Citation Nr: 1325534 Decision Date: 08/13/13 Archive Date: 08/16/13 DOCKET NO. 09-16 962 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to a rating in excess of 20 percent for a back disability. 2. Entitlement to a rating in excess of 10 percent prior to March 24, 2012 and a rating in excess of 40 percent thereafter for residuals of left knee injury. 3. Entitlement to a rating in excess of 10 percent prior to July 28, 2012 and a rating in excess of 30 percent thereafter for chronic depression. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Amanda Christensen, Associate Counsel INTRODUCTION The Veteran had active military service from September 1985 to August 1997. This appeal comes to the Board of Veterans' Appeals (Board) from a May 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. The Board notes that in April 2012 the Veteran was awarded an increased evaluation of 40 percent for his knee disability effective March 24, 2012 and in October 2012 he was awarded an increased evaluation of 30 percent for his depression effective July 28, 2012. Those ratings constitute a partial grant of benefits, such that the issues remain on appeal and are for consideration by the Board. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. Throughout the rating period on appeal, the Veteran's back disability has been manifested by forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees with no diagnosis of invertebral disc syndrome, no ankylosis, no vertebral fracture, and no neurologic disability. 2. Prior to March 24, 2012, the Veteran's left knee disability was not manifest by flexion less than 45 degrees or extension greater than 10 degrees. 3. From March 24, 2012, the Veteran's left knee disability was manifested by left knee flexion to 140 degrees or greater and extension to 35 degrees or greater with no loss of range of motion but less movement than usual and pain on repetition. 4. At no time has the Veteran's left knee disability involved ankylosis, recurrent subluxation or lateral instability, or removal or dislocation of semilunar cartilage. 5. Prior to February 17, 2011, the Veteran's depressive disorder was manifested by no more than mild or transient symptoms that decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. 6. From February 17, 2011, the Veteran's depressive disorder was manifested by some social impairment, anxiety, periods of depression, and sleep impairment, but no reports of specific occupational interference, panic attacks, or problems with thinking or judgment. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for the Veteran's back disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242-5243 (2012). 2. The criteria for an evaluation in excess of 10 percent prior to March 24, 2012 and in excess of 40 percent thereafter for the Veteran's left knee disability have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003, 5010, 5256-5263, 5055 (2012). 3. Prior to February 17, 2011 the criteria for a rating in excess of 10 percent for depressive disorder are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9434 (2011). 4. From February 17, 2011 the criteria for a rating of 30 percent, but no higher, for major depressive disorder are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9434 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2012). Where, as here, entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim, if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The following discussion addresses the Veteran's level of disability from the time the increased rating claim was filed in April 2007. Francisco, 7 Vet. App. 55; Hart, 21 Vet. App. 505. Back In April 2007 the Veteran filed a claim for an increased disability rating in excess of 20 percent for his service-connected back disability. The regulations provide that back disabilities are rated under either the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a. Under the current Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 20 percent rating is assigned when intervertebral disc syndrome causes incapacitating episodes with a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months; a 40 percent rating is assigned when intervertebral disc syndrome causes incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months; and a 60 percent rating is assigned when intervertebral disc syndrome causes incapacitating episodes having a total duration of at least 6 weeks, during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id., Note (1). Here, no incapacitating episodes of intervertebral disc syndrome have been noted on either VA examination during the course of the Veteran's appeal. In fact, at the Veteran's March 2012 VA examination, the examiner specifically indicated that the Veteran did not have intervertebral disc syndrome. Moreover, the evidence of record simply does not show that at least four weeks of bed rest has been prescribed during any twelve month period over the course of his appeal. Neither VA examination reports, nor VA treatment records, show that bed rest was ever prescribed. While the Veteran's back condition indisputably causes some impairment, the criteria for a rating in excess of 20 percent based on incapacitating episodes of intervertebral disc syndrome have simply not been met. As such, it is more beneficial to evaluate the Veteran's lower back disability under the General Rating Formula for Diseases and Injuries of the Spine. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent evaluation is warranted when forward flexion of the thoracolumbar spine is greater than 30 degrees, but not greater than 60 degrees; when the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or when muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation requires either that forward flexion of the thoracolumbar spine is limited to 30 degrees or less, or that favorable ankylosis of the entire thoracolumbar spine is shown. A rating in excess of 40 percent is not available unless there is unfavorable ankylosis. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. 38 C.F.R. § 4.71a, Note 2. The Veteran has had range of motion testing conducted on two occasions during the course of his appeal, once at an initial physical therapy evaluation in 2010 and once at a VA examination in 2012. At the physical therapy initial evaluation in September 2010 the Veteran's flexion was measured to 20 degrees, extension to 0 degrees, right and left lateral flexion to 10 degrees, left rotation to 30 degrees, and right rotation to 26 degrees. Therapy goals included increasing pain-free range of motion by 15 degrees in two weeks and reaching full range of motion by five weeks, however VA records indicate the Veteran did not return for additional physical therapy sessions after the initial evaluation. The Veteran was afforded a VA examination in March 2012. The examiner noted the Veteran had been diagnosed with degenerative joint disease at T12-L1 in the mid-1990s. The Veteran reported flare-ups in the form of low back stiffness and pain as a result of prolonged sitting and walking. He reported being unable to participate in sports due to back pain. The Veteran reported occasionally using a cane. On range of motion testing the Veteran was found to have forward flexion to 45 degrees with painful motion at 45 degrees, extension to 25 degrees with painful motion at 25 degrees, right lateral flexion to 20 degrees with painful motion at 20 degrees, left lateral flexion to 30 degrees or greater with painful motion at 30 degrees or greater, and right and left lateral rotation to 30 degrees or greater with painful motion at 30 degrees or greater. He had no loss of range of motion on repetition. He did have less movement than normal, weakened movement, and pain on movement with repetition. The Veteran had localized tenderness or pain to palpation in the soft tissue of his thoracolumbar spine but no guarding or muscle spasm. His muscle strength was measured as active movement against some resistance. For the Veteran to be entitled to the next higher rating under Diagnostic Code 5242, a 40 percent rating, he must have either forward flexion of the thoracolumbar spine limited to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Upon examination in March 2012, the Veteran had neither. No ankylosis was noted at his VA physical therapy appointment in September 2010 either; however, the physical therapist found the Veteran had forward flexion only to 20 degrees at that time. The Board has considered both sets of range of motion testing, but finds the measurements taken at the March 2012 VA examination more accurately reflect the Veteran's level of disability than the range of motion testing done in September 2010 after the Veteran's referral to physical therapy. The physical therapy report does not indicate how the measurements were taken, whether they represent motion only to the point of pain, or whether they represent the Veteran's condition during a flare-up. No other measurements are available other than those taken at the VA examination a year and a half later that show significantly greater range of motion in forward flexion, extension, and left and right lateral flexion. The Veteran has not argued that the range of motion measurements taken at the VA examination are not an accurate representation of his current condition or that they reflect a recent, significant improvement in his condition during the course of his appeal such that they can be reconciled with the much lower September 2010 physical therapy range of motion measurements. No other subjective or objective observations are available contemporaneous with the September 2010 physical therapy range of motion testing that would offer a more complete picture of the severity of the Veteran's back disability at that time and lend credence to the range of motion testing results. Thus, the Board gives greater weight to the March 2012 range of motion testing. The Board must also consider functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45 when deciding whether a higher disability evaluation is warranted. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. A part that becomes painful on use must be regarded as seriously disabled. Id.; see also DeLuca. In this case, the March 2012 examiner noted no additional loss of range of motion on repetition, although he did note less movement, weakened movement, and pain with repetition. However, even considering the additional symptoms, the Board finds the Veteran's disability does not manifest additional functional loss so as to functionally limit the Veteran's forward flexion to 30 degrees and more closely approximate a 40 percent rating. The Board has also considered the Veteran's complaints of no longer being able to participate in sports and pain and stiffness after prolonged sitting and walking. However, it is important for the Veteran to understand that the assigned 20 percent rating contemplates marked limitation and pain and accounts for the symptoms the Veteran has described. Additionally, the presence of ankylosis has not been shown, and was specifically noted not to be present by the VA examiner in March 2012. As such, a higher rating is not warranted on that basis. Therefore, a rating in excess of 20 percent is not warranted for orthopedic back impairment. However, the regulations also provide that in addition to orthopedic considerations, any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. However, in this case, the evidence of record does not support a finding that the Veteran has a chronic neurologic disability as a result of his service-connected back disability, and, overall, provides evidence against such a finding. To this end, VA treatment records reflect that the Veteran has complained of pain radiating into his lower extremities on occasion, but no neurologic disability has ever been diagnosed. Moreover, neurologic testing at the March 2012 VA examination was normal. The March 2012 examiner specifically noted the Veteran had no radicular pain or any other signs or symptoms due to radiculopathy, although he did have a positive straight leg raise test in both legs. The Veteran's reflex and sensory examinations were normal and muscle strength testing was 4 out of 5 in both lower extremities. The examiner stated that the Veteran did not have any other neurologic abnormality or findings related to his back condition such as bowel or bladder incontinence or pathologic reflexes. As such, the Board concludes that a separate neurologic rating is not warranted by the evidence of record. The Board has carefully reviewed the Veteran's statements, treatment records, and VA examination and finds that the specific criteria necessary to merit a rating in excess of 20 percent for a lower back disability are not demonstrated by the evidence. Overall, the preponderance of the evidence is against the Veteran's claim for a rating higher than 20 percent for his back disability. In reaching this determination, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55; 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. Left Knee The Veteran contends he is entitled to an increased disability rating in excess of 10 percent prior to March 24, 2012 and a rating in excess of 40 percent thereafter for his service-connected knee disability. He filed his increased rating claim in April 2007. The regulations provide that when degenerative (meaning either osteoarthritis or hypertrophic) arthritis is established by x-ray findings, it is to be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. If, 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. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. For purposes of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f). In the absence of limitation of motion, when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations a 20 rating is to be assigned. 38 C.F.R. § 4.71a, DC 5003. However, the 20 percent rating based on x-ray findings, above, will not be combined with ratings based on limitation of motion. Id at NOTE (1). Moreover, 38 C.F.R. § 4.59 states that the intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Limitation of motion of the knee is addressed in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. The Veteran is currently rated under Diagnostic Code 5261 for knee extension. Diagnostic Code 5261 provides for a 10 percent rating where extension is limited to 10 degrees, 20 percent rating where extension is limited to 15 degrees, 30 percent rating where extension is limited to 20 degrees, 40 percent rating where extension is limited to 30 degrees, and 50 percent rating where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The Veteran's VA treatment records from when the Veteran filed his increased rating claim until he was afforded a VA examination in March 2012 reflect only mention of intermittent knee pain with no range of motion testing or evaluation of the Veteran's knee condition. The Veteran has also made no statements regarding his knee condition during that period other than to say merely that he believed it had worsened since his last rating decision. As the record is devoid of both objective testing and significant subjective complaint regarding the Veteran's knee condition prior to March 2012, the Board finds no evidence is of record on which to base a finding that the Veteran's disability had increased in severity prior to the March 2012 VA examination. The Veteran was afforded a VA examination on his knee in March 2012. The Veteran reported discomfort in his left knee when walking up stairs and reported he could no longer ride a bike or jog on a treadmill. The Veteran's left knee flexion was measured to 140 degrees or greater and his extension to 35 degrees or greater with no loss of range of motion on repetition. Less movement than usual and pain on movement was found with repetition in the left knee. The Veteran also reported tenderness or pain to palpation in his left knee. His muscle strength was measured as active movement against some resistance. His stability was normal. The Veteran is not entitled to the next higher rating under Diagnostic Code 5261, 50 percent, for the period beginning March 24, 2012, unless his knee extension is limited to 45 degrees. At his March 2012 examination, the Veteran's left knee extension was limited only to 35 degrees, and no other range of motion testing or evaluation of his knee condition is found in the Veteran's treatment records. The Veteran is also not entitled to a higher rating under Diagnostic Code 5260, which provides for a 10 percent rating where flexion is limited to 45 degrees, 20 percent rating where flexion is limited to 30 degrees, and 30 percent rating where flexion is limited to 15 degrees. The Veteran's flexion was measured to 140 degrees or greater at his VA examination. In deciding the Veteran is not entitled to a higher rating for range of motion, the Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board notes that knee pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 43; see 38 C.F.R. § 4.40. The March 2012 VA examiner found that the Veteran had no additional loss of range of motion due to pain or on repetition, although the examiner did note less movement than normal and pain on movement after repetition. The Board has also considered the Veteran's complaints of knee discomfort on stairs and inability to bike and jog, but finds his disability picture does not warrant a higher rating based on those complaints. The Board finds any additional functional loss the Veteran experiences due to pain is not so significant as to more closely approximate the criteria for a 50 percent rating. Other Diagnostic Codes relevant to knee disabilities include 5003, 5010, 5256 through 5259, 5262-5263, and 5055. Under Diagnostic Codes 5003 and 5010, arthritis established by x-ray findings is rated on the basis of limitation of motion of the affected joints. When however, the limited motion of the specific joint or joints involved would be noncompensable under the appropriate diagnostic codes, a 10 percent rating is assigned for each involved major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. 38 C.F.R. § 4.71a. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Diagnostic Code 5256, which evaluates ankylosis of the knee, assigns a 30 percent rating for favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. A 40 percent rating is assigned when there is ankylosis of the knee in flexion between 10 and 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5256. However, there has been no suggestion the Veteran has ankylosis in his knee, therefore Diagnostic Code 5256 is inapplicable. Diagnostic Code 5257 evaluates recurrent subluxation or lateral instability of a knee, and assigns a 10 percent disabling for a slight impairment, 20 percent disabling for a moderate impairment, and 30 percent disabling for a severe impairment. 38 C.F.R. § 4.71a. However, records do not indicate the Veteran has experienced knee instability or subluxation. Specifically, on examination the March 2012 VA examiner found the Veteran had normal anterior, posterior, and medial-lateral instability and no recurrent patellar subluxation/dislocation. Under Diagnostic Code 5258, when semilunar cartilage is dislocated with frequent episodes of locking, pain and effusion into the joint a 20 percent rating is assigned. 38 C.F.R. § 4.71a. When semilunar cartilage has been removed, but remains symptomatic, a 10 percent rating is assigned. Id., Diagnostic Code 5259. The March 2012 VA examiner noted the Veteran has not had any meniscal conditions or surgical procedures for a meniscal condition, therefore, Diagnostic Codes 5258 and 5259 do not apply. There has also not been any indication of impairment of the tibula and fibula so as to warrant a rating under Diagnostic Code 5262, no finding of genu recurvatum so as to warrant a rating under Diagnostic Code 5263, and no knee replacement so as to warrant a rating under Diagnostic Code 5055. 38 C.F.R. § 4.71a. As the preponderance of the evidence is against a rating in excess of 10 percent prior to March 24, 2012 and a rating in excess of 40 percent thereafter, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Depressive Disorder The Veteran contends he is entitled to an increased disability rating in excess of 10 percent prior to July 28, 2012 and a rating in excess of 30 percent thereafter for his service-connected depressive disorder. He filed his increased rating claim in April 2007. Major depressive disorder is evaluated according to Diagnostic Code 9434, which is governed by the General Rating Formula for Mental Disorders. A 10 percent rating is assignable for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is assignable for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment 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. A 70 percent evaluation requires 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 period of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation requires 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. 38 C.F.R. § 4.130, Diagnostic Code 9434 (2012). The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The nomenclature employed in the portion of VA's Rating Schedule that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "DSM-IV"). 38 C.F.R. § 4.130. DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. Higher scores correspond to better functioning of the individual. Under DSM-IV, GAF scores ranging between 61 and 70 are assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 41 and 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging between 31 and 40 are assigned when there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be 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. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. 38 C.F.R. § 4.126(b). At a VA medical appointment in June 2007 the Veteran reported suicidal ideation without a plan. He reported difficulty with finances since losing his job due to working too slow as a result of leg and back pain. In October 2007 he attended a VA psychiatry appointment and was found to be alert, friendly, medicine complaint, busy with schooling, and not suicidal or homicidal. He continued to deny suicidal and homicidal ideation in February 2010 and said he last saw a therapist three years prior. On February 17, 2011 the Veteran sought treatment at the Washington, D.C. VA Medical Center, reporting feeling depressed and agitated with a loss of interest in pleasurable activities, social isolation, sleep disturbance, and concentration difficulties. He denied suicidal or homicidal ideation. The Veteran reported he had been separated from his wife for seven months and had "off and on" contact with a stepdaughter. He indicated he had limited peer/family support and was interested in improving his socialization skills. The Veteran reported he last worked in 2009. The psychologist noted the Veteran's grooming and hygiene were normal, as was his speech, perception, and receptive language. He further noted fair eye contact, unremarkable thought content, and logical thought process. He found his attitude to be evasive, his attention to be distractible, and his affect flat. He judged him to have partial awareness with regard to insight but good judgment. He determined his memory to be intact. The psychologist assigned a GAF of 50. At an appointment later in February 2011, the Veteran reported poor sleep, being easily agitated, poor concentration, isolating himself, and no longer watching sports like he used to enjoy. In July 2012, the Veteran underwent a VA psychiatric examination. The examiner found the Veteran to have occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The examiner assigned a GAF score of 60. The examiner found the Veteran suffered from depressed mood; anxiety; chronic sleep impairment; disturbances of motivation and mood; and difficulty adapting to stressful circumstances, including work or a worklike setting. The Veteran reported he had tried various psychiatric medications over the years and had been in mental health treatment in the past but had difficulty making appointments. He reported his mood recently was "ok" with his main stressors as his physical health and pain, as well as unemployment and marriage problems. He related that he had been married for 14 years and the relationship "hasn't been easy." He reported he had one step child and is raising a niece. He said he has five siblings and reported staying in touch with family. The examiner noted "limited social supports and somewhat more isolated." The Veteran reported having eight jobs in the last 12 years due to different circumstances. He reported his relationship with others at work had been good. He reported he still gets into periods of depression and sadness. He noted frustration with trying to remember material for information technology certifications and reported regular concentration and memory problems. He reported anxiety "all the time" with a desire to get things done right. He reported some problems with sleep and said he usually gets five to six hours a night, interrupted with tossing and turning. He denied suicidal or homicidal ideation. He reported trying to find hobbies outside of work and the examiner noted his motivation in general was within normal limits. He said he sometimes remembers scary experiences in Bosnia but said there were no particular triggers for the memories. In this case, the Board has considered all of the evidence but finds that a rating in excess of 30 percent is not warranted. While the record reflects the Veteran has experienced some social impairment, no examples of occupational impairment are in the record. Although the Veteran's VA treatment records and examination note the Veteran experiences some social isolation, the Veteran also reported staying in touch with family. He also noted a 14-year marriage, although records indicate troubles with the relationship. Occupationally, the Veteran professed that when he was working he had a good relationship with others at work. There is no indication in the records that the Veteran's depressive disorder was the cause of his frequent job changes, and the records suggest he relocated frequently due to his wife's job. Nor did the Veteran identify any difficulties at work or missed work due to his depressive disorder. The GAF score of 60 assigned by the VA examiner in July 2012 represents the top of the range assigned for moderate symptoms or difficulty in social, occupational, or school functioning. Notably, the examiner specifically found the Veteran to have occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. Such impairment is reflective of a 30 percent disability evaluation. Thus, the Board finds the July 2012 examiner's assessment of the Veteran's condition is in line with a disability evaluation of 30 percent. The Board recognizes the lower GAF score of 50 assigned by the VA psychologist in February 2011, which represents the top of the range assigned for serious symptoms or impairment in social, occupational, or school functioning. However, notwithstanding that rating, the evidence, including the descriptions of the Veteran's symptoms in his VA treatment records and VA examination report, supports a finding that a disability rating in excess of 30 percent is not warranted considering the Veteran's condition overall. The GAF, while important, is not the only evidence the Board looks at in deciding a claim. The Board has carefully considered the Veteran's reported symptoms and the observations of those who have examined him. Specifically, the Veteran has not reported experiencing panic attacks, describing only sometimes being reminded of scary experiences in service with no particular triggers. He has also never endorsed suicidal or homicidal ideation, with the exception of one mention of suicidal ideation without a plan in 2007. The Veteran has referenced having some memory difficulties, but the VA psychologist in February 2011 found the Veteran to have intact memory and the July 2012 VA examiner did not note memory loss among the Veteran's symptoms. He was noted to have good judgment, unremarkable thought content, and logical thought process in February 2011, and the July 2012 VA examiner did not note that the Veteran had impaired judgment or abstract thinking or difficulty understanding complex commands. The July 2012 VA examiner found the Veteran's motivation in general was within normal limits. Considering the Veteran's symptoms as a whole, including his statements to his examiners, the Board finds that overall the Veteran's condition does not more closely approximately a higher 50 percent rating. In this regard, it is important for the Veteran to understand that without problems associated with his depressive disorder, there would be no basis for a compensable evaluation, let alone a 30 percent evaluation. The medical evidence clearly supports a finding, overall, of a mild disability or, at minimum, a disability that does not meet the requirements of the next higher 50 percent evaluation. The Veteran's depressive disorder does not cause occupational and social impairment with reduced reliability and productivity due to such symptoms as (for example only) flattened affect; circumstantial, circumlocutory, or stereotyped speech; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Even taking into consideration all of the Veteran's cited problems as the Veteran himself has indicated, a preponderance of the evidence is against a rating in excess of 30 percent. However, the Board does find that the evidence shows that the Veteran's disability approximated a 30 percent rating as of February 17, 2011, the date he saw a VA psychologist reporting essentially the same symptoms as he professed at his July 2012 VA examination. Thus, the Board finds the Veteran's 30 percent rating should be effective as of February 17, 2011, as that is the date as of which an increase in his disability above 10 percent is reflected in the medical records. Prior to February 17, 2011, there is not sufficient evidence showing an increase in severity of the Veteran's condition to warrant a rating higher than the assigned 10 percent. There is little information at all in the treatment records about the Veteran's depressive disorder between 2007 and 2011 and certainly not enough to warrant an increased rating. There is only one mention of suicidal ideation without a plan in 2007 and four months later he not only denied current suicidal ideation, but was found to be alert, friendly, and attending school. As the preponderance of the evidence is against a rating in excess of 10 percent prior to February 17, 2011, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Extraschedular Further, the Board has also considered whether referral for consideration of an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. This means that initially there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. However, in this case, the medical evidence fails to show anything unique or unusual about the Veteran's service-connected disabilities that would render the schedular criteria inadequate. With regard to the Veteran's back and knee disabilities, his symptoms, including loss of range of motion and pain, are contemplated in the ratings assigned. As such, it would not be found that his disability met the "governing norms" of an extraschedular rating. Accordingly, referral for consideration of an extraschedular rating is not warranted. Further, the Board finds that schedular evaluation assigned for the Veteran's service-connected depressive disorder is not inadequate in this case. The diagnostic criteria adequately describe the severity and symptomatology of the Veteran's service-connected depressive disorder. His depressed mood, anxiety, sleep impairment, and difficulty adapting to stressful circumstances are all among the symptoms considered by the rating schedule. Moreover, even if it were argued that the schedular rating criteria were inadequate with regard to the Veteran's back, knee, or depressive disorder disabilities, the Board still finds the case should not be referred to the Compensation and Pension Service to consider whether an extraschedular rating is warranted. In this case, there is no evidence of any recent hospitalization or marked interference with employment associated with the Veteran's disabilities. The Board has also considered if individual employability has been raised by the record. However, this issue was addressed, and not appealed, by the RO, in October 2012. In any event, based on a review of the record as a whole, the Board finds that this issue is not be indirectly raised within this record at this time. The manifestations of the Veteran's disabilities are considered by the schedular rating. Based on the foregoing, the Board finds the schedular evaluations are adequate, and referral is not required. 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, it is important for the Veteran to understand that not all evidence in this case supports the current evaluations and grants, let alone higher evaluations. Without consideration of all of the Veteran's subjective complaints, the current evaluations could not be justified. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). While the required notice should be furnished prior to the issuance of the appealed rating decision, any initial errors of notice will not be prejudicial if: 1) corrective actions (e.g., issuance of a post-adjudication notice letter containing the required information) are taken, and 2) the appeal is readjudicated (e.g., in a Supplemental Statement of the Case). See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Here, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in July 2007. In the letter, the RO informed the Veteran of what evidence was required to substantiate the claims and of the Veteran's and VA's respective duties for obtaining evidence. In the letter the RO also provided notice with regard to how VA assigns disability ratings and effective dates. As such, the VCAA duty to notify was satisfied by way of the July 2007 letter. VA also has a duty to assist the Veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The Board finds that all necessary development has been accomplished. The RO has obtained the Veteran's VA treatment records. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. The Veteran was afforded VA medical examinations in March 2012 for his back and knee and July 2012 for his depressive disorder. The examiners obtained an accurate history and listened to the Veteran's assertions. The examiners provided the Board with sufficient information to rate the Veteran's disabilities. Therefore, the Board finds that the examinations are adequate and contains sufficient information to decide the issues on appeal. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. 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, 16 Vet. App. 183. ORDER A rating in excess of 20 percent for a back disability is denied. A rating in excess of 10 percent prior to March 24, 2012 and a rating in excess of 40 percent thereafter for residuals of left knee injury is denied. A rating in excess of 10 percent for depressive disorder prior to February 17, 2011 is denied. A rating of 30 percent, but no greater, for depressive disorder is granted effective February 17, 2011, subject to regulations governing the payment of monetary benefits. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs