Citation Nr: 1334129	
Decision Date: 10/28/13    Archive Date: 11/06/13

DOCKET NO.  09-16 710	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in St. Petersburg, Florida


THE ISSUES

1.  Entitlement to service connection for bleeding ulcer, to include as secondary to service-connected posttraumatic stress disorder (PTSD).  

2.  Entitlement to service connection for sleep apnea with CPAP, to include as secondary to service-connected PTSD.  

3.  Entitlement to service connection for psoriasis, to include as secondary to service-connected PTSD.  

4.  Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected PTSD.  

5.  Entitlement to service connection for degenerative joint disease, left knee (left knee disability), to include as secondary to service-connected right total knee arthroplasty, residuals of a shell fragment wound (right knee disability).  

6.  Entitlement to an evaluation in excess of 10 percent for right knee disability, prior to June 9, 2009.  

7.  Entitlement to an evaluation in excess of 30 percent for right total knee arthroplasty, residuals of a shell fragment wound (right knee disability), from August 1, 2010.  

8.  Entitlement to a separate evaluation for a scar, residual of shall fragment wound with retained bodies, right knee, with posttraumatic arthritis.  

9.  Entitlement to an evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD), from October 13, 2007.  

10.  Entitlement to an evaluation in excess of 70 percent for PTSD, from June 12, 2008.  

11.  Entitlement to a compensable evaluation for bilateral hearing loss.  


REPRESENTATION

Appellant represented by:	John S. Berry, Attorney


ATTORNEY FOR THE BOARD

Jarrette A. Marley, Associate Counsel









INTRODUCTION

The Veteran served on active duty from June 1965 to April 1969 and from April 1976 to April 1980, including combat service in the Republic of Vietnam.  His decorations include the Purple Heart Medal.  

These matters come before the Board of Veterans' Appeals (Board) from rating decisions by the St. Petersburg, Florida Department of Veterans Affairs (VA) Regional Office (RO).  

The Board notes that a July 2009 rating decision granted an increased 30 percent disability rating for the Veteran's right knee disability, effective August 1, 2010.  Such decision also assigned a temporary total (convalescence) rating for the right knee disability, effective from June 9, 2009 through July 31, 2010.  Consequently, the matter of the rating for this period of time is not before the Board.  

These matters were previously before the Board in April 2011 when they were remanded for additional development.  The Board notes that the April 2011 decision granted service connection for a heart disorder.  A July 2011 rating decision implemented the Board's decision, assigning a 10 percent disability rating, effective October 13, 2007, for coronary artery disease status post myocardial infarction, and a 30 percent rating effective May 27, 2011.  The Veteran initiated an appeal to this decision, and an April 2013 statement of the case was provided to the Veteran.  However, the Veteran did not perfect his appeal.  Hence, the matter of entitlement to increased evaluations for his heart disorder is not before the Board.  

As was previously noted in the Board's April 2011 decision, the Veteran has been granted a total disability rating for individual unemployability due to service-connected disabilities (TDIU), effective March 7, 2009.  Although he had filed a claim for increased evaluations and such includes a claim for TDIU under Rice v. Shinseki, 22 Vet. App. 447 (2009), because the Veteran has been awarded TDIU effective the day after he retired from full-time employment, the issue of the effective date for TDIU is no longer before VA.  

The issues of service connection for a left knee disability, bleeding ulcer, and erectile dysfunction are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office.


FINDINGS OF FACT

1.  The Veteran served in the Republic of Vietnam during the Vietnam era.  

2.  Sleep apnea was not manifested in service or in the first year following the Veteran's discharge from active duty; was not caused by or permanently worsened by his service-connected PTSD; and it is not shown to be related to his service, to include as due to herbicide exposure therein.  

3.  Psoriasis was not manifested in service or in the first year following the Veteran's discharge from active duty; was not caused by or permanently worsened by his service-connected PTSD; and it is not shown to be related to his service, to include as due to herbicide exposure therein.  

4.  For the period prior to June 9, 2009, the Veteran's right knee disability is manifested by x-ray evidence of degenerative joint disease with range of motion from 0 degrees extension to no worse than 120 degrees flexion.  

5.  Throughout the appeal period prior to June 9, 2009, resolving all reasonable doubt in the Veteran's favor, the Veteran's right knee was manifested by slight instability; however, the preponderance of the evidence is against a finding of moderate right knee instability.  

6.  At no time since August 1, 2010 is the Veteran's right knee disability shown to have been manifested by chronic residuals of total knee arthroplasty consisting of severe weakness or severe painful motion of impairment approximating such level of severity, or compensable limitations of flexion or extension or instability.   

7.  The Veteran's right knee scar is deep, stable, not painful on objective examination, measure less than 6 square inches in size and does not limit motion or function.  

8.  Throughout the appeal period, resolving all reasonable doubt in the Veteran's favor, the Veteran's PTSD has been manifested by occupational and social impairment with deficiencies in most areas; total occupational and social impairment has not been shown.  

9.  Prior to April 7, 2012, the Veteran had, at best, Level II hearing in the right ear and Level IV hearing in the left ear; from April 7, 2012, the Veteran had Level II hearing acuity in the right ear and Level V hearing acuity in the left ear; the rating criteria contemplate the Veteran's hearing loss symptoms.  


CONCLUSIONS OF LAW

1.  Service connection for sleep apnea is not warranted.  38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 1131, 1137, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306, 3.307, 3.309, 3.310 (2013).   

2.  Service connection for psoriasis is not warranted.  38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 1131, 1137, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306, 3.307, 3.309, 3.310 (2013).  

3.  The criteria for a rating in excess of 10 percent for right knee degenerative joint disease for the period prior to June 9, 2009 have not been met.  38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260, 5261 (2013).  

4.  The criteria for a separate 10 percent disability rating for right knee instability throughout the appeal period prior to June 9, 2009 have been met.  38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.71a, Diagnostic Code 5257 (2013).  

5.  The criteria for a rating in excess of 30 percent status post total right knee arthroplasty with degenerative joint disease for the period since degenerative joint disease for the period since August 1, 2010 have not been met.  38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.21, 4.71a, Diagnostic Codes 5055, 5256, 5260, 5261, 5262 (2013).  

6.  The criteria for a compensable rating is not warranted for the Veteran's right knee scar.  38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.118, Diagnostic Codes (Codes) 7801, 7802, 7803, 7804, 7805 (as in effect for claims filed prior to October 23, 2008).  

7.  Throughout the appeal period, the criteria for a 70 percent rating, but no higher, is warranted for the Veteran's PTSD.  38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013).  

8.  Effective April 7, 2012, the criteria for a 10 percent rating for bilateral hearing loss have been met.  38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100 (2013).  


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

A. Veterans Claims Assistance Act of 2000 (VCAA)

The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits.  38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a).  The VCAA applies to the instant claims.  

Regarding the service connection claims, proper notice from VA must inform the claimant of any information and medical or lay 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 expect to provide.  Quartuccio v. Principi, 16 Vet. App. 183 (2002).  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 notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability.  See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).  Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded.  Id. at 486.  

In this case, the VCAA duty to notify was satisfied by way of a December 2007 letter.  The December 2007 letter was sent prior to the initial RO decision in this matter.  The December 2007 letter informed the Veteran of what evidence was required to substantiate the claim, including on a secondary basis, and of his and VA's respective duties for obtaining evidence.  The Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content as to the appellant's claim.  The December 2007 letter also provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date in accordance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91 (2006).  In any event, the appellant has not demonstrated any prejudice with regard to the content of the notice.  See Shinseki v. Sanders, 556 U.S. 396 (2009) (reversing prior case law imposing a presumption on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination).  

Regarding the increased rating claims, in a claim for increase, the VCAA requirement is generic notice, that is, notice of the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as generic notice regarding how disability ratings and effective dates are assigned.  Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009).  A July 2008 letter provided the Veteran notice that is Vazquez-Flores compliant.  A September 2012 supplemental statement of the case readjudicated the matter.  It is not alleged that notice in this case was less than adequate.  See Shinseki v. Sanders, 556 U.S. 396 (2009) (discussing the rule of prejudicial error).  

As discussed above, the VCAA provisions have been considered and complied with.  The Veteran was notified and aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence.  He has been an active participant in the claims process by reporting for VA examinations, responding to notices, and submitting evidence and argument.  Thus, the Veteran has been provided with a meaningful opportunity to participate in the claims process and has done so.  Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication or to cause injury to the claimant.  Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits.  See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004); Dingess/Hartman, 19 Vet. App. 473 (2006).  

The Board also finds that all necessary development of evidence has been completed.  VA has obtained the Veteran's available post-service treatment records, including records from the Social Security Administration (SSA), and he has been provided appropriate VA examinations.  

Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file.  See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007).  Accordingly, the Board finds that the duty to notify and the duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal.  

B. Legal Criteria, Factual Background and Analysis

The Board has reviewed all of the evidence in the record.  Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on her behalf be discussed in detail.  Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what evidence in the claims file shows, or fails to show, with respect to the claim.  See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000).  

Service Connection Claims

Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability.  See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table).  

Additionally, under 38 C.F.R. § 3.310(a), service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury.  Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability.  Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).  The provisions of 38 C.F.R. § 3.310 were amended, effective from October 10, 2006; however, the new provisions require that service connection not be awarded on an aggravation basis without establishing a pre-aggravation baseline level of disability and comparing it to current level of disability.  

If a veteran was exposed to an herbicide agent (to include Agent Orange) during active military, naval or air service and has contracted an enumerated disease manifested to a degree of 10 percent or more the veteran is entitled to a presumption of service connection even though there is no record of such disease during service.  38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307, 3.309(e).  

In making all determinations, the Board must fully consider the lay assertions of record.  A layperson is competent to report on the onset and continuity of his current symptomatology.  See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge).  Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.  Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).  

The Board is charged with the duty to assess the credibility and weight given to evidence.  Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001).  Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that the Board had inherent fact-finding ability.  Id. at 1076; see also 38 U.S.C.A. § 7104(a).  Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and address the evidence.  Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992).  

In determining the probative value to be assigned to a medical opinion, the Board must consider three factors.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).  The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case.  A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a veteran for a long period of time or through a factually accurate medical history reported by the veteran.  See id. at 303-04.  

The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion.  See id.  A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence.  See McLendon v. Nicholson, 20 Vet. App. 79 (2006).  

The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis.  The most probative value of a medical opinion comes from its reasoning.  Therefore, a medical opinion containing only data and conclusions is not entitled to any weight.  In fact, a review of the claims file does not substitute for a lack of a reasoned analysis.  See Nieves-Rodrigues, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.").  

Sleep Apnea

The Veteran asserts that his sleep apnea is related to his active duty service, to include as secondary to his service-connected PTSD.  

The Veteran's service treatment records are silent for complaints, findings, treatment, or diagnosis for sleep apnea or problems sleeping, including on March 1969 and March 1980 service separation examination.  

Post-service evidence includes private treatment records from Dr. C. L. Slack that include a January 2007 progress report noting the Veteran's account of snoring, fatigue and witnessed apnea.  The impression was obstructive sleep apnea.  A CT scan of the sinus and a sleep study were to be planned.  January 2007 CT scan of the sinuses revealed a complex nasal septal deviation and minimal chronic inflammatory changes.  A February 2007 polysomnogram report (split night study) revealed severe obstructive sleep apnea.  

The instant claim for sleep apnea was received in November 2007.  

In June 2008, the Veteran submitted treatise evidence consisting of a case report entitled "Posttraumatic Stress Disorder and Obstructive Sleep Apnea Syndrome," wherein it was opined that the treatment of PTSD will be more successful if treatment of sleep complaints is emphasized and if sleep apnea and other sleep disorders are treated aggressively.  The case report further suggested that there was a "possibility of a connection between sleep-disordered breathing and PTSD . . ."  

In his June 2008 notice of disagreement, the Veteran's attorney argued that the above-noted case report suggested that PTSD may either cause or aggravate obstructive sleep apnea.  

VA treatment records note the Veteran's complaint of sleep problems and sleep apnea with the use of a CPAP machine.  

In April 2011, the Board remanded this matter for additional development.  

In April 2012, a VA medical opinion was obtained regarding whether it is at least as likely as not the Veteran's sleep apnea is related to or had its onset in service, or is secondary to his service-connected PTSD.  After a review of the claims file, it was opined that the Veteran's sleep apnea was less likely than not incurred in or caused by his service.  It was noted that there is no evidence that the Veteran had sleep apnea on active duty.  His sleep apnea was diagnosed long after his discharge.  It was also opined that the Veteran's sleep apnea was less likely than not proximately due to or the result of his PTSD.  After reviewing the above-noted treatise evidence case report, it was stated that the treatise evidence did not state or suggest that PTSD causes or aggravates sleep apnea.  It was related that sleep apnea is a very common entity and there is a large body of literature relating to it, and there is no evidence anywhere that PTSD is a risk factor for or causes sleep apnea.  Definite risk factors for sleep apnea are: obesity, craniofacial abnormalities, upper airways soft tissue abnormalities.  Possible risk factors include heredity, smoking, nasal congestion, and diabetes.  PTSD is not a known risk factor.  There are also no physical examination findings related to sleep apnea except for obesity.  The examiner conceded that while the Veteran has sleep apnea, it is clear from the medical literature that PTSD does not cause or aggravate sleep apnea.  

As noted above, certain diseases may be service connected on a presumptive basis as due to herbicide (Agent Orange) exposure if manifested in a veteran who served in the Republic of Vietnam during the Vietnam era, based on presumptive exposure to certain herbicide exposure.  38 U.S.C.A. § 1116.  Those diseases are listed in 38 C.F.R. § 3.309(e); sleep apnea is not listed.  

Inasmuch as sleep apnea is not among the diseases listed in 38 C.F.R. § 3.309(e) (determined to be related to Agent Orange/herbicide exposure), the presumptive provisions of 38 U.S.C.A. § 1116 do not apply, and service connection on a presumptive basis for sleep apnea as due to Agent Orange exposure is not warranted.  The Board observes that extensive scientific studies have produced a limited list of disabilities related to Agent Orange exposure (see 38 C.F.R. § 3.309(e)).  

There is no evidence that sleep apnea was manifested in service or in the initial year following the Veteran's discharge from active duty.  Indeed, the Veteran does not report that his sleep apnea was manifested in service or in the initial year following his discharge from active duty.  Post-service evidence shows that sleep apnea was first diagnosed in January 2007.  As such, service connection for this disability on the basis that it became manifest in service and persisted is not warranted.  

What remains for consideration is whether in the absence of manifestation in service and/or post-service recurrence of symptoms, the Veteran's sleep apnea may nonetheless somehow otherwise be related to his service.  The Board notes that he has submitted treatise evidence regarding sleep apnea and PTSD, and in which it was suggested that there was a "possibility" of a connection between sleep-disordered breathing and PTSD.  The Board finds such language is significant due to its speculative nature.  See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (holding that medical evidence that is speculative, general, or inconclusive cannot be used to support a claim).  Hence, the Board finds that the probative value of the treatise evidence submitted by the Veteran is of limited probative value.  In contrast, the April 2012 VA examiner opined that the Veteran's sleep apnea was less likely than not proximately due to or the result of his service-connected PTSD, noting that review of medical literature makes it clear that PTSD does not cause or aggravate sleep apnea.  Such opinion was provided after review of the Veteran's claims file, medical literature, and the submitted treatise evidence, and by a professional competent to opine as to the etiology of his sleep apnea.  On this basis, the Board finds that the April 2012 VA examination opinion is the most probative evidence of record, and is against the Veteran's claim for service connection for sleep apnea.  

While the Veteran is competent to report that he had sleep problems he is not competent to diagnose sleep apnea, a diagnosis that is based on the results of diagnostic testing, or opine as to the etiology of the disorder.  See Jandreau, 492 F.3d at 1377 n.4.  Thus, the Veteran's and his attorney's assertions are not competent or sufficient.  

The weight of the competent medical evidence demonstrates that the Veteran's sleep apnea began many years after his active service, was not caused by any incident of service, and is not proximately due to or the result of his service-connected PTSD.  The Board thus finds that the preponderance of the evidence is against service connection, that is, neither direct nor secondary service connection for sleep apnea is warranted.  

Psoriasis

The Veteran asserts that his psoriasis is related to his active duty service, to include as secondary to his service-connected PTSD.  

The Veteran's service treatment records are silent for complaints, findings, treatment, or diagnosis for psoriasis or skin problems, including on March 1969 and March 1980 service separation examination.  

On May 1969 VA examination, physical examination of the skin was found to be clear.  

Post-service evidence includes VA treatment records showing in a July 2000 primary care report the Veteran was a new patient and his skin was manifested by lichenified areas (scaly/irritated), and that his past medical history included psoriasis.  The assessment was psoriasis and he was issued ointment and referred to dermatology.  A January 2002 primary care report noted the Veteran's complaint of psoriasis.  It was also indicated that he was non-compliant with follow-ups.  A November 2002 orthopedic consult report found on physical examination the Veteran had psoriasis on both lower extremities, about the knee and proximal thighs.  

The instant claim for psoriasis was received in October 2007.  

Private treatment records from the Water's Edge Dermatology from May to November 2007 document treatment for psoriasis located all over the Veteran's body.  

In June 2008, the Veteran submitted treatise evidence consisting of a couple of medical abstracts.  In one abstract, it was noted that recent findings, indicating that victims of PTSD have higher circulating T-cell lymphocytes and lower cortisol levels, suggest that chronic sufferers of PTSD may be at risk for autoimmune diseases.  The association between chronic PTSD in a sample of a couple thousand Vietnam veterans and the prevalence of common autoimmune diseases, including psoriasis, was assessed in the abstract.  The analysis suggested that chronic PTSD was associated with all of identified autoimmune diseases, including psoriasis.  The other abstract analyzed the potential role of hypocortisolism in the pathophysiology of PTSD and psoriasis.  

In a July 2008 letter by M.J. Leach, PA-C, it was noted he had been treating the Veteran for psoriasis for approximately five years that has included several topical and oral medications.  It was related that the psoriasis was having a large negative impact on his overall emotional well-being, causing a significant amount of stress and unhappiness to his life.  

VA treatment records from June 2008 to April 2009 note the Veteran's complaint of psoriasis.  

On April 2012 VA skin diseases examination, it was noted the Veteran has had psoriasis since 1987 (i.e., 7 years after his discharge from service).  The examiner noted the treatment history of the disease, conducted a physical examination of the Veteran (which revealed the psoriasis affected approximately less than 5 percent of his total body area and exposed areas).  After a review of the claims file, it was opined that the Veteran's psoriasis was less likely than not incurred in or caused by his service, noting that the Veteran stated that his psoriasis developed in 1987 and his service medical records are silent for psoriasis.  It was also opined that the Veteran's psoriasis was less likely than not proximately due to or the result of his service-connected PTSD.  The examiner noted that the treatise evidence submitted by the Veteran was reviewed, along with general literature on the subject.  While there is some limited literature of a "possible" association between psoriasis and PTSD, the bulk of the literature does not support such an association (emphasis added).  The examiner emphasized that there is a difference between "association" and "cause and effect."  The examiner concluded that "[t]here is absolutely no literature supporting a cause and effect relationship of PTSD causing or aggravating psoriasis."  

As noted above, certain diseases may be service connected on a presumptive basis as due to herbicide (Agent Orange) exposure if manifested in a veteran who served in the Republic of Vietnam during the Vietnam era, based on presumptive exposure to certain herbicide exposure.  38 U.S.C.A. § 1116.  Those diseases are listed in 38 C.F.R. § 3.309(e); psoriasis is not listed.  

Inasmuch as psoriasis is not among the diseases listed in 38 C.F.R. § 3.309(e) (determined to be related to Agent Orange/herbicide exposure), the presumptive provisions of 38 U.S.C.A. § 1116 do not apply, and service connection on a presumptive basis for psoriasis as due to Agent Orange exposure is not warranted.  The Board observes that extensive scientific studies have produced a limited list of disabilities related to Agent Orange exposure (see 38 C.F.R. § 3.309(e)).  

There is no evidence that psoriasis was manifested in service or in the initial year following the Veteran's discharge from active duty.  Indeed, the Veteran does not appear to be alleging that his psoriasis was manifested in service or in the initial year following his discharge from active duty.  The earliest evidence of psoriasis in the medical evidence is July 2000.  Nonetheless, the Veteran reported on April 2012 VA skin diseases examination that his psoriasis began in 1987, or approximately 7 years after his discharge from active service.  The Board has no reason to question the credibility of the Veteran's account of when his psoriasis began.  Such is evidence though that service connection for this disability on the basis that it became manifest in service and persisted is not warranted.  

What remains for consideration is whether in the absence of manifestation in service and/or post-service recurrence of symptoms, the Veteran's psoriasis may nonetheless somehow otherwise be related to his service.  The Board notes that the Veteran has submitted treatise evidence regarding psoriasis and PTSD, and in which it was noted that chronic PTSD was "associated" with psoriasis.  The Board finds such language is significant due to its speculative nature.  See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (holding that medical evidence that is speculative, general, or inconclusive cannot be used to support a claim).  Hence, the Board finds that the probative value of the treatise evidence submitted by the Veteran is of limited probative value.  In contrast, the April 2012 VA skin diseases examiner opined that the Veteran's psoriasis was less likely than not proximately due to or the result of his service-connected PTSD.  The examiner noted that there was no literature supporting a cause and effect relationship of PTSD causing or aggravating psoriasis.  Such opinion was provided after review of the Veteran's claims file, medical literature, and the submitted treatise evidence, and by a professional competent to opine as to the etiology of the Veteran's psoriasis.  On this basis, the Board finds that the April 2012 VA skin diseases examination opinion is the most probative evidence of record, and is against the claim for service connection for psoriasis.  

While the Veteran is competent to report that he had skin problems since 1987 he is not competent to diagnose psoriasis or opine as to the etiology of the disorder.  See Jandreau, 492 F.3d at 1377 n.4.  

The weight of the competent medical evidence demonstrates that the Veteran's psoriasis began many years after his active service, was not caused by any incident of service, and is not proximately due to or the result of his service-connected PTSD.  The Board therefore concludes that the preponderance of the evidence is against service connection, which is neither direct nor secondary service connection for psoriasis is warranted.  


Higher Rating Claims

Disability evaluations are determined by the application of a schedule of ratings, which 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.  The percentage ratings in VA's Schedule for Rating Disabilities (Rating Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations.  38 C.F.R. § 4.1.  

Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.  When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant.  38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3.  

Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern.  See Francisco v. Brown, 7 Vet. App. 55 (1994).  However, "staged" ratings are appropriate where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings.  See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999).  

Right Knee Disability

For the period prior to June 9, 2009, the Veteran's service-connected right knee disability was rated under Diagnostic Codes 5010-5260 (for degenerative arthritis and limitation of flexion).  

When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria.  See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995).  The Court clarified that although § pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded.  See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991).  

Instead, the Court in Mitchell explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing.  See 38 C.F.R. §§ 4.40, 4.45.  Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above.  In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors.  

The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record.  Burton v. Shinseki, 25 Vet. App.1 (2011).  

Historically, the Veteran incurred an open wound of the right knee in Vietnam in May 1967 from combat.  A July 1969 rating decision granted service connection for residuals of a shell fragment wound (SFW), right knee with retained foreign bodies, and assigned a 10 percent disability rating effective from April 3, 1969.  The 10 percent rating for residuals of a SFW, right knee with retained foreign bodies has been in effect well in excess of 20 years, and is "protected" (i.e., it may not be reduced).  See 38 C.F.R. § 3.951(b).  

The Veteran reports that his right knee disability is manifested by symptoms of chronic pain, giving way, stiffness, crepitus, weakness, and locking.  The evidence shows that his right knee symptoms include instability and degenerative changes.  Therefore, the Board finds that it is more appropriate to rate the Veteran's right knee disability under Diagnostic Codes 5257 and 5003 for the period prior to prior to June 9, 2009.  See Butts v. Brown, 5 Vet. App. 532 (1993) (choice of diagnostic code should be upheld if it is supported by explanation of evidence).  

Under Diagnostic Code 5257, slight recurrent subluxation or lateral instability warrants a 10 percent evaluation.  A 20 percent evaluation requires moderate recurrent subluxation or lateral instability, and a 30 percent evaluation is warranted for severe subluxation or lateral instability.  38 C.F.R. § 4.71a, Diagnostic Code 5257.  The words "slight," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities.  Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just."  38 C.F.R. § 4.6.  

Degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved.  38 C.F.R. § 4.71a, Diagnostic Code 5003.  When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003.  Id.  Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.  Id.  

The diagnostic codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 and 5261.  Normal range of motion of the knee is extension to zero degrees and flexion to 140 degrees.  See 38 C.F.R. § 4.71a, Plate II.  

Under Diagnostic Code 5260, a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees.  See 38 C.F.R. § 4.71a, Diagnostic Code 5260.  

Under Diagnostic Code 5261, a noncompensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees.  38 C.F.R. § 4.71a, Diagnostic Code 5261.  

In VAOPGCPREC 23-97, the General Counsel held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257 and that evaluation of a knee disability under both of these codes would not amount to pyramiding under 38 C.F.R. § 4.14 (2007).  VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63,604 (1997).  A separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59 and DC 5003.  VAOPGCPREC 9-98 (1998).  VA's General Counsel has also held that separate ratings are also available for limitation of flexion and limitation of extension under DCs 5260 and 5261.  VAOPGCPREC 9-2004 (2004). 

As noted above, the Veteran is currently in receipt of a 10 percent disability rating for the period prior to June 9, 2009.  Following a review of the record, the Board finds that there is sufficient evidence as to warrant the assignment of a separate 10 percent disability rating for right knee instability throughout the appeal period.  See 38 C.F.R. § 4.71a, Diagnostic Code 5257.  

The instant claim for an increased rating for the right knee disability was received in October 2007.  

For the purposes of clarity, the Board notes that VA treatment records show that the Veteran was fitted for a right knee brace in November 2002.  

VA treatment records include an August 2007 orthopedic consult report that found on physical examination the Veteran had diffuse pain to palpation throughout both knees, more significantly on the medial joint line.  His ligaments were stable, but crepitus was appreciated.  There was no significant effusion appreciated in either knee.  June 2007 x-rays revealed arthritic changes, right knee worse than the left knee.  The impression was bilateral knee degenerative joint disease.  Knee braces were ordered for both knees.  

On March 2008 VA joints examination, the Veteran complained of progressively worsening bilateral knee pain.  He related he has right knee pain, giving way, stiffness, weakness, episodes of locking (daily or more often), and flare-ups every 3 to 4 months, lasting for hours in duration.  He denied any instability, incoordination, effusion, inflammation, or episodes of dislocation or subluxation.  He reported his flare-ups are precipitated by going upstairs or downstairs and prolonged walking and standing; his flare-ups are alleviated by a heating pad in addition to medication.  He indicated he is unable to stand for more than a few minutes or walk for more than a few yards.  On physical examination, the Veteran's gait was normal and there was no evidence of abnormal weight bearing.  There was evidence of crepitus and guarding of movement.  There was no evidence of clicking or snapping, instability, or patellar or meniscus abnormality.  Range of motion studies revealed flexion to 120 degrees and extension to 0 degrees.  There was no evidence of pain following repetitive motion or additional limitations after repetitive range of motion.  X-rays revealed bilateral degenerative changes, more pronounced on the right, as well numerous shrapnel fragments.  

In July 2008 correspondence, the Veteran reported that his knees lock-up and that his balance is bad, resulting in occasional falls.  He also indicated difficulty with stairs, and reported he is unable to do any kind of running.  

VA treatment records note the Veteran's complaint of right knee pain, instability, and reflect his treatment included injections for relief of his symptoms.  On June 9, 2009, the Veteran underwent right total knee arthroplasty.  

On September 2010 VA joints examination the Veteran reported he has been asymptomatic since the right total knee arthroplasty in June 2009.  He did relate that he experiences right knee pain and swelling, and flare-ups every 3 to 4 months, of mild severity, lasting 1 to 2 days.  The flare-ups are precipitated by prolonged driving and alleviated by elevating his leg.  He related he is only able to stand for 10 minutes and walk 150 feet.  He occasionally uses a cane for mobility.  On physical examination, the Veteran's gait was normal and there was no evidence of abnormal weight bearing.  There was evidence of crepitation.  There was no evidence of clicking or snapping, grinding, weakness, instability, patellar or meniscus abnormality, or other knee abnormalities.  Range of motion studies revealed flexion to 120 degrees and extension to 0 degrees.  There was evidence of pain following repetitive motion, but there was no additional limitations after repetitive range of motion testing.  There was no evidence of joint ankylosis.  

On April 2012 VA knees and lower leg conditions examination, the Veteran reported he has occasional right knee pains.  Range of motion studies revealed flexion to 130 degrees and extension to 0 degrees, with no limitation of motion following repetitive use testing.  However, it was noted he has less movement than normal after repetitive use.  There was no tenderness or pain on palpation of the right knee.  Muscle strength testing was normal (5/5) on flexion and extension.  Joint stability testing was also normal.  There was no evidence of recurrent patellar subluxation or dislocation.  The diagnosis was osteoarthritis of the right knee.  

For an increase based on limitation of motion, the evidence must minimally establish that the Veteran's right knee disability is manifested by flexion limited to 45 degrees (Diagnostic Code 5260), and/or by extension limited to 10 degrees (Diagnostic Code 5261).  Following a review of the record, the Board finds that an increase based upon limitation of motion of the right knee is not met.  At no point during the period prior to June 9, 2009 is the Veteran's right knee flexion shown to be less than 120 degrees, or extension shown to be other than normal (i.e., to zero degrees) (even with consideration of pain on range of motion testing, and after repetitive range of motion testing).  Such findings do not meet the criteria for an increased rating under either Diagnostic Code 5260 or Diagnostic Code 5261.  Notably, there is no other evidence of record other than that listed above for the period prior to June 9, 2009 providing range of motion findings so as to warrant consideration under Diagnostic Codes 5260 and 5261.  

In considering the applicability of other diagnostic codes, the Board notes that the Veteran is entitled to a separate 10 percent disability rating for slight instability of the right knee throughout the appeal period prior to June 9, 2009.  The evidence shows that the Veteran has complained of right knee instability throughout the appeal period for the period prior to June 9, 2009.  While such has not been objectively found on physical examination, the Board does not question the Veteran's credibility as to the instability he reports in his right knee.  As instability is something as to which the Veteran is personally able to report and experience, the Board also finds him competent to report his instability.  Moreover, his account is consistent with the prescription of a knee brace, which in and of itself is suggestive of some instability in the right knee.  Therefore, the Board finds that it is appropriate to assign a separate 10 percent disability rating, but no more, for the Veteran's right knee instability throughout the appeal period for the period prior to June 9, 2009.  

In an effort to afford the Veteran the highest possibility disability rating for his right knee disability, the Board has considered the disability under all other potentially appropriate diagnostic codes.  The Veteran has never demonstrated or been diagnosed with ankylosis of the right knee, dislocated semilunar cartilage, symptomatic removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum (hyperextended knee).  Therefore, 38 C.F.R. § 471a, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 are not applicable.  

In sum, the Board finds that the preponderance of the evidence is against a disability rating greater than a 10 percent limitation of motion (as compensable limitation of motion has not been shown, but there is evidence of arthritis) and a separate rating of 10 percent for right knee instability for the period prior to June 9, 2009.  

For the period from August 1, 2010, the Veteran's right knee disability is rated 30 percent disabling under Codes 5010-5055.  Under Code 5055 (for knee replacement (prosthesis)), a 100 percent rating is to be assigned for 1 year following implantation of the prosthesis.  With chronic residuals consisting of severe painful motion or severe weakness in the affected extremity a 60 percent rating is warranted.  Intermediate degrees of residual weakness, pain or limitation of motion are to be rated by analogy to Codes 5256, 5261, or 5262.  The minimum rating is 30 percent.  38 C.F.R. § 4.71a.  

To warrant an increased rating, the Veteran has to show either chronic residuals of severe motion limitation or weakness (which would warrant a 60 percent rating under Code 5055) or that he has impairment warranting an intermediate level of disability (40 or 50 percent) under Codes 5256, 5261, or 5262.  

A 40 percent rating under Code 5261 is warranted where extension is limited to 30 degrees.  However, on September 2010 and April 2012 VA examination, range of motion studies revealed extension to 0 degrees (i.e., normal).  In addition, on September 2010 and April 2012 VA examination, there was no additional limitation of motion noted due to repetitive range of motion testing (although the April 2012 examination report did note the Veteran's complaints of increasing pain/less movement than normal with repetitive use testing.  Therefore, even when considering DeLuca criteria of functional impairment and viewed in a light most favorable to the Veteran,  a rating in excess of 30 percent under Code 5261 is not warranted.  

As was previously noted, the Veteran's right knee is not ankloysed, and he is not shown to have malunion or nonunion of the tibia or fibula; consequently, an intermediate rating under Codes 5256 or 5262 is not warranted.  

What remains for consideration is whether the next higher (60 percent) rating under Code 5055 is warranted.  September 2010 VA examination found that flexion was limited to 120 degrees, April 2012 VA examination found that flexion was limited to 130 degrees.  Notably, September 2010 VA examination found no evidence of weakness or instability nor was weakness or instability/giving way of the right knee alleged.  In addition, the April 2012 VA examiner found that joint stability testing was normal for the right knee.  None of the findings reported reflect severe painful motion or weakness (even with consideration of limitation of function and motion on repetitive use).  Consequently, a 60 percent rating under Code 5055 is not warranted for the period from August 1, 2010.  

Separate Rating for Scar of Right Knee

The Veteran also seeks a separate rating for his scar related to his service-connected right knee disability.  

The Board notes that the criteria for rating skin disability were revised, effective October 23, 2008.  73 Fed. Reg. 54,708 (Sept. 23, 2008).  The new criteria apply "to all applications for benefits received by VA on or after October 23, 2008" and that a Veteran rated under the skin criteria in effect prior to that date may request review under the clarified criteria.  As neither the Veteran nor his attorney has requested such review, and his claim was received prior to October 23, 2008, it is not necessary to consider the revised criteria.  

Scars, other than those on the head, face, or neck, are rated under 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805.  

A 10 percent rating is authorized for scars other than the head, face, or neck, that are deep or that cause limited motion if the area or areas exceed 6 square inches (39 sq. cm).  A deep scar is one associated with underlying soft tissue damage.  38 C.F.R. § 4.118, Diagnostic Code 7801.  

A 10 percent rating is authorized for superficial scars that do not cause limited motion that encompass an area or areas of 144 square inches (299 sq. cm.) or greater.  38 C.F.R. § 4.118, Diagnostic Code 7802.  A note following Diagnostic Code 7802 provides that a superficial scar is one not associated with underlying soft tissue damage.  

A 10 percent rating is authorized for superficial, unstable scars.  38 C.F.R. § 4.118, Diagnostic Code 7803.  A note following Diagnostic Code 7803 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of the skin over the scar.  

Under Diagnostic Code 7804, a 10 percent rating is authorized for superficical scars that are painful on examination.  38 C.F.R. § 4.118.  

Diagnostic Code 7805 provides that other scars will be rated on limitation of motion of the affected part.  38 C.F.R. § 4.118.  

In every instance where the schedule does not provide a 0 percent evaluation for a diagnostic code, a 0 percent rating shall be assigned where the requirements for a compensable rating are not met.  38 C.F.R. § 4.31.  

As noted above, the Veteran's service treatment records show that the Veteran incurred an open wound of the right knee in Vietnam in May 1967 from combat.  

On December 2007 VA scars examination, the examiner indicated that the Veteran's right knee scar was located medial to the patella above the medial condyle, and measured 3x12 cm.  There was no tenderness on palpation, adherence to underlying tissue, skin ulceration or breakdown over the scar, or limitation of motion or loss of function.  There was underlying soft tissue damage.  

On April 2012 VA examination, the examiner noted the Veteran had no scar of the extremities that was painful or unstable with frequent loss of covering of the skin over the scar.  The examiner found there was a vertical scar measuring 22cm, running from above the midline knee and down medially around the knee and traveling back to the midline.  It was also found that the scar does not result in limitation of function, and that there were no other pertinent physical findings, complications, conditions, signs and/or symptoms associated with the scar.  The examiner also opined that the scar had no impact on his ability to work.  

The Board has considered whether there is any schedular basis for granting a compensable rating for the Veteran's service-connected residual scar of the right knee, but has found none.  In particular, there is no medical evidence that the scar is unstable, painful, or causes limitation of motion.  Moreover, while the scar appears to be deep, there is no evidence that it encompasses an area of 6 square inches (39 sq. cm) or greater.  See Diagnostic Codes 7801-7804.  Although the Veteran has complained of a painful right knee, there is no indication that such pain is due to the right knee scar, but rather has been attributed to his service-connected right knee disability.  There has no finding of limitation of function or pain on examination.  Therefore, a compensable rating under Code 7805 would be inappropriate.  

In sum, the Board finds that a compensable rating is not warranted in this case.  In reaching this determination, the Board has considered the December 2007 and April 2012 VA examination reports which were based on physical examinations and contain sufficient information such that the Board is able to render an informed determination.  Further, the Veteran did not demonstrate pain when the examiners manipulated his scars on objective examination.  Higher evaluations are not warranted for any period of time that is covered by this appeal.  See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999).  

PTSD

PTSD is rated under 38 C.F.R. § 4.130, Code 9411 (General Rating Formula for Mental Disorders (General Formula)), which provides for a 50 percent rating 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 command; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships.  Id.  

To warrant a 70 percent rating, the evidence must show 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); and inability to establish and maintain effective relationships.  Id.  

A 100 percent rating is warranted when the evidence shows 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.  Id.  

Ratings are assigned according to the manifestation of particular symptoms.  However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating.  Mauerhan v. Principi, 16 Vet. App. 436 (2002).  When determining the appropriate disability evaluation to assign, however, the Board's "primary consideration" is the veteran's symptoms.  Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013).

When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of all psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission.  38 C.F.R. § 4.126(a).  The rating agency shall assign an evaluation 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.  However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment.  38 C.F.R. § 4.126(b).  

The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness."  Richard v. Brown, 9 Vet. App. 266, 267 (1996).  A score of 41 to 50 is assigned where there are "[s]erious 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).  DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV) 47 (4th ed. 1994).  A score of 51 to 60 is appropriate where there are "[m]oderate 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)."  Id.  

It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances.  38 C.F.R. § 4.21.  

The Veteran's service-connected PTSD is rated 50 percent from October 13, 2007, and 70 percent from June 12, 2008.  

Following a review of the relevant evidence of record, which includes VA treatment and Social Security Administration records, private treatment records, the Veteran's lay statements, lay statements by his spouse, and VA examination reports dated in December 2007 and August 2012, the Board concludes that the Veteran's PTSD warrants an initial rating of 70 percent, but no higher, effective October 13, 2007.  

The Board finds that, for the entire appeal period, the Veteran's PTSD is manifested by occupational and social impairment with deficiencies in most areas due to such symptoms as nightmares, anxiety and depression, difficulties with concentration, inappropriate behavior, obsessive and ritualistic behavior, irritability, suicidal ideation, recurrent and intrusive distressing recollections and dreams of service, effects to avoid thoughts, feelings or conversations associated with his service trauma, efforts to avoid activities, places or people that arouse recollections of the trauma, markedly diminished interest or participation in significant activities, feeling of detachment or estrangement from others, restricted range of affect, sense of foreshortened future, exaggerated startle response, without more severe manifestations that more nearly approximate total occupational and social impairment.  

The Board finds that the Veteran's overall disability picture since the date of service connection has been more severe than that contemplated by a 50 percent rating.  A 50 percent rating is awarded for PTSD that is manifested by occupational and social impairment with reduced reliability and productivity.  

Based on the evidence of record, the Board finds that the Veteran's PTSD results in occupational and social impairment with deficiencies in most areas.  Such finding is supported by the December 2007 VA examination report wherein the examiner opined that the Veteran appears to be displaying serious symptoms and serious impairment in social and industrial adaptive functioning.  Moreover, the examiner assigned a GAF score of 50, reflecting serious symptoms or serious impairment in social, occupational, or school functioning.  Notably, such GAF score was also assigned on August 2012 VA examination report, reflecting that his PTSD symptoms and impairment have been consistent throughout the appeal period.  

The Veteran does not demonstrate all of the symptoms listed in the criteria for a 70 percent disability rating for PTSD.  However, the listed symptoms are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating.  Mauerhan, 16 Vet. App. at 442.  

Conversely, the Board finds that the symptoms do not more nearly approximate a rating in excess of 70 percent under the General Rating Formula as they are not of such severity or frequency to result in total occupational and social impairment.  The Board did not find any of the criteria for a 100 percent rating, nor is there any evidence or medical opinion that the Veteran has deficiencies in most areas or is totally occupationally and socially impaired.  

With respect to the criteria for a 100 percent rating, the Board notes that there is no evidence of persistent delusions or hallucinations, disorientation to time or place, or intermittent inability to perform activities of daily living.  On December 2007 and August 2012 VA examinations, and in the Veteran's VA treatment records, the Veteran denied all such symptoms, and there was no evidence the Veteran was not fully oriented or was unable to perform activities of daily living.  

The record also reflects that the Veteran does not have gross impairment in thought processes or communication.  In this regard, the Board notes that on both VA examinations, the Veteran was noted to have problems with concentration, and on December 2007 VA examination, it was indicated that his thoughts are poorly organized at times, as reflected by word finding problems, difficulties with complex concept formation, difficulties with distractibility.  However, such findings are not consistent with gross impairment in thought processes or communication, and there is no opinion that such difficulties approximate or are consistent with gross impairment in thought processes or communication.  

In addition, the record also does not show the Veteran's PTSD symptoms are manifested by grossly inappropriate behavior.  On December 2007, it was noted that the Veteran's symptomatology included some inappropriate behavior, as reflected by his need to keep the curtains closed at his home.  However, such does not reflect grossly inappropriate behavior, and there is no opinion that his symptomatology is manifested by behavior rising to the level of severity as to be characterized as being grossly inappropriate.  

The evidence also does not show the Veteran has a persistent danger of hurting himself or others.  On December 2007 VA examination, the Veteran did report suicidal thoughts, but indicated that they were passive in nature, and there is no evidence of a history of suicide attempts.  The examination report also reflects that he denied having homicidal thoughts and VA treatment records consistently note his denial of suicidal or homicidal ideation.  While there are reports of complaints of irritability and angry outbursts, such have never been reported to be physical.  In this regard, the Board notes that it is aware of the single incident reported in a June 2010 VA telephone report wherein the Veteran related he had an incident about one month earlier when he had a nightmare of being in a fight and strangling a man and woke up with his hands on his wife.  While such an incident may be presented as evidence of danger of hurting others, such is not consistent with the requisite severity of a 100 percent rating, persistent danger of hurting self or others.  

In addition, the evidence does not show memory loss for names of close relatives, own occupation, or own name.  On October 2007 VA examination, the examiner found the Veteran had mildly impaired memory loss, as manifested by forgetting names, where he puts things, who he is trying to contact, directions, or to pick up items at the store.  VA treatment records also show complaints of some memory problems.  And on August 2012 VA examination, the Veteran reported short-term memory problems, indicating that he recently forgot the name of his orthopedic doctor.  Moreover, the evidence also shows that in April 2008, he was reprimanded for his work performance, and such reflects that he was having difficulties with locators (used to connect all locate equipment conductively), and most recently had failed to follow established procedures, resulting in damaged equipment, as well as the risk of danger to other employees.  Such evidence shows that the Veteran clearly has some memory problems.  However, there is no evidence that such has risen to the level of severity such that he forgets his own name, his occupation, or the names of close relatives.  

The Board has also considered the GAF scores assigned during the pendency of the Veteran's appeal.  In particular, the Board notes that the Veteran has been assigned GAF scores ranging from 45 to 50 in VA treatment records.  Notably, scores as low as 45 reflect serious symptoms or serious impairment in social, occupational, or school functioning, consistent with the currently assigned 70 percent rating for the Veteran's PTSD.  In addition, the scores of 45 and others below 50 are consistent with the GAF scores of 50 assigned on VA examinations in December 2007 and August 2012.  

In sum, the Board finds that the Veteran is entitled to a rating of 70 percent, but no higher, for his PTSD.  The preponderance of the evidence is against the assignment of any higher rating at any point during this appeal.  38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).  


Bilateral Hearing Loss

The VA Schedule for Rating Disabilities (Rating Schedule) provides a table for rating purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, based on testing (by a state-licensed audiologist) including puretone thresholds and speech discrimination (Maryland CNC test).  See 38 C.F.R. § 4.85.  Where there is an exceptional pattern of hearing impairment (as defined in 38 C.F.R. § 4.86), the rating may be based solely on puretone threshold testing.  See 38 C.F.R. § 4.85, Table VIa.  One exceptional pattern of hearing impairment occurs when the puretone thresholds in each of the four frequencies (1000, 2000, 3000, and 4000 Hertz) are 55 decibels or greater.  38 C.F.R. § 4.86(a).  Another pattern occurs when the puretone threshold at 1000 Hertz is 30 decibels or less, and the threshold at 2000 Hertz is 70 decibels or more.  38 C.F.R. § 4.86(b).  Table VII is used to determine the rating assigned by combining the Roman numeral designations for hearing impairment in each ear.  Ratings for hearing impairment are derived by the mechanical application of the Rating Schedule to the numeric designations assigned after audiometry evaluations are rendered.  Lendenmann v. Principi, 3 Vet. App. 345 (1992).  

The Veteran contends that his hearing loss is more severe than the noncompensable (0 percent) rating currently assigned and believes that a higher rating should be assigned.  

Historically, a July 2003 rating decision granted service connection for bilateral hearing loss and assigned a noncompensable (0 percent) rating, effective January 25, 1996.  The instant claim for increase was received in October 2007.  

On December 2007 VA audiological evaluation, puretone thresholds, in decibels, were: 




HERTZ


	

1000
2000
3000
4000
RIGHT

10
40
75
70
LEFT

15
50
80
80

The average puretone thresholds were 49 decibels in the right ear and 56 in the left ear.  Speech audiometry revealed speech recognition ability of 92 percent bilaterally.  The Veteran reported difficulty understanding conversations in the presence of noise even with use of hearing aids.  The diagnosis was bilateral normal sloping to severe sensorineural hearing loss.  

On August 2010 VA audiological evaluation, puretone thresholds, in decibels, were: 




HERTZ


	

1000
2000
3000
4000
RIGHT

10
40
75
70
LEFT

20
60
80
85

The average puretone thresholds were 49 decibels in the right ear and 61 decibels in the left ear.  Speech audiometry revealed speech recognition ability of 90 percent in the right ear, and 82 percent in the left ear.  The Veteran was noted to have difficulty understanding conversational level speech in most listening environments, especially in the presence of competing noise and in groups, as well as asking speakers for frequent repetitions of their statements.  The diagnosis was bilateral normal to severe sensorineural hearing loss.  

On April 7, 2012 VA audiological evaluation, puretone thresholds, in decibels, were: 




HERTZ


	

1000
2000
3000
4000
RIGHT

10
55
70
70
LEFT

25
70
80
80

The average puretone thresholds were 51 decibels in the right ear and 64 decibels in the left ear.  Speech audiometry revealed speech recognition ability of 90 percent in the right ear, and 86 percent in the left ear.  The Veteran was noted to have difficulty hearing conversations when in crowds, and having to turn up everything to a loud level.  The diagnosis was bilateral sensorineural hearing loss.  

In this case, the audiometric findings during the pendency of this appeal show that the Veteran is warranted an increased 10 percent rating, effective April 7, 2012.  

Applying the results of the December 2007 VA examination to Table VI produces a finding that the Veteran had Level I hearing acuity in the right ear, and Level I hearing acuity in the left ear (warranting a 0 percent rating).  

Applying the results of the August 2010 VA examination to Table VI produces a finding that the Veteran had Level II hearing acuity in the right ear, and Level IV hearing acuity in the left ear (warranting a 0 percent rating).  

Applying the results of the April 2012 VA examination to Table VI produces a finding that the Veteran had Level II hearing acuity in the right ear, and Level III hearing acuity in the left ear (warranting a 0 percent rating).  Applying the results to Table VIa (as there is an exceptional pattern of hearing impairment in the left ear under § 4.86(b)) produces a finding that the Veteran had Level V hearing acuity in the left ear (warranting a 10 percent rating).  

Based on the foregoing, the Board finds that the Veteran is entitled to an increased 10 percent rating, effective April 7, 2012, for his bilateral hearing loss.  As noted above, ratings for hearing impairment are derived by the mechanical application of the Rating Schedule to the numeric designations assigned after audiometry evaluations are rendered.  Lendenmann v. Principi, 3 Vet. App. 345 (1992).  On this basis, the Veteran is entitled to a "staged" increased 10 percent rating, effective April 7, 2012 (the date of VA examination).  To the extent the Veteran seeks a rating in excess of 10 percent, the preponderance of the evidence is against such a claim, and the benefit of the doubt doctrine does not apply.  




Extraschedular Consideration

In exceptional cases an extraschedular rating may be provided.  38 C.F.R. § 3.321.  The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice.  Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009).  

In this case, regarding the Veteran's right knee disability, the Board finds that the rating criteria considered reasonably describe the Veteran's disability level and symptomatology.  Although the March 2008 VA joints examination opined the Veteran's bilateral knee degenerative joint disease had a significant effect on his usual occupation, the September 2010 VA joints examination opined the Veteran's right knee disability general occupational effect was not being employed, the Veteran has not described any unusual or exceptional features associated with his right knee disability that cannot be evaluated under the rating schedule (particularly in light of the fact that this decision awards a separate rating for right knee instability for the period prior to June 9, 2009).  The assigned schedular evaluation for the service-connected right knee disability is therefore adequate to evaluate the disability, and referral for consideration of an extraschedular rating is not warranted.  Thun v. Peake, 22 Vet. App. 111 (2008).  

Regarding the Veteran's residual right knee scar, there is no evidence of any unusual or exceptional features associated with his right knee scar that cannot be evaluated under the rating schedule.  The assigned schedular evaluation for the service-connected right knee scar is therefore adequate to evaluate the disability, and referral for consideration of an extraschedular rating is not warranted.  Id.  

Regarding the Veteran's PTSD, the Board finds that the rating criteria considered in this case reasonably describe the Veteran's disability level and symptomatology.  The Veteran's PTSD is characterized by occupational and social impairment with deficiencies in most areas.  These manifestations are contemplated in the applicable rating criteria.  The Board has carefully compared the level of severity and symptomatology of the Veteran's PTSD with the criteria found in the rating schedule.  In sum, the Board finds that the Veteran has not described functional effects that are exceptional or not otherwise contemplated by the assigned evaluation.  Rather, his descriptions of his PTSD are consistent with the degree of disability addressed by such evaluation.  The rating criteria are therefore adequate to evaluate the Veteran's PTSD and referral for consideration of an extraschedular rating is not warranted.  Id.  

Regarding the Veteran's bilateral hearing loss, the Board notes that the Veteran's attorney raised the argument that he was warranted a 10 percent rating on an extraschedular basis.  However, this decision grants a 10 percent rating on a schedular basis.  In addition, after a review of the evidence and the Veteran's claims file, the medical evidence fails to show anything unique or unusual about the Veteran's bilateral hearing loss.  While the disability undoubtedly causes some impairment, no symptoms have been described that would render the schedular criteria inadequate.  The Board does not find that the Veteran's bilateral hearing loss interferes with his work beyond the interference contemplated by the currently assigned 10 percent rating.  The functional loss noted and self-reported by the Veteran, in essence, difficulty hearing people, needing people to repeat things, and having to turn things up loud, is fully contemplated by the schedular criteria.  See 38 C.F.R. § 4.1.  

In making this determination, the Board is cognizant of the holding of Martinak v. Nicholson, 21 Vet. App. 447, 455-56 (2007).  In that decision, the Court noted that unlike the rating schedule for hearing loss, the extraschedular provisions do not rely exclusively on objective test results to determine whether referral for an extra-schedular rating was warranted.  The Court held that in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report.  Id. at 455.  Here, the April 2012 VA examiner discussed the impact of the Veteran's hearing loss on the ordinary conditions of daily life.  As such, the criteria are not inadequate.  See Thun v. Peake, 22 Vet. App. 111 (2008); see also Martinak.  Therefore, referral for consideration of an extraschedular rating is not warranted.  


ORDER

Service connection for sleep apnea is denied.  

Service connection for psoriasis is denied.  

For the period prior to June 9, 2009, a rating in excess of 10 percent for degenerative joint disease of the right knee is denied.  

For the period prior to June 9, 2009, a separate 10 rating for right knee instability is granted, subject to law and regulations governing the effective date of an award of monetary compensation.  

A compensable rating for right knee scar is denied.  

Effective October 13, 2007, a 70 percent rating is granted for the Veteran's PTSD, subject to law and regulations governing the effective date of an award of monetary compensation.  

Effective April 7, 2012, a 10 percent rating is granted for the Veteran's bilateral hearing loss, subject to law and regulations governing the effective date of an award of monetary compensation.  


REMAND

The Veteran also seeks entitlement to service connection for a bleeding ulcer and erectile dysfunction, claimed as secondary to service-connected PTSD, as well as service connection for a left knee disability, secondary to service-connected right knee disability.  After a review of the claims file, the Board finds that further development is necessary for proper adjudication of the claims.  

As to the Veteran's claim of service connection for a bleeding ulcer, Dr. C.L. Slack treatment records noted the Veteran had a heart attack in 2004, was placed on Plavix, and developed peptic ulcer disease with bleeding.  Martin Memorial Hospital treatment records include December 2005 reports showing he was hospitalized and endoscopy revealed a duodenal ulcer and gastritis.  The diagnosis was GI bleed.  He was instructed to discontinue Plavix.  On April 2012 VA examination, it was noted that the overwhelming body of medical literature indicates that mental stress has not been linked to the development of new peptic ulcers.  Notably, the Veteran is service-connected for coronary artery disease status post myocardial infarction associated with his PTSD.  

The Board finds that the April 2012 VA examination is inadequate because the examiner did not address whether the Veteran's bleeding ulcer was caused by or aggravated by his coronary artery disease.  See Roebuck v. Nicholson, 20 Vet. App. 307, 313 (2006) (multiple theories constitute the same claim if they "pertain to the same benefit for the same disability").  Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one.  Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence ... is essential for a proper appellate decision").  On remand, the Veteran should be afforded another examination to obtain a nexus opinion as to the etiology and onset of his bleeding ulcer, to include as secondary to his service-connected coronary artery disease.  38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79 (2006).  

As to the claim for service connection for erectile dysfunction, the Veteran reported he has had erectile dysfunction for 20 years.  It was noted that his erectile dysfunction appears to have begun well before he started on any mental health medications.  The examiner also indicated that the causes of erectile dysfunction are multifactorial.  The Veteran's inability to obtain any erections the last few years coincides with the initiation of his selective serotonin reuptake inhibitor treatment (presumably for his service-connected PTSD), and while such causes sexual dysfunction, actual erectile dysfunction is rare.  On this basis, the examiner opined that the Veteran's erectile dysfunction was less likely than not (less than 50 percent probability) proximately due to or the result of his service-connected PTSD.  

The Board finds that this opinion is inadequate.  First, the opinion does not appear to address the question of aggravation under 38 C.F.R. § 3.310(b).  Secondly, the examiner's finding that actual erectile dysfunction from selective serotonin reuptake inhibitor treatment is rare leaves unresolved whether in the Veteran's case, it is at least as likely as not his erectile dysfunction is secondary to such treatment and his service-connected PTSD.  On remand, the Veteran should be afforded another examination to obtain a nexus opinion as to the etiology of his erectile dysfunction, to include as secondary to his service-connected PTSD, including consideration of aggravation.  38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79 (2006).  

Finally, as to the claim for service connection for a left knee disability, the Veteran was afforded a VA examination in March 2008.  On March 2008 VA examination, the Veteran was diagnosed with left knee degenerative joint disease.  It was opined that such was less likely as not (less than 50/50 probability) caused by or a result of post-traumatic arthritis right knee.  It was rationalized that he is obese, and the development of degenerative joint disease of the knee is increased in obese patients.   The Board finds that this opinion is inadequate.  Significantly, the opinion does not appear to address the question of aggravation under 38 C.F.R. § 3.310(b).  

In addition, the Board notes that there appears to be outstanding evidence.  On April 2012 VA examination, it was noted the Veteran underwent left total knee replacement in January 2012, records of which are not associated with the claims file.  Any outstanding pertinent VA treatment records as to the remaining matters on appeal should either be made accessible on Virtual VA or be printed and added to the Veteran's claims file.  See 38 C.F.R. § 3.159(c)(2); Bell v. Derwinski, 2 Vet. App. 611 (1992).  

Accordingly, the case is REMANDED for the following action:

1. Obtain and associate with the claims file, physically or electronically, all updated VA treatment records regarding the Veteran's claims for a bleeding ulcer, erectile dysfunction, and a left knee disability, to specifically include all records leading up to, of, and following the January 2012 left total knee replacement surgery.  

2. Contact the Veteran and his attorney and request that they provide sufficient information, and if necessary, authorization, to enable the RO to obtain any additional evidence pertinent to his claims on appeal that are not otherwise of record.  After securing the necessary authorizations for release of this information, the RO should undertake appropriate efforts to attempt to obtain any identified records.  The RO must make at least two requests to any custodian of private records, if relevant, in an effort to obtain such records, unless it is made evident by the first request that a second request would be futile in obtaining such records.  Any negative response should be in writing and associated with the claims file.  All development efforts should be associated with the claims file.  

3. After the above has been completed, the RO should schedule the Veteran for a VA examination to determine the current nature, onset and likely etiology of a bleeding ulcer or gastrointestinal disorder.  The claims file should be made available to and reviewed by the examiner.  All indicated studies should be performed, and all findings should be reported in detail.  

The examiner must provide an opinion as to whether it is at least as likely as not any diagnosed bleeding ulcer or other gastrointestinal disorder is related to or had its onset in service.  

The examiner must also provide an opinion as to whether it is at least as likely as not that any diagnosed bleeding ulcer or other gastrointestinal disorder was caused or aggravated by his service-connected PTSD and/or coronary artery disease status post myocardial infarction associated with his PTSD.  Aggravation is defined for legal purposes as a worsening of the underlying condition versus a temporary flare-up of symptoms.  

The examiner should provide a detailed rationale for any opinion expressed.  If an opinion cannot be rendered without resorting to speculation, the examiner should state why that is so, to include a recitation of any missing facts necessary to render a non-speculative opinion.  

4. The RO should also schedule the Veteran for a VA examination to determine the current nature, onset and likely etiology of his erectile dysfunction.  The claims file should be made available to and reviewed by the examiner.  All indicated studies should be performed, and all findings should be reported in detail.  The examiner must provide an opinion as to whether it is at least as likely as not his erectile dysfunction is related to his psychiatric disability or had its onset in service.  

The examiner must also provide an opinion as to whether it is at least as likely as not that his erectile dysfunction was caused or aggravated, at least in part, by his psychiatric disability, to include consideration of his selective serotonin reuptake inhibitor treatment as noted in the April 2012 VA examination.  Aggravation is defined for legal purposes as a worsening of the underlying condition versus a temporary flare-up of symptoms.  

The examiner should provide a detailed rationale for any opinion expressed.  If an opinion cannot be rendered without resorting to speculation, the examiner should state why that is so, to include a recitation of any missing facts necessary to render a non-speculative opinion.  
		
5. The RO should also schedule the Veteran for a VA joints examination to determine the current nature, onset and likely etiology of his left knee disability.  The claims file should be made available to and reviewed by the examiner.  All indicated studies should be performed, and all findings should be reported in detail.  

The examiner must provide an opinion as to whether it is at least as likely as not his left knee disability is related to or had its onset in service.  

The examiner must also provide an opinion as to whether it is at least as likely as not that his left knee disability was caused or aggravated by his service-connected right knee disability.  Aggravation is defined for legal purposes as a worsening of the underlying condition versus a temporary flare-up of symptoms.  

The examiner should provide a detailed rationale for any opinion expressed.  If an opinion cannot be rendered without resorting to speculation, the examiner should state why that is so, to include a recitation of any missing facts necessary to render a non-speculative opinion.  

6. Then readjudicate the matters remaining on appeal.  If the benefits sought on appeal are not granted in full, issue the Veteran and his attorney a supplemental statement of the case and provide the Veteran and his attorney an opportunity to respond.  

The appellant 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).




______________________________________________
STEVEN D. REISS
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs