Citation Nr: 1329536 Decision Date: 09/16/13 Archive Date: 09/20/13 DOCKET NO. 11-11 530 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to February 8, 2013. 2. Entitlement to an initial rating in excess of 50 percent for PTSD after February 8, 2013. 3. Entitlement to a rating in excess of 10 percent for degenerative joint disease (DJD) and arthritis of the left knee. 4. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD Laura E. Collins, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1967 to March 1969 and June 1973 to June 1977, including combat service in the Republic of Vietnam and his decorations include the Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) that (1) granted service connection for PTSD and assigned an initial rating of 30 percent effective April 16, 2009, and (2) confirmed and continued a 10 percent evaluation for patellofemoral pain syndrome of the left knee with degenerative joint disease, status post surgery. By way of background, a June 1977 rating action granted service connection for chondromalacia of the left knee, assigning a 10 percent disability evaluation. Within one year of this determination, the Veteran did not express disagreement with this initial disability evaluation, nor was any relevant new and material evidence, medical or lay, physically or constructively received by VA prior to the expiration of the appellate period. See 38 U.S.C.A. § 7105 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.156(b); 20.201 (2013); see also Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2011). As such, the June 1977 rating action became final. In a March 2011 rating decision, the RO assigned a temporary evaluation of 100 percent for PTSD from April 16, 2009 to May 31, 2009, based on a hospitalization, with a 30 percent evaluation effective June 1, 2009. In February 2013, following the receipt of new evidence (the February 2013 VA examination) the RO issued a rating decision increasing the rating of the Veteran's PTSD to 50 percent, effective February 8, 2013. In his substantive appeal, the Veteran checked a box stating that he desired a Board hearing in Washington, D.C. However, he handwrote next to this selection, "Will not attend. But send to Washington, D.C. for another decision." (Emphasis in original.) Reading this in context with the entire document, the Veteran's checkmark and handwritten note were construed as a reiteration of his desire for an appeal, and not as a hearing request. Thus, no hearing was scheduled. The Board concurs with this interpretation and finds that the Veteran did not request a hearing. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. The issue of entitlement to a TDIU was not certified for appeal. However, when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for a TDIU will be considered part of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). As the evidence suggests that the Veteran may be unemployable due to symptoms of his service-connected disabilities, the issue of entitlement to a TDIU has been raised and is within the jurisdiction of the Board. The Board also notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are potentially relevant to the issue on appeal. Thus, any future consideration of this Veteran's case should take into account the existence of this electronic record. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. Since June 1, 2009, the Veteran's PTSD has been manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as chronic sleep impairment, disturbances of mood and motivation, flattened affect, difficulty establishing and maintaining relationships, irritability with outbursts of anger, and nightmares, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas. 2. For the entire appeal period, the preponderance of the evidence shows that the Veteran's DJD and arthritis of the left knee have been manifested by painful motion with flexion limited to no less than 120 degrees and extension limited to 0 degrees, without evidence of ankylosis, recurrent subluxation or instability, dislocated or removed cartilage, impairment of tibia or fibula, or genu recurvatum. CONCLUSIONS OF LAW 1. From June 1, 2009 to February 8, 2013, the criteria for an initial rating of 50 percent for PTSD have been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). 2. Since February 8, 2013, the criteria for an initial rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). 3. The criteria for an evaluation in excess of 10 percent for limitation of flexion of the left knee have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b), 7104 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The notice requirements apply to all five elements of a service connection claim, including Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on the claim for VA benefits. 38 U.S.C.A. § 5103(a) (West 2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. The Veteran's claim for a higher initial rating for PTSD arises from his disagreement with the initial evaluation following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). With respect to the Veteran's claim for a rating in excess of 10 percent for left knee disability, the Board finds that VA has satisfied its duty to notify. Specifically, a May 2009 letter, sent prior to the decision on appeal, provided notice regarding what information and evidence was needed to substantiate his claim for increased rating, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The same letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records, pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records and VA treatment records have been obtained and considered. The Veteran has not identified any additional outstanding records that VA should seek to obtain on his behalf. The Veteran was provided with VA PTSD examinations in June 2009 and February 2013, and with VA knee examinations in May 2009 and February 2013. The Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected disabilities as they included interviews and physical examinations of the Veteran. Three of the examiners also reviewed the claims file. The Veteran has not reported, nor does the record show, that his service- connected PTSD or left knee disabilities have worsened in severity since the most recent examinations in 2013. As such, new examinations are not required. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). The Board finds that all relevant facts have been properly developed, and all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claims, and no further assistance to develop evidence is required. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Higher Rating Claims Disability evaluations are determined by the application of a schedule of ratings that is based on the average impairment of earning capacity. Separate diagnostic codes (DCs) identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is reviewed when making disability evaluations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where the evidence contains factual findings that demonstrate distinct time periods in which the service- connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2009); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit, citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). A. PTSD Service connection is in effect for PTSD, rated 100 percent disabling for a temporary period effective April 16, 2009, 30 percent disabling effective June 1, 2009, and 50 percent disabling effective February 8, 2013. The Veteran contends that throughout the entire appeal period his PTSD symptoms have been more severe than the assigned ratings and that he is entitled to a higher initial rating. The Veteran's PTSD is currently rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, DC 9411 (2013). Ratings are assigned according to the manifestation of particular symptoms. The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When determining the appropriate disability evaluation to assign for psychiatric disabilities, however, the Board's "primary consideration" is the Veteran's symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013.) Under the General Rating Formula for Mental Disorders, 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 and maintaining 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. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). Following a review of the relevant evidence of record, which includes VA treatment records dated since January 2009, the Veteran's lay statements, and VA examination reports dated June 2009 and February 2013, the Board concludes that the Veteran's PTSD warrants an initial rating of 50 percent, but not higher, effective June 1, 2009, immediately following the temporary period of 100 percent disability. As to symptoms indicative of a 50 percent rating, the record shows that the Veteran has had difficulty establishing and maintaining effective relationships throughout the appeal period. He was hospitalized for PTSD symptoms including suicidal and homicidal ideation in April 2009 and May 2009. This episode was triggered by his spouse telling him to move out of the family home, and his homicidal ideation was directed at his spouse. The Veteran has a temporary 100 percent disability evaluation for this period of hospitalization. Following the hospitalization, his VA treatment records show significant improvement and response to regular treatment, and he has consistently denied suicidal or homicidal ideation ever since. In his first post-hospitalization VA mental health treatment record, dated June 1, 2009, he reported that he and his spouse had decided to separate. He had been the primary caregiver for his children and felt a bond with them. At the June 2009 VA examination, he reported conflicts with his spouse. A March 2010 treatment record mentions his spouse filing for divorce. At the February 2013 VA PTSD examination, the examiner noted he was married, but had feelings of detachment or estrangement from others and an inability to establish and maintain effective relationships. An April 2013 VA treatment note states he is living with his spouse. Thus the Board finds that for the entire appeal period, the Veteran has had difficulty establishing and maintaining effective relationships. The record also shows flattened affect, as noted by the 2013 VA PTSD examiner, who found both flattened affect and restricted range of affect. VA treatment records show a stable mood after November 2009, but the 2013 examiner also found markedly diminished interest or participation in significant activities and anxiety, indicating disturbances of motivation and mood. The Veteran does not demonstrate all of the symptoms listed in the criteria for a 50 percent disability rating for PTSD. However, the listed symptoms are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan. The Board finds that the Veteran demonstrated symptoms characteristic of a 50 percent rating (viz. disturbances of mood and motivation, flattened affect, and difficulty establishing and maintaining relationships) that have resulted in moderate social impairment. The Board notes that the evidence of record shows that the Veteran has additional symptomatology that is not enumerated in the rating criteria, including nightmares. The Board finds that the Veteran's disability picture and symptomatology, taken as a whole and in combination with the objective mental status examinations, has most nearly approximated the criteria for a 50 percent rating since June 1, 2009. Conversely, the Board finds that the symptoms do not more nearly approximate a rating in excess of 50 percent under the General Rating Formula as they are not of such a severity or frequency to result in occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. There is no evidence or medical opinion that the Veteran has deficiencies in most areas or is totally occupationally and socially impaired. In this regard, there is no evidence in the record of obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; neglect of personal appearance and hygiene; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; difficulty in adapting to stressful circumstances (including work or a worklike setting); gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. As to suicidal and homicidal ideation, the Veteran only experienced these symptoms in April 2009 when he was hospitalized. He has accordingly been assigned a 100 percent evaluation for that period. He has consistently denied suicidal or homicidal ideation ever since, and has not been found to be in persistent danger of hurting himself or others. At the 2009 VA examination, the Veteran reported some irritability and angry outbursts, sometimes with the urge to destroy something. The 2013 examiner found irritability or outbursts of anger. However, there is no evidence of violence. Thus, while the Veteran struggles with irritability and anger, the Board finds that there is no evidence of impaired impulse control resulting in periods of violence sufficient to warrant a 70 percent evaluation. Nor does the Veteran show an inability to establish and maintain effective relationships. Though the 2013 VA examiner used this language, he also reported that the Veteran is married and lives with his spouse and two children. The Veteran has reported a strong bond with his daughters. While he feels isolated and detached from others, and was separated from his spouse for a portion of the appeal period, it appears that he and his spouse have reconciled. Thus he is not unable to establish or maintain effective relationships, though he does experience difficulty in this area. Finally, neither VA examiner found that the Veteran had deficiencies in most areas, or was totally occupationally and socially impaired. Rather, the 2009 examiner found mild impact on social functioning from his psychiatric symptoms. The 2013 examiner found 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). The Board has also considered the Veteran's Global Assessment of Function (GAF) scores assigned during the course of the appeal. The GAF is a scale indicating the psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness. A GAF score between 31and 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). GAF scores ranging from 41 to 50 reflect 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 51and 60 indicates 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). GAF scores of 61 to 70 are indicative of 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, with some meaningful interpersonal relationships. A GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM- IV); Massey v. Brown, 7 Vet. App. 204, 207 (1994). VA treatment records show a GAF of 50 in January 2009, before his hospitalization, and a GAF of 45 in April 2009, when he was hospitalized. The 2009 and 2013 VA PTSD examiners assigned GAF scores of 65 and 60, respectively. These scores reflect both the serious symptoms of his hospitalization, for which he has a 100 percent temporary disability rating, and the more moderate symptoms from June 2009 to the present. Thus, the Board finds that the Veteran's symptoms and functional impairment fall into the moderate range, rather than serious or major, and are best represented by a 50 percent rating. Likewise, the Veteran's PTSD results in no more than occupational and social impairment with reduced reliability and productivity. In sum, the Board finds that the Veteran is entitled to an initial rating of 50 percent, but no higher, for his PTSD beginning June 1, 2009. The preponderance of the evidence is against the assignment of any higher rating. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Left knee disability Service connection is in effect for chondromalacia of the left knee, more recently diagnosed as DJD and arthritis, rated 10 percent disabling under 38 C.F.R. § 4.71a, DC 5260. The Veteran contends that his disability is more severe than the currently assigned rating and that he is entitled to an increased rating. The regulations at 38 C.F.R. § 4.71a, DC 5003 establish, essentially, three methods of evaluating degenerative arthritis that is established by X-rays: (1) when there is a compensable degree of limitation of motion, (2) when there is a noncompensable degree of limitation of motion, and (3) when there is no limitation of motion. Generally, when documented by X-rays, arthritis is rated on the basis of limitation of motion under the appropriate DC for the joint involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasms, or satisfactory evidence of painful motion. Read together, DC 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, that is established by X-ray, is deemed to be limitation of motion and warrants the minimum compensable rating for the joint, even if there is no actual limitation of motion. Lichtenfels v. Derwinski; 1 Vet. App. 484, 488 (1991). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath, 1 Vet. App. at 592. Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59 relating to painful motion are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Pursuant to DC 5260, under which limitation of leg flexion is evaluated, the following evaluations are assignable: for flexion limited to 45 degrees, 10 percent; for flexion limited to 30 degrees, 20 percent; and for flexion limited to 15 degrees, 30 percent. Pursuant to DC 5261, under which limitation of leg extension is evaluated, the following evaluations are assignable: for extension limited to 10 degrees, 10 percent; for extension limited to 15 degrees, 20 percent; for extension limited to 20 degrees, 30 percent; for extension limited to 30 degrees, 40 percent; for extension limited to 45 degrees, 50 percent. Following a review of the relevant evidence of record, including the Veteran's lay statements, VA treatment records, and VA examination reports, the Board concludes that the Veteran's left knee disability does not warrant a rating in excess of 10 percent for limitation of motion. A review of the evidence shows that, during the course of the appeal, the Veteran's left knee disability has been productive of pain and some functional impairment. The Board reiterates, however, that this manifestation of the Veteran's service-connected left knee disability is evaluated based on limitation of flexion due to pain. The record contains two measurements of the Veteran's left leg flexion during the appeal period. It was limited to 120 degrees at the May 2009 VA examination. On repetition, subjective complaints of increased pain with repetition occurred but the same degree of motion was reached. There were no objective signs of fatigability, lack of endurance, or incoordination. At the February 2013 VA examination, flexion was limited to 130 degrees, with objective evidence of painful motion at 130 degrees. After repetitive testing, flexion was limited to 120 degrees, and the knee had less movement than normal, excess fatigability, and pain on movement. There was no incoordination, weakened movement, swelling, deformity, atrophy, or instability. The record does not contain many VA treatment records addressing the left knee. In March 2011, the DJD was noted and Tylenol was continued, but no referral to orthopedics was needed and no support devices were recommended. In April 2013 he reported walking two miles daily and using a brace. He had minimal crepitus, no edema, and normal gait. In August 2013 he a normal gait without edema. Thus, at most his flexion was limited to 120 degrees by pain during the appeal period. Although that limitation of flexion is not of a level compensable under DC 5260, which requires that flexion be limited to 45 degrees, in light of the Veteran's documented pain and functional impairment, as well as the mandate of 38 C.F.R. § 4.59 and the Court's decision in Lichtenfels, as well as VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998), VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997), and VAOPGCPREC 9-2004, 69 Fed. Reg. 59,990 (2004), the criteria for the Veteran's current 10 percent rating have been shown. In cases where functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria, VA must consider granting a higher rating. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. In this case, the Veteran showed functional limitation on repetitive motion due to pain and fatigue. The 2009 examiner reported no incoordination, weakness, or lack of endurance. The Veteran has made subjective complaints of pain and locking and reported to the 2009 VA examiner that he had daily flare-ups brought on by sudden turning, prolonged standing, and climbing stairs. He reported that he cannot squat or kneel on the left knee and that he has cut down on physical activity due to pain. Because he was retired, it did not affect his employment. The 2013 examiner found additional limitation in ROM of the knee following repetition, but no functional loss or impairment. In 2013 he also reported walking two miles daily. Taking all of the above into consideration, the overall functional impairment due to these factors is subjective and predominantly due to painful motion. As these factors are not contemplated in the relevant rating criteria, it is appropriate for the Board to consider a higher rating. However, because no more than slightly limited knee flexion has been exhibited throughout this appeal, even considering that the Veteran may have subjective functional loss due to pain, the preponderance of the evidence demonstrates that the criteria for a 20 percent rating have not been met. In reaching this latter determination, the Board acknowledges that the Veteran treats his left knee disability with a brace. That said, given the objective findings, there simply is no showing of disabling pain to such an extent as to indicate disability comparable to limitation of motion of the legs to 30 degrees on flexion. The Board finds that the Veteran is not entitled to a rating in excess of 10 percent for limitation of flexion due to pain in the left leg. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Finally, the Board has considered whether it may be appropriate to rate the Veteran's DJD and arthritis of the left knee under other DCs. Diagnostic Codes 5256, 5257, 5258, and 5259 provide ratings for ankylosis, recurrent subluxation or lateral instability, dislocated cartilage, and removed cartilage, respectively. The evidence shows that the Veteran suffers none of these symptoms. Diagnostic Codes 5262 and 5263 provide ratings for impairment of tibia and fibula and genu recurvatum, respectively. The medical evidence shows no such impairment. Therefore, a higher rating is not available under these DCs. The Veteran's left leg extension was normal at 0 degrees at both the May 2009 and February 2013 VA examinations, with no objective evidence of painful motion, including on repetition. Therefore, a higher rating is not available under DC 5261, under which limitation of leg extension is evaluated. C. Other considerations The Board has considered whether staged ratings are appropriate for the Veteran's service-connected disabilities. The 100 percent temporary disability period for PTSD is undisturbed. The Board finds that the Veteran's overall PTSD symptomatology since June 1, 2009 has been stable. Similarly, his left knee symptomatology has been stable throughout the period of the appeal. Therefore, additional staged ratings are not warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the Veteran's disability. His PTSD is characterized by occupational and social impairment with reduced reliability and productivity due to such symptoms as chronic sleep impairment, disturbances of mood and motivation, flattened affect, difficulty establishing and maintaining relationships, and irritability with outbursts of anger. These manifestations are contemplated in the applicable rating criteria. The Board has carefully compared the level of severity and symptomatology of the Veteran's PTSD with the criteria found in the rating schedule. The Board has also considered the symptom of nightmares, which is not found in the rating schedule. As to his left knee, the disability is characterized by flexion limited to no less than 120 degrees, including on repetition and extension limited to 0 degrees, without evidence of ankylosis, recurrent subluxation or lateral instability, dislocated or removed cartilage, impairment of tibia or fibula, or genu recurvatum. These manifestations are contemplated in the applicable rating criteria. Further, the additional functional effect of painful motion is contemplated in his current 10 percent evaluation under DeLuca. In sum, the Board finds that the Veteran has not described other functional effects that are "exceptional" or not otherwise contemplated by the assigned evaluations. Rather, his descriptions of PTSD and left knee symptoms are consistent with the degrees of disability addressed by such evaluations. The rating criteria are therefore adequate to evaluate the Veteran's disabilities and referral for consideration of an extraschedular rating is not warranted. ORDER Effective June 1, 2009, an initial rating of 50 percent is granted for PTSD, subject to the law and regulations governing payment of monetary benefits. Since February 8, 2013, an initial rating in excess of 50 percent is denied. A rating in excess of 10 percent for DJD and arthritis of the left knee is denied. REMAND Service connection is in effect for PTSD (50 percent), coronary artery disease (30 percent), left knee disability (10 percent), and two scars (noncompensable), with a combined disability rating of 70 percent. Therefore, the minimum percentage requirements for a TDIU set forth in 38 C.F.R. § 4.16(a) have been met. The Veteran has filed a claim for TDIU, asserting his service-connected PTSD, left knee disability, and coronary artery disease (CAD) have resulted in an inability to secure or follow a substantially gainful occupation. In an August 2013 rating decision, the RO denied this claim with respect to CAD, but stated that the issue of TDIU with respect to PTSD and left knee disability was inextricably intertwined with the appeal before the Board and thus, the RO was unable to address that issue. The record shows that the Veteran is not working and the evidence suggests that he may be unemployable due to his service-connected PTSD, CAD, and/or left knee disability, to include the combined impact of these conditions. The Board thus finds that a remand is necessary to afford the Veteran a VA examination so as to ascertain whether these service- connected disabilities render him unemployable. Accordingly, the case is REMANDED for the following actions: 1. Send the Veteran and his representative a letter addressing VA's duty to notify as to his TDIU claim. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge of the nature, extent and severity of his service-connected disability and the impact of the conditions on his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 3. Schedule the Veteran for an appropriate VA examination, to be conducted, if possible, by a vocational rehabilitation specialist. The claims file must be made available to and reviewed by the examiner. All appropriate tests and studies should be conducted. Thereafter, the examiner should opine as to whether, without regard to the Veteran's age or the impact of any nonservice-connected disabilities, it is at least as likely as not that his service-connected disabilities (PTSD, CAD, left knee disability, and scars), either alone or in the aggregate, render him unable to secure or follow a substantially gainful occupation. The examiner should take into consideration the Veteran's level of education, special training, and previous work experience. The examiner should describe what type of employment activities would be limited by his service-connected disabilities. A complete rationale for any opinion expressed and conclusion reached should be set forth in a legible report. 4. Then, readjudicate the claim for TDIU. If the claim remains denied, the Veteran and his representative must be furnished a supplemental statement of the case and given an opportunity to submit written or other argument in response before the claims file is returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs