Citation Nr: 1327769 Decision Date: 08/29/13 Archive Date: 09/05/13 DOCKET NO. 09-03 854 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD), prior to June 27, 2013, and in excess of 50 percent thereafter. 2. Entitlement to a disability rating in excess of 10 percent for post gunshot wound, lower left thigh (Muscle Group [MG] XIII) with two retained pellets and scar. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. Layton, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from December 1950 to December 1953. This case comes before the Board of Veterans' Appeals (Board) on appeal from June 2007 and August 2010 rating decisions of the Montgomery, Alabama Regional Office (RO) of the Department of Veterans Affairs (VA). In a June 2013 decision, the Board dismissed the appeals of entitlement to service connection for sleep apnea, hypertension, sinusitis, peripheral neuropathy, and an eye injury; and remanded the appeals for service connection for a bilateral hearing loss disability and entitlement to an initial disability rating in excess of 30 percent for PTSD to the RO, via the Appeals Management Center (AMC), for additional development. In a July 2013 rating decision, service connection was granted for a bilateral hearing loss disability, thus satisfying that portion of the appeal in full. In June 2013, the Board also discussed the issue of entitlement to an increased rating for post gunshot wound, lower left thigh (Muscle Group [MG] XIII) with two retained pellets and scar. Although the text of the Board's decision explained that the preponderance of the evidence was against the claim, and that it was being denied, the Board notes that the issue was inadvertently left out of the "Order" section of the Board's decision. The Board has considered issuing a Corrective Order on the matter; however, it appears that the AMC treated the issue as remaining on appeal, and that a Supplemental Statement of the Case was issued in July 2013 continuing the previous denial of an increased evaluation for post gunshot wound, lower left thigh (Muscle Group [MG] XIII) with two retained pellets and scar. The Veteran's representative subsequently submitted written argument in support of such claim. Under these circumstances, the Board finds that it would be inappropriate to merely issue a Corrective Order, as the exclusion of such issue from the "Order" section of the June 2013 Board decision clearly led both the AMC and the representative to believe that the appeal remained pending on that issue. Therefore, the Board will proceed with a de novo review of such claim herein below. The Veteran participated in a videoconference hearing before the undersigned in April 2013. A transcript of that proceeding has been associated with the claims file. During the course of the appeal, by rating decision in July 2013, the AMC granted an increased 50 percent rating for PTSD, effective June 27, 2013. However, inasmuch as a higher rating is available for PTSD, and the Veteran is presumed to seek the maximum available benefit for a disability, the claim for a higher rating remains viable on appeal. Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35, 38 (1993). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. For the period prior to June 27, 2013, the Veteran's service-connected PTSD was manifested by symptoms of intrusive thoughts, chronic sleep impairment, and nightmares; the weight of the evidence is against a finding of occupational and social impairment with reduced reliability and productivity during this period. 2. Beginning on June 27, 2013, the Veteran's service-connected PTSD was manifested by symptoms of anxiety, intrusive thoughts, chronic sleep impairment, nightmares, depression, mild impairment of memory; the weight of the evidence is against a finding of occupational and social impairment with deficiencies in most areas during this period. 3. Residuals of a gunshot wound to the left thigh, with injury to MG XIII, have been manifested primarily by pain on movement; and has been productive of no more than moderate muscle disability. CONCLUSIONS OF LAW 1. For the period prior to June 27, 2013, the criteria for an initial evaluation in excess of 30 percent disabling for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.130, Diagnostic Code 9411 (2012). 2. For the period beginning on June 27, 2013, the criteria for an initial evaluation in excess of 50 percent disabling for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.130, Diagnostic Code 9411 (2012). 3. The criteria for an evaluation in excess of 10 percent for residuals of a gunshot wound of the left thigh with injury to MG XIII have not been met. 38 U.S.C.A. §§ 1155; 38 C.F.R. § 4.73, Diagnostic Code 5313 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim, 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 & Supp. 2012); 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 claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 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 Court held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. For initial rating claims or claims for an earlier effective date, where service connection has been granted and the initial rating and effective date have been assigned, the claim of service connection has been more than substantiated, as it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Once a claim for service connection has been substantiated, the filing of a notice of disagreement (NOD) with the rating or the effective date of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. See Dingess v. Nicholson, 19 Vet. App. 473, 490-491; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). In any case, VCAA letters dated in VCAA letters dated in November 2007, June 2009, and March 2010 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was aware that it was ultimately his responsibility to give VA any evidence pertaining to the claim. The letter informed him that additional information or evidence was needed to support his claim, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. Furthermore, this letter described how appropriate disability ratings and effective dates were assigned. The Board also concludes VA's duty to assist has been satisfied. The Veteran's available service treatment records and relevant VA and private medical records are in the file. The majority of the Veteran's service treatment records could not be obtained because of a fire-related incident. Attempts to obtain this information from other sources were unsuccessful. Any further attempts to obtain the Veteran's service treatment records would be futile. The Board finds that all relevant records identified by the Veteran as relating to this claim have been obtained, to the extent possible. The record contains sufficient evidence to make a decision on the claims. VA has fulfilled its duty to assist. 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). In this case, the Veteran was provided VA examinations in March 2009, April 2010, July 2010, October 2012, and June 2013. The examiners considered the Veteran's claims of experiencing psychiatric symptoms, as well as the service treatment records, post-service treatment records, and conducting a psychological examination. 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 an increased disability rating for PTSD. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (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 claim. 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). Rules and Regulations The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). But where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). PTSD The Board notes that the Veteran was granted service connection in a July 2009 rating decision for PTSD and assigned a 30 percent disability rating under Diagnostic Code 9411. During the course of the appeal, an increased disability rating of 50 percent, effective June 27, 2013, was granted. The Veteran is seeking increased ratings. PTSD is to be rated under the general rating formula for mental disorders under 38 C.F.R. § 4.130. The pertinent provisions of 38 C.F.R. § 4.130 concerning the rating of psychiatric disabilities read in pertinent part as the following. A 30 percent rating is warranted when psychiatric disability causes 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, and mild memory loss. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent evaluation requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating may be assigned where there is 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; obsessed rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. Global Assessment of Functioning (GAF) scores are 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); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more 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 co- workers). See 38 C.F.R. § 4.130 (2011) [incorporating by reference the VA's adoption of the DSM-IV for rating purposes]. Gunshot wound residuals The Board notes that the Veteran was granted service connection in a July 2004 rating decision for gunshot wound to the lower left thigh with retained fragment and assigned a 10 percent disability rating under Diagnostic Code 5313. The Board notes that gunshot wounds often result in impairment of muscle, bone, and/or nerve. Through and through wounds and other wounds of the deeper structures almost invariably destroy parts of muscle groups. See 38 C.F.R. § 4.47. Muscle Group (MG) damage is categorized as slight, moderate, moderately severe and/or severe and evaluated accordingly under 38 C.F.R. § 4.56. For rating purposes, the skeletal muscles of the body are divided into 23 muscle groups in 5 anatomical regions: 6 muscle groups for the shoulder girdle and arm (diagnostic codes 5301 through 5306); 3 muscle groups for the forearm and hand (diagnostic codes 5307 through 5309); 3 muscle groups for the foot and leg (diagnostic codes 5310 through 5312); 6 muscle groups for the pelvic girdle and thigh (diagnostic codes 5313 through 5318); and 5 muscle groups for the torso and neck (diagnostic codes 5319 through 5323). 38 C.F.R. § 4.55(b) (2012). The Board notes that the combined evaluation of Muscle Groups acting on a single unankylosed joint must be lower than the evaluation for unfavorable ankylosis of that joint, except in the case of Muscle Groups I and II acting upon the shoulder. 38 C.F.R. § 4.55(d). For compensable Muscle Group injuries which are in the same anatomical region but do not act on the same joint, the evaluation for the most severely injured Muscle Group will be increased by one level and used as the combined evaluation for the affected Muscle Groups. 38 C.F.R. § 4.55(e). For Muscle Group injuries in different anatomical regions which do not act upon ankylosed joints, each Muscle Group injury shall be separately rated and the ratings combined under the provisions of 38 C.F.R. § 4.25 (2012). 38 C.F.R. § 4.55(f). Evaluation of residuals of gunshot wound injuries includes consideration of resulting impairment to the muscles, bones, joints and/or nerves, as well as the deeper structures and residual symptomatic scarring. 38 C.F.R. §§ 4.44, 4.45, 4.47, 4.48, 4.49, 4.50, 4.51, 4.52, 4.53, 4.54 (2012). In considering the residuals of such injuries, it is essential to trace the medical-industrial history of the disabled person from the original injury, considering the nature of the injury and the attendant circumstances, and the requirements for, and the effect of, treatment over past periods, and the course of the recovery to date. 38 C.F.R. § 4.41 (2012). For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c) (2012). The criteria of 38 C.F.R. § 4.56 are guidelines for evaluating muscle injuries from gunshot wounds or other trauma, and the criteria are to be considered with all factors in the individual case. See Robertson v. Brown, 5 Vet. App. 70 (1993), Tropf v. Nicholson, 20 Vet. App. 317 (2006). Under 38 C.F.R. § 4.56, characteristics of a slight disability of affected muscles include a simple wound of muscle without debridement or infection, service department record of superficial wound with brief treatment and return to duty; with healing with good functional results. Objective findings include minimal scar, no evidence of fascial defect, atrophy, or impaired tonus; no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56(d)(2) describes moderate disability of muscles: (i) Type of injury: through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection; (ii) History and complaint: service department record or other evidence of in-service treatment for the wound; record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles; (iii) Objective findings: entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. A moderately severe disability of the muscles anticipates a through-and-through or deep open penetrating wound by a small high velocity missile or a large low-velocity missile, with debridement, prolonged infection, or sloughing of the soft parts, and intermuscular scarring. There should be a history of hospitalization for a prolonged period of treatment of the wound in service. A record of cardinal symptoms, such as loss of power, weakness, lowered threshold of fatigue, fatigue- pain, impairment of coordination and uncertainty of movement, and evidence of unemployability because of inability to keep up work requirements should be considered. Objective findings should include entrance and exit scars indicating a track of a missile through one or more muscle groups. Objective findings should also include indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared to a sound side. Tests of strength and endurance compared with sound side should demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(c) (2012). A severe muscle disability results from a through-and-through or deep-penetrating wound due to high velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, with intermuscular binding and cicatrization and service treatment records or other evidence showing hospitalization for a prolonged period for treatment of the wound. Objective findings may include a ragged, depressed and inherent scars indicating wide damage to muscle groups in missile track, palpation showing loss of deep fascia or muscle substance, or soft flabby muscles in wound area and abnormal swelling and hardening of muscles in contraction. Tests of strength, endurance, or coordinated movements compared with corresponding muscle of the uninjured side indicate severe impairment of function. 38 C.F.R. § 4.56(d) (2012). The evidence in this case indicates that the Veteran's gunshot injury has been evaluated under 38 C.F.R. § 4.73, Diagnostic Codes 5313. The Board notes that in a separate rating decision dated in June 2008, the RO initially denied claims for service connection for left hip and left knee disorders to include as secondary to service-connected gunshot wound of the left thigh. As those issues were not appealed, the Board will focus on the disability rating of the muscle injury. Diagnostic Code 5313 pertains to impairment of Muscle Group (MG) XIII. MG XIII is the posterior thigh muscle group. The functions of this muscle group are extension of the hip, and flexion of the knee, outward and inward rotation of flexed knee, acting with MG XIV, 1, 2 synchronizing simultaneous flexion of hip and knee and extension of hop and knee by belt-over-pulley action at knee joint. The involved muscles include the biceps femoris, the semimembranosus and the semitendinosus. Under Diagnostic Code 5313, a slight injury warrants a noncompensable rating. A moderate injury warrants a 10 percent rating. A moderately severe injury warrants a 30 percent rating. A severe injury warrants a maximum 40 percent rating. 38 C.F.R. § 4.73 (2012). A muscle injury rating will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions. 38 C.F.R. § 4.55(a) (2012). PTSD Analysis A VA treatment record from May 2008 reflects that the Veteran experienced nightmares and flashbacks. The treatment provider noted that the Veteran was not depressed as long as he took medication, although he still had intrusive thoughts and hypervigilance. No suicidal or homicidal ideation was present. His sleeping pattern was interrupted but had improved. The examiner felt that the Veteran's memory was within normal limits for his age. The Veteran displayed an euthymic mood with a blunt affect. Anxiety but no panic attacks were present. Insight and judgment were deemed adequate. A GAF score of 61 was assigned. During a September 2008 follow-up visit, the Veteran said he still had nightmares almost every night. His sleeping pattern had improved, and he reported that he was not as depressed as he had been previously. Intrusive thoughts and hypervigilance were present. No suicidal or homicidal ideation was reported. The examiner observed that the Veteran's affect was reactive and full. His speech was clear, productive, and goal directed. Anxiety but no panic attacks were present. His memory was within normal limits. A GAF score of 60 was assigned. Similar findings were noted in January 2009. On VA compensation and pension examination in March 2009, the examiner noted that the Veteran had a positive relationship with his wife and children. He enjoyed several close friendships. While the Veteran had had several altercations in the past, serious violence during recent years was denied. The examiner noted that the Veteran was clean, neatly groomed, and appropriately dressed. He was cooperative, friendly, relaxed, and had an appropriate affect. He was intact to person, time, and place. The Veteran was unable to spell a word forward and backward or do serial sevens. His thought content was unremarkable but rambling. No delusions or hallucinations were present. No obsessive behavior, panic attacks, homicidal thoughts, or suicidal thoughts were reported. The examiner found that the Veteran's remote memory was normal, although his recent and immediate memory were mildly impaired. The examiner further noted that the Veteran had retired from his prior employment. The examiner found reduced reliability and productivity due to PTSD symptoms, but he opined that PTSD did not result in deficiencies in judgment, thinking, family relations, work, mood, or school. A VA treatment summary from May 2009 reflects that the Veteran experienced anxiety, nightmares, sleep disturbances, and sensitivity to loud noises. The Veteran was attending PTSD therapy sessions and a Basic Anger Management class. On VA compensation and pension examination in April 2010, the Veteran reported that he experienced persistent nightmares and night sweats. He said that he sometimes experienced irritability with his grandchildren. He had retired from his work seven years previously. He said that he slept poorly. The examiner found that the Veteran was friendly, cooperative, and had good eye contact. His affect was appropriate. His mood appeared to be mildly depressed and anxious. His memory for recent and remote events was fair, although the Veteran had difficulty concentrating on serial sevens. Judgment and insight were deemed to be good. A GAF score of 60 was assigned. Treatment records from the Vet Center dated from 2010 through 2013 reflect that the Veteran regularly attended a PTSD group. A June 2012 VA treatment record shows that the Veteran experience flashbacks and nightmares a couple of times a week. The examiner found that the Veteran was calm but tired. His mood was euthymic, and his affect was flat. It was noted that his speech was productive, coherent, and focused on the topic of conversation. He said he only had two friends. He experienced occasional depression but no suicidal or homicidal ideation. A GAF score of 55 was assigned. A VA follow-up record from October 2012 reflects that the Veteran was calm and cordial. The treatment provider indicated that the Veteran's speech was productive, coherent, and clear. The Veteran reported nightmares. He said that he only socialized with his family. No suicidal or homicidal thoughts were present. The Veteran said he was depressed. A GAF score of 55 was assigned. During his April 2013 Board hearing, the Veteran remarked that his PTSD was treated with medication and group therapy. He said that he enjoyed fishing and had a fishing partner. He did not like to be around groups of people. Collectively, the aforementioned medical evidence reflects that prior to June 27, 2013, the Veteran's PTSD disability was manifested predominantly by symptoms no more severe than the following: sleep impairment, nightmares, recurrent thoughts, avoidance, and hyper-startled responses. The March 2009 VA examiner found reduced reliability and productivity due to PTSD symptoms, but he opined that PTSD did not result in deficiencies in judgment, thinking, family relations, work, mood, or school. Although the April 2010 VA examiner wrote that the Veteran's symptoms were moderate in nature, the rest of his report suggests that his PTSD symptoms were characterized by an appropriate affect, fair memory, and good judgment and insight. The Veteran takes Zoloft for his PTSD symptoms, which does provide him with some relief. Overall, the Veteran's symptomatology does not support an evaluation in excess of 30 percent. See 38 C.F.R. § 4.130, Diagnostic Code 9411. At no point prior to June 27, 2013, does the Veteran's overall PTSD symptomatology meet the criteria for a rating in excess of 30 percent. In this regard, the medical evidence does not show the Veteran to have circumstantial, circumlocutory, or stereotyped speech, panic attacks, 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, and impaired abstract thinking, or other symptoms that are characteristic of a 50 percent rating. Rather, the Veteran was cooperative and participated effectively during his examinations, he denied any suicidal or homicidal thoughts, and he has demonstrated that his speech, thought process, though content, judgment and his memory were intact. Although the Veteran has demonstrated mild memory loss, the evidence does not reflect that the memory loss is severe enough to manifest itself in symptoms such as retention of only highly learned material or forgetting to complete tasks. Although the Veteran has reported that he has difficulty in establishing and maintaining relationships, the Veteran has reported that he continues to enjoy fishing with a friend, and he has good family relationships with his wife and children. The Board has considered that on two occasions, June 2012 and October 2012, the Veteran was assigned GAF scores of 55, which ostensibly represent moderate symptoms. However, these GAF scores do not appear to be supported by the other evidence of record. Notably, both the June 2012 and October 2012 treatment records reflect that the Veteran was calm and coherent. Although he was depressed, no suicidal or homicidal ideation was present. In addition, the other GAF scores assigned throughout this period, range from 60 to 61. As described above, a GAF scaled score between 61 and 70 is indicative of some mild symptoms or some difficulty in social, occupational, or school functioning, not severe symptoms which must be shown to warrant the 50 percent disability rating. The evidence of record does not support an evaluation of 50 percent for PTSD disability prior to June 27, 2013. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Turning to the time period from June 27, 2013, on VA compensation and pension examination in June 2013, the examiner noted that the Veteran had a close relationship with his children. The Veteran also would go fishing with another person. The examiner observed that the Veteran had nightmares, feelings of detachment, a restricted affect, difficulty falling asleep, periods of irritability, and difficulty concentrating. Suspiciousness, circumstantial speech, and impaired abstract thinking were noted. The Veteran's immediate memory was within normal limits, but he demonstrated difficulty in delayed recall. No suicidal or homicidal thoughts were present. The examiner opined that the Veteran's PTSD symptoms resulted in occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress or were controlled by medication. A GAF score of 70 was assigned. In June 2013, the Veteran stated that not a day had passed that he did not fear for his life. He felt safe at the Vet Center. He said he had not had a good night of sleep in years. The evidence of record from June 27, 2013, does not support entitlement to a higher 70 or 100 percent disability rating. There is no indication of occupational and social impairment with deficiencies in most areas or total occupational and social impairment, as would be required by either higher rating. There is no evidence of suicidal ideation; obsessed rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships. There is no evidence of gross impairment in thought processes and communication or persistence danger of hurting self or others; nor is there persistent delusions and hallucinations, intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives or own name. Significantly, the only GAF score assigned during this period is 70, which is indicative of mild symptoms. The evidence as shown above does not show the level social and occupational impairment as contemplated by the 70 or 100 percent schedular evaluations. In short, after a review of all the evidence of record, the Board finds that the objective medical findings of record do not demonstrate that Veteran's PTSD disability supports an evaluation in excess of 30 percent prior to June 27, 2013, or in excess of 50 percent thereafter. At no point does the medical evidence show or approximate that his symptomatology warrants an assignment of a higher rating. Accordingly, increased disability ratings or further staged ratings are not warranted. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Gunshot Wound Analysis The only service medical record in the claims file is a December 1953 separation examination which noted a gunshot wound to the left thigh, date not given, with no residual. The report of a May 2004 VA examination did not include a claims file review. However, the veteran related a medical history of having a gunshot wound to the left thigh in 1951 during basic training. He indicated he was hospitalized for close to a month, with reports apparently of having surgery on the left thigh. VA progress note indicate on-going complaints of leg and knee pain. An August 2007 VA progress note indicated muscle strength was within normal limits. During a December 2007 VA examination, the Veteran complained of pain, decreased coordination, fatigability, weakness, and moderate daily flare-ups with walking. The Veteran denied any additional limitation of motion or other functional impairment. The examiner noted that the left thigh muscle, at MG XIII, sustained a semimembranous injury. Muscle strength of MG XIII, MG XIV, and MG XV were normal at 5/5. There was no intermuscle scarring, though there was a scar that is not painful or tender to touch or adherent. There were no separate entry and exit wounds. The examiner noted no residuals of nerve damage, tendon damage, bone damage, muscle herniation, loss of deep fascia or muscle substance, and no joint was limited by muscle disease or injury. The Veteran was not employed, and his status-post gunshot wound, lower left thigh with two retained pellets, prevented chores, shopping, sports, and recreation due to pain in the area with increased activity. In a March 2009 VA mental health examination, the Veteran reported that he was employed by a machine-sales company as a supervisor for 22 years. He was employed by the Montgomery Board of Education as a school bus driver for 17 years. He retired in 2003, because he was eligible by age or duration of work. During a July 2010 VA examination, the Veteran complained of posterior muscle pain as a 7 on the pain scale without warmth, redness, or swelling. He reported a slight itching to the scar. Functionally, he has problems climbing stairs and ladders and problems with extended walking. He denied any other treatment or any other residuals secondary to the gunshot wound. Upon physical examination, the examiner noted a 1cm in length scar that is hyperpigmented. There was no particular tenderness, warmth, redness or swelling. The lower extremities had no evidence of tremor, muscular fasciculation or atrophy. During an October 2012 VA examination, the examiner noted the Veteran had full range of motion of the left knee with no objective evidence of painful motion. The examiner noted that the Veteran had no functional loss and/or functional impairment of the knee and lower leg. Muscle strength testing was normal on knee flexion and extension. The Veteran has a scar related to his thigh injury, but the scar is not painful or unstable, nor is the area of the scar greater than 39 square cm. Based on review of the foregoing, the Board finds that the evidence more closely approximates the criteria for no more than a 10 percent rating for residuals of a gunshot wound to the left thigh for moderate injury to the MG XIII. Though the Veteran's service treatment records are missing, there is no objective indication on the part of the Veteran or any health care provider that his initial injury would be classified as the type contemplated by the criteria for moderately severe or severe disability of the muscle. The Board notes that the Veteran has complained of one or more of the cardinal signs and symptoms of muscle disability-e.g., fatigue-pain. However, there is no evidence of loss of power, weakness, lowered threshold of fatigue, impairment of coordination and uncertainty of movement, or evidence of inability to keep up work requirements, which warrant a finding of a moderately severe muscle disability. The Board finds that moderately severe or severe muscle injury has not been demonstrated. The Veteran's injuries more closely meet the criteria for a slight disability specifically which states that the objective findings of slight disability. 38 C.F.R. § 4.56 (d)(1)(iii). The Board also finds that there is no basis for the assignment of any higher rating based on consideration of any of the factors addressed in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, 8 Vet. App. at 204-7. Competent medical evidence reflects that the currently assigned 10 percent rating properly compensates him for the extent of functional loss resulting from any such symptoms. Though during the VA examination dated in July 2010 the Veteran complained of difficulty with stairs and extended walking, there was no objective evidence of pain and no increased pain on repetitive motion. Furthermore, the October 2012 examiner found no functional loss or functional impairment of the knee and lower leg. Thus, even with consideration of functional loss due to pain and other factors, pursuant to 38 C.F.R. §§ 4.40 and 4.45 and DeLuca v. Brown, 8 Vet. App. 202 (1995), the overall evidence reflects no more than moderate injury of the left thigh. While the Veteran has indicated decreased sensation to the left foot and pain in the left knee, the Board notes that VA examiners have determined neither is a residual of the Veteran's left thigh injury. The July 2010 VA examiner found that his knee pain was not related to his service-connected left thigh injury, and his feet symptoms are related to his nonservice-connected diabetic neuropathy. Here, the objective clinical findings consistently fail to show that his disability meets the criteria for an increased rating, and the Board concludes that those findings outweigh his lay assertions regarding severity. Hence, the criteria for an increased rating under Diagnostic Code 5313 are not met. Other Considerations The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b) (1). The United States Court of Appeals for Veterans Claims has held that the threshold factor for extra-schedular consideration is a finding on part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008). In the case at hand, the record reflects that the manifestations of his service connected PTSD or residuals of a gunshot wound are not in excess of those contemplated by the schedular criteria. In sum, there is no indication that the average industrial impairment from the disability would be in excess of that contemplated by the assigned ratings. Accordingly, the Board has determined that referral of the issue of entitlement to higher ratings for extra-schedular consideration is not in order. Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service- connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. Here, while the record shows that the Veteran retired from his previous employment, he has not argued, and the record does not otherwise reflect, that his PTSD and/or his service-connected gunshot wound residuals render him totally unemployable. Accordingly, the Board concludes that a claim for TDIU has not been raised. ORDER Entitlement to an initial disability rating in excess of 30 percent for PTSD, prior to June 27, 2013, and in excess of 50 percent thereafter, is denied. Entitlement to a disability rating in excess of 10 percent for post gunshot wound, lower left thigh (Muscle Group [MG] XIII) with two retained pellets and scar, is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs