Citation Nr: 1333205 Decision Date: 10/23/13 Archive Date: 10/24/13 DOCKET NO. 10-10 874 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for the service-connected psychiatric disability, to include adjustment disorder with mixed anxiety and depressed mood (a psychiatric condition). 2. Entitlement to an initial rating in excess of 10 percent for the service-connected post-operative degenerative changes in the left knee (left knee condition). 3. Entitlement to an initial rating in excess of 10 percent for the service-connected right ankle sprain (right ankle condition). 4. Entitlement to an initial rating in excess of 10 percent for the service-connected degenerative disc disease of the thoracic spine (back condition). 5. Entitlement to service connection for plantar fasciitis of the left foot (left foot condition). 6. Entitlement to service connection for pseudofolliculitis barbae (PFB). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Andrea Johnson, Associate Counsel INTRODUCTION The Veteran had active service from June 1997 to February 2008. This appeal comes to the Board of Veterans' Appeals (Board) from an October 2008 rating decision by the RO. The Board must note that, in considering this case, the Board has not only reviewed the Veteran's paper claims file, but also his file on the "Virtual VA" system to ensure a total review of the evidence. The issues of an increased rating for the service-connected back condition and service connection for a left foot condition are being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The service-connected psychiatric disability is not shown to have been manifested occupational and social impairment with reduced reliability and productivity at any point during the period on appeal. 2. The service-connected left knee disability is not shown to have resulted in incapacitating exacerbations or flexion limited to 30 degrees or extension limited to 15 degrees at any point during the period on appeal. 3. The service-connected right ankle disability is not shown to have resulted in marked limitation of motion at any point during the period on appeal. 4. The currently demonstrated pseudofolliculitis barbae is shown as likely as not to have had its clinical onset during the Veteran's period of active service. CONCLUSIONS OF LAW 1. The criteria for the assignment of an initial rating in excess of 30 percent for the service-connected psychiatric disability manifested by an adjustment disorder with mixed anxiety and depressed mood have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.126, 4.130 including Diagnostic Code 9440 (2013). 2. The criteria for the assignment of an initial rating in excess of 10 percent for the service-connected disability manifested by post-operative degenerative changes of the left knee have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.27, 4.71a including Diagnostic Code 5259-5010 (2013). 3. The criteria for the assignment of an initial rating in excess of 10 percent for a the service-connected disability manifested by a right ankle sprain have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.59, 4.71a including Diagnostic Code 5271-5024 (2013). 4. By extending the benefit of the doubt to the Veteran, his disability manifested by pseudofolliculitis is due to disease or injury that was incurred in active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Ratings The Veteran is currently seeking an increased initial rating assigned for several of his service connected conditions. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. 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. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is propriety of the initial evaluations assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board will discuss each of the Veteran's claims for increase in turn, and then will discuss additional considerations regarding the schedular rating criteria assigned for each condition. Psychiatric The Veteran is currently seeking an increased rating for his service-connected psychiatric disability manifested by an adjustment disorder with mixed anxiety and depressed mood. His condition is currently rated as 30 percent under Diagnostic Code 9440 for major depressive disorder, which is rated using the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Under the General Rating Formula a 30 percent rating is assigned when a mental disorder causes occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. An increased 50 percent rating is assigned when a mental disorder causes 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-term 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; or difficulty in establishing and maintaining effective work and social relationships. Id. The nomenclature employed in the portion of VA's Rating Schedule that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "DSM-IV"). 38 C.F.R. § 4.130. DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of an individual. Under DSM-IV, GAF scores ranging between 61 and 70 are assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 41 and 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Symptoms listed in VA's general rating formula for mental disorders 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). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). In this case, the Veteran sought psychiatric treatment from VA in March 2008. The nurse indicated the Veteran was alert, oriented, pleasant, and cooperative with good eye contact and an appropriate mood. The Veteran spoke with coherent, relevant speech and organized thoughts. The nurse noted no delusions or hallucinations, and his insight and judgment were good. The medication the Veteran began during service was continued. The Veteran returned in the following month in April 2008 and reported having depression and lack of motivation. He endorsed experiencing depressed mood most of the day, markedly diminished interest in almost all activities, insomnia, loss of energy, appetite disturbance, and problems with concentration. The psychiatrist noted that the Veteran presented as well groomed with appropriate behavior, good eye contact, and normal speech, although his mood was sometimes depressed. However, despite these described symptoms suggesting minor impairment, a GAF score of 50 was assessed, suggesting moderate to serious symptoms. In May 2008, the Veteran was provided with a VA examination to evaluate the nature and severity of his current psychiatric disability. The Veteran reported feeling depressed and sleeping a lot. He described increased social isolation, irritability, frequent crying, recurrent suicidal thoughts, and sleep difficulties since service. The examiner noted the Veteran was forthcoming and cooperative, maintained eye contact, was truthful, and was orientated in all spheres. The examiner further noted the Veteran's speech was goal directed, and memory, insight, and judgment were good; no psychomotor abnormalities were observed. The examiner diagnosed the Veteran with an adjustment disorder with mixed anxiety and depressed mood and assigned a GAF score of 55, suggesting moderate symptoms. The Board finds in the spring of 2008 relevant treatment records established that the Veteran was experiencing moderate symptoms. For example, the Veteran reported depressed mood and chronic sleep impairment, symptoms associated with a 30 percent rating. Accordingly the Board finds a 30 percent rating was warranted. However the Board finds the records do not reflect that the Veteran was experiencing symptoms of the severity associated with the criteria for a 50 percent rating. For example, all mental health professionals during this time noted the Veteran spoke with normal speech, not flattened affect and circumstantial or circumlocutory speech associated with a higher 50 percent rating. Additionally no impairment of memory, judgment or panic attacks were noted. The Board notes that, in April 2008, the psychiatrist assigned a GAF score of 50, suggesting symptoms on the lower end of the 'serious' range. However, this psychiatrist described symptoms more closely associated with a 30 percent rating. For example, the psychiatrist indicated the Veteran was anxious and depressed, but added that his thoughts were logical, that his speech was at a normal rate, tone and volume, and that his insight and judgment were not impaired. The Board notes that while GAF scores may be highly probative, they are not determinative. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). Therefore, the Board finds that although the GAF score assigned in April 2008 does suggest that the Veteran experienced serious symptoms. The Board finds the psychiatrist's written description of the Veteran's symptomatology is more persuasive and more closely aligns with the criteria for a 30 percent rating. Accordingly, on this record, the Board finds a rating in excess of 30 percent was not warranted. In July 2008 the Veteran reported having a persistent depressed mood and marital strife. He reported tolerating his medication, but not seeing much improvement. For example, he still slept only 2 to 3 hours per night, spent "considerable energy" avoiding thoughts of what he experienced in Afghanistan, and kept his weapons in strategic locations throughout his house. The physician noted no mood swings, racing thoughts, or hyperactivity, but instead described the Veteran as pleasant, cooperative, alert and oriented with good eye contact, well organized thoughts, and coherent speech at normal rate and tone. Finally the physician opined the Veteran's insight and judgment were not impaired. In October 2008, the Veteran returned to VA for a psychology assessment. He reported his overall pain was influenced by interpersonal factors, in that his symptoms were worse after an argument with his wife and improved by spending time with his family. The psychologist noted the Veteran was "articulate" and "knowledgeable." He opined the Veteran had "PTSD-like symptoms" and appeared "at least mildly depressed." In May 2009, the Veteran reported feeling better with medication, but admitted that he had not been taking his medication daily. He reported feeling lethargic despite sleeping through the night. The Veteran was living with his girlfriend and also spent time with his two sons. At his appointment, the Veteran was neatly dressed and spoke at a normal rate and volume with neutral affect. The care provider opined the Veteran's insight and judgment were limited, diagnosed depressive disorder, and assigned a GAF score of 60, again suggesting mild to moderate symptoms. The Board finds the Veteran's symptoms for this period are shown to continue to more closely align with a 30 percent rating. The Veteran experienced depression, lethargy and difficulty sleeping. However, the evidence did not establish that the Veteran had impaired abstract thinking, disturbances of motivation and mood, or difficult establishing and maintaining effective relationships, criteria associated with a rating higher than 30 percent. Instead the record noted that the Veteran began a relationship with a new girlfriend and continued to have a relationship with both sons. The Board acknowledges psychologist in May 2009 opined the Veteran's insight and judgment were limited, one of the criteria for a 50 percent rating. However, that psychologist assigned a GAF score of 60, suggesting the Veteran's symptoms were in the low end of the 'moderate' range and nearly mild. Moreover, the psychologist overall described improvement in the Veteran's condition, noting the Veteran was eating and sleeping better and was less angry. Therefore the Board finds GAF score suggesting moderate impairment and additional description of the Veteran's improved condition outweigh the notation the Veteran's judgment was limited. Therefore, the Board finds the evidence does not establish a rating in excess of 30 percent was warranted at this time. In November 2009 the Veteran returned to VA and reported feeling melancholy and optimistic. He admitted to crying at times due to missing his sons, as well as sleeping too much or too little. He also reported sometimes going over 24 hours without eating while upset. He stated that he sometimes felt "caught in a loop" in which he was compelled to clench his teeth multiple times and, on other occasions, was compelled to check activities multiple times, such as ensuring he had his keys on his person when leaving the car. The physician noted the Veteran began to shake and sweat when asked about his combat experience in Afghanistan, and described "significant hypervigilance." The physician also noted the Veteran's history of treatment noncompliance, particularly poor attendance. The Veteran described a strained relationship with his girlfriend and stated that he was estranged from his wife and mother, but had become closer to brother and sister in the past few years. He did not maintain friendships from college, but had one friend from the military. During the interview, the Veteran was alert, attentive, cooperative, displayed appropriate grooming, and spoke with a normal rate and volume of speech. Mood generally was euthymic, but became anxious when talking of combat experiences. The physician noted the Veteran displayed "evidence of hypervigilance moving towards paranoia." Insight was poor; judgment was fair, and memory was average. The Veteran admitted to suicidal ideation with multiple plans in the past, but denied having any suicidal thoughts in last 12 months. The physician diagnosed depressive disorder, "sub-clinical" PTSD, and obsessive-compulsive features. A GAF score of 65 was assigned, suggesting mild symptoms. This report reflects that some of the Veteran's symptoms increased in severity, when discussing his experiences in the military and having hypervigilance. However, the Board finds the record does not reflect such symptoms increased sufficiently to meet the criteria for a rating in excess of 30 percent. Although the Veteran's relationship to his wife was strained he continued to be close to his siblings and his friend from the military, suggesting he was able to maintain effective relationships. Additionally, the Veteran's speech was normal, without flattened affect, circumstantial speech, or panic attacks. Finally, although the Veteran's memory was average and judgment was fair, these descriptions do not suggest that the Veteran's judgment was impaired or that he had impairment of memory such as to forget to complete tasks. Accordingly the Board finds the evidence does not establish a rating in excess of 30 percent was warranted at this time. In March 2010, the Veteran reported no longer having "rage attacks," and the physician noted his condition was stable. Throughout 2011, the Veteran's condition was noted to be stable, and he reported feeling that he continued to experience hypervigilance but stated it did not negatively impact his life anymore. In February 2012, the Veteran reported that he had stopped psychological treatment and medication since 2010 because he felt he did need it anymore. He admitted to brief feelings of sadness, but overall reported good energy, appetite for food, and sleep. The physician noted that the Veteran presented with good hygiene, was oriented to all spheres, and remained cooperative and pleasant while speaking with appropriate mood and tone. In March 2012, The Veteran reported previously experiencing 10 months of depression until he separated from his wife. He was currently feeling well and relayed short and long term plans for employment and school. He was now living with his girlfriend and reported a good relationship. The Veteran presented with good hygiene, appeared oriented in all spheres, and was pleasant and cooperative. Mood was appropriate; speech was coherent; thought process were organized, and insight, judgment, and memory were good. The examiner opined the Veteran had a "major depressive disorder, single episode, in full remission" and assessed a GAF score of 65, suggesting mild symptoms. The Board finds the most recent treatment records suggest that the Veteran's condition has improved. The psychologist from March 2012 even suggested the Veteran's depression was in "full remission." Accordingly, the Board finds a 30 percent rating continues to be warranted. The evidence does not establish a higher rating was warranted at this time. Based on the foregoing, the Board finds that the service-connected psychiatric disability does not meet the criteria for the assignment of rating higher than 30 percent during any period on the appeal. Accordingly, on this record, the claim for an increase must be denied. Left Knee The Veteran is also seeking an increased rating for his left knee disability. It is currently rated as 10 percent under Diagnostic Code 5259-5010. 38 C.F.R. § 4.71a. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Diagnostic Code 5259 provides a maximum 10 percent rating for removal of seminulnar cartilage which is symptomatic. Diagnostic Code 5010 provides that arthritis due to trauma shall be rated as degenerative arthritis under Diagnostic Code 5003. Diagnostic Code 5003 provides that a 10 percent rating is warranted when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is warranted if there are also occasional incapacitating exacerbations. 38 C.F.R. § 4.71a. A 20 percent rating may be warranted if flexion is limited to 30 degrees, or extension is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260, 5261. By way of background the Veteran had surgery in October 2002 during service to repair a torn anterior cruciate ligament (ACL). The surgery went well with no complications. After service, the Veteran was afforded a VA examination in May 2008 to evaluate the nature and severity of his current left knee disability. The Veteran reported having weakness, stiffness, swelling, lack of endurance, locking, dislocation, and pain in his left knee. He described the pain as being a constant, squeezing, sharp pain of 4/10 severity level. The pain was elicited by physical activity and relieved by rest. The X-ray studies were normal. The range of motion was also normal, with flexion to 140 degrees and extension to 0 degrees. The examiner opined the Veteran had status post ACL surgical repair without any current residuals. The Board finds a 10 percent rating was appropriate for painful motion in the Veteran's left knee. 38 C.F.R. § 4.59. However, the evidence does not establish an increased rating is warranted. The Veteran did not experience incapacitating exacerbations or have flexion that was limited to 30 degrees or extension that was limited to 15 degrees. Accordingly a higher 20 percent rating was not warranted. In July 2008, the Veteran was provided with an additional VA examination. The examiner reported that the Veteran's left knee injury during service was managed conservatively without surgery. However, the Board finds the examiner's understanding of the history of the Veteran's left knee condition is factually inaccurate as his condition is shown to have required ACL surgery during military service. Accordingly the Board finds this examination has limited probative value in regards to the Veteran's left knee condition. See Reonal v. Brown, 5 Vet. Appl. 458, 461 (1993). The Board notes that the Veteran was not prejudiced by this inadequate examination, however, as he had already been afforded an adequate examination merely two months earlier and had not alleged his condition has worsened since that time. In September 2008, the Veteran sought treatment for his left knee condition noting his pain was 4/10 severity. The treating care provider noted the Veteran's left knee condition was status post ACL repair with "no evidence of significant meniscal pathology." Accordingly, the Board finds a 10 rating continued to be warranted for painful motion without incapacitating exacerbations or limitation of motion. In February 2010, the Veteran reported having pain in his left knee that was 8/10 at most intense, 3/10 on average, and 7/10 currently. The Veteran received acupuncture treatment on his left knee and afterwards his pain level was 3/10. He received additional acupuncture treatment for his knee the following month and again received temporary pain relief. In May 2011, the Veteran reported the pain in his left knee was chronic and 7/10 in severity. In December 2011, he again reported chronic pain in his left knee due to status-post ACL reconstruction. Accordingly, the Board finds the evidence reflects that the Veteran continued to experience pain in his left knee. However, the evidence does not include any findings that the Veteran began to experience incapacitating exacerbations or any limitation of motion in his left knee at any point during the period on appeal. Accordingly, on this record, the evidence does not establish that a higher rating is warranted. The Veteran's claim for an increased rating is denied. Right Ankle The Veteran is also seeking an increased rating for his service connected right ankle condition. His condition is currently rated 10 percent under Diagnostic Code 5271-5024. Diagnostic Code 5024 provides that tenosynovitis will be rated based on limitation of motion of the affected parts. Diagnostic Code 5271 provides that a 10 percent rating is warranted for moderate limitation of motion of the ankle, while marked limitation merits a 20 percent rating. 38 C.F.R. § 4.71a. The terms "moderate" and "marked" are not defined in VA regulations, and the Board must arrive at an equitable and just decision after having evaluated the evidence. 38 C.F.R. § 4.6. As guidance, the regulations provide normal range of motion in the ankle is dorsiflexion from 0 to 20 degrees and plantar flexion from 0 to 45 degrees. 38 C.F.R. § 4.71a, Plate II. An April 2008 x-ray study of the right ankle revealed "very slight cortical thickening of the medial malleolus," but was otherwise normal. The reviewing radiologist opined "probably residual of minor old trauma to the medial malleolus." As discussed, the Veteran was afforded a VA examination in May 2008. He reported experiencing weakness, stiffness, swelling, pain, and lack of endurance in his right ankle. He stated he had significant ankle pain for one year that did not travel to other areas. He described the pain as severity level of 3/10. The pain was elicited by physical activity and relieved by rest. Upon testing range of motion was normal with no additional loss of motion after repetitive use. The X-ray studies were normal. The examiner opined "there is no pathology to render a diagnosis." In July 2008, the Veteran was provided with an additional VA examination and reported having stiffness and pain in lateral aspect of right ankle occurring on a constant basis without radiation. He described the pain was "aching," but occasionally "sharp" with severity of 7/10. The Veteran stated that the pain was elicited with use and relieved with rest. Range of motion was that of dorsiflexion to 20 degrees, pain beginning at 10 degrees, and plantar flexion to 45 degrees, pain beginning at 20 degrees. There was no additional loss of motion after repetitive use testing. The Board finds this report reflects the Veteran had normal range of motion in his right ankle, although he had pain upon movement. As discussed, a 10 percent rating is appropriate for painful motion of a joint. 38 C.F.R. § 4.59. Accordingly, on this record, a 10 percent rating is warranted for painful motion of the right ankle. Because the Veteran had a full range of motion, the evidence does not establish a higher rating based on having a marked limitation of motion is not assignable. Additional post-service treatment records continue to reflect the Veteran had pain in his right ankle. Similar to his left knee, the Veteran was also given acupuncture treatment for his right ankle in early 2010 which provided some relief for pain. The Veteran's ongoing pain was noted as recently as July 2012, when he was provided with a flexibrace for his right ankle. However, no limitation of range of motion was noted at any point during the period on appeal. Accordingly, on this record, the Board finds the Veteran's continued pain in his right ankle warrants no higher than a 10 percent rating. The evidence does not establish that his condition warrants a higher rating at any point during the appeal. Other Considerations In each of these claims the Board has also considered whether referral for consideration of an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a veteran is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. This means that initially there must be a comparison between the level of severity and symptomatology of the veteran's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the veteran's disability level and symptomatology, then the veteran's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is adequate, and no referral is required. If the criteria do not reasonably describe the veteran's disability level and symptomatology, a determination must be made whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. However, in each of these cases the medical evidence fails to show anything unique or unusual about the Veteran's claims that would render the schedular criteria inadequate. Regarding the psychiatric claim, his main complaints were depression, anxiety, hypervigilance, and difficulty sleeping. Regarding his left knee and right ankle claims, the Veteran's main complaint was pain. As discussed, these symptoms were all specifically contemplated in the schedular ratings that were assigned. As such, the Board believes that the schedular rating criteria adequately describe the Veteran's disability picture and even if it does not, it would not be found that his disability met the "governing norms" of an extraschedular rating. Accordingly, referral for consideration of an extraschedular rating is not warranted. The Board has also considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. The Board acknowledges that, for part of the appeals period, the Veteran was not employed. However, more recent treatment records reflect the Veteran temporarily worked as a delivery man. More persuasively in March 2012 the Veteran's physician signed a statement indicating the Veteran did not have any medical conditions that would impair his ability to participate in the police academy training. Thus, the Board finds that Rice is inapplicable since there is no evidence of unemployability due to the Veteran's service connected conditions. Service Connection for PFB The Veteran is also seeking service connection for his pseudofolliculitis barbae (PFB), a condition involving persistent irritation of the skin caused by shaving. As will be discussed the Board grants this claim. Accordingly only limited, relevant evidence will be discussed. In seeking VA disability compensation, a Veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. Establishing service connection generally requires (1) medical evidence of a 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 disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The service treatment records were reviewed and reflect that the Veteran had PFB during military service. For example in May 2002, a health care professional noted the Veteran had PFB "for years" that he treated with topical medications. Additionally this condition was included on the list of problems on a medical evaluation from January 2008, one month before the Veteran's separation from service. Accordingly, the Board finds the evidence establishes the Veteran had a chronic PFB condition during military service. Post-service treatment records also reflect that the Veteran currently has PFB. For example, this condition was included on a list of active problems from April 2008 and the Veteran was provided with topical medications to treat this condition in March 2009. Accordingly the Board finds the evidence establishes the Veteran currently has PFB. Finally, the Board finds the evidence establishes the Veteran's PFB condition has been constant since his military service. The Board finds that the symptoms of PFB, including irritating of the skin, are observable by the Veteran's senses and therefore are capable of lay observation. Layno v. Brown, 6 Vet. App. 465 (1994). In May 2008, the Veteran reported that he first experienced the symptoms of PFB while in Afghanistan in 2007 and that they had been constant since that time. Therefore, the evidence establishes the Veteran has experienced PFB continuously since his military service. Based on the foregoing, the Board finds the evidence to be in relative equipoise in showing as likely as not that the Veteran's PFB had its clinical onset during service. In resolving all reasonable doubt in the Veteran's favor, service connection is warranted. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to veterans. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a veteran before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and must: (1) inform the veteran about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the veteran about the information and evidence that VA will seek to provide; and (3) inform the veteran about the information and evidence the veteran is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to service connection claims, a section 5103(a) notice should also advise a veteran of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In the present case, required notice was provided by a letter dated in April 2008, which informed the Veteran of all the elements required by the Pelegrini II Court as stated above. The letter also informed the Veteran how disability ratings and effective dates were established. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The service treatment records and post-service VA treatment records have been obtained; the Veteran has not indicated he received any private treatment for the conditions on appeal. Additionally, the Veteran was offered the opportunity to testify at a hearing before the Board, but he declined. The Veteran was also provided with several VA examinations (the reports of which have been associated with the claims file). The Board finds the VA examinations were thorough and adequate and provide a sound basis upon which to base a decision with regard to the Veteran's claim. The VA examiners personally interviewed and examined the Veteran, including eliciting a history from him, and provided the information necessary to evaluate his disability. As discussed, although one of the VA examiners based his report on an inaccurate factual understanding of the Veteran's left knee condition, the Veteran was provided with an adequate VA examination two months prior regarding his knee. As the Veteran has not alleged his condition worsened during that time the Board finds the Veteran was not prejudiced by the inadequate second examination regarding his left knee condition. As discussed, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER An increased compensation for the service-connected psychiatric disability, to include adjustment disorder with mixed anxiety and depressed mood, left knee disability, and right ankle disability is denied. Service connection for pseudofolliculitis barbae is granted. REMAND Increased Rating for Back Condition The Veteran is also seeking an increased rating for his back condition, currently rated at 10 percent for painful motion. The Veteran was previously provided with two VA examinations in 2008 which each reflected the Veteran had normal range of motion of his back at that time. However the record suggests the Veteran's condition has worsened since that time. Specifically in April 2009 a VA physical therapist noted the Veteran had limited motion in his back and could only bend forward to 8 inches from the ground. Unfortunately the record does not include diagnostic testing to measure the Veteran's range of motion after 2008, nearly five years ago. Therefore the record contains probative evidence suggesting the Veteran's back condition has increased in severity and a new examination is required. 38 C.F.R. §§ 3.326, 3.327(a). Service Connection for a Left Foot Condition The Veteran is also seeking service connection for a left foot condition. Service treatment records reflect the Veteran had "mild pes planus" at entry, and included plantar fasciitis on the list of problems on a medical evaluation one month before separation from service. Accordingly, the Board finds the service treatment records contain some suggestion of a left foot condition during military service. Post-service treatment records were reviewed and reflected the Veteran had pes planus, bilaterally. Additionally a record from February 2012 notes the Veteran was recovering from his bilateral plantar fasciitis. Accordingly, the record contains some suggestion of a current left foot condition. The Veteran was provided with an examination in May 2008 for, among other conditions, his left foot condition. However the examiner did not provide a nexus opinion and instead opined "there is no pathology to render a diagnosis." However, as discussed, there is a suggestion from more recent treatment records that the Veteran has pes planus and/or plantar fasciitis in his left foot. Accordingly, the Board finds remand is required to obtain a VA examination and medical nexus opinion. Accordingly, these remaining matters are REMANDED for the following actions: 1. The RO should take all indicated action in order to obtain the Veteran's VA treatment records from July 2012 to present. 2. Only after obtaining updated VA medical records, the RO should have the Veteran scheduled for an examination to evaluate the nature and severity of the Veteran's current back condition. The examiner should be provided with the Veteran's claims file and a complete rationale should be provided for any opinion expressed. Any required diagnostic testing should be performed. 3. Only after obtaining updated VA medical records, the RO should have the Veteran scheduled for an examination to evaluate the nature of his current left foot condition, if any. The examiner should be provided with the Veteran's claims file and a complete rationale should be provided for any opinion expressed. All required testing and evaluation should be completed. Consistent with the factual history, including the notations of mild pes planus and plantar fasciitis on service treatment records, as well as post-service treatment records regarding pes planus and plantar fasciitis, the examiner should provide an opinion as to the following questions: a) Does the Veteran currently have a left foot condition? If so, separately identify each condition. b) For each condition identified is it as likely as not (50 percent or greater) that the Veteran's current left foot condition began during or was aggravated by his active military service? 4. After completing all indicated development, the RO should readjudicate the claims remaining on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEPHEN L.WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs