Citation Nr: 1327097 Decision Date: 08/23/13 Archive Date: 08/29/13 DOCKET NO. 09-03 060 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for residuals of heat exposure, to include dizziness and headaches. 2. Entitlement to service connection for a sleep disorder. 3. Entitlement to service connection for bilateral pes planus/flat feet, to include as secondary to service-connected thoracolumbar strain. 4. Entitlement to service connection for alcohol dependence. 5. Entitlement to an increased evaluation for posttraumatic stress disorder (PTSD), evaluated as 30 percent disabling prior to July 9, 2012, and 50 percent disabling thereafter. 6. Entitlement to an initial disability rating in excess of 10 percent for retropatellar pain syndrome (RPPS) of the right knee. 7. Entitlement to an initial disability rating in excess of 10 percent for lateral instability of the right knee. 8. Entitlement to an initial disability rating in excess of 10 percent for lateral instability of the left knee. 9. Entitlement to an effective date earlier than July 26, 2012, for the grant of service connection for lateral instability of the left knee. 10. Entitlement to service connection for a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Veteran represented by: John S. Berry, Attorney ATTORNEY FOR THE BOARD Helena M. Walker, Counsel INTRODUCTION The Veteran served on active duty in the United States Marine Corps from October 2002 to October 2006. This case comes before the Board of Veterans' Appeals (the Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In a June 2008 rating decision, the RO denied service connection for alcohol dependence and continued a 30 percent disability evaluation for PTSD. In March 2009, the RO granted service connection for a right knee disability and assigned a 10 percent disability evaluation, effective January 23, 2009. Then in a July 2009 rating decision, the RO denied service connection for heat exposure with dizziness, heat exposure with headaches, a sleep disorder, and flat feet. The Veteran has perfected appeals of all of these issues. In a March 2011 decision, the Board, in pertinent part, denied the Veteran's claims for increased evaluations for PTSD with depression and right knee disability. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). The Veteran's attorney and the Secretary of Veterans Affairs filed with the Court a Joint Motion for Partial Remand. On October 14, 2011, the Court issued an Order which granted the Joint Motion for Remand and remanded the case to the Board, directing the Board to comply with its directives therein. The Veteran specifically indicated that he did not wish to pursue an appeal as to the rating for his left knee disability. In the March 2011 decision, the Board also remanded the issue of service connection for alcohol dependence, to include as due to PTSD with depression, for further development, which has been completed. The case has been returned to the Board for appellate consideration. In the December 2012 rating decision, a separate disability rating for lateral instability of the left knee was granted. A 10 percent rating was assigned, effective August 3, 2012. The Veteran appealed the rating and effective date assigned for this separate grant of service connection for instability of the left knee. In a December 2012 Supplemental Statement of the Case (SSOC) the Veteran's PTSD rating was increased to 50 percent disabling, effective July 9, 2012 and he was awarded a separate 10 percent rating for lateral instability of the right knee, effective August 3, 2012. Although this was a partial grant of the benefits sought, the Board notes that the Veteran has indicated continued disagreement with the ratings assigned for his PTSD and right knee disabilities and he has not been granted the maximum benefit allowed; thus, the claim is still active. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran's claims were most recently remanded in April 2012 for further development. The case has since been returned to the Board for appellate consideration. In addition to the paper claims files, the Veteran also has an electronic claims file in Virtual VA. The Board has reviewed both the paper and electronic claims files in rendering this decision. As observed in the Board's March 2011 decision, the Veteran's attorney raised the issue of entitlement to an earlier effective date for service connection of PTSD with depression in its April 2009 notice of disagreement to the June 2008 rating decision. This issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is again REFERRED to the AOJ for appropriate action. The issues of entitlement to service connection for residuals of heat exposure, to include dizziness and headaches, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran has a sleep disorder that is separately manifested from his service-connected PTSD and that is etiologically related to a disease, injury, or event in service. 2. The preponderance of the evidence is against a finding that the Veteran has a bilateral flat foot disability that is etiologically related to a disease, injury, or event in service, or related to a service-connected disorder. 3. The Veteran's alcohol dependence is not due to or aggravated by his service-connected PTSD. 4. Throughout the entire appeal period, the Veteran's PTSD has been manifested by symptoms such as anxiety, depression, flashbacks, nightmares, intrusive memories, avoidance, sleep impairment, irritability, anger outbursts, violent acts, hypervigilance, startle response, and obsessive thoughts, all resulting in moderate social and occupational impairment; occupational and social impairment with deficiencies in most areas is not shown 5. Throughout the entire appeal period, the Veteran's right knee disabilities have been manifested by pain, subjective locking, swelling, and giving way, but not by objective evidence of flexion limited to 30 degrees or less; extension limited to 15 degrees or more; recurrent subluxation, or objective evidence of moderate to severe lateral instability; dislocated semilunar cartilage with frequent locking, pain, or effusion into the joint; or impairment of the tibia or fibula. 6. Throughout the entire appeal period, the Veteran's left knee disabilities have been manifested by pain, subjective locking, swelling, and giving way, but not by objective evidence of flexion limited to 30 degrees or less; extension limited to 15 degrees or more; recurrent subluxation, or objective evidence of moderate to severe lateral instability; dislocated semilunar cartilage with frequent locking, pain, or effusion into the joint; or impairment of the tibia or fibula. 7. The Veteran's service-connected PTSD and bilateral knee disabilities have not presented an exceptional or unusual disability picture. 8. Lateral instability of the left knee was first shown during an examination in July 25, 2012. CONCLUSIONS OF LAW 1. A sleep disorder was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. A bilateral flat foot disability was not incurred in or aggravated by service, or proximately due to a service-connected disorder. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 3. Alcohol dependence was not incurred in or aggravated by active service and is not proximately due to service-connected PTSD. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.310 (2012). 4. Prior to July 9, 2012, the criteria for a 50 percent disability rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2012). 5. Beginning July 9, 2012, the criteria for a disability rating greater than 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2012). 6. The criteria for a disability rating greater than 10 percent for RPPS of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5299-5019 (2012). 7. The criteria for a disability rating greater than 10 percent for lateral instability of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (2012). 8. The criteria for a disability rating greater than 10 percent for lateral instability of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5299-5257 (2012). 9. Application of the extraschedular rating provisions is not warranted in this case. 38 C.F.R. § 3.321(b) (2012). 10. An effective date earlier than July 26, 2012, is not warranted for the award of service connection for lateral instability of the left knee. 38 U.S.C.A. §§ 5101, 5110, 7105 (West 2002 & Supp. 2012); 38 C.F.R. § 3.400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (noting that the Board 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 claim. 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) (finding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. VCAA letters dated in May 2008, June 2008, January 2009, and May 2009 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claims. These letters informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. The letters also explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). If any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome in this case by the following: (1) based on the communications sent to the Veteran over the course of this appeal, the Veteran clearly has actual knowledge of the evidence the Veteran is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to the Veteran by VA, it is reasonable to expect that the Veteran understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). In this case, the Veteran has been continuously represented by an experienced attorney and has submitted argument in support of his claims. These arguments have referenced the applicable law and regulations necessary for a grant of an increased rating, as well as argument referencing the evidence in support of his service-connected claims. Thus, the Board finds that the Veteran has actual knowledge as to the information and evidence necessary for him to prevail on his claims and is not prejudiced by a decision in this case. As such, a remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (noting that remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records (STRs) and VA medical records are in the file. The Veteran's attorney argued that evidence contained in his file at the District Court of Lancaster County would be relevant to the claims on appeal. Pursuant to the April 2012 remand directive, the Veteran was provided an August 2012 letter with VA Form 21-4142 attached. The RO requested that the Veteran complete this form that would authorize and provide consent to obtain the relevant records from the District Court of Lancaster County. Neither the Veteran, nor his attorney returned the release form. The Board notes that the RO made attempts to secure these identified records as described by the Veteran's attorney, but absent the required authorization to obtain these records, any further attempts to obtain them would be futile. Additionally, the Veteran has a duty to be cooperative in the development of his claims, and such duty includes signing releases to obtain outstanding records. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Veteran has at no time referenced any other outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4)(i) (2012). With respect to claims for increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO provided the Veteran appropriate VA examinations most recently in July 2012 and August 2012 for his increased rating claims. A Disability Benefits Questionnaire (DBQ) was also completed by a prison physician and he addressed the current severity of the Veteran's bilateral knee disabilities. The VA examination and DBQ reports are thorough and supported by the other treatment evidence of record. The examination reports discussed the clinical findings and the Veteran's reported history as necessary to rate the disabilities under the applicable rating criteria. The examination reports also discussed the impact of the disability on the Veteran's daily living. Based on the examinations, the absence of evidence of worsening symptomatology since the examinations, and the fact there is no rule as to how current an examination must be, the Board concludes the July 2012 and August 2012 examination reports in this case are adequate upon which to base a decision. As to the Veteran's service connection claims, the Veteran was provided a records review examination in July 2012 and August 2012, an in-person VA psychiatric examination in July 2012, and a in-person examination with a prison physician those same months. The examiner considered the Veteran's history and documented complaints, as well as the service treatment records, post-service treatment records. Based on the foregoing, the July 2012 VA examiner (psychologist) concluded that the Veteran's claimed sleep disorder and alcohol dependence was not due to or aggravated by an event, disease, or injury incurred during active service, nor was it caused or aggravated by a service-connected disability. The July 2012 and August 2012 examiners did not show any complaints related to bilateral pes planus or other foot disorder, to include on that was caused or aggravated by his service-connected back disability. Therefore, as the opinions were based on review of the claims file, including the Veteran's statements, and provided an extensive rationale for the opinions provided, the Board concludes that the opinions provided are adequate. As noted in the Board's April 2012 remand, the Veteran is an incarcerated Veteran and he is entitled to the same care and consideration given to fellow Veterans. See Bolton v. Brown, 8 Vet. App. 185, 191 (1995). The Board finds that adequate attempts were made to obtain the requisite opinions/findings with respect to the service connection and increased rating claims on appeal. The RO tailored their assistance to the particular circumstances of the Veteran's confinement by allowing the prison medical professionals to submit DBQs with respect to some of the Veteran's disabilities, additionally, a VA psychiatric examination was performed at the prison in which the Veteran resides. Finally, a records review was performed by a VA physician and opinions were submitted as to the issues on appeal. The Board finds that to the extent possible, the requirements presented in Bolton were met. Given the foregoing, the Board finds the evidence of record to be thorough, complete, and sufficient upon which to base a decision with respect to the Veteran's claim for service connection. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (finding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As such, the Board finds that the medical evidence of record is sufficient to adjudicate the Veteran's claims. Given the July 2012 and August 2012 VA examination and DBQ reports, attempts to retrieve the outstanding District Court records, and the subsequent readjudication of the claim, the Board finds that there has been substantial compliance with its April 2012 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Board acknowledges the June 2013 letter from the Veteran's representative requesting that VA inform him of what issues are on appeal. He also requested that the Board hold the record open for another 90 days. The Board notes that the Veteran's representative is an experienced attorney and has represented many veterans before the Board. SSOCs dated in December 2012 and March 2013 clearly delineate the issues on appeal as noted on the cover page of this decision. Moreover, the attorney has not argued that there is any outstanding evidence that he wishes to submit in support of the Veteran's claims. As such, the Board finds that the Veteran's attorney has had actual notice of the issues on appeal since the December 2012 and March 2013 SSOCs. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Legal Criteria A. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b). A recent decision of the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court), however, clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for disability that is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. In certain circumstances, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, the Board must direct its attention to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a Veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Routen v. Brown, supra. The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (determining that evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). B. Increased Ratings Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 . In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14. The Court has held that a veteran may not be compensated twice for the same symptomatology as "such a result would over compensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Court has acknowledged, however, that when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different Diagnostic Codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (finding that staged ratings are appropriate when the factual findings show distinct period where the service-connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. The Board is required to analyze the credibility and probative value of the evidence, account for any evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Daye v. Nicholson, 20 Vet. App. 512, 516 (2006). It is noted that competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (noting that "although interest may affect the credibility of testimony, it does not affect competency to testify"). In determining whether statements are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). C. Effective Date Initially, the Board notes that while the claim has been styled as a claim for an earlier effective date for the grant of entitlement to service connection for a left knee disability secondary to right knee RPPS, the award of service connection was granted for a separate manifestation of the Veteran's previously service-connected right knee RPPS. Unless specifically provided otherwise in the statute, the effective date of an award based on an original claim shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400. A specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. 38 U.S.C.A. § 5101(a); 38 C.F.R. § 3.151(a). The term "claim" or "application" means a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). Any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA, from a veteran or his representative, may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the veteran, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155 (2012). The applicable statute specifically provides that the effective date of an award of increased compensation shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if an application is received within one year from such date. 38 U.S.C.A. § 5110(b)(2); see also 38 C.F.R. § 3.400(o)(2). However, if the increase became ascertainable more than one year prior to the date of receipt of the claim, then the proper effective date would be the date of the claim. In a case where the increase became ascertainable after the filing of the claim, then the effective date would be the date of increase. See generally, Harper v. Brown, 19 Vet. App. 125 (1997). A specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by VA. See 38 U.S.C.A. § 5101(a); 38 C.F.R. § 3.151. Factual Background and Analysis A. Service Connection Sleep Disorder and Flat Feet The Veteran seeks service connection for a sleep disorder and bilateral pes planus. In his claim, he indicated that he believes he stops breathing in his sleep and he has flat feet caused or aggravated by his service-connected back disability. A review of the Veteran's service treatment records shows that prior to enlistment in August 2001, he was found to have a normal arch in his feet. An August 2005 treatment record indicated that a withdrawal symptom from alcohol included insomnia. On separation physical examination in September 2006, there were no findings of any disability of the feet or any sleep disorder. The Veteran's own report of medical history showed that he denied any foot trouble or frequent trouble sleeping. The Veteran was afforded a general medical examination in February 2007, during which he specifically denied experiencing left or right foot problems. The Veteran did not report any sleeping problems. During his PTSD examination that same month, he endorsed some bad dreams, but no history of any other sleep problems was noted. In a May 2007 VA treatment record, the Veteran specifically denied any history of sleep apnea. During a May 2008 VA examination regarding his PTSD, the Veteran endorsed continued sleep problems, but there was no indication that these were separate manifestations of his PTSD symptoms. A December 2007 treatment record reflected that the Veteran complained of irritability and sleep problems. He recalled being involved in a blast while deployed, and at the time it occurred he was dazed and confused. The VAMC attempted to schedule the Veteran for a TBI examination, but it does not appear that it was ever performed. A review of the Veteran's prison medical records shows that he was offered a sleep study in April 2010, but he refused it. He mainly described his sleep problems in connection with his PTSD symptoms. In July 2012, the Veteran's claims file was presented to a VA examiner to perform a records review and provide opinions related to his service-connected claims. The examiner reviewed the claims file and indicated that there were no complaints of or diagnoses related to a flat foot disability. After service, the Veteran did not seek treatment for complaints of flat feet. The examiner indicated that he could not find any evidence showing foot complaints related to service or his service-connected back. The examiner indicated that it was unknown whether the Veteran service-connected back disability aggravates his claimed bilateral pes planus because an examination was not possible. Again, there was no evidence of a current bilateral foot disability. Regarding the Veteran's claimed sleep disorder, the examiner indicated that the Veteran was ordered to undergo a sleep study while incarcerated. He could not determine whether the study was performed or whether it was performed with use of proper technology. He did not find any documentation of any sleep apnea in the prison records. From a medical point of view, the examiner found that there was no evidence of a specific medical sleep disorder, and indicated that any sleep disorder related to the mental health issues were documented in the mental health examiner's comments. In an August 2012 addendum report, the July 2012 examiner indicated the same findings as in his July 2012 VA examination report. He also indicated that the prison physician did not find that the Veteran had any sleep disorder or flat foot disability. In the August 2012 addendum report, the July 2012 VA examiner (psychologist) indicated that the Veteran has reported difficulty falling and staying asleep. He opined that this was specific to his PTSD diagnosis under Criteria D. As such, the Veteran does not have a separate diagnosis for insomnia or DSM-IV sleep disorder. Upon careful review of the evidence of record, the Board finds that the Veteran does not have a sleep disorder that is separate from his PTSD symptoms, nor does he have a current bilateral flat foot disability. In order to warrant service connection, the threshold requirement is competent medical evidence of the existence of the claimed disability at some point during a veteran's appeal. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (noting that requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim...even though the disability resolves prior to the Secretary's adjudication of the claim"). Absent competent evidence of the existence of a disability, service connection cannot be granted. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). In this case, the most probative opinion of record specifically states that the diagnosis of a sleep disorder, other than symptoms related to PTSD and bilateral pes planus, is not conferred. Therefore, the Board finds that the most persuasive medical evidence of record does not show that the Veteran has a separate sleep disorder or bilateral flat foot disability, and service connection for these claimed disabilities is not warranted. In reaching this decision, the Board has considered the Veteran's assertions that he has a sleep disability, manifested by being unable to breath during his sleep, separate from his PTSD, and current bilateral pes planus that is aggravated by his service-connected low back disability. The Veteran certainly can attest to factual matters of which he has first-hand knowledge, such as difficulty falling and staying asleep and bilateral foot pain, and his assertions in that regard are entitled to some probative weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). In addition, the Board recognizes that lay persons are competent to provide opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Given the Veteran's lack of demonstrated medical expertise and the complexity of diagnosing a sleep disorder such as sleep apnea and bilateral pes planus, however, the Board concludes that in this case his statements regarding any such diagnoses are not competent evidence and, in the case of the sleep disorder, significantly outweighed by the July 2012 VA examiner's conclusions in his August 2012 addendum that the Veteran did not suffer from a separate sleep disorder and his symptoms are a manifestation considered under the criteria for rating PTSD. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). The Board finds that the Veteran's contentions that he has a current bilateral flat foot disability particularly problematic given that his enlistment physical specifically noted a normal arch, and at service separation he explicitly denied a history of associated problems such as foot pain and sleep problems at the time. Additionally, there is no clinical evidence showing treatment for any sleep related problems that are disassociated from his PTSD. Attempts were made to schedule the Veteran for a sleep study in April 2010, and he refused the same. Moreover, the Veteran sought extensive post-service treatment for his musculoskeletal problems and did not report any bilateral foot problems to treating personnel. In light of the foregoing, the Board finds the Veteran's contentions of ongoing bilateral foot and sleep disorder unrelated to PTSD from service not to be credible evidence. See Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has "the authority to discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence."); see also Caluza v. Brown, 7 Vet. App. 498 (1995) (holding that in weighing an applicant's credibility, the Board may consider any evidence of interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, and desire for monetary gain). In summary, there is no evidence of a current chronic sleep disorder other than that which is related to PTSD symptoms, or a bilateral flat foot disability. As discussed above, the Board affords far greater weight to the medical professionals who concluded that the Veteran did not have a sleep problem other than one associated with the criteria for a PTSD diagnosis or a current bilateral flat foot disability than to the incompetent lay representations of the Veteran. In light of the foregoing, the Board finds that the preponderance of the evidence is against the claims, and the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). Alcohol Dependence The Veteran contends that he experiences alcohol dependence secondary to his service-connected PTSD. It is important to note that direct service connection may be granted only when a disability was incurred or aggravated in line of duty, and not the result of the Veteran's own willful misconduct or, for claims filed after October 31, 1990, the result of his or her abuse of alcohol or drugs. 38 C.F.R. § 3.301(a). Additionally, an injury or disease incurred during active military, naval, or air service shall not be deemed to have been incurred in line of duty if such injury or disease was a result of the abuse of alcohol or drugs by the person on whose service benefits are claimed. 38 C.F.R. §§ 3.1(m) & (n), 3.301. The simple drinking of alcoholic beverage is not of itself willful misconduct. If, in the drinking of a beverage to enjoy its intoxicating effects, intoxication results proximately and immediately in disability or death, the disability or death will be considered the result of the person's willful misconduct. 38 C.F.R. § 3.301(c) (2). VA's General Counsel has confirmed that direct service connection for a disability that is a result of a claimant's own abuse of alcohol or drugs is precluded for purposes of all VA benefits for claims filed after October 31, 1990. See VAOPGCPREC 7-99; VAOPGCPREC 2-98. See generally, Allen v. Principi, 237 F.3d 1368, 1377 (Fed. Cir. 2001). Alcohol abuse is the use of alcoholic beverages over time, or such excessive use at any one time, sufficient to cause disability to or death of the user. See 38 C.F.R. § 3.301. Alcohol abuse and drug abuse, unless they are a secondary result of an organic disease or disability, are considered to be willful misconduct. See 38 C.F.R. § 3.301(c)(2), (3). The isolated and infrequent use of alcohol by itself will not be considered willful misconduct. However, the progressive and frequent use of drugs to the point of addiction will be considered willful misconduct. See 38 C.F.R. § 3.301(c)(3). Again, no compensation will be paid if a disability is the result of a veteran's own willful misconduct or abuse of alcohol or drugs. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. A review of the Veteran's service treatment records shows treatment for alcohol abuse disorder and major depressive disorder. Soon after discharge from service, the Veteran began VA treatment for his alcohol abuse disorder. As there is no question that the Veteran has a history of alcohol dependence, the main question before the Board is whether it is secondary to his service-connected PTSD. Again, alcohol abuse, alone, is considered willful misconduct. Thus, service connection on a direct basis is not warranted. The Veteran was afforded a VA examination in May 2008 to determine the etiology of his alcohol abuse disorder. The Veteran was diagnosed as having PTSD, depression, and alcohol dependence, in remission. Following review of the claims file and interview and examination of the Veteran, the examiner opined that the Veteran's alcohol dependence was not caused by his PTSD. He based this opinion on medical literature and his interview of the Veteran. The examiner further opined that the Veteran's alcohol dependence could not be aggravated by his PTSD because he was no longer alcohol dependent. The Board finds that the rationale in this opinion is flawed inasmuch as the Veteran was shown to have alcohol abuse disorder during the timeframe on appeal. As such, the Board assigns this opinion no probative value. In August 2011, the Veteran's claims file was sent to a VA examiner for a records review and opinion as to the etiology of his alcohol abuse. Upon review of the claims file and medical literature, the examiner provided his professional opinion that the Veteran's alcohol dependence was not caused or aggravated by his service-connected PTSD. In reaching this conclusion, the examiner based his opinions on the analysis of the Veteran's unique psychiatric history as well as upon review of relevant treatise evidence showing no causal relationship between PTSD and other mental disorders such as alcohol dependence. As such, the examiner concluded that the Veteran's alcohol dependence was not caused or aggravated by his PTSD. The Veteran was afforded another VA psychiatric examination in July 2012. On the examination report, the examiner again noted that just because two conditions occur simultaneously, does not prove that one causes the other. The examiner diagnosed alcohol dependence, in full, sustained remission. He reviewed the Veteran's psychiatric history and relevant scientific literature on the topic of PTSD and substance abuse, and concluded that the Veteran's PTSD did not cause or aggravate his alcohol dependence. Following careful review of the evidence of record, including the Veteran's lay testimony and arguments, the Board finds that preponderance is against the Veteran's claim of entitlement to service connection for alcohol dependence on a secondary basis. In reaching this determination, the Board notes that no medical professional has linked the Veteran's alcohol dependence to his service-connected PTSD. In that regard, the Board finds that the opinions of the medical professionals above, other than the 2008 VA opinion, are of great probative weight with respect to nexus. These opinions are uniform inasmuch as based upon interview and physical examination of the Veteran, and review of the claims file, the clinicians found that the Veteran's current alcohol dependence was not caused or chronically worsened by his service-connected PTSD. A detailed rationale was provided as was a discussion of pertinent medical literature on the topic. The examiner's and reviewing psychologist's overall conclusions are fully explained and consistent with the evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The Board appreciates the arguments set forth by the Veteran and his representative, including the citation of treatise evidence and internet articles showing a link between PTSD and substance abuse. With regard to the treatise evidence that the Veteran has offered, the Board observes that medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin v. West, 11 Vet. App. 509, 514 (1998); see also 38 C.F.R. § 3.159(a)(1) (noting that competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). Medical evidence that is speculative, general, or inconclusive in nature cannot, however, support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). In this case, the submitted citations to studies and internet printouts related to PTSD and alcohol abuse do not specifically relate to the Veteran's particular case. These submissions do not analyze the relationship between the Veteran's service-connected conditions his alcohol abuse, and they do not consider the relationship between the Veteran's alcohol abuse and conditions for which he was not service-connected. Although some of the treatise evidence is conclusive in nature, it is also generalized in nature; in other words, it considers none of the specific facts in the Veteran's case. As such, the Board places little weight on these submissions. Additionally, as to the Veteran's lay assertions regarding a link between PTSD and substance abuse, the Board notes the Veteran's lack of demonstrated medical expertise and the complexity of addressing such a relationship. Therefore, the Board concludes that in this case his statements regarding any such nexus are significantly outweighed by medical evidence of record. See Jandreau, supra. In sum, the Board finds that the opinions of the VA treating professionals are of significantly greater probative weight than the Veteran's lay assertions and internet printouts showing a link between alcohol dependence and PTSD. In light of the foregoing, the Board finds that the preponderance of the evidence is against the claim, and the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). B. Increased Ratings PTSD The Veteran contends that his PTSD warrants a disability rating in excess of 30 percent prior to July 9, 2012, and in excess of 50 percent thereafter. When evaluating a mental disorder, the rating agency shall consider the frequency, severity and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustments during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on the social and occupational impairment rather than solely on the examiner's assessment of the level of disability at the moment of examination. The rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. PTSD (Diagnostic Code 9411) is rated under the schedule of ratings for mental disorders, 38 C.F.R. § 4.130. In relevant part, the rating criteria are as follows. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted 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; difficulty in establishing effective work and social relationships. A 70 percent rating is warranted for 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 that 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); inability to establish and maintain effective relationships. A 100 percent rating is warranted for 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. In evaluating psychiatric disorders, the VA has adopted and employs the nomenclature in the rating schedule based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). See 38 C.F.R. § 4.130. As such, the diagnosis of a mental disorder should conform to DSM-IV. See 38 C.F.R. § 4.125(a). Diagnoses many times will include an Axis V diagnosis, or a Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). According to the DSM-IV, a GAF score between 41 and 50 is indicative of 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); a GAF score between 51 and 60 is indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers); a GAF between 61 and 70 is indicative of mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships; a GAF between 71 to 80 is indicative that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). By way of background, service connection for PTSD was originally awarded in a March 2007 rating decision. The RO assigned a 30 percent rating, effective October, 29, 2006. The Veteran filed his claim for increase in April 2008. A higher rating was denied in a June 2008 rating decision, and the Veteran appealed this denial. In a December 2012 SSOC, however, the RO awarded a 50 percent rating, effective July 9, 2012. The Veteran continues to appeal the ratings assigned. Following service, the Veteran sought treatment at the VA Medical Center for his psychiatric complaints. He was mainly treated for his alcohol abuse disorder and anger management, but also reported PTSD symptoms. In 2007, the Veteran was terminated from his post-service employment, and it was likely due to his drinking and behaviors. He was again terminated from his employment in 2009 following an outburst in front of his peers. He indicated that it appeared that his peers were afraid of him. Legally, he had multiple DUIs and was currently incarcerated for sexual assault. During the timeframe on appeal, the Veteran's GAF scores ranged from 50 to 55. Following his request for an increased rating, the Veteran was afforded a VA psychiatric examination in May 2008. The Veteran reported current treatment for his PTSD symptoms with fair effectiveness. He endorsed continued depression and that his symptoms "bounce around." He continued to endorse sleep problems and decreased interest and energy. The Veteran indicated that he was able to concentrate effectively and had no weight gain. He did not show any slowing or agitation. The Veteran denied suicidal ideation. The examiner noted that the Veteran no longer experienced alcohol dependence. At the time of the examination, the Veteran was attending school to become a paralegal. He had a good relationship with his family and friends, and lived with his sister. His activities and leisure included golf and caring for his dog. There was no history of suicide attempts or violence/assaultiveness-other than a dismissed domestic assault charge in December 2007. He denied use of drugs or alcohol. Mental status examination revealed that the Veteran was clean, neatly groomed, and appropriately dressed. His speech and psychomotor activity were within normal limits, and his attitude towards the examiner was cooperative, friendly, relaxed, and attentive. His affect was full and appropriate. The Veteran described his mood as being short with people and that he kept to himself. Attention was intact as was orientation. Thought processes and content were unremarkable and without delusions. His judgment was intact and his intelligence was above average. The Veteran endorsed sleep impairment, but denied any hallucinations or inappropriate behavior. The examiner indicated that the Veteran did not have any obsessive/ritualistic behavior, panic attacks, or homicidal or suicidal thoughts. He had good impulse control and maintained a minimal level of personal hygiene. He had no problems performing his activities of daily living. Memory was intact. The Veteran's PTSD symptoms included recurrent and intrusive recollections of the event that includes images, thoughts, perceptions, and recurrent distressing dreams of the event. He experienced intense psychological distress at exposure to internal or external cues that symbolize or resemble and aspect of the traumatic event, and he had physiological reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. The Veteran indicated that he avoided thoughts, feelings, or conversations associated with the trauma, and made an effort to avoid activities, places, or people that aroused recollections of the trauma. He endorsed markedly diminished interest or participation in significant activities and felt detached or estranged from others. He experienced a restricted range of affect. The Veteran further endorsed difficulty falling or staying asleep, and irritability or outbursts of anger, hypervigilance, and exaggerated startle response. He reported that several times per week he had unwanted daytime memories of combat. When it occurred, he isolated himself and it took him 45 to 90 minutes to calm himself down. Three to four times in the previous month he experienced nightmares. These nightmares caused him to be up the rest of the night after they occurred. The examiner indicated that although the Veteran had intense memories, they did not rise to the level of a dissociative episodes. In the past month, he had to consciously suppress his feelings about combat. He did not like to be around crowds and avoided trash along the road that reminded him of IED sites. The Veteran endorsed some mild decrease in his interests and most of the time he felt cut off and distant from people, which the examiner considered to be moderate in nature. The examiner indicated that the Veteran's emotional numbing was of a moderate degree, but he had no sense of a foreshortened future. Additionally, he had difficulty falling asleep and maintaining sleep, which the examiner indicated was a moderate symptom of his PTSD. The examiner indicated that the Veteran had irritability two to three times per month, but he did not get physical. He could be verbally loud. Concentration was difficult at times for the Veteran, but he was able to keep his grades up. He had constant watchfulness, and wanted to know what was going on around him. His startle reaction occurred two to three times weekly and took him some time to calm his nerves. The examiner opined that the Veteran's PTSD symptoms were within the moderate range. At the time of the examination, he was employed by a law firm. The examiner diagnosed the Veteran as having chronic PTSD, depression, not otherwise specified (NOS), and alcohol dependence in remission. The examiner assigned a GAF of 56. The examiner opined that the Veteran's PTSD symptoms had not affected his ability to maintain his employment and his current grades were all As. His social life was constricted and he had been limited in his leisure activities dependent on his distressing symptoms. The examiner opined that the Veteran's PTSD symptoms caused some reduced reliability and productivity. This was evidenced by him skipping class if he had an increase in symptoms, but if he stayed home, he studied during that time. The examiner opined that the Veteran did not have total occupational and social impairment due to his PTSD symptoms. In May 2008, the Veteran's sister submitted a statement describing the Veteran's PTSD symptoms. She indicated that she observed her brother had impaired judgment, forgot to complete tasks, and had disturbed moods and motivation. She indicated that he had difficulty establishing and maintaining effective work and social relationships. She stated that his rage and drinking took over and his behaviors became more out of control. She related the domestic violence incident that involved the Veteran and his girlfriend. She also related that he continued to struggle with anger, sleepless nights, anxiety, and depression, but not to the same degree as before he sought professional help. In a January 2009 VA treatment record, a notation was made that the Veteran was charged with domestic violence and strangulation. The Veteran indicated that he used to undergo treatment for his PTSD, but stopped it. It was at that time that the Veteran wished to be admitted into the VAMC's substance abuse program. In an April 2009 VA treatment record, the Veteran indicated current suicidal ideation. The Veteran continued to get treatment for his PTSD symptoms while in prison. His GAF scores ranged from 45 to 50. He denied any suicidal or homicidal ideations, and the treating professional observed no overt signs of psychotic behavior. The Veteran reported difficulty falling and staying asleep. He endorsed nightmares and flashbacks of dead bodies and had significant anger issues. While incarcerated, he had not had any aggressive/assaultive behaviors despite his history of the same. He continued to have contact with his family, but has decreased interest in activities. He did not experience hallucinations or delusions. He had some anxiety and panic symptoms, and still experienced hypervigilance, detachment, and generally kept to himself. The Veteran's speech, concentration, attention, cognition were normal. He had some obsessional thoughts and obsessive cleaning. The treating professional indicated that although the Veteran has these symptoms, it was not causing any significant functional impairment. Compliant with the April 2012 remand, the Veteran was afforded a VA psychiatric examination in July 2012. The examiner was able to interview the Veteran at the prison in which he was then currently incarcerated. The examiner continued the diagnosis of PTSD with depressive features, and alcohol dependence, in full sustained remission. He also diagnosed the Veteran as having adult anti-social behavior. He assigned the Veteran's GAFs of 50-55 for all three. The examiner indicated that the Veteran's PTSD symptoms were severe in nature, but were separate from the alcohol dependence and adult anti-social behavior diagnoses. The examiner opined that the Veteran's false imprisonment and rape of another were not related to or caused by his service-connected PTSD. Those actions were entirely separate from PTSD symptomatology and were anti-social acts. In other words, the false imprisonment and rape were not results of outbursts and anger that were associated with PTSD. The examiner further indicated that the Veteran's alcohol dependence was in full sustained remission. His history was a pattern of alcohol use that led to serious problems both socially and occupationally-eventually landing him in prison for serious offenses. The examiner opined that the Veteran's problems with judgment and impulse control related to his adult anti-social behavior and not his service-connected PTSD. The examiner did not find that the Veteran had a diagnosis of traumatic brain injury (TBI). The Veteran reported symptoms including anxiety, chronic sleep impairment, difficulty establishing/maintaining effective work and social relationships, impaired impulse control, reexperiencing, avoidance, and increased arousal. Following review of the claims file, and interview and examination of the Veteran, the examiner indicated that the Veteran's mental disorders caused occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, and/or mood. When asked to determine whether it was possible to differentiate a portion of occupational and social impairment for each mental disorder, the examiner indicated that he could. He opined that the Veteran's nonservice-connected adult anti-social behavior caused the occupational and social impairment with deficiencies in most areas and his PTSD only caused occupational and social impairment with reduced reliability and productivity. As the Veteran's alcohol dependence was in full, sustained remission, the examiner assigned a GAF of 80 for that disorder. The examiner opined that although the Veteran's PTSD symptoms had been identified as severe, the severity of the symptoms was not the same as social or occupational functional impairment. The examiner listed the functional impairment from the Veteran's PTSD (as described above), but other symptoms were a result of his adult anti-social behavior that were separate and distinct from PTSD. The examiner indicated that the Veteran's PTSD symptoms would lead to impairment in productivity and reliability, but his impaired impulse control (violence) towards others was related to adult anti-social behavior, unrelated to service. Upon thorough review of the evidence of record, the Board finds that preponderance of the evidence supports a finding that the Veteran has more nearly approximated reduced reliability and productivity required for a 50 percent rating. In other words, the Board finds that the Veteran's PTSD symptoms warrant a 50 percent rating, but no higher, for the entire timeframe on appeal. In this case, the Board has considered the requirement of 38 C.F.R. § 4.3 to resolve any reasonable doubt regarding the level of the Veteran's disability in his favor. The Board concludes, however, that the symptoms and manifestations of his PTSD as shown during the numerous VA examinations and the course of outpatient treatment, as well as based on statements by the Veteran do not demonstrate a degree of disability that warrants assignment of a rating greater than 50 percent at any point during the appeal period. See 38 C.F.R. § 4.7. Furthermore, the symptoms and manifestations shown throughout the Veteran's treatment are generally consistent throughout the pendency of the applicable appellate time period. For this reason, further staged ratings are not applicable. See Fenderson, 12 Vet. App. at 119. Initially, the Board acknowledges the assigned GAF scores during this period range from 45 to 55, which suggests moderate to serious impairment of functioning. That said, an examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned. The percentage rating is to be based on all the evidence that bears on occupational and social impairment. 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (1995); 60 Fed. Reg. 43186 (1995). In this case, the Veteran's manifestations included anxiety, depression, flashbacks, nightmares, intrusive memories, avoidance, sleep impairment, irritability, anger outbursts, violence, some hypervigilance, startle response, panic attacks, lack of motivation, loss of interest, and some obsessive cleaning. However, the Veteran did not exhibit regular suicidal ideation, display obsessional rituals which interfere with routine activities, spatial disorientation, exhibit illogical, obscure, or irrelevant speech, exhibit neglect for personal appearance or hygiene, or near continuous panic attacks. The Board acknowledges that the Veteran's reported signs and symptoms included some panic attacks, occasional suicidal ideation, and depression and that he tends to keep to himself due to his symptoms. The Board notes, however, that the Veteran's symptoms otherwise did not prevent him from functioning independently or, as will be discussed in greater detail below, otherwise result in occupational and social impairment with deficiencies in most areas during the timeframe on appeal. In addition, and as instructed by the October 2011 JMR, the Board has considered the Veteran's history of violence and assaultiveness in relation to his occupational and social impairment due to his PTSD. The Board acknowledges the Veteran's competency to report his symptoms, but concludes that the medical evidence of record during the appellate time period that universally finds the Veteran to experience moderate symptoms related to his PTSD of significantly greater probative value. Additionally, there is evidence showing that the Veteran still has a relationship with his family despite being incarcerated, and has little or no concentration or memory problems. The Board notes that when considering the Veteran's overall level of social and occupational impairment, the medical professionals have a presumed greater level of training and expertise in evaluating the severity of PTSD symptoms. See Sklar v. Brown, 5 Vet. App. 140 (1993). Moreover, even if the Board were to concede that the Veteran's PTSD symptoms are sometimes severely disabling, there is no evidence to indicate that such problems adversely affected his social and occupational functioning to a significant degree as to warrant an evaluation in excess of 50 percent. Additionally, the most recent VA examiner has attributed many of the Veteran's more severe psychiatric symptoms to his nonservice-connected adult anti-social disorder. As noted above, the Board acknowledges that a Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. See Mauerhan, 16 Vet. App. at 442 (holding that without the examples noted in the rating criteria differentiating a 50 percent rating from a 70 percent rating, evaluation of the psychiatric disability for rating purposes would be extremely ambiguous). The Board is to consider all symptoms of a Veteran's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. If the evidence demonstrates that a Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the Diagnostic Code, the appropriate equivalent rating should be assigned. Id. In this case, however, the Board concludes that the Veteran's PTSD symptoms did not cause occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, as contemplated by a 70 percent rating. Nor did the Veteran exhibit total occupational and social impairment as contemplated for a 100 percent rating. With respect to the Veteran's occupational functioning and impairment, the Board observes the Veteran most recently worked as a runner for a law firm and was going to school simultaneously. He was doing well with school and even when his symptoms prevented him from attending school, he used that time to study and prepare for school. It is well-documented that the Veteran is currently incarcerated due to a sexual assault and false imprisonment. This has been attributed by the most recent July 2012 VA examiner to his adult anti-social behavior and completely unrelated to his PTSD. Although the Veteran reported that his psychiatric symptoms caused him to lose his jobs, the record clearly demonstrates that the Veteran lost his employment due to his alcohol abuse and anti-social behavior. Thus, the Veteran's PTSD did not result in marked or substantial occupational impairment during the timeframe on appeal. As such, although the Veteran may have some level of occupational impairment due to his PTSD symptoms, the Board finds that based on the Veteran's work history he did not have deficiencies in work functioning as contemplated for a 70 percent rating or total occupational impairment as contemplated for a 100 percent rating. In this regard, the Board notes that the 50 percent rating assigned is recognition of significant industrial impairment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). As to the Veteran's social functioning and impairment, the Board recognizes that the Veteran has self-limited his social activities due to his psychiatric symptoms. However, his social activities are limited due to his long-term incarceration due to nonservice-related psychiatric problems. Although the Veteran has certainly experienced problems due to his PTSD symptoms, such problems are contemplated in the current 50 percent rating. Moreover, while he may limit his social interaction and has a relatively few number of friends, the record demonstrates that the Veteran did have a girlfriend in the past and his family contacts him in prison. As such, although the Veteran may have significant social impairment due to his PTSD symptoms, the Board finds that based on the lay and medical evidence of record he did not have deficiencies in social functioning as contemplated for a 70 percent rating or total social impairment as contemplated for a 100 percent rating. In summary, during the entire timeframe on appeal, Veteran did not have the degree of deficiencies in social or occupational functioning as contemplated for a 70 percent rating or total social and occupational impairment as contemplated for a 100 percent rating. He certainly did have deficiencies in these areas, but the greater weight of evidence demonstrates that it was to a degree no more than contemplated by the 50 percent rating currently assigned. Furthermore, even resolving any reasonable doubt in the Veteran's favor, the Board finds that he did not meet the requirements for an evaluation greater than the current 50 percent schedular rating. Although the Veteran had some of the criteria for a 70 percent rating, the Board concludes his overall level of disability did not exceed his current 50 percent rating. See Mauerhan, 16 Vet. App. at 442. Some of the GAF scores, in this case, could support a higher rating if taken alone. However, the actual reported symptoms and manifestations repeatedly noted in the record are commensurate with the degree of social and industrial impairment required for the assignment of the current 50 percent disability evaluation. The Veteran's speech has not been illogical, obscure or irrelevant. He has not been in a near-continuous state of panic or disorientation. He has not experienced hallucinations. He has exhibited some concentration and memory problems, but his thought processes and communication have been overall logical and coherent. He has not exhibited inappropriate behavior and his personal hygiene has been appropriate. He has had some social impairment, but he continues to be in contact with his family. Again, in determining that a rating in excess of 50 percent is not warranted, the Board has considered the Veteran's complaints regardless of whether they are listed in the rating criteria, but concludes that the Veteran's level of social and occupational impairment does not warrant a rating in excess of the currently assigned 50 percent rating at any time during the appeal period. In sum, the Board finds reasonable doubt and assigns the Veteran a 50 percent rating for his PTSD for the entire timeframe on appeal. The Board has considered the Veteran's claim and the lay and medical evidence, but concludes the preponderance of the evidence is against granting a rating in excess of 50 percent for PTSD, and thus, the benefit-of-the-doubt rule does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Knees The Veteran seeks ratings in excess of 10 percent each for right knee retropatellar pain syndrome (RPPS) and bursitis, right knee lateral instability, and left knee lateral instability. By way of background, the RO granted service connection for right knee RPPS in a March 2009 rating decision. A 10 percent rating was assigned, effective January 23, 2009. The Veteran appealed the rating assigned, and in a December 2012 SSOC, he was awarded a separate 10 percent rating for lateral instability of the right knee. An effective date of August 3, 2012, was assigned. As noted above, the Veteran did not pursue his increased rating claim for his left knee disability, but in a December 2012 rating decision, service connection was separately awarded for lateral instability of the left knee. A 10 percent rating was assigned, effective August 3, 2012. The Veteran appealed the effective date (see below) and the rating assigned. In a March 2013 rating decision, the effective date was moved to July 26, 2012, for the grant of lateral instability of the bilateral knees. The Veteran's right knee RPPS was originally rated under the criteria for bursitis, which stated that the disability should be rated on the limitation of motion of the affected part. 38 C.F.R. § 4.71a, Diagnostic Code 5019. The Veteran's lateral instability of both knees is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257. Potential rating criteria applicable to knee disabilities are as noted below. Diagnostic Code 5003 provides that degenerative arthritis that is 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. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate Diagnostic Codes, Diagnostic Code 5003 provides a rating of 10 percent 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. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate Diagnostic Codes, the compensable limitation of motion should be rated under the appropriate Diagnostic Codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. The general rating schedules for limitation of motion of the knee are 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5260, a 10 percent disability rating is warranted for flexion limited to 45 degrees. A 20 percent disability rating is assigned for flexion limited to 30 degrees; and a 30 percent disability rating is assigned for flexion limited to 15 degrees. Under Diagnostic Code 5261, a 10 percent disability rating is warranted for extension limited to 10 degrees. A 20 percent disability rating is assigned for extension limited to 15 degrees. A 30 percent disability rating is assigned for extension limited to 20 degrees. A 40 percent disability rating is assigned for extension limited to 30 degrees; and a 50 percent disability rating is assigned for extension limited to 45 degrees. See 38 C.F.R. § 4.71a. In addition, separate ratings may be assigned for compensable limitation of both flexion and extension. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5257 provides for the assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability of a knee; a 20 percent rating when there is moderate recurrent subluxation or lateral instability; and a 30 percent evaluation for severe knee impairment with recurrent subluxation or lateral instability. Id. Subluxation of the patella is "incomplete or partial dislocation of the knee cap." Rykhus v. Brown, 6 Vet. App. 354, 358 (1993) (citing Dorland's Illustrated Medical Dictionary at 1241, 1599 (27th edition 1988)). The Board observes that 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 (2012). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. The Veteran was afforded a VA joints examination in September 2007, during which his left knee was examined. The Veteran reported the onset of his left knee pain as occurring while he was stationed in Fallujah. He described experiencing "excruciating pain" in his left knee and it gave out. At the time of the examination, at least three times he experienced left knee buckling. The Veteran endorsed a "crunching noise" in the left knee as well as anterior knee pain that went into the leg. Pain increased upon ascending and descending stairs. He denied use of assistive devices, constitutional symptoms, arthritis, or incapacitating episodes. He was limited to standing for up to one hour and was able to walk 1/4 of a mile. The joint symptoms in the left knee included giving way, instability, pain, stiffness, and weakness. There was no evidence of deformity, effusion, locking, or episodes of dislocation or subluxation. The Veteran endorsed severe flare-ups in the left knee every two to three weeks that lasted one to two days. Range of motion testing in the left knee revealed normal flexion from 0 to 140 degrees and extension to 0 degrees, both without pain. Valgus and varus testing revealed no motion at 0 or 30 degrees. The examiner opined that there was not additional limitation of motion due to pain, fatigue, lack of endurance, incoordination, or weakness in the left knee joint. The Veteran did not have any meniscal abnormalities; and laxity, Lachman, and McMurray testing were all negative. X-ray of the left knee revealed large medial femoral condyle osteochondral lesion with unstable fragment and tiny popliteal cyst. The resulting diagnosis was osteochondritis dissecans medial condyle of the left knee. The examiner opined that the Veteran's left knee disability had significant effects on his general occupation due to decreased mobility, lack of stamina, and pain. As a result, he was assigned different duties and he had increased absenteeism. His left knee disability caused severe impact on his ability to participate in exercise and sports, moderately impacted chores and recreation, and mildly impacted his ability to shop and travel. Following service until prior to his incarceration, the Veteran sought treatment at the VA Medical Center for his bilateral knee problems. In a January 2008 treatment note, the Veteran's left knee range of motion was from nearly full extension to 110 degrees of flexion. He had recently had his left medial femoral condyle OCD repaired. Following his request for service connection for a right knee disability, the Veteran was afforded a VA joints examination in February 2009. The Veteran described stiffness, pain, popping, grinding, and catching of the medial, posterior, and subpatellar aspect of the right knee. He denied any treatment for this condition. He reported weekly flare-ups lasting from one to two days that were moderate in nature. His right knee flared-up when his left knee flares, when he was exposed to cold weather, or during participation in weight-bearing activities. He denied any surgical intervention or use of assistive devices/braces. The Veteran indicated that he avoided high impact activities to prevent a flare-up. He was able to walk 1/4 of a mile and could tolerate standing for up to one hour. He described his right knee problems as gradually worsening. The Veteran had no history of trauma to the joints or symptoms of arthritis. He had a normal gait and normal weight bearing. Range of motion testing in the right knee revealed flexion from 0 to 130 degrees, with tenderness at 125 degrees, and extension to 0 degrees, with tenderness at 5 degrees. In addressing the DeLuca criteria, the examiner indicated that the Veteran had some increase in pain upon range of motion, but without additional weakness, fatigability, incoordination, or lack of endurance. He found no additional loss of range of motion upon repetitive testing. The examiner indicated that he could not express additional limitation due to repetitive use during a flare-up without resort to speculation. The knee was examined for effusion, swelling, erythema, warmth, crepitus, snapping/popping, grinding, subpatellar tenderness, tenderness to palpation, laxity, and McMurray's testing. All findings were normal except crepitus, snapping/popping, grinding, and tenderness to palpation. X-ray of the right knee was normal. The examiner diagnosed the Veteran as having right knee RPPS and bursitis. This caused decreased mobility, problems with lifting/carrying, and pain. The examiner opined that the Veteran's right knee problems severely impacted participation in sports, moderately impacted recreation and exercise, and mildly impacted chores and traveling. In the October 2011 JMR, the parties agreed that the February VA examination was inadequate inasmuch as the examiner did not indicate why he could not quantify additional limitation of motion in the right knee joint during a flare-up without resort to speculation. A review of the Veteran's prison treatment records show complaints of left knee pain, but he also indicated that he exercised regularly (running). DBQ forms were sent to the Veteran to present to the prison treating professionals to determine the current severity of his bilateral knee disability. The physician diagnosed the Veteran as having osteochondritis dissecans and osteochondromalacia of the bilateral knees. The Veteran described chronic pain, but when it flared-up, his knees got weak and buckled, causing considerably more pain. He indicated that his right knee locked at times, and he experienced bilateral knee swelling during flare-ups. Range of motion testing revealed right knee flexion from 0 to 140 degrees, with painful motion at 70 degrees, and extension to 0 degrees. Left knee flexion was from 0 to 140 degrees, with objective evidence of painful motion at 105 degrees, and extension to 0 degrees. The physician indicated that the Veteran was able to perform repetitive testing with resultant bilateral flexion to 110 degrees and bilateral extension to 0 degrees. Following repetitive testing, the Veteran experienced additional functional loss/impairment in the form of pain and less movement than normal. The examiner noted that the pain began at 80 degrees of flexion in both knees with the maximum flexion of 110 degrees. Strength, anterior instability, and posterior instability were all within normal limits. Medial-lateral stability was decreased to 1+ in both knee joints. The physician found no evidence of recurrent subluxation or dislocation of either knee. Regarding meniscus problems, the Veteran reported a left knee arthroscopy in 2007 with a meniscus repair at that time. The physician indicated that had both a meniscal dislocation and tear in the left knee. He has frequent right knee joint locking, and frequent episodes of joint pain and effusion in both knee joints. The examiner indicated that the Veteran had scars on his left knee, but they were not painful, unstable, or have a total area of more than 39 square cm. Additionally, the physician indicated that the Veteran did not require the use of any assistive devices. There was no x-ray evidence of arthritis or patellar subluxation in the bilateral knees. X-ray of the left knee showed findings consistent with osteochondritis dissecans involving the medial femoral condyle. The physician indicated that the Veteran could not tolerate long periods of standing, and although he could sit for long periods of time, he was unable to perform more strenuous activities involved with certain jobs. A review of the record also showed that the Veteran continued to receive treatment at the prison for his knee complaints. These records, however, did not show any additional range of motion testing or other findings pertinent to the rating criteria as outlined above. Upon careful review of the evidence of record, the Board finds that the Veteran is not entitled to a rating in excess of 10 percent each under Diagnostic Code 5257 for lateral instability of the right and left knees, and he is not entitled to a rating in excess of 10 percent for RPPS of the right knee. In other words, the objective evidence of record does not support a higher rating of the Veteran's right knee disabilities or left knee disability. In this regard, the Board notes that VA must consider all the evidence of record to determine when an ascertainable increase occurred in the rated disability. See Hazan v. Gober, 10 Vet. App. 511 (1997); see also Swanson v. West, 12 Vet. App. 442 (1999). As noted above, the Veteran has objective evidence of mild, lateral instability of the left and right knees and painful motion in the right knee. Although the Veteran claims that he is entitled to higher ratings due to the subjective complaints of chronic right knee pain, as discussed above, the evidence of record reflects painful motion (at its worst) beginning at 70 degrees of flexion (with pain) without loss of extension. As the evidence does not show limitation of flexion to 30 degrees or less, a 20 percent rating is not applicable under Diagnostic Code 5260. 38 C.F.R. § 4.71, Plate II. Similarly, as the record does not show extension limited to 10 degrees or greater, a separate compensable evaluation based on limitation of extension under Diagnostic Code 5261 is not warranted. The Board has also considered the Veteran's subjective complaints of weakness, swelling, locking, and giving way, and the Board recognizes that he is competent to describe his symptoms. Such symptoms are fully contemplated in the current 10 percent rating under Diagnostic Code 5257. As to an increased rating, the Board finds the results of physical examination by multiple competent health care specialists showing no evidence of significant instability to be more persuasive. In that regard, the Board notes that records and examinations during the timeframe on appeal did show some mild instability and this was the basis for the Veteran's 10 percent rating assigned in each knee. That said, during the applicable appellate time period the VA examiners found evidence of mild right and left knee laxity or instability. Moreover, the evidence of record shows that the Veteran is a regular runner while serving his sentence in prison, and although he expresses complaints of left knee pain, there is no evidence that these disabilities have prevented his running routine. Based on the Veteran's reports of weakness, swelling, locking, and giving way and the consistent medical findings of mild laxity without objective evidence of subluxation, the Board concludes that the Veteran's right and left knee disabilities are not manifested by moderate or severe instability or subluxation, such as to warrant a higher rating under Diagnostic Code 5257. In addition, no higher or alternative rating under a different Diagnostic Code can be applied. The Board notes that there are other Diagnostic Codes relating to knee disorders, such as Diagnostic Code 5256 (ankylosis of the knee), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (removal of semilunar cartilage, symptomatic), Diagnostic code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (for genu recurvatum). The Veteran's right and left knee disabilities are not manifested by nonunion or malunion of the tibia and fibula, or genu recurvatum. Ankylosis is "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). The Veteran is able to move his right and left knees, albeit with some limitation of motion, so it is clearly not ankylosed. There are no reports or evidence of dislocated or removed semilunar cartilage. As such, he cannot receive a higher rating under Diagnostic Code 5258 or 5259 for either knee. The Board notes that the Veteran's functional loss was considered, as the medical evidence shows that the Veteran has consistently complained of pain in the bilateral knees. 38 C.F.R. §§ 4.40, 4.45. However, the limitation of motion documented in the medical records as resulting from pain is already contemplated in the disability ratings currently assigned. In fact, the prison physician indicated that following repetitive motion, the Veteran's range of motion in both knees was reduced to 80 degrees. Moreover, although the Veteran had pain on repetitive motion that pain did not result in limitation of flexion or extension to the level that a separate or higher rating would be warranted. Nor is there objective evidence of calculable decreased motion on repetition due to fatigue, weakness, incoordination, or lack of endurance. Although the Veteran has reported weakness and decreased endurance, objective medical evaluation has found no evidence of such. Indeed, the Board finds it extremely significant that multiple examination and treatment records have noted normal lower extremity strength, as well as normal stance and gait. Thus, despite the Veteran's reported problems associated with his bilateral knees, he clearly is able to use the knee in close to a normal manner, to include duration of use, and, in fact, does so. There is otherwise no evidence of significant impairment of motor skills, muscle function, or strength attributable to the Veteran's bilateral knee disabilities. Consequently, the Board finds that a higher disability rating based on functional loss is not warranted. The Board is aware that VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). Accordingly, in arriving at the determinations above the Board has considered not only the medical evidence but also the competent lay evidence presented by the Veteran in the form of his correspondence to VA, arguments provided by the Veteran's representative, and the statements provided to medical professionals and VA examiners. As shown above, and as required by Schafrath, 1 Vet. App. at 594, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, regardless of whether they have been raised by the Veteran. In this case, the Board finds no provision upon which to assign a rating greater than 10 percent for limitation of flexion in the right knee or greater than 10 percent for instability of either knee. Furthermore, the Board concludes that based on the foregoing evidence assignment of further staged ratings is not for application. Hart, 21 Vet. App. at 505. C. Extraschedular Considerations The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected PTSD and bilateral knee disabilities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's bilateral knee disabilities and PTSD with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, the Veteran primarily reports painful motion, locking, and instability in his knees and psychiatric symptoms including anxiety, depression, flashbacks/nightmares, and anger outbursts. As discussed above, the current 10 percent ratings for lateral instability of each knee and RPPS of the right knee, and the current 50 percent rating for PTSD are adequate to fully compensate the Veteran for his symptoms. In short, the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. D. Effective Date The Veteran contends that his separately awarded lateral instability of the left knee should have an effective date prior to July 26, 2012. Again, a separate rating for lateral instability of the left knee was awarded in a December 2012 rating decision and a 10 percent rating was assigned, effective August 3, 2012. The Veteran appealed the rating assigned (discussed above) and the effective date. As noted above, in a March 2013 rating decision the effective date for the grant of lateral instability was changed to July 26, 2012. As shown in the increased rating section above, the Veteran has sought treatment for his left knee disability and has undergone multiple VA examinations to determine the current severity of his left knee disability. It is undisputed that the RO performed a special review of the Veteran's claim in December 2012 and granted a separate rating for lateral instability of the left knee, effective August 3, 2012. The effective date was later changed to July 26, 2012. A review of the claims files shows that there is no communication, formal or informal, that could be interpreted as a claim for service connection for lateral instability of the left knee prior to that date. Moreover, the record is uncontroverted as to the fact that objective evidence of left knee medial-lateral instability was not present prior to July 26, 2012, when it was made in conjunction with an examination by a prison physician. This is the date entitlement arose. Given the foregoing, there is no basis for the assignment of an effective date for the grant of service connection prior to July 26, 2012. See 38 C.F.R. § 3.400. Again, under applicable law and regulation, the effective date of an award based on an original claim for compensation benefits received more than one year after the claimant's discharge from service shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400. The Board therefore finds that the preponderance of the evidence is against the claim for an effective date prior to July 26, 2012, for service connection for lateral instability of the left knee. ORDER Entitlement to service connection for a sleep disorder is denied. Entitlement to service connection for bilateral pes planus is denied. Entitlement to service connection for alcohol dependence is denied. For the entire timeframe on appeal, a 50 percent rating, but no higher, for PTSD is granted. Entitlement to a disability rating in excess of 10 percent for RPPS of the right knee is denied. Entitlement to a disability rating in excess of 10 percent for lateral instability of the right knee is denied. Entitlement to a disability rating in excess of 10 percent for lateral instability of the left knee is denied. An effective date prior to July 26, 2012, for the award of service connection for lateral instability of the left knee, is denied. REMAND Upon preliminary review of the evidence of record, the Board finds that further evidentiary development is necessary regarding the Veteran's claim of entitlement to service connection for residuals of heat exposure, including headaches and dizziness, and entitlement to a TDIU. Heat Exposure The Veteran contends that while exposed to heat during deployment he began to experience dizziness and headaches. He reports that he currently has headaches and dizziness when the weather is hot. The Veteran complained of headaches during deployment that ended in 2005. He denied dizziness. In his separation physical examination in 2006, he denied any heat exposure residuals such as headaches or dizziness. In his own report of medical history, he specifically denied frequent dizziness or fainting spells, or frequent or severe headaches. Following service in December 2007, the Veteran reported headaches and dizziness. He recalled being involved in a blast that caused him to be dazed and confused. A TBI examination was scheduled, but there is no indication that it was performed. In July 2012, the Veteran's claims file was presented to a VA examiner to perform a records review and provide opinions related to his service-connected claims. The examiner indicated that the Veteran had never been diagnosed as having a chronic headache disorder. He indicated that he could not find any reports of headaches/dizziness other than one vague report in February 2007. The examiner further noted that he could not find any evidence that heat exposure could be manifested in dizziness or headaches. He stated that the Veteran's post-deployment questionnaires do not include any complaints of headaches or dizziness. The examiner then provided a negative opinion based upon no post-service complaints of residuals of heat exposure. The Board finds that the July 2012 opinion is inadequate inasmuch as it is based upon an inaccurate factual basis. There is evidence that the Veteran reported headaches during service, and he has clearly indicated post-service headaches and dizziness. A DBQ form was given to the medical professional at the prison in which the Veteran is incarcerated. In an August 2012 response, the examiner indicated that the Veteran did not have a history of headaches, and the Veteran denied any current headache complaints. He did not, however, address heat exposure residuals or dizziness as requested in the April 2012 remand. The Board notes that once VA undertakes the effort to provide an examination when developing a service connection claim, the examination must be an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As the July 2012 and August 2012 opinions are inadequate, the Board finds that another examination, if feasible, should be performed to determine the etiology of any heat exposure residuals. TDIU The Board notes that a claim for a total disability rating based on unemployability (TDIU) may be presented informally or may be raised by the facts. "Once a veteran submits evidence of a medical disability and makes a claim for the highest rating possible, and additionally submits evidence of unemployability, the 'identify the benefit sought' requirement of 38 C.F.R. § 3.155(a) is met and the VA must consider TDIU." Roberson v. Principi, 251 F. 3d 1378, 1384 (Fed. Cir. 2001). The evidence of record shows the Veteran's contentions that he believes he is unemployable due to his PTSD, and there are notations in his treatment records that his PTSD symptoms impact his employability. The Board finds that a claim for a TDIU has been raised by this case. The Board notes that according to the VA General Counsel, the question of TDIU entitlement may be considered as a component of an appealed increased rating claim if the TDIU claim is based solely upon the disability or disabilities which are the subject(s) of the increased rating claim(s). See VAOGCPREC 6-96. VA General Counsel opinions are binding on the Board. See 38 U.S.C.A. § 7104 (c) (West 2002); 38 C.F.R. § 14.507 (2012). Here, the Veteran has essentially claimed that the disability on appeal is the cause of his unemployability. Therefore, the Board finds that further action is required of the originating agency before the Board decides the TDIU issue. Accordingly, the case is REMANDED for the following actions: 1. The RO should provide all required notice in response to the Veteran's claim of entitlement to a TDIU. 2. The RO should undertake appropriate development to obtain a copy of any outstanding records pertinent to the Veteran's claims. 3. Schedule the Veteran for a VA examination for the purpose of ascertaining the etiology of any disability due to heat exposure manifested by dizziness and/or headaches. If that is not possible, coordinate efforts with the correctional facility to accommodate the Veteran by arranging for an examination to be conducted at the correctional facility at which he is incarcerated to determine whether it is at least as likely as not that any current disability due to heat exposure manifested by dizziness and/or headaches is related to service. If it is not possible to have him examined at the prison facility, forward the Veteran's claims file for review by a VA examiner for the purpose of rendering an opinion as to whether the Veteran's claimed disabilities are related to service. The examiner must elicit from the Veteran the history of his disabilities and consider them in rendering the following inquires. See Dalton v. Nicholson, 21 Vet. App. 23 (finding that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury and relied on the lack of evidence in the service medical records to provide a negative opinion). The examiner should determine whether the Veteran currently has a disability due to heat exposure manifested by dizziness and/or headaches, or has had any heat exposure residuals during the appeal period. If either disability is found, the examiner should provide an opinion as to whether there is a 50 percent or better probability that it is related to the Veteran's military service. The examiner is asked to address both headaches and dizziness in his or her opinion. In addition, the examiner must comment on the approximate date of onset and etiology of the disabilities shown by the evidence of record. If the complaints are attributable to factors unrelated to his military service or service-connected disabilities, the examiner should specifically so state. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). The claims file must be reviewed by the examiner and the examination report should note that review. The examiner should provide the rationale for all opinions provided, with citation to relevant medical findings. 4. The RO should also undertake any other development it determines to be warranted. 5. Then, the RO should readjudicate the Veteran's claims-including his claim for a TDIU due to PTSD. If the benefits sought on appeal are not granted to the Veteran's satisfaction, a Supplemental Statement of the Case should be issued to the Veteran and his representative and they should be afforded the requisite opportunity to respond before the case is returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the Veteran until he is otherwise notified but he has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case 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). ______________________________________________ LANA K. JENG Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs