his spouse, although any history of physical altercations was denied. He described experiencing recurrent intrusive thoughts all the time, being triggered by construction on the route to get to his evaluator's office. He also described having flashbacks, recurrent nightmares and night sweats. The Veteran also reported cognitive and physiological responses to trauma cues in reaction to the sight of debris in a roadway and in reaction to loud noises. He described a history of avoidance of thoughts, feelings, conversations, activities, places and people associated with his traumatic experiences. A pattern of markedly diminished interest and participation of significant activities was reported. Feelings of detachment or estrangement from others were reported, as was a restricted range of affect. Severe troubles with irritability and angry verbal outbursts were descried. Concentration problems were markedly apparent during the evaluation. Hypervigilance, in the form of walking the perimeter of his home, was described. Exaggerated startle responses were also reported. Recurrent thoughts of death, including suicidal ideation, were described, but the Veteran reported he would not commit such an act because of his children. Intermittent homicidal ideation was also described, although intent was denied. On mental status examination, the Veteran's impulse control was noted to fall below normal limits, as demonstrated by his history of substance abuse. His speech was normal in terms of manner and content. His thought content was consistent with suicidal and homicidal ideation. He also described experiencing noises that other individuals were unable to hear. His affect was somewhat blunted, though stable, during the examination, and also appropriate. He was oriented to person, place, and time. His attention capacities appeared to fall below normal limits, as evidenced by his circumstantial speech during the examination. His concentration abilities fell within normal limits. His immediate memory abilities fell below normal limits, although his memory for recent events fell within normal limits, as did his memory for recent past events. His remote memory also appeared to be intact. His judgment and insight appeared to fall below normal limits. The diagnoses were PTSD and depressive disorder not otherwise specified. A GAF score of 39 was assigned. It was noted that the GAF score was based on his difficulties in multiple areas, including social functioning, employment functioning, family relationships, judgment-related issues, thinking difficulties, and mood. In a May 2010 Paul J. Yocon, D.C., private treatment report, it was noted that the Veteran's PTSD is manifested by anxiety, depression, recurring troublesome dreams, and disturbance to his thought processes. It was opined that the Veteran's PTSD is more serious than has previously been evaluated. In a May 2010 Wende J. Anderson, Psy. D. private treatment report, the Veteran reported a continued pattern of social isolation. He also reported a problem with anger control, including inexplicable anger and arguing with his wife. On mental status evaluation, it was noted that his impulse control appeared to fall below normal limits. His speech was normal in terms of manner and content. His thought content was consistent with the presence of suicidal ideation, which he described occurs all the time. He also described intermittent, impulsive homicidal ideation. His affect was somewhat blunted, though stable. He was oriented to person, place and time. His attention capacities fell below normal limits, as evidenced by his circumstantial speech. His concentration abilities fell within normal limits. His immediate memory abilities, recent memory, and remote memory fell within normal limits, although his memory for recent past events appeared to fall below normal limits. His judgment and insight were noted to also fall below normal limits. The diagnoses were PTSD and depressive disorder not otherwise specified. A GAF score of 39 was assigned. It was noted that the GAF score was based on his difficulties in multiple areas, including social functioning, employment functioning, family relationships, judgment-related issues, thinking difficulties, and mood. In an October 2010 VA primary care report, the Veteran reported little interest or pleasure in doing things and feeling down, depressed or hopeless for several days. He denied experiencing nightmares, avoidance of thoughts or situations reminding him of his active service, being constantly on guard, watchful or being easily startled, or feeling numb or detached from others, activities, or his surroundings. He also denied suicidal or homicidal ideation in the past months. In a June 2011 VA primary care report, the Veteran denied suicidal or homicidal ideation. On September 2011 VA examination, it was found that the Veteran's level of occupational and social impairment with regards to his mental diagnoses was manifested by occupational and social impairment with reduced reliability and productivity. It was noted that some of the Veteran's symptoms may be reduced should he obtain gainful employment as this is the primary stressor for his adjustment disorder. On mental status examination, the Veteran admitted to frequent irritability and frustration due to his unemployment which has affected his relationship with his wife of 11 years. He reported good relationships with his children. He denied any social contacts outside his family, and stated that he rarely leaves his house. For leisure, he watches sports and helps his cousin coach little league. He indicated he has lost motivation to obtain employment. He denied any treatment for his PTSD since 2009. He reported his alcohol use to be occasional, with no problematic effects. He indicated he experiences recurrent and distressing recollections of his service, and acting or feeling as if traumatic events of his service were recurring. The Veteran further reported efforts to avoid thoughts, feelings, conversations, activities, places and people associated with traumatic events of his service. He also related markedly diminished interest or participation in significant activities and feelings of detachment or estrangement from others. He stated he has difficulty falling or staying asleep, irritability or outbursts of anger, hypervigilance, and exaggerated startle response. He further reported experiencing a depressed mood and anxiety. He also reported having a flattened affect, impaired abstract thinking, and obsessional rituals which interfere with routine activities. The diagnoses were PTSD and adjustment disorder with depressed mood. The examiner indicated it was not possible to differentiate what symptoms are attributable to each diagnosis. A GAF score of 53 was assigned. An October 2011 VA primary care report noted the Veteran denied suicidal or homicidal ideation. He indicated he had little interest or pleasure in doing things for several days. He also related feeling down, depressed or hopeless for several days. Following a review of the evidence of record, the Board finds that the Veteran's PTSD warrants a rating of 50 percent throughout the appeal period. The Board finds that, for the entire appeal period, the Veteran's PTSD is manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as anger/irritability, disturbance of sleep, exaggerated startle response, isolation/estrangement from others, nightmares, paranoia, intrusive thoughts, constricted to blunted affect, auditory hallucinations, memory problems, panic attacks, depression, anxiety, diminished interest in activities, flashbacks, avoidance of traumatic thoughts/events during service, and hypervigilance, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. However, based on the evidence above, the Board finds that an evaluation in excess of 50 percent, to include "staged" ratings, is not warranted for any period of the appeal period. While the symptoms appear to have ranged from mild to serious, there was no evidence showing symptomatology consistent with: obsessional rituals which interfere with routine activities; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; suicidal ideation; speech intermittently illogical, obscure, or irrelevant; or neglect of personal appearance and hygiene. 38 C.F.R. § 4.130. The evidence viewed from a longitudinal perspective persuasively shows that the PTSD disability picture has not more nearly approximated the criteria for a rating in excess of 50 percent during any period contemplated by the appeal. While there is some suggestion the Veteran has diminished concentration and impairment of judgment and insight, as noted in the March 2009 and May 2010 Wende J. Anderson, Psy. D. private treatment reports, a February 2009 VA psychiatry report noted his concentration was adequate, and November 2008 and September 2011 VA examination reports made no notation of impaired or diminished concentration. Moreover, February 2009 VA psychiatry report and September 2011 VA examination found no evidence of impaired judgment. The Board finds significant that the March 2009 and May 2010 private treatment reports provide no rationale for why the Veteran's judgment and insight is impaired. The Board also notes that while suicidal ideation was noted in the March 2009 and May 2010 Wende J. Anderson, Psy. D. private treatment reports, described as occurring "all the time" in the May 2010 report, the record is otherwise free of any complaints of findings or reports of suicidal ideation, plan or intent. See, e.g., November 2008 VA examination report. Significantly, there is no evidence of spatial disorientation, although the Board does acknowledge the Veteran's report of auditory hallucinations. Indeed, the Veteran has consistently found to be oriented to person, place and time throughout the appeal period. There is also no evidence of neglect of personal appearance and hygiene, as the Veteran has consistently been noted to have adequate hygiene throughout the appeal period. Moreover, there is no evidence of near-continuous panic or depression affecting the ability to function independently, appropriately and effectively. Significantly, on November 2008 VA examination, the Veteran reported that the only time he has a panic attack is when he is in tunnels, elevators and confined spaces, and as the Veteran responded "not really" as to whether he has panic attacks, it can be concluded that even conceding that he does experience panic attacks, they do not rise to the frequency as to be near-continuous, or to be so severe as to affect his ability to function independently, appropriately and effectively. Although there is evidence that the Veteran suffers from depression, as reflected by the diagnoses of depressive disorder and adjustment disorder with depressed mood, there is no evidence that such has affected his ability to function independently, appropriately and effectively. Notably, there is evidence he has been largely unemployed throughout the appeal, and there is also evidence of diminished interest and motivation in seeking employment. However, on November 2008 PTSD VA examination, the Veteran associated his unemployment with his service-connected low back disability keeping him from doing certain jobs, as well as stating that he was not willing to take a job that would pay him less than what he needs to support his family. In addition, the Board notes that the September 2011 VA examiner indicated that some of the Veteran's symptoms would be reduced if he obtained gainful employment, which is the primary stressor for his adjustment disorder with depressed mood. Hence, while the Veteran's unemployment may have caused his depression to become worse, his depression is not the cause for his unemployment, as he appears to support in the November 2008 PTSD VA examination report. Nonetheless, even conceding for the purpose of this appeal that the Veteran has near-continuous depression, there is no evidence that such has affected his ability to function independently, appropriately and effectively. The Board also notes that there is no evidence of an inability to establish and maintain effective relationships. In reaching this conclusion, the Board concedes that there is evidence of isolation/estrangement from others. However, the record shows that the Veteran has been married to his spouse for at least 12 years. While there appears to be some irritability/anger and arguing in their relationship, there is no evidence that the relationship is not effective. In addition, to the extent the Veteran has remained married to her for at least 12 years reflects that he is able to maintain a relationship. The Board also notes that the Veteran has reported good relationships with his children. Significantly, the September 2011 VA examiner found that there was only difficulty in establishing and maintaining effective work and social relationships. Finally, the Board notes the Veteran's report of a loss of motivation in seeking employment because he applies for various jobs and never hears a response. See September 2011 VA PTSD examination report. While such may reflect some occupational impairment and difficulty adapting to stressful circumstances, it is also significant that the Veteran has been noted to be a student for at least one year during the appeal period. See September 2011 VA TDIU examination report. The Board also finds significant that the Veteran has not received a GAF score lower than 53 (reflective of moderate symptoms or moderate difficulty in social, occupational, or school functioning) in VA treatment records and examination reports. In addition, the September 2011 VA examiner found the Veteran's PTSD signs and symptoms do not result in deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. Overall, the Veteran's disability picture is more consistent with symptomatology described under the 50 percent rating currently assigned. Even then, the Veteran does not meet some of the criteria set forth as examples of the types of symptoms for a 50 percent rating, i.e., circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex command; impairment of long-term memory. Should the Veteran's disability picture change in the future, he may be assigned a higher rating. To the extent the Veteran has argued that the March 2009 and May 2010 Wende J. Anderson, Psy. D. private treatment reports should be afforded more probative value than the VA examination reports of record due to the supposed length of the VA examinations, the Board finds that such argument lacks merit. See, e.g., April 2010 Veteran correspondence. The Board is unaware of any caselaw (or other basis) for finding that the simple length, or lack thereof, of an examination is a basis for finding an examination to be inadequate. The Veteran has not identified anything that is otherwise inadequate or erroneous in either VA examination report. Hence, the Board finds no reason to find the March 2009 and May 2010 Wende J. Anderson, Psy. D. private treatment reports more probative than the VA examination reports on the simple basis of the length of the examination conducted. The Board has also considered the GAF scores assigned during the pendency of the Veteran's appeal. In particular, the Board notes the GAF score of 39 assigned in the March 2009 and May 2010 Wende J. Anderson, Psy. D. private treatment reports. Notably, such score would reflect some impairment in reality testing or communication or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood. Significantly, such a score is widely inconsistent with contemporaneous reports and records. Vazquez-Claudio v. Shinseki. The Board further notes that there is no evidence of impairment of reality testing or communication, as the Veteran's speech has consistently been found to be of normal rate, volume, and content, and there has been no evidence of impairment of his thought process. While there evidence of complaints of auditory hallucinations, there is no evidence visual hallucinations, and the Veteran has been found throughout the appeal period to be oriented to person, time and place. Moreover, his thought content has been routinely noted to be logical, relevant and goal-directed. While there is clearly evidence of some, even significant, impairment in several areas (e.g., work, mood), the Board finds that the evidence is not consistent with major impairment in several areas, as described above. Nonetheless, although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered but is not determinative of the VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126. In sum, the Board finds that the Veteran is entitled to a rating of 50 percent, but no higher, for his PTSD. The preponderance of the evidence is against the assignment of any higher rating at any point during this appeal. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In this case, regarding the Veteran's low back disability, the Board finds that the rating criteria considered reasonably describe the Veteran's disability level and symptomatology. Although the August 2011 VA examination report reflects that the Veteran's low back disability would impact his occupational activities due to decreased mobility, problems with lifting and carrying, problems with bending and twisting, and pain, the Veteran has not described any unusual or exceptional features associated with his low back disability that cannot be evaluated under the rating schedule (particularly in light of the fact that he has been awarded separate ratings for associated objective neurologic abnormalities). The assigned schedular evaluation for the service-connected low back disability is therefore adequate to evaluate the disability, and referral for consideration of extraschedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). Regarding the Veteran's left knee disability, the Board finds that the rating criteria considered in this case reasonably describe the Veteran's disability level and symptomatology. Although the May 2010 Paul J. Yocon, D.C., private treatment report noted that the Veteran's degenerative disease does not answer the issue of the locking of the knee, the Board also notes that there is no evidence of dislocated semilunar cartilage as to account for the locking of the left knee. In addition, the Veteran's report of locking of the knee has been inconsistent. See August 2008 and August 2011 VA examination reports (wherein the Veteran denied locking of the knee); cf. May 2010 Paul J. Yocon, D.C., private treatment report (wherein the Veteran reported locking of the knee). Hence, it is not clear if the Veteran in fact has locking of the knee, or if the mentioning of locking was in fact intended to be a report of instability of the knee, which the Board in this decision has granted a separate 10 percent rating for slight instability of the left knee. In addition, although the August 2011 VA examination report reflects that the Veteran's left knee disability would impact his occupational activities due to lack of stamina and pain, the Veteran has not described any unusual or exceptional features associated with his left knee disability that cannot be evaluated under the rating schedule (particularly in light of the fact that he has been awarded a separate rating for instability of the knee). The assigned schedular evaluation for the service-connected left knee disability is therefore adequate to evaluate the disability, and referral for consideration of extraschedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). Regarding the Veteran's PTSD, , the Board finds that the rating criteria considered in this case reasonably describe the Veteran's disability level and symptomatology. The Veteran's PTSD is characterized by occupational and social impairment with reduced reliability and productivity. These manifestations are contemplated in the applicable rating criteria. The Board has carefully compared the level of severity and symptomatology of the Veteran's PTSD with the criteria found in the rating schedule. In sum, the Board finds that the Veteran has not described functional effects that are exceptional or not otherwise contemplated by the assigned evaluation. Rather, his descriptions of his PTSD are consistent with the degree of disability addressed by such evaluation. The rating criteria are therefore adequate to evaluate the Veteran's PTSD and referral for consideration of an extraschedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER A rating in excess of 40 percent for lumbar spine degenerative disc disease since May 7, 2010, is not warranted. A rating in excess of 10 percent for degenerative joint disease of the left knee is denied. A separate 10 percent throughout the appeal period for left knee instability is granted, subject to law and regulations governing the effective date of an award of monetary compensation. Effective April 3, 2008, a 50 percent rating (and no more) is granted for the Veteran's PTSD, subject to law and regulations governing the effective date of an award of monetary compensation. An evaluation in excess of 50 percent for PTSD since September 9, 2011, is denied. REMAND In July 2011, the Board remanded the issue of entitlement to TDIU, in pertinent part, so that an opinion could be obtained regarding the impact of the Veteran's service-connected disabilities, alone and in the aggregate, on his ability to secure and maintain substantially gainful employment. The Veteran was afforded a general VA examination in September 2011, as well as examinations regarding his left knee, low back, PTSD, and right hand/wrist disabilities. Notably, the VA general examination physician stated that the Veteran's sleep apnea, rhinitis, erectile dysfunction, spine condition, bilateral lower extremity neuropathy, bilateral knee disability, and hand condition would not individually affect his employability. The Board finds that the September 2011 general VA examination report is inadequate as there is no collective or aggregate assessment of the impact of his service-connected disability on his ability to secure and follow a substantially gainful occupation. Moreover, the Board's favorable determinations in this decision should be considered on remand. On this basis, the Board finds that the Veteran should be afforded another VA examination regarding his claim of entitlement to TDIU. Finally, the most recent VA treatment records in the claims file are dated from January 2013. Any outstanding pertinent VA treatment records as to the remaining matter on appeal should either be made accessible on Virtual VA or be printed and added to the Veteran's claims file. See 38 C.F.R. § 3.159(c)(2); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Ensure that all VA treatment records dated since January 2013 have been associated with the claims file, either physically or electronically. 2. Then, afford the Veteran an appropriate VA examination, or obtain a medical opinion (to include, if available, from a vocational rehabilitation specialist or physiatrist), if possible, regarding the effect of the Veteran's service-connected disabilities on his employability. Based on the review of the claims file, the examiner must state whether the Veteran is unable to obtain or retain employment due solely to his service-connected disabilities, either alone or in the aggregate, consistent with his education and occupational experience, but irrespective of his age and any nonservice-connected disabilities. If the Veteran's service-connected disabilities do not cumulatively render him unemployable, the examiner should suggest the type or types of employment in which the Veteran would be capable of engaging with his current service-connected disabilities, given his current skill set and educational background. The examiner must provide a rationale for any and all opinions expressed, which should be set forth in a legible report. If an opinion cannot be provided without resorting to speculation, it must be noted in the examination report, and an explanation must be provided for that conclusion. 3. When the above development has been completed, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs