Citation Nr: 1334147 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 10-24 986 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to a rating in excess of 10 percent for residuals of a right knee injury with degenerative arthritis, from December 31, 2008, to June 10, 2013, and in excess of 30 percent from June 11, 2013, forward. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his ex-wife ATTORNEY FOR THE BOARD Jeanne Schlegel, Counsel INTRODUCTION The Veteran served on active duty from February 1967 to February 1970, with service in Vietnam from August 1967 to August 1968. This appeal to the Board of Veterans' Appeals (Board) arose from an August 2009 rating decision in which the RO declined to reopen a service connection claim for PTSD, and denied a rating in excess of 10 percent for a right knee disability. In December 2009, the Veteran filed a notice of disagreement. A statement of the case (SOC) was issued in June 2010, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) also in June 2010. In November 2010, the Veteran and a witness testified during a Board video-conference hearing held before the undersigned Veterans Law Judge at the RO; a transcript of that hearing is of record. In November 2010, the Veteran submitted additional evidence, along with a waiver of the Veteran's right to have this evidence initially considered by the RO. See 38 C.F.R. §§ 20.800, 20.1304 (2012). This case was previously before the Board in March 2013, at which time the Board reopened the previously-denied claim for service connection for PTSD ,and remanded the merits claim for development. The increased rating claim for a right knee disability was also remanded for additional evidentiary development at that time. An October 2013 review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. For purposes of clarification, it appears that Disabled American Veterans has been the Veteran's representative, as appointed in December 2012. The service connection claim for PTSD, is addressed in the remand following the order; and is being remanded to the RO, via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran when further action, on his part, is required. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim herein decided have been accomplished. 2. For the period extending from December 31, 2008, to March 4, 2013, the Veteran's service-connected right knee condition was manifested by findings of arthritis with pain, but without: additional limitation of motion due to pain; weakness, incoordination or fatigue so as to limit flexion to 30 degrees or less or limit extension to 15 degrees or more; recurrent subluxation or instability; or frequent episodes of locking and effusion into the joint. 3. For the period from March 5, 2013 forward, extension of the right knee has been shown as limited to between 20 and 29 degrees, but has not been limited to 30 degrees or greater; a separate rating for a knee scar has been granted. 5. The schedular criteria are adequate to rate the right knee disability under consideration at all pertinent points. CONCLUSIONS OF LAW 1. For the appeal period extending from December 31, 2008, to March 4, 2013, the criteria for a rating in excess of 10 percent for residuals of a right knee injury, with degenerative arthritis, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.71a, 5010, 5257, 5260, 5261, 5262 (2013). 2. For the appeal period extending from March 5, 2013 forward, the criteria for a 30 percent rating, but no greater, for residuals of a right knee injury, with degenerative arthritis, are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.71a, 5010, 5257, 5260, 5261, 5262 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2013)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353-23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. With respect to the increased rating claims generally, the VCAA requirement is generic notice, that is, 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 general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. Sept. 4, 2009). A March 2009 letter set forth the schedular criteria for a higher rating for the Veteran's right knee disability. After issuance of that notice, and opportunity for the Veteran to respond; a June 2010 SOC and July 2013 Supplemental SOC (SSOC) reflects readjudication of the increased rating claim. Hence, the Veteran is not shown to be prejudiced by the timing of the notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided. Pertinent medical evidence associated with the claims file consists of service, private, and VA treatment records current to March 2013, and VA examination reports of March 2009 and June 2013. Also of record and considered in connection with the appeal are various statements provided by the Veteran and his representative, on his behalf, and November 2010 Board video conference hearing testimony. Further, there has been substantial compliance with the actions requested in prior Board Remand of March 2013. See also D'Aries v. Peake, 22 Vet. App. 97 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board's remand directives is required). In this regard, a VA examination was recently conducted in June 2013, the report of which is on file. The appellant and his representative have not maintained that the 2012 VA examination was in any way inadequate. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011), (in the absence of a challenge to the adequacy of the examination, the Board is not required to explicitly explain why each medical opinion is adequate). The Board also finds that no additional RO action to further develop the record prior to appellate consideration, is warranted. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO, the Veteran has been notified and made aware of the evidence needed to substantiate the increased rating claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matters herein decided, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Factual Background Service connection for right knee disability was initially established in an August 1998 rating action, for which a 10 percent evaluation was assigned effective from January 1998. On December 31, 2008, the Veteran filed an increased rating claim for his right knee disability. A VA examination of the joints was conducted in March 2009. A history of a right knee injury during service in 1969, sustained while playing football was recorded, with surgery occurring shortly after discharge. The history also revealed that the Veteran had not had any knee treatment since it was last evaluated by VA in February 2004. The Veteran complained of constant, sharp. achy, right knee pain, increased with daily activities. He also reported having manifestations of stiffness, weakness, redness, fatigue, and lack of endurance. The Veteran stated that knee swelling occurred twice a week and indicated that knee locking occurred if the knee was in one position for too long or during sleeping, occurring 2 to 3 times a day and resolving after a couple of minutes with massaging. The report documented symptoms of instability with activities such as climbing a ladder or stairs, but reflected that the Veteran did not complain of flare-ups and did not use assistive devices. On examination, gait was mildly antalgic, slowly decreasing with ambulation. The Veteran reported having tenderness along the joint line. There were o indications of: swelling; redness; or obvious deformities. Crepitus was present on active and passive motion. The Veteran did not perform Lachman's, drawer, or McMurray's testing, secondary to concerns of possible pain. The Veteran was able to perform range of motion tests from 0 to 100 degrees, repetitively, with reports of slight pain at the extremes, and no greater pain, weakness, fatigue, decreased endurance, or limitation of motion, with repeated tests. The examiner indicated that range of motion lacked 40 degrees of full extension, with pain as the limiting factor. Degenerative arthritis of the right knee, confirmed by X-ray films, was diagnosed. The Veteran presented testimony at a Board video conference hearing held in November 2010. He mentioned that in colder weather the knee was more painful and swelled more often. He also stated that that the knee had recently given way and that he had nearly fallen. The transcript reflected that the Veteran often wore a brace provided by VA, which gave support, but did not stop pain. He indicated that the knee condition had become worse since last examined by VA. wearing a The file also contains records and a June 2009 decision from the SSA indicating that the Veteran was found to be disabled from December 1997 due to a primary diagnosis of PTSD, with no listed secondary diagnosis. The Veteran's VVA file contains records dated from May 16, 2008 to March 5, 2013, and the July 2013 SSOC reflects consideration of those records. The records reflect on-going treatment for the Veteran's right knee disability. An October 23, 2012 orthopedic surgery note mentioned that right knee range of motion is from about 0 to 95 degrees, and it was stable to varus and valgus. A history of medial meniscus removal in the past with varus was noted and it was observed that the knee was in varus alignment secondary to this. Advanced degenerative joint disease was assessed. On November 19, 2012, the Veteran underwent right total knee replacement surgery. A March 5, 2013 record, indicates that about 3-1/2 months out of surgery range of motion was only up to 20-80 degrees. It was noted that the Veteran walked with a cane and had minimal effusion. It was noted that there was no real pain with sitting and walking, just really some sense of instability when he is lying down, and a little bit of difficulty ambulating because of the contractures. A VA examination of the knee was conducted on June 11, 2013 and the claims file was reviewed. Diagnoses of right knee torn medial meniscus with repair and degenerative arthritis, status post right total knee replacement, were made. The Veteran complained of daily pain assessed as 4-7/10, and 10/10 with bending the knee. He reported exercising daily, with swelling thereafter. The Veteran denied having symptoms of locking or giving out, and no evidence of instability was shown on examination. Range of motion testing of the right knee revealed extension of 25 degrees and flexion to 120 degrees, with painful motion reported, but no further limitation on repetitive testing. The report indicated that the following knee symptoms were applicable: less movement than normal; pain on movement; disturbance of locomotion; and crepitus. Muscle strength was 5/5, and various stability tests were normal. The report reflects that there was no history of subluxation or dislocation. It was reported that the Veteran did have a meniscus (semilunar cartilage) condition, which had no associated symptoms. Regular use of a cane and occasional use of a brace were reported. The examiner indicated that the Veteran's knee condition did not impact his ability to work. In a July 2013 rating action, an increased rating of 30 percent was assigned for the right knee disability, effective from June 11, 2013. III. Analysis The Veteran seeks a rating in excess of 10 percent for residuals of a right knee injury with degenerative arthritis, from December 31, 2008, to June 10, 2013, and in excess of 30 percent from June 11, 2013, forward. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). 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). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 506 (2007). In this case, the RO has already awarded staged ratings for the Veteran's right knee disability. Hence, the Board will consider the propriety of the rating at each stage, as well as whether any further staged rating is warranted. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). See also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. For the portion of the period extending from December 31, 2008, to June 10, 2013, the Veteran's right disability was assigned a 10 percent rating under Diagnostic Code 5010; from June 11, 2013 (the effective date of an increased rating) forward, Codes 5010-5261, were used in tandem. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Under DC 5010, traumatic arthritis is rated as degenerative arthritis under DC 5003, which provides that 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-here, for the knee, Diagnostic Codes 5260 and 5261. When, however, the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint (such as the knee) or group of minor joints affected by limitation of motion. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a. Under Diagnostic Code 5260, a noncompensable rating warranted when flexion is limited to 60 degrees; a 10 percent rating is warranted when flexion is limited to 45 degrees. A 20 percent rating is warranted when flexion is limited to 30 degrees. Under Diagnostic Code 5261, a noncompensable rating is warranted when extension is limited to 5 degrees; a 10 percent rating is for assignment when extension is limited to 10 degrees, a 20 percent rating is for assignment when extension is limited to 15 degrees. Normal range of motion of the knee is 0 to 140 degrees of extension to flexion. 38 C.F.R. § 4.71a, Plate II (2013). The VA General Counsel has issued a precedential opinion holding that "separate ratings may be assigned under Diagnostic Code 5260 and Diagnostic Code 5261, where a Veteran has both a limitation of flexion and limitation of extension of the same leg; limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg." See VAOPGCPREC 9-2004 (September 17, 2004). The Board must also consider a Veteran's pain, swelling, weakness, and excess fatigability when determining the appropriate evaluation for a disability using the limitation of motion diagnostic codes. 38 C.F.R. §§ 4.40, 4.45; See Johnson v. Brown, 9 Vet. App. 7, 10 (1996); DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the United States Court of Appeals for Veterans Claims (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); 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 Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40), 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 (38 C.F.R. § 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. Therefore, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2013). Under Diagnostic Code 5257, knee impairment with recurrent subluxation or lateral instability is rated 10 percent when mild and 20 percent when moderate. 38 C.F.R. § 4.71a, Diagnostic Code 5257. In addition, VAOPGCPREC 23-97 provides that a Veteran may be assigned separate ratings for arthritis with limitation of motion under Diagnostic Code 5260 or 5261 and for instability under Diagnostic Code 5257. See VAOPGCPREC 23-97 (July 1, 1997). In VAOPGCPREC 9-98, General Counsel held that if a Veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also X-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. Throughout the pendency of the claim on appeal, there has been evidence of right knee arthritis, as well as painful motion. The Board observes that prior to March 5, 2013, extension was shown as full to 0 degrees, with some limitation of flexion - at worst reported as 80 degrees in March 2013. Range of motion findings made prior to March 5, 2013 did not technically meet the criteria for a noncompensable (i.e., 0 percent) rating under codes 5260 or 5261, much less the requirements for a compensable 10 percent rating under those codes. The range of motion findings do not even arguably meet the criteria for the assignment of a 20 percent rating under codes 5260 or 5261, as the Veteran has no limitation of extension and there was no clinical evidence on file showing that his right knee flexion is limited to 30 degrees. Essentially, a disability rating of 10 percent has been assigned in this case from December 31, 2008, and is warranted in the case in light of evidence indicative of arthritis with painful motion, and functional loss due to pain. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202, 204-08 (1995). Significantly, a VA medical record of March 5, 2013 reveals extension limited to 20 degrees. Such findings were again shown upon VA examination of the knee conducted on June 11, 2013, at which time extension was limited to 25 degrees. Such findings warrant the assignment of a 30 percent evaluation for extension limited to 20 to 29 degrees, as provided under diagnostic code 5261, and to that extent, an earlier effective date for the grant of a 30 percent evaluation in granted, effective from March 5, 2013. However, at no time pertinent to this appeal has extension been limited to 30 degrees or greater, warranting a rating in excess of 30 percent on that basis. Having established that staged ratings of 10 percent, from December 31, 2008, to March 4, 2013; and of 30 percent, from March 5, 2013, forward are warranted, the Board will also address whether any further increase may be warranted. Even giving full consideration to the Veteran's complaints of pain on motion, higher disability ratings are not warranted for the knee disability under 38 C.F.R. §§ 4.40, 4.45, 4.59, and with consideration of the DeLuca and Mitchell factors. No higher compensation is not warranted under these provisions because there is no persuasive evidence of additional functional loss due to pain, weakness, fatigue, or incoordination which would limit motion to such a degree so as to warrant a rating in excess of the currently assigned 10 and 30 percent ratings. VA examinations have reflected that pain was elicited only at the end ranges on flexion. Further, the 2009 and 2013 VA examination found that range of motion remained the same on repetitive testing. Accordingly, the Veteran is already receiving the appropriate amount of compensation for the extent of her limited motion, pain, functional impairment based on the other DeLuca and Mitchell factors. In addition, evidence pertinent to the appeal period does not reflect that the Veteran's right knee disability has been productive of even slight subluxation or instability. When examined in 2013, there was no evidence of recurrent subluxation or dislocation and stability was normal. Unfortunately, stability tests could not be conducted in full during the 2009 examination, providing no basis for increase. Therefore, the Board finds that no higher or additional rating is assignable under Diagnostic Code 5257. Turning to the remaining, potentially applicable diagnostic codes for evaluating knee disability under 38 C.F.R. § 4.71a, the Board finds that no higher rating is assignable. Diagnostic Code 5256 would not apply in this case because the pertinent medical evidence of record has not documented any ankylosis of either knee. With regard to Diagnostic Code 5258 (rating criteria for dislocation of semilunar cartilage with frequent episodes of locking, pain and effusion into the joint), the clinical evidence fails to reveal objective evidence of such manifestations, and the Veteran denied having manifestations of locking on VA examination of June 2013. The Board also points that a separate rating for a right knee scar was granted in a July 2013 rating decision.. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his right knee disability. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal is been more severe than the assigned disability rating reflects. Medical evidence is generally required to address questions requiring medical expertise. Cromley v. Brown, 7 Vet. App. 376, 379 (1995). However, lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). In this regard, the Veteran is generally competent to report his subjective symptoms relating to the knee. Lay reports of symptoms and history associated with the right knee disability have been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. However, the clinical evidence offering detailed, specific, objective determinations pertinent to the rating criteria and manifestations associated with the right knee condition is found to be the most probative and credible evidence with regard to evaluating the pertinent symptoms for the knee disability on appeal. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (personal interest may affect the credibility of the evidence). In sum, for period extending from December 31, 2008, to March 4, 2013, the eight of the evidence supports the continuation of a 10 percent rating or service-connected right knee disability. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). However, an earlier effective date of March 5, 2013, is warranted for the assignment of a 30 percent rating and the benefit sought on appeal is granted to this limited extent. See Hart v. Mansfield, 21 Vet. App. 505 (2007). IV. Final Considerations The above determinations are based on application of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no point since the December 2008 claim for increase has the right knee disability been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321 (cited and discussed in the January 2013 SSOC). The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996). Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, supra. In this case, the Board finds that schedular criteria are adequate to rate the knee disability under consideration. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than that assigned based on more significant functional impairment. Significantly, there is no medical indication or argument from the Veteran or his representative on file, indicating that the applicable criteria are inadequate to rate the knee disability. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board further notes that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which a higher rating is sought, then part and parcel to that claim for a higher rating is the matter of whether a total rating based on individual unemployability (TDIU) as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the Veteran has not asserted that he is unemployable due to his knee disability. As such, consideration of a TDIU due to the knee disability is not warranted at this time. ORDER For the period extending from December 31, 2008, to March 4, 2013, the criteria for a rating in excess of 10 percent for residuals of a right knee injury, with degenerative arthritis, is denied. For the period extending from March 5, 2013 forward, the criteria for a 30 percent rating for residuals of a right knee injury, with degenerative arthritis, is granted, subject to the legal authority governing the payment of VA compensation. REMAND The Board's review of the claims file reveals that additional RO action relating to the service connection claim for PTSD is warranted. In a Supplemental Statement of the Case issued in July 2013, the RO indicated that PTSD had been diagnosed on at least 2 occasions in this case. The RO, on its own accord, determined that those diagnoses were "inconsistent with the correct utilization of the DSM-IV [Diagnostic and Statistical Manual of Mental Disorders, 4th Edition]" and determined that they were in error, explaining that the event supporting that diagnosis was not clear. Significantly, pursuant to 38 C.F.R. §4.125(a), if the diagnosis of a mental disorder does not conform to DSM-IV or is not supported by the findings on the examination report, the rating agency shall return the report to the examiner to substantiate the diagnosis. However, in Cohen v. Brown, 10 Vet.App. 128, 140 (1997), the United States Court of Veterans Appeals (now, United States Court of Appeals for Veterans Claims (Court) held that mental health professionals making PTSD diagnoses "are presumed to know the DSM-IV requirements applicable to their practice and to have taken them into account." The DSM-IV cannot be used "as a basis for rejecting the Veteran's favorable medical evidence as to the sufficiency of a stressor or the adequacy of the Veteran's symptomatology." Id. Accordingly, additional action is required in this case to reconcile prior positive VA PTSD screens of 2005 and 2006 and prior diagnoses of PTSD made by private providers, with the VA examiner's failure to diagnose PTSD upon examination of June 2013. In any event, consistent with the above discussion, it is not appropriate for the RO to base the denial of a PTSD claim on an asserted "incorrect" diagnosis of PTSD. Furthermore, the RO has repeatedly failed to mention, including in the June 2013 SSOC, the fact that it appears that the Veteran at issue in this case may have combat status. While no combat citations or indications of combat are shown in the original DD 214 Form, the file contains a June 2003 copy of proceedings of the Department of the Army Board for Correction of Military Records, recommending the award of a Combat Infantryman Badge. The RO failed to follow up on this information in any way, requiring further action pursuant to this Remand. Furthermore, it appears that the little has been done in the way of stressor identification in this case. The Board notes that the Veteran provided some stressor information in his November 2010 hearing testimony; yet nearly no stressor information was elicited upon VA examination of 2013. In this regard, in the March 2013 Board Remand, it was requested that the entire claims file, to include a complete copy of the remand and any written stressor information, be made available to the individual designated to examine the Veteran. It does not appear that this instruction was followed in this case, requiring correction. See Stegall v. West, 11 Vet. App. 268 (1998). Given the numerous critical gaps evident in this case, a remand is required both in fairness to the Veteran and consistent with VA's duty to assist. While this matter is on remand, to ensure that all due process requirements are met, the RO should give the Veteran another opportunity to provide additional information and/or evidence pertinent to the claim remaining on appeal. The RO's letter to the Veteran should explain that he has a full one-year period for response. See 38 U.S.C.A. § 5103(b)(1) (West 2002); but see 38 U.S.C.A. § 5103(b)(3) (West Supp. 2012) (amending the relevant statute to clarify that VA may make a decision on a claim before the expiration of the one-year notice period). Thereafter, the RO should obtain any additional evidence for which the Veteran provides sufficient information and, if necessary, authorization following the procedures prescribed in 38 C.F.R. § 3.159 (2013). The actions identified herein are consistent with the duties to notify and assist imposed by the VCAA. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2013). However, identification of specific actions requested on remand does not relieve the RO of the responsibility to ensure full VCAA compliance. Hence, in addition to the actions requested above, the RO should also undertake any other development or notification action deemed warranted by the VCAA prior to adjudicating the remaining claim on appeal. Accordingly, this matter is hereby REMANDED for the following action: 1. Furnish to the Veteran and his representative a letter requesting that the Veteran provide information and, if necessary, authorization, to obtain any additional evidence pertinent to the claim that is not currently of record. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 2. If the Veteran responds, obtain all identified outstanding pertinent records of evaluation and/or treatment not currently of record, following the procedures set forth in 38 C.F.R. § 3.159 (2013). All records and responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran and his representative of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 3. The Veteran should be specifically requested to identify, in as much detail as possible, his service-related stressors. In this regard, it is asked that to the extent possible, he provide approximate dates, locations and descriptions of his reported stressors, as well as identifying the unit with which he was serving during such events. A VA Form 21-0781, Statement in Support of Claim for PTSD, should be enclosed with the request. 4. Determine whether the Veteran has been awarded a combat citation, and provide such information in a specific annotation in the record. In this regard, any and all pertinent official sources should be contacted for verification and all efforts in this regard should be documented for the file. 5. After the aforementioned actions have been completed, arrange for the Veteran to undergo VA PTSD/mental disorders examination, by a psychiatrist or psychologist, at a VA medical facility. The entire claims file, to include a complete copy of the REMAND and any written stressor information received from the Veteran pursuant to this Remand or previously, must be made available to the individual designated to examine the Veteran, and the examination report should include discussion of the Veteran's documented psychiatric history and assertions. All indicated tests and studies ( to include psychological testing, if deemed warranted) should be accomplished (with all results made available to the examiner prior to the completion of his or her report) and all clinical findings should be reported in detail. A history of military related stressors should be specifically elicited from the Veteran on examination and documented in the report. Based on examination of the Veteran, any testing results, and consideration of his documented history and assertions, the examiner should clearly indicate whether the Veteran meets the DSM-IV criteria for a diagnosis of PTSD. In rendering such determination, the examiner is instructed that only (an) in-service stressful event(s) associated with his combat service or his fear of hostile military or terrorist activity may be considered for the purpose of determining whether exposure to such in-service event(s) has have/resulted in PTSD. If a diagnosis of PTSD is deemed appropriate, the examiner must identify the specific stressor(s) underlying the diagnosis, and should comment upon the link between the current symptomatology and the established stressor(s). If the criteria for a DSM-IV diagnosis of PTSD are not met, this fact should be specifically annotated in the report and explained. Specifically, in the event that PTSD is not diagnosed, this fact should be reconciled with prior evidence showing private diagnoses of PTSD, and positive VA PTSD screens. The examiner should set forth all examination findings, as well as testing results (if any), along with complete rationale for the conclusions reached, in a printed (typewritten) report. 6. If the Veteran fails to report for the scheduled examination, obtain and associate with the claims file a copy of any notice(s) of the date and time of the examination sent to him by the pertinent VA medical facility. 7. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App. 268 (1998). 8. After completing the requested action, and any additional notification and/or development deemed warranted, adjudicate the service connection claim for PTSD in light of all pertinent evidence and legal authority. 9. If the benefit sought on appeal remains denied, furnish to the Veteran and his representative an appropriate supplemental SOC that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefit requested should be granted or denied. The appellant need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). This claim must be afforded expeditious treatment. The law requires that all claims 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). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs