Citation Nr: 1331201 Decision Date: 09/27/13 Archive Date: 10/01/13 DOCKET NO. 10-40 893 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for left wrist ankylosis with ulnar neuropathy, to include as secondary to the service-connected left wrist disability. 2. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 3. Entitlement to an initial compensable rating for left wrist, non-displaced fracture. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD T. Adams, Counsel INTRODUCTION The Veteran had active military service from January 1966 to December 1968, and from March 1969 to June 1974. This matter comes before the Board of Veterans' Appeals (Board) from January 2010 and February 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The January 2010 rating decision granted service connection for PTSD, and assigned an initial 30 percent disability rating, effective June 4, 2009. The February 2010 rating decision granted service connection for a non-displaced fracture of the left wrist (claimed as a left wrist condition), assigning an initial 0 percent (non-compensable) disability rating, effective from June 4, 2009; and denied service connection for left wrist ankylosis with ulnar neuropathy (also claimed as a left wrist condition). In Rice v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that a TDIU rating claim is part of an increased rating claim when such claim is raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). In this case, however, the record does not appear to raise a claim that the Veteran is no longer able to work due to his service-connected disabilities. Thus, the issue of entitlement to a TDIU rating is not properly before the Board. Id. The Board notes that the Veteran submitted multiple treatment records from his private psychologist, and that the bulk of these records were submitted subsequent to the September 2010 statement of the case (SOC), and were not encompassed in any subsequent supplemental statement of the case (SSOC). The Veteran submitted a waiver for several of these treatment records, but not for all of them. Normally, any pertinent evidence must be referred to the agency of original jurisdiction (AOJ) for initial review unless this procedural right is waived by the appellant. See 38 C.F.R. § 20.1304(c) (2013). In this case, however, in light of the favorable decision regarding the claim for a higher rating for PTSD, as well as the fact that these records tend to be duplicative of prior treatment records, the Board finds no prejudice to the Veteran in considering such records herein. In May 2013, the Board requested an expert medical opinion from an orthopedic surgeon at the Veterans Health Administration (VHA) which was received by the Board in May 2013 pursuant to 38 C.F.R. § 20.901(d) (2013). The Board issued a copy of the VHA opinion to the Veteran in May 2013, and informed him that he had 60 days from the date of the notice letter in which to review the medical opinion and submit additional evidence or argument. See 38 C.F.R. § 20.903 (2013). In June 2013, the Veteran's representative stated that he had no additional evidence to submit and waived the 60-day waiting period. The Board has reviewed the Veteran's physical claims file, and his electronic file through the "Virtual VA" system, to ensure a complete review of the evidence in this case. FINDINGS OF FACT 1. The competent and probative medical evidence of record preponderates against a finding that the Veteran's left wrist ankylosis with ulnar neuropathy are related to his active military service or to the service-connected left wrist disability. 2. The preponderance of the evidence indicates that the Veteran's left wrist, non-displaced fracture, is manifested by subjective complaints of pain on use; there is no limitation of motion, loss of strength or other evidence of impairment of function. 3. The preponderance of the evidence indicates that the Veteran's PTSD is productive no more than occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood, due to such symptoms as: depression, nightmares, intrusive thoughts, irritability, sleep difficulties, social isolation and avoidance behaviors, problems with memory, attention, and concentration, suicidal ideation, difficulty in adapting to stressful circumstances, and difficulty with establishing and maintaining effective relationships. CONCLUSIONS OF LAW 1. The Veteran's left wrist ankylosis with ulnar neuropathy was not incurred in or aggravated by active service, or otherwise related to the Veteran's service-connected left wrist disability. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2013). See Allen v. Brown, 7 Vet. App. 439 (1995). 2. The criteria for a compensable rating for left wrist, non-displaced fracture, have not been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.31, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5215 (2013). 3. The criteria for an initial rating in excess of 70 percent for PTSD, but no higher, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.10, 4.14, 4.126, 4.130, DC 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the holding in Dingess v. Nicholson, 19 Vet. App. 473 (2006) requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date. With regard to the Veteran's increased rating claims, the appeal arises from disagreement with the initial ratings following the grant of service connection for PTSD and a left wrist disability. Courts have held that 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). Regardless, the RO provided notice as to how VA assigns disability ratings in a letter sent to the Veteran in June 2009. With regard to the Veteran's service connection claim, the RO advised the Veteran of what the evidence must show to establish entitlement to service-connected compensation benefits in a notice letter sent in June 2009. The RO also explained what evidence VA would obtain and make reasonable efforts to obtain on the Veteran's behalf in support of his claim. The RO further described what evidence that the Veteran should provide in support of his claim. Moreover, the RO explained how VA determines the disability rating and effective date of a disability once service connection has been established, which satisfied Dingess notice requirements. Because the Veteran was provided with proper notice with respect to his service connection claim by way of the June 2009 pre-adjudication notice letter, the Board concludes that VA's duty to notify has been met, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. Moreover, the Veteran and his representative were provided with copies of the above rating decision and the SOC, which include discussion of the facts of the claim, pertinent laws and regulations, notification of the bases for the decision, and a summary of the evidence considered to reach the decision. Regarding VA's statutory duty to assist in claims development, the record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the claim. Pertinent medical evidence associated with the claims files consists of service and VA treatment records. The Board notes that it does not appear that an attempt was made to obtain the treatment records related to the Veteran's left wrist injury and surgery in 1992, apparently at Wake Hospital. However, the Board finds that the Veteran himself has reported he injured his wrist after a fall from three stories and required surgical fixation, and there is no indication from the Veteran that his wrist fracture in service caused this accident in 1992, nor is there any indication that such records would provide pertinent information regarding the service-connected non-displaced left wrist fracture. In any case, in view of the face that over 20 years have passed since the 1992 post-service left wrist injury, any attempt to secure such records would be futile. In all likelihood, such records have long since been disposed of. With regard to the Veteran's increased rating claims, the Veteran was afforded VA examinations in December 2009. The Board acknowledges that the Veteran has complained that the 2009 VA examinations lasted only 20 minutes. Nevertheless, the length of time afforded to an examination does not necessarily determine the quality of the examination. Moreover, a review of those reports reveals that all subjective and objective findings necessary for evaluation of the Veteran's PTSD and left wrist, non-displaced fracture claims were observed and recorded. Both examination reports were quite comprehensive and adequately addressed the Veteran's orthopedic and psychiatric symptomatology. In addition, the findings made in the December 2009 VA PTSD examination support the grant of an initial 70 percent increased rating. Accordingly, the examinations appear complete and adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). With regard to the Veteran's service connection claim, on VA joints examination in December 2009 the VA examiner addressed whether the Veteran's left wrist ankylosis and ulnar neuropathy was related to or caused by service (and the service-connected left wrist, non-displaced fracture), but did not specifically address whether the Veteran's left wrist ankylosis and ulnar neuropathy was aggravated or worsened by his service-connected left wrist, non-displaced fracture. Accordingly, as noted in the Introduction above, a specific outside medical opinion (OMO) was obtained in May 2013 to determine the etiology of the Veteran's left wrist ankylosis and ulnar neuropathy. This opinion was provided by an orthopedic surgeon and is adequate for decision-making purposes, as it included a full review of the Veteran's claims file, including the service treatment records and extensive post-service treatment records, is supported by sufficient detail, refers to specific documents and medical history, and is supported by sufficient rationale. See Barr, supra. Indeed, the medical evidence has been thoroughly developed in this case. As explained below, the competent and credible evidence fails to support a finding that any currently diagnosed left wrist ankylosis and ulnar neuropathy are etiologically related to his period of active military service or to his service-connected left wrist, non-displaced fracture. Thus, no additional medical examination or opinion is necessary under the circumstances of this case. Also of record and considered in connection with the appeal are various statements submitted by the Veteran and his attorney, on his behalf. The Board recognizes that the last orthopedic and psychiatric examinations are now over three (3) years old. The mere passage of time since that examination is not reason enough, alone, to require reexamination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). Here, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's left wrist disability since the December 2009 VA examination. The Veteran has contended and the record reflects that his PTSD has worsened since the December 2009 VA examination which are the bases for the assignment of an increased initial rating of 70 percent as will be discussed in more detail below. Neither the Veteran nor his representative throughout the course of this appeal has made the RO or the Board aware of any other evidence relevant to his appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims adjudicated herein. Therefore, in view of the foregoing, the Board will proceed with appellate review. II. Service Connection for Left Wrist Ankylosis with Ulnar Neuropathy The Veteran essentially contends that he his left wrist ankylosis with ulnar neuropathy is merely part of his already service-connected left wrist disability of non-displaced fracture. Specifically, the Veteran asserts that the in-service left wrist injury weakened the joint and as result, predisposed him to having the more significant wrist injury he sustained in 1992. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. In order to prevail on the issue of service connection, there must be medical evidence of a (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (2006 & 2013). The secondary condition shall be considered a part of the original condition. Id. The phrase "due to or the result of" encompasses disability caused or aggravated by the service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439 (1995). Medical evidence is generally required to establish a medical diagnosis or to address questions of medical causation and etiology; however, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a) ; 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Service treatment records (STRs) show that in April 1970, the Veteran was seen in the emergency room complaining of left wrist pain after falling while playing basketball and landing on his outstretched left hand. The assessment was compression fracture of the distal aspect of the left wrist, not displaced, no ankylosis. A short arm cast was placed and he was to be put on a profile for eight weeks. Although the handwritten treatment note is hard to decipher, it appears that in October 1973 he was seen for complaints of numbness in the left arm for the past two weeks. He reported he fell and hurt his left elbow two weeks prior. The impressions include ulnar injury. On his hardship discharge examination in June 1974, the Veteran's clinical evaluation was essentially normal. On a VA examination in December 2009, it was noted that in 1992 the Veteran was in the construction business and fell down from a three-story building and broke his wrist, which was dislocated and required surgery. He reported having problems with the left hand, including worsening pain up to the elbow, a loss of feeling in his 4th and 5th fingers, and a weak grip. It was noted that he was treated at Wake Hospital in 1992 for fixation of the left injured wrist. An X-ray report of the left wrist showed probable old comminuted fractures of the radius and ulna, a distal ulnar head fused to the radius traversed by a lag screw, and a resected distal ulnar head. The diagnoses included left wrist ankylosis, with healed old comminuted radial fracture, and ulnar neuropathy. The examiner opined that the Veteran's left wrist ankylosis and ulnar neuropathy were most likely caused by or a result of the 1992 construction accident based on the rationale that the Veteran stated his problems started in 1992 after the construction accident with no evidence of a left wrist problem until 1992. The examiner further indicated that the Veteran had surgery in 1992 where his left wrist was fused which is the reason why his current ankylosis and neuropathy were most likely the result of the 1992 accident. In May 2013, VHA orthopedic surgeon discussed the Veteran's STRs which indicate treatment of a non-displaced compression fracture after a fall in 1970. He stated that although there were no X-rays available for review, "based on the mechanism of injury and the description of the fracture in the medical records, it probably was a non-displaced compression fracture of the distal left radius. The type of fracture that the Veteran suffered in 1970, as described in the medical records ... is a common fracture that orthopedic surgeons treat and is a fracture that would be expected to heal uneventfully, without resulting in any residual deficit of bone or muscle strength in the involved extremity." The medical expert opined that there is no medical basis to support a finding that the non-displaced distal left radius fracture that the Veteran suffered in 1970 had any likelihood of causing weakness in or about his left wrist. He further opined that there is no likelihood that the 1970 wrist injury caused any residual bone weakness, residual weakness of the surrounding muscle tissue or residual weakness of the tendons or ligament in that anatomic area based on the Veteran's normal clinical evaluation on June 1974 discharge examination. This is further supported by the subsequent 18-year period between 1974 and 1992 during which there is no record that the Veteran complained of any problems or symptoms that could be related to his 1970 wrist injury. The medical expert concluded that it is far more likely than not that the extensive trauma to the Veteran's left wrist while working in 1992 was the sole cause of the severe bony injury to his left wrist and that it is far more likely than not that the extensive trauma to the Veteran's left wrist while working in 1992 (the severe bony injury and associated ulnar nerve injury) was "NOT" aggravated or worsened in any way by the service-connected non-displaced left wrist fracture that he suffered in 1970. The orthopedic surgeon also opined that "[i]t is far more likely than not that the [Veteran] was NOT in any way predisposed to experiencing a more severe left wrist injury (following the extensive trauma to the [Veteran's] left wrist while working in 1992) because of the service-connected non-displaced left wrist fracture that the [Veteran] suffered in 1970." The Board finds that the claim must be denied. The Veteran was not shown to have left wrist ankylosis and ulnar neuropathy during service. Rather, the earliest post-service medical evidence of any relevant findings is dated in December 2007. This is about 33 years after separation from his second period of active duty service. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a lengthy period without complaint or treatment is evidence that there has not been a continuity of symptomatology, and weight heavily against the claim). In this regard, both the December 2009 VA examiner and the May 2013 VHA orthopedic surgeon have opined that the Veteran's left wrist ankylosis and ulnar neuropathy were most likely caused by or a result of the 1992 construction accident. The May 2013 VHA orthopedic surgeon further opined the following: 1) that there is no medical basis to support a finding that the non-displaced distal left radius fracture that the Veteran suffered during service likely caused weakness in or about his left wrist; 2) that it is far more likely than not that the extensive trauma to his left wrist in 1992 was the sole cause of the severe bony injury to the left wrist; 3) that it is far more likely than not that the extensive trauma to the left wrist from the 1992 injury was not aggravated or worsened in any way by the service-connected non-displaced left wrist fracture that he suffered in 1970; and 4) that it is far more likely than not that he was not in any way predisposed to experiencing a more severe left wrist injury (following the extensive trauma to the Veteran's left wrist while working in 1992) because of the service-connected non-displaced left wrist fracture. There is also no persuasive evidence that the Veteran has been experiencing chronic symptoms of left wrist ulnar neuropathy since service. He really makes no such contention. Put another way, service connection based on the theories of direct onset (38 C.F.R. § 3.303(a)), a presumption of service connection (38 C.F.R. § 3.307, 3.309), or continuity of symptomatology (38 C.F.R. § 3.303(b)) is not established. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, an opinion as to the etiology and onset of left wrist ankylosis and ulnar neuropathy and whether this disease is etiologically related to the Veteran's active service or to his service-connected left wrist disability, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Left wrist ankylosis and ulnar neuropathy are not the types of conditions/diseases that are readily amenable to mere lay diagnosis or probative comment regarding its etiology, as the evidence shows that range of motion and neurological testing and other specific findings are needed to properly assess and diagnose the disorders. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, although the Board readily acknowledges that Veteran is competent to report symptoms such as stiffness, pain, and numbness, there is no indication that the Veteran is competent to etiologically link any such symptoms to his active service or to his service-connected left wrist disability. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he has received any special training or acquired any medical expertise in evaluating endocrine disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. For these reasons, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for left wrist ankylosis and ulnar neuropathy on either a direct, presumptive, or secondary basis. In reaching this conclusion, the Board notes that under the provisions of 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102, a reasonable doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board also acknowledges that, as a practical matter, even if service connection were to be granted for left wrist ankylosis and/or ulnar neuropathy, the Veteran may receive no greater benefit or compensation. It is specified at 38 C.F.R. § 4.14 that evaluation of the same manifestations of a disability under different diagnoses, a process called "pyramiding," is to be avoided. However, in cases where the record reflects that the Veteran has separate and distinct manifestations of his disability, § 4.14 does not bar assignment of separate ratings. Esteban v. Brown, 6 Vet. App. 259, 261 (1994). The critical element is that none of the symptomatology for any of the conditions is duplicative or overlapping with the symptomatology of the other conditions. Id. III. Increased Ratings-Generally Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (2002). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). In cases in which a reasonable doubt arises as to the appropriate degree of disability to be assigned, such doubt shall be resolved in favor of the Veteran. See 38 C.F.R. § 4.3 (2013). VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). In this case, the evidence of record does not establish additional, distinct time periods in which the issue on appeal resulted in symptoms that would warrant staged ratings. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2013). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). A. Compensable Rating for Left Wrist, Non-displaced Fracture The Veteran contends he should be entitled to an initial compensable rating for the service-connected non-displaced fracture of the left wrist. He basically has contended that his left wrist ankylosis with ulnar neuropathy is merely part of his already service-connected left wrist disability of non-displaced fracture and that his left wrist disability should warrant a compensable rating. The record reflects that the Veteran's service-connected left wrist, non-displaced fracture, is rated under DC 5215, which provides a maximum 10 percent evaluation when there is limitation of motion by either the minor or the major wrist with dorsiflexion less than 15 degrees or with palmar flexion limited in line with forearm. 38 C.F.R. § 4.71a, DC 5215. Full range of motion of the wrist is measured from 0 degrees to 70 degrees in dorsiflexion (extension), 0 degrees to 80 degrees in palmar flexion, 0 degrees to 45 degrees in ulnar deviation, and 0 degrees to 20 degrees in radial deviation. 38 C.F.R. § 4.71, Plate I. When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. 38 C.F.R. § 4.45. Also, VA General Counsel held in VAOPGCPREC 9-98 after reiterating its holding in VAOPGCPREC 23-97 that pain as a factor must be considered in the evaluation of a joint disability with arthritis and that the provisions of 38 C.F.R. § 4.59 are for consideration. Turning to the merits of the claim, the Board notes that the only medical evidence of record pertaining to the left wrist shows that on VA examination in December 2009, evaluation of the left wrist revealed pain, stiffness, weakness, incoordination, and decreased speed of joint motion. There was no findings of deformity or giving way. The Veteran reported that when he tried to use his wrist too much the wrist got very stiff and almost locked. He had no episodes of dislocation, subluxation, or locking. However, there was evidence of warmth, redness, and swelling. It was also noted that the condition did not affect the motion of the joint, that there were no flare-ups of joint disease, and there were no symptoms of arthritis, but there was crepitus, tenderness, and instability. Range of motion testing of the left wrist revealed objective evidence of pain with active motion, dorsiflexion to 35 degrees, palmar flexion to 42 degrees, radial deviation to 0 degrees, and ulnar deviation to 32 degrees. There was objective evidence of pain following repetitive motion, but no additional limitations after three repetitions of range of motion. The diagnoses included left wrist ankylosis with healed old comminuted radial fracture. There were significant effects on the Veteran's usual occupation, including decreased mobility, decrease manual dexterity, pain, and affects on his usual daily activities. It was also noted that the Veteran had decided on retirement because he was not able to perform his job with problems in his wrist, back, and hip. After careful consideration of the record, including the Veteran's statements and the VA examination report, and applying the rating criteria to the facts of this case, the objective assessment of the Veteran's impairment from residuals of his left wrist, non-displaced fracture, does not show that he had sufficient limitation of motion and/or other symptoms, as may be associated with his service-connected left wrist disability, so as to a warrant a compensable evaluation for the left wrist at any time during the pendency of this appeal. Even considering the factors of left wrist pain and pain on use, the Board finds that the medical evidence does not show sufficient wrist symptomatology that, based on the factors noted in DeLuca, 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, more nearly approximates the criteria for a compensable evaluation during the appeal period for limitation of motion of the wrist under DC 5215. To the extent that the Veteran does suffer from noncompensable yet real limitation of motion, accompanied by pain and other symptoms, the Board finds that such symptoms are the result of the post-service 1992 injury that has already been determined herein to be unrelated to the service-connected disability. As the VA examiner opined, since there were no problems with the wrist prior to the 1992 injury, the current symptoms are the result solely of the post-service 1992 injury. In fact, on VA examination in 2009, the examiner noted no additional limitations on repetitive testing. Accordingly, the Board finds that the Veteran's left wrist non-displaced fracture is not manifested by the objective findings necessary for a compensable evaluation under DC 5215. The Board acknowledges that, as noted above, the Veteran's left wrist has been diagnosed with (non-service-connected) ankylosis. However, considering the range of motion findings, as noted above, a compensable evaluation could not even be assigned under DC 5214. The medical evidence simply does not show ankylosis or impairment of either wrist commensurate with ankylosis. See Lewis v. Derwinski, 3 Vet. App. 259 (1992) (defining ankylosis as "immobility and consolidation of a joint due to disease, injury, surgical procedure"). Thus the Board finds that the Veteran is not entitled to a compensable evaluation for his service-connected left wrist disability. 38 C.F.R. § 4.71a, DCs 5214, 5215. Moreover, the preponderance of the evidence is against the Veteran's claim on a schedular basis. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5101(b); Gilbert v. Derwinski, supra. B. PTSD The Veteran's PTSD has been evaluated as 30 percent disabling, effective from June 4, 2009, pursuant to 38 C.F.R. § 4.130, DC 9411. Under Diagnostic Code 9411, the General Rating Formula for Mental Disorders is used. The General Rating Formula provides that a 30 percent rating is assigned 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 assigned 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 assigned 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 which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Finally, a 100 percent rating is assigned 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. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Although PTSD is rated under the General Rating Formula, the use of the term "such as" in 38 C.F.R. § 4.130 indicates that the listed symptoms are not intended to constitute an exhaustive list. Rather, the symptoms listed under the General Rating Formula for Mental Disorders are to serve as examples of the type and severity of symptoms or their effects that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The symptoms to be considered when rating a Veteran's PTSD are not limited to those listed in 38 C.F.R. § 4.130. Instead, VA shall consider all symptoms of a Veteran's PTSD that affect his level of occupational and social impairment, including, if applicable, those identified in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) provided additional guidance in rating psychiatric disability. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Specifically, the Federal Circuit emphasized that the list of symptoms under a given rating is a nonexhaustive list, as indicated by the words "such as" that precede each list of symptoms. Id. at 2. It held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration. Id. at 4. Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 2. Within the DSM-IV, 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). A GAF score is, of course, just one part of the medical evidence to be considered and is not dispositive. The same is true of any physician's statement as to the severity of a disability. It remains the Board's responsibility to evaluate the probative value of any doctor's opinion in light of all the evidence of record. A GAF score of 31 to 40 reflects some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A GAF of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 is defined as 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). A GAF of 61 to 70 is defined as 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, has some meaningful relationships. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). As an initial matter, the Board is precluded from differentiating between symptomatology attributed to a non-service connected disability and a service-connected disability in the absence of medical evidence which does so. Mittleider v. West, 11 Vet. App. 181, 182 (1998). The Board will thereby attribute all the Veteran's psychiatric symptoms to his service-connected PTSD. Turning to the merits of the claim, the pertinent evidence of record includes a VA examination report dated in December 2009 VA examination at which time the Veteran reported sporadic symptoms and stated that he felt bad about 50 percent of the time. He reported having trouble sleeping every night, nightmares twice a week, and daily intrusive thoughts. He reported being anxious, easily startled, short tempered, hypervigilant, and uncomfortable in crowds. With regard to employment, he reported that he was no longer employed due to a 1992 left wrist injury. He reported he dressed and fed himself, attended to his own needs, and did chores around the house. He lived with his wife, had no friends, and stayed at home and watched television. He occasionally went to church, but had limited recreational and leisure pursuits. On examination, he was alert, oriented, cooperative, and appropriately dressed. He answered questions and volunteered information, and there were no lucid disassociations or flight of ideas. His mood was a bit tense, but cooperative and friendly with an appropriate affect. He had no suicidal or homicidal ideation or intent. There was no impairment of thought processes or communication, no delusions or hallucination, and no ideas of reference or suspiciousness. His memory, insight, and judgment were adequate. He was diagnosed with PTSD and assigned a GAF score of 55. The examiner opined that the Veteran had moderate and persistent symptoms of PTSD with no remissions. Private treatment records from psychologist Dr. W.J.A. reflect ongoing and periodic counseling for the Veteran's PTSD from May 2009 through August 2012. During an initial consultation in May 2009, the Veteran reported that he worked in construction until his injury in 1992, but that he returned to work in construction, including having his own firm, until he retired in 2008. After the injury in 1992, he had marked difficulties with maintaining employment due to his physical injuries. He reported that he had been fired from a position of employment with a construction company due to flare-ups of PTSD. He also reported a history of numerous heated arguments with supervisors and coworkers. He was married with two children with whom he had good relationships. His PTSD symptoms included recurrent intrusive thoughts; flashbacks; recurrent nightmares; night sweats; avoidance of thoughts feelings and conversations associated with his traumatic experiences; markedly diminished interest in significant activities; feelings of detachment and estrangement from others; restricted range of affect; sleep problems; severe trouble with irritability and angry outbursts; hypervigilance; an "okay" mood; anhedonia; concentration difficulties; significant experiences of fatigue and loss of energy; feelings of worthlessness and guilt; and cognitive difficulties. He also had recurrent thoughts of death and suicidal ideation without intent and denied homicidal ideation. On mental status examination, he was oriented. His attention capacity, concentration abilities, immediate memory abilities, judgment, insight, and impulse control were below normal limits. Speech was circumstantial, but normal in terms of manner and content. There was evidence of perceptual abnormalities. Affect was somewhat blunted, but appropriate. His remote memory was intact. Diagnoses included PTSD and depressive disorder and a GAF score of 40 was assigned. The examiner noted that the Veteran's GAF score was based on his difficulties in social functioning, family relationships, judgment-related issues, thinking difficulties, and mood. He described a marked pattern of social isolation which began subsequent to his Vietnam service. His history of problems in employment functioning was apparent in his description of conflict with supervisors and coworkers, and his difficulties with impulse control and irritability were likely to substantially negatively impact his employment. His symptoms were classified as "severe." Subsequent treatment records from Dr. W.J.A., dated from June 2009 through August 2012 show that the Veteran continued to experience persistent and severe symptoms including depression; nightmares; intrusive thoughts; irritability; diminished interest in activities; sleep difficulties; social isolation and avoidance behaviors; problems with memory, attention, and concentration; and suicidal ideation. Additionally, a GAF score of 40 was continually assigned to assess the Veteran's functioning. Considering the evidence in light of the criteria noted above, and with resolution of all reasonable doubt in the Veteran's favor, the Board finds that the totality of the evidence indicates that the Veteran's PTSD meets the criteria for the assignment of an initial 70 percent rating. The record shows that the Veteran's symptoms have somewhat increased, but have remained consistent in interfering with his daily functioning, particularly with regard to his interactions with others and his own personal recurrent feelings and recollections of his military traumas. Although the Veteran maintains relationships with family members, he has continued to experience severe symptoms including depression, isolation, nightmares, and suicidal ideation. In sum, his PTSD results in severe occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood. Thus, the Board concludes that the criteria for a 70 percent rating for PTSD have been approximated. The Board also notes that the Veteran's GAF scores have ranged from 40 (over the course of treatment from 2009 through 2012 with Dr. W.J.A.) to 55 (on VA examination in 2009), but overall show severe impairment in his emotional functioning, despite his participation in therapy. The Board finds that the aforementioned GAF scores indicate a moderate to severe impairment, in line with a 70 disability rating. However, at no point during the appeal period does the evidence demonstrate that the Veteran's PTSD symptomatology meets the criteria for an initial 100 percent rating. While the Veteran's PTSD would certainly affect his employability and his ability to work with others, the competent evidence of record simply does not show total occupational impairment or that the Veteran is unable to obtain or retain employment due to his PTSD. Additionally, he does not have gross impairment in thought processes or communication, and has shown no psychotic behaviors. He has not reported persistent delusions or hallucinations. He is able to perform activities of daily living, has been, on mental status examinations, alert, oriented and cooperative, and has not exhibited inappropriate behavior. He has been found to be active in dealing with his symptoms, and continued to attend regular therapy sessions. While he has been reported to have suicidal ideation, he denied any plan or intent and also denied homicidal ideation. The Board acknowledges that the Veteran experiences other symptoms due to his PTSD which are not specifically listed in the criteria for a 100 percent rating. However, even considering the magnitude of these symptoms, the Board does not find these symptoms produce total social or occupational impairment. See Vasquez-Claudio. Thus, the Board concludes that the preponderance of the evidence of record does not show that the Veteran's disability picture due to his PTSD more nearly approximates the criteria for a 100 percent schedular rating at any point during the appeal period. 38 C.F.R. § 4.7. C. Additional Considerations In reaching the above conclusions, the Board has also not overlooked the Veteran's statements in support of his claims. In this regard, the Veteran is competent to report on factual matters of which he has first-hand knowledge, e.g. psychiatric symptomatology including memory loss and depression, and orthopedic symptoms including pain and limitation of motion. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, while the Board may consider the Veteran's subjective statements regarding the severity of the disabilities, the Board notes that with respect to the Rating Schedule, the criteria set forth therein generally require medical expertise which the Veteran has not been shown to have. See King v. Shinseki, 700 F.3d 1339, 1344 (Fed. Cir. 2012). Furthermore, the Board finds the objective medical findings and opinions provided by the expert of record should be accorded the greater probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches . . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators."). The above determination is based upon consideration of applicable rating provisions. It should also be noted that there is no showing that the Veteran's disabilities have reflected so exceptional or unusual a disability picture as to warrant the assignment of any higher evaluations on an extra-schedular basis. See 38 C.F.R. § 3.321(b) (1). In this case, there has been no showing that the Veteran's PTSD and left wrist disability could not be contemplated adequately by the applicable schedular rating criteria discussed above. In light of the foregoing, the Board finds that an initial rating of 70 percent for PTSD is warranted. With regard to left wrist, non-displaced fracture, the Veteran's claim for an initial compensable rating, must be denied. Since the preponderance of the evidence is against the claim for an initial compensable rating for the Veteran's left wrist disability, the benefit of the doubt doctrine is not for application with regard to this claim. 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has considered additional staged ratings, under Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007), but concludes that they are not warranted. [Continued on Next Page] ORDER Service connection for left wrist ankylosis with ulnar neuropathy, to include as secondary to the service-connected left wrist disability, is denied. An initial compensable rating for left wrist, non-displaced fracture, is denied. An initial 70 percent schedular rating for PTSD is granted, subject to the law and regulations governing the payment of monetary benefits. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs