Citation Nr: 1338232 Decision Date: 11/21/13 Archive Date: 12/06/13 DOCKET NO. 10-35 701 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Evaluation of headaches, initially rated as noncompensable prior to March 2, 2009. 2. Evaluation of headaches, rated as 30 percent disabling since March 2, 2009. 3. Evaluation of posttraumatic stress disorder (PTSD), initially rated as noncompensable prior to March 2, 2009. 4. Evaluation of PTSD, rated as 50 percent disabling since March 2, 2009. 5. Entitlement to service connection for a right knee disorder. 6. Entitlement to service connection for a disability manifested by stiff and swollen joints, including as secondary to an undiagnosed illness. 7. Whether new and material evidence has been received to reopen a claim for service connection for residuals of a fracture of the right great toe. 8. Entitlement to service connection for residuals of a fracture of the right great toe. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Hallie E. Brokowsky, Counsel INTRODUCTION The Veteran served on active duty from November 2003 to February 2008. These matters come before the Board of Veterans' Appeals (Board) on appeal from March 2008 and January 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. The March 2008 rating decision granted service connection for PTSD and headaches and assigned a noncompensable disability evaluation for each, effective February 14, 2008. The January 2010 rating decision denied the Veteran's claims for service connection for a right knee disorder and a disability manifested by joint pain and stiffness, including as due to undiagnosed illness, as well as denied his petition to reopen service connection for residuals of a fracture of the right great toe. During the appeal, a May 2009 rating decision granted increased 30 percent disability evaluations for PTSD and headaches, effective from March 2, 2009. A subsequent, August 2010 rating decision granted another increased rating for PTSD, to 50 percent disabling, also effective March 2, 2009. The Veteran continued to disagree with the ratings assigned; therefore, the grant of a higher rating is not a full grant of the benefit sought on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the U.S. Court of Appeals for Veterans Claims held that a TDIU claim is part of an increased rating claim when such claim is reasonably raised by the record. In this case, however, the Veteran has not reported or testified that he cannot work due to his service-connected disabilities. Therefore, a TDIU claim is not raised by the record in this case. The Virtual VA claims file has been reviewed. As will be explained below, the issue of entitlement to service connection for a disability manifested by joint pain and stiffness, including as due to undiagnosed illness, is being remanded for additional development. As such, these issues are REMANDED to the RO via the Appeals Management Center in Washington, DC. VA will notify the Veteran if further action is required on his part. If the Veteran wants to appeal the denial of service conenction for fungus and cellulitis, he should enter a notice of disagreement. FINDINGS OF FACT 1. Throughout the initial rating period on appeal, the Veteran's headaches most closely approximates prostrating attacks occurring at least once a month over the last several months. 2. Throughout the initial rating period on appeal, the Veteran's PTSD most closely approximates occupational and social impairment with reduced reliability and productivity due to such symptoms as impaired memory, anxiety, irritability, intrusive thoughts, sleep impairment, and difficulty in establishing and maintaining effective social relationships. 3. In a March 2008 rating decision, the RO denied the claim of service connection for residuals of a fracture of the right great toe, on the basis that the evidence did not demonstrate that the Veteran had residuals of a fracture of the right great toe. 4. The evidence received since the March 2008 rating decision is cumulative. 5. Enthesopathy of the right knee is attributable to service. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating of 30 percent for headaches have been met for the period prior to March 2, 2009. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8100 (2013). 2. The criteria for a disability rating in excess of 30 percent for headaches have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8100 (2013). 3. The criteria for an initial disability evaluation of 50 percent for PTSD have been met for the period prior to March 2, 2009. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2013). 4. The criteria for a disability rating in excess of 50 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2013). 5. The March 2008 rating decision denying service connection for residuals of a residuals of a fracture of the right great toe is final. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 20.1103 (2013). 6. New and material evidence has not been received and the claim of service connection for residuals of a fracture of the right great toe is not reopened. 38 U.S.C.A. §§ 5108 (West 2002); 38 C.F.R. §§ 3.156 (2013). 7. Enthesopathy of the right knee was incurred in wartime service. 38 U.S.C.A. § 1110 ( West 2002); 38 C.F.R. § 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In addition, in Kent v. Nicholson, 20 Vet. App. 1, 11-12 (2006), the CAVC held that, in the context of an application for reopening, VCAA notice (1) must notify a claimant of the evidence and information that is necessary to reopen the claim and (2) must notify the claimant of the evidence and information that is necessary to establish entitlement to the underlying benefit sought by the claimant. The CAVC elaborated that VA is required, in response to an application to reopen, to look at the bases for the denial in the prior decision and send a notice letter that describes what evidence would be necessary to substantiate that element or elements required to establish service connection that were found insufficient in the previous denial. In this case, the agency of original jurisdiction (AOJ) issued notice letters, dated in December 2007, March 2009, April 2009, and November 2009 to the Veteran. These letters explained the evidence necessary to substantiate the Veteran's claims for increased disability ratings and service connection, as well as the legal criteria for entitlement to such benefits. The Veteran was also informed of the appropriate definitions of new and material evidence and of the evidence needed to substantiate the underlying claim for residuals of a fracture of the right great toe; therefore, the November 2009 letter provided the new and material evidence notice required by the Kent decision. The letters also informed him of his and VA's respective duties for obtaining evidence. The AOJ decision that is the basis of this appeal was decided after the issuance of an initial, appropriate VCAA notice. As such, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA also has a duty to assist a veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The claims file contains the Veteran's available service treatment records, reports of VA and private post-service treatment, and the Veteran's own statements in support of his claims. The Veteran was afforded VA examinations responsive to the claim for service connection of the right knee and the petition to reopen the previously denied claim of entitlement to service connection for residuals of a fracture of the right great toe. McClendon v. Nicholson, 20 Vet. App. 79 (2006). The opinion was conducted by a medical professional, following thorough examination of the Veteran, solicitation of history, and review of the claims file. The Veteran was also afforded a VA examination responsive to the claims for increased ratings. The examination reports contain all the findings needed to rate the Veteran's service-connected headaches and PTSD, including history and clinical evaluation. The Board has reviewed the examination reports, and finds that they are adequate for the purpose of deciding the issues on appeal. The Veteran's appeal for higher evaluations is distinguished from the facts in Proscelle v. Derwinski, 2 Vet. App. 629, 633 (1992), where no VA examination was provided during the rating claim, and a veteran specifically stated that his disability "has increased in severity [such] that I rate a higher disability," constituting at least both some assertion by the veteran and some evidence of worsening of disability since the last VA examination. Proscelle, 2 Vet. App. at 632. In the Veteran's case currently on appeal to the Board, there is no evidence of worsening of the Veteran's headaches and PTSD since the 2009 VA examination, including no assertion by the Veteran of worsening since the last VA examination. The Veteran here does not assert that his headaches and PTSD worsened since the April 2009 VA examinations; he merely asserts entitlement to a higher disability evaluations for the rating periods on appeal. The Veteran has not submitted evidence of worsening, and the evidence of record, including the medical evidence reflecting on the severity of the disability on appeal, does not suggest that this disability worsened since the most recent VA examination, or since the most recent VA treatment records. As there is no evidence of worsening since the last VA examination, a remand for a new VA examination is not warranted, and is not required by the VCAA. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (mere passage of time does not require VA to provide a new medical examination); VAOPGCPREC 11-95 (interpreting that a new examination is appropriate when there is an assertion of an increase in severity since the last examination). The Veteran has been afforded adequate examinations on the issue decided herein. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Additionally, the Veteran has not alleged that any examination is inadequate to decide the claims being adjudicated herein, so the examinations are presumed to have been adequate. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of the opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). The Board has reviewed the Veteran's statements and medical evidence of record and concludes that there is no outstanding evidence with respect to the Veteran's claims. For these reasons, the Board finds that the VCAA duties to notify and assist have been met. Disability Evaluation Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 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. The 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 has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, although staged ratings were initially granted, the disabilities had not materially changed and uniform evaluations are warranted. Headaches The Veteran's headaches are rated as noncompensable for the initial rating period prior to March 2, 2009 and as 30 percent disabling for the period since March 2, 2009 pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8100. A 10 percent disability evaluation is assigned for prostrating attacks averaging one in 2 months over the last several months. For the next higher 30 percent disability evaluation, there must be characteristic prostrating attacks occurring on average once a month over the last several months. For a higher, 50 percent disability evaluation to be warranted, there must be migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The Veteran was afforded a VA general medical examination in January 2008. That report indicates that the Veteran complained of chronic headaches, causing him to miss work 2 times over the past year; the Veteran reported that he works part-time and is a full-time student. He reported that the headaches are acute, and are located in the front or right side of the head behind his eye socket. He complained of difficulty focusing, fatigue, and some photophobia, but denied nausea. He reported that the headaches are brought on by noise or commotion, occur weekly, and lasted for hours; the headaches are relieved by Tylenol or Aleve and rest. The diagnosis was chronic headaches. The Veteran was afforded another VA examination in April 2009. At that time, the Veteran complained of 4 to 6 headaches per week, usually on the right side of his head in the temporal area; they occur unilaterally. He described the pain as dull and heavy throbbing, 8-10 on a scale of 1 to 10. He complained of difficulty concentrating, fatigue, and photophobia during headaches. He reported that the headaches are alleviated with medication and rest. The Veteran's headaches were described as prostrating, and lasted for hours. Examination showed normal sensation, muscle tone and bulk, and normal reflexes. Cerebellar examination was normal and cranial nerves were intact. CT scan was normal. The diagnosis was migraine headaches. The VA examiner noted that the Veteran missed work and school due to his headaches. VA treatment records dated 2008 through 2011 show continued treatment for headaches and that the Veteran was provided prescription medication to take as needed for his headaches. After a review of the evidence, the Board finds that the Veteran's headaches most closely approximate the criteria for a 30 percent disability evaluation for the period prior to and since March 2, 2009. The Board finds that the Veteran's symptoms due to his headaches have been relatively consistent and that the 30 percent evaluation takes into account the frequency and severity of the Veteran's headaches for the entire rating period. Throughout the rating period, the Veteran's headaches have been characterized by characteristic prostrating attacks occurring on an average of once a month over the last several months. The evidence also shows that the Veteran does not experience very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability; rather the Veteran is in school full-time and working part-time. In conclusion, the evidence of record reveals manifestations consistent with a 30 percent evaluation, but no more, for the entire rating period on appeal, for headaches. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). PTSD The Veteran's PTSD is evaluated as noncompensable for the initial rating period and 50 percent disabling from March 2, 2009 under 38 C.F.R. § 4.130, Diagnostic Code 9411. A 10 percent disability evaluation is warranted where there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent disability rating is warranted where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, and mild memory loss. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Under 38 C.F.R. § 4.130, Diagnostic Code 9411, a 50 percent disability rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. For the next higher 70 percent evaluation to be warranted, there must be occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to symptoms such as: suicidal ideation; obsessive 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 work-like setting); and an inability to establish and maintain effective relationships. Id. A 100 percent rating is provided for total occupational and social impairment, due to such symptoms as: Gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. §§ 4.125-4.130. The GAF is a scale reflecting the "'psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness.'" Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (1994) (DSM-IV)). See also 38 C.F.R. § 4.130. A GAF score of 41-50 indicates "Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. A GAF score of 51-60 indicates "Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers)." Id. When determining the appropriate disability evaluation under the general rating formula, the Board's primary consideration is the veteran's symptoms, but it must also make findings as to how those symptoms impact the veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, __ F.3d __, __, No. 2012-7114, slip op. at 10-11 (Fed. Cir. Apr. 8, 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability rating under the general rating formula by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, __ F.3d at __, slip op. at 7, 9. The Veteran was afforded a VA examination in January 2008. The report indicates that the Veteran complained of flashbacks, intrusive thoughts, nightmares, anxiety, difficulty concentrating, irritability, hypervigilance, and hyperarousal. He denied panic attacks, depression, and suicidal thoughts. The Veteran reported that he is taking college classes and working part-time. Mental status examination indicated that the Veteran had good eye contact and normal, appropriate behavior. His thought processes appeared coherent and logical. There was no evidence of delusions or hallucinations. His cognitive functioning was intact. Memory, insight, and judgment were intact. The diagnosis was PTSD and a GAF score of 60 was assigned. VA treatment records dated October 2008 through November 2009 indicate that the Veteran complained of nightmares, flashbacks, irritability, hypervigilance, intrusive thoughts, and sleep disturbance. He denied suicidal or homicidal ideation; his thought processes were not delusional or psychotic. Insight and judgment were good and memory was intact. In December 2008, his mood was slightly anxious, with a congruent affect; a GAF score of 52 was assigned. At the April 2009 VA examination, the Veteran complained of nightmares, anger, depression, anxiety, agitation, suspiciousness, difficulty concentrating, and irritability. He denied hallucinations. Upon evaluation, there was no evidence of psychosis or thought disturbance, and insight, judgment, and problem solving were fair. Abstract thinking was appropriate. The diagnosis was PTSD, his symptoms were described as moderate, and a GAF score of 40-45 was assigned. The VA examiner stated that there was an occasional decrease in the Veteran's work efficiency with decreased ability to perform occupational tasks, but generally satisfactory functioning, with routine self care and conversation. A February 2010 letter from the Princeton Veterans Center indicates that the Veteran presented with hypervigilance, emotional numbing, sleep disturbance, intrusive thoughts of war experiences, decreased concentration, loss of interest in activities, panic attacks multiple times per week, irritability and anger, anxiety, and depression. The Veteran was diagnosed with PTSD and with generalized anxiety disorder and major depression as sequelae of his PTSD. No GAF score was assigned; in lieu of a GAF score, the social worker stated that the Veteran's psychiatric symptoms were moderate to severe and that the Veteran had major impairment of judgment, thinking, and mood, with current depression. In June 2011, the Veteran was seen at VA on several occasions. He complained of sleep disturbance, lack of motivation, hypervigilance, and panic attacks. He described himself as a loner, even prior to his military service, but reported having pretty good relationships with his siblings. He had a depressed mood, but speech and thought processes were normal. His affect was blunted, but he had adequate eye contact and good hygiene; he was cooperative and oriented. He denied suicidal or homicidal ideation, hallucinations, and delusions. His memory was intact and his insight and judgment were good. A GAF score of 50 was assigned. After a review of all the evidence, the Board finds that the Veteran's service-connected PTSD more nearly approximates the criteria for an initial 50 percent disability evaluation for the entire rating period on appeal, prior to March 2, 2009 and since March 2, 2009. The Board finds that the Veteran's psychiatric symptoms have been relatively consistent, and that the 50 percent evaluation takes into account the Veteran's social and occupational impairment for the entire initial rating period. Throughout the initial rating period, the Veteran's PTSD has been characterized by occupational and social impairment with reduced reliability and productivity due to such symptoms decreased concentration, anxiety, irritability, intrusive thoughts, sleep impairment, and difficulty in establishing and maintaining effective social relationships. The Board acknowledges that the Veteran reported experiencing panic attacks in February 2010 and June 2011, but points out that the evidence shows that the Veteran does not have symptoms such as obsessional rituals, impaired impulse control, delusions or hallucinations, spatial disorientation, or illogical speech or thought processes as a result of his PTSD; he is alert, oriented, and cooperative upon examination, he does not have a hyperstartle response, and his depression and anxiety do not prevent him from functioning independently. Significantly, his panic attacks are not nearly continuous and do not interfere with his ability to function independently. The Board acknowledges that VA examiners assessed that the Veteran has moderate PTSD symptoms, which interfered with occupational functioning and social relationships for the Veteran, but do not cause such social and occupational impairment as to render him deficient in most areas. The VA examiners and treating VA providers assigned GAF scores of 40-45 and from 50 to 60 from 2008 through 2011, and that the most recent GAF score was 50 in June 2011 for the Veteran's PTSD. A GAF score is probative, as it relates directly to a veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). A GAF score of 51-60 contemplates moderate symptoms or moderate impairment in social or occupational functioning. See DSM-IV at 44-47. The Board notes that the Veteran's GAF scores are consistent with the symptomatology shown in contemporaneous treatment records. The GAF scores of the VA examiners and treating providers take into account all of the medical evidence of record, lay and objective, for the rating period on appeal, such that a fuller picture of the nature and history of the Veteran's major depressive disorder is provided. See 38 C.F.R. § 4.2 (2013) (it is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present). The Board is aware that a GAF of 40-45 was entered in April 2009. However, this score is remarkably inconsistent with the other scores and is supported by few clinical evaluations. Furthermore, the same examiner reported the disability as moderate. We find the other scores to be consistent with the record and more probative. We accord the GAF of 40-45 little probative value. However, the report of moderate disability is accorded probative weight. The Board acknowledges that the Veteran complained of complained of nightmares, anger, irritability, difficulty concentrating, memory loss, hypervigilance, and depression at his VA examinations and in seeking treatment. The Board notes that the Veteran is compensated for his memory loss and difficulty concentrating as part of his residuals of a TBI. When considering separate ratings under different diagnostic codes generally, VA must avoid pyramiding, i.e., evaluating the same disability under different diagnostic codes or evaluating the same manifestation under different diagnostic codes. 38 C.F.R. § 4.14. Moreover, the current 50 percent disability evaluation accounts for the Veteran's moderate social and occupational impairment, as caused by these symptoms. In this regard, the Board finds that the criteria for a disability rating of 70 percent have not been met or more nearly approximated for any part of the rating period on appeal. The evidence does not show that the Veteran experiences occupational and social impairment with deficiencies in most areas, and has not experienced symptoms such as obsessional rituals, near continuous panic or depression affecting the ability to function independently, impaired impulse control, or spatial disorientation, as contemplated by a 70 percent disability rating under Diagnostic Code 9411. As previously discussed, at the January 2008 and April 2009 VA examinations, the Veteran had depression and anxiety, but did not have suicidal or homicidal ideation, delusions or hallucinations, or impaired thought processes. At both examinations, the Veteran complained of depression, sleep impairment, intrusive thoughts, irritability, and difficulty concentrating, but reported that he worked and attended college. Although VA treatment notes, dated from 2008 through 2011, indicate that the Veteran is alert and oriented, with appropriate speech and behavior, and without evidence of suicidal or homicidal ideation. The Veteran's insight and judgment have been no worse than fair and his hygiene has been consistently good. The VA providers and examiners also note the Veteran's symptoms, such as irritability, anger, difficulty concentrating, and depression; however, the Board reiterates that those symptoms are nearly the same as those listed in the criteria for a 50 percent rating and the examiners' characterization of these symptoms were indicative of at most moderate impairment caused by the disorder. Moreover, there was no specific indication to the contrary in the Veteran's written statements. Although fluctuations in symptomatology, GAF scores, and overall impairment are inevitable during the course of such a lengthy appeal period, the Board finds that the Veteran has consistently had symptoms of anxiety and depression, sleep impairment, and flashbacks; there is no evidence of ritualistic or obsessive behavior, hallucinations, delusions, suicidal or homicidal ideation, or impaired speech or thought processes. The Board also acknowledges the February 2010 assessment by the Princeton Veterans Center of moderately severe symptoms, but finds that this assessment is not supported by the other VA examination reports and the Veteran's treatment records at the VA Medical Center. The Veteran has not stated that his psychiatric symptoms impaired his occupational functioning in any way when he did work. Consequently, the weight of the evidence is against a rating higher than 50 percent for PTSD. For these reasons, the Board finds that the is entitled to a an initial disability evaluation of 50 percent for PTSD, but no higher, for the entire period on appeal. 38 C.F.R. §§ 4.3, 4.7. Extraschedular Considerations As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms of the Veteran's headaches and PTSD are fully contemplated by the applicable rating criteria. As shown above, the criteria include symptoms, each of which were addressed in the VA examination reports and treatment records and which provided the basis for the disability ratings that were assigned. The Veteran primarily complained of weekly headaches, with fatigue, difficulty concentrating, and photophobia, for which the assigned rating criteria adequately compensated him; these complaints were considered as part of determining his evaluations. With regard to his PTSD, he complained of depression, recurrent recollections, sleep impairment, and hypervigilance, which were clearly contemplated in the currently assigned disability evaluation. In any event, the evidence does not reflect that there has been frequent hospitalization or that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. The Veteran does not allege that his service-connected disabilities interfere with his ability to work; he indicated that he went to college and worked part-time. Therefore, referral for consideration of extraschedular ratings for the Veteran's headaches and PTSD is not warranted. 38 C.F.R. § 3.321(b)(1). In the absence of exceptional factors associated with headaches and PTSD, the Board finds that the criteria for submission for assignment of extraschedular ratings pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Legal Criteria to Reopen Service Connection In general, rating decisions and Board decisions that are not timely appealed are final. See 38 U.S.C.A. §§ 7104, 7105 (West 2002); 38 C.F.R. § 20.1103. If new and material evidence is presented or secured with respect to a claim that has been finally disallowed, the claim shall be reopened and reviewed. See 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. When a veteran seeks to reopen a final decision, the first inquiry is whether the evidence presented or secured since the last final disallowance of the claim is "new and material." Under 38 C.F.R. § 3.156, a claimant may reopen a finally adjudicated claim by submitting new and material evidence. "New" evidence is defined as evidence not previously submitted to agency decision makers. "Material" evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The CAVC has interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold. Shade v. Shinseki, 24 Vet. App 110 (2010). New and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed (including evidence received prior to an appellate decision and referred to the AOJ by the Board without consideration in that decision in accordance with the provisions of 38 C.F.R. § 20.1304(b)(1)), will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). If VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim as an original claim for benefits. 38 C.F.R. § 3.156(c). If it is determined that new and material evidence has been submitted, the claim must be reopened. The evidence is presumed credible for the purposes of reopening a claim, unless it is inherently false or untrue or, if it is in the nature of a statement or other assertion, it is beyond the competence of the person making the assertion. Justus v. Principi, 3 Vet. App. 510 (1992). As to the claim for service connection for residuals of a fracture of the right great toe, the RO denied the Veteran's claim in a March 2008 rating decision. Although notified of this decision, the Veteran did not appeal. Therefore, the March 2008 denial became final. See 38 U.S.C.A. § 7105(c); 38 C.F.R. §§ 3.156(b), 20.1103. In its March 2008 denial, the RO found that the evidence did not show that the Veteran had residuals of a fracture of the right great toe. The RO stated that the medical evidence of record did not show that a fracture of the right great toe was clinically diagnosed and that a January 2008 VA x-ray did not show any bony abnormalities; the VA examiner stated that the Veteran had a healed fracture of the right great toe Since the denial of the Veteran's claim in March 2008, additional medical records have been associated with the Veteran's claims file. In particular, a June 2012 VA examination report provided a diagnosis of right big toe nail fungal infection. The VA examination also acknowledged January 2005 x-ray findings showing a history of a fracture of the right great toe, but stated that a March 2010 x-ray did not show evidence of a fracture. The report also indicated that the Veteran was treated for right foot cellulitis in 2005 and a right great toe fungal infection in 2006. The VA examiner opined that the Veteran's right foot cellulitis was acute, and less likely than not incurred in or caused by an in-service event, injury, or illness. The evidence submitted subsequent to the March 2008 rating decision is not new and material. Of note, the added evidence does not address any element which was not of record, mainly the presence of a fracture of the right great toe during service and the presence of residuals of the fracture. At the time of the prior denial, there was no reliable evidence of residuals of a fracture other than the lay evidence, nothing has changed. There remains no evidence of residuals of a fracture. See Kent v. Nicholson, 20 Vet. App. 1, 10 (2006)(finding that "the question of what constitutes material evidence to reopen a claim for service connection depends on the basis on which the prior claim was denied"). To the extent that the examiner noted the fungus and the history of cellulitis, the RO addressed and denied such issues. The Veteran is at liberty to file a notice of disagreement. However, there remains no evidence of residuals of the in-service trauma and the claim is not reopened. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2013). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. As arthritis is considered to be chronic diseases for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection is also warranted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Service treatment records indicate that, at the Veteran's November 2007 military examination, he reported a history of a right knee patellar repair in 1999, due to a high school football injury. According to the Veteran, the surgery was arthroscopic, and without complication. At that examination, the Veteran also reported a history of arthritis of the knees, and complained that he had "something wrong" with his right knee. Service treatment records dated in September 2005 show complaints of minor knee pain. At the January 2008 VA general medical examination, the Veteran complained of right knee pain. He reported a history of a football injury to the right patellar tendon in high school, treated with surgery. He described constant aching pain in both his knees during his military service; he also complained of right knee weakness and stiffness. Range of motion was normal, but x-rays showed enthesopathy at the lower patellar pole, and a suggestion of it at the tibial tuberosity. The x-ray impression was enthesopathy and the diagnosis was right knee strain. The Veteran was afforded another VA examination in January 2010. That report indicates that the Veteran reported the history of a football injury to the right knee and right patellar repair. The Veteran reported a history of right knee pain since the start of military service. X-ray showed mild lower patellar enthesopathy. The diagnosis was right knee torn patella, status-post repair. The VA examiner opined that the Veteran's current right knee condition was not caused or aggravated by his service. The VA examiner noted that the Veteran had daily right knee pain which is a natural progression of the disease and that it was not aggravated by service. The Board finds that the medical evidence of record supports the Veteran's contention that he has a right knee disorder related to service. The Board finds that the Veteran's onset of enthesopathy of the right knee manifested in service and has continued since that time. Likewise, the Veteran was seen in service for complaints of right knee pain and reports of arthritis of the knees. The Board acknowledges that the Veteran had a history of right knee patellar repair prior to service, but that his enthesopathy, a form of arthritis, was initially confirmed by x-ray in January 2008, and that the Veteran reported a diagnosis of arthritis at his separation examination in November 2007. In addition, he has consistently sought treatment for his right knee pain in the years since service; he credibly reported a lengthy history of complaints and treatment for his right knee. More importantly, this Judge finds the Veteran's report of an in-service onset of the enthesopathy to be credible, and supported by the evidence of record. Therefore, the Board finds that service connection for enthesopathy of the right knee is warranted. ORDER Entitlement to a 30 percent disability evaluation for headaches is granted for the period prior to March 2, 2009, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to a disability evaluation in excess of 30 percent for headaches is denied. Entitlement to a 50 percent disability evaluation for PTSD is granted effective for the period prior to March 2, 2009, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to a disability evaluation in excess of 50 percent for PTSD is denied. The application to reopen the claim for service connection for residuals of a fracture of the right great toe is denied. Entitlement to service connection for enthesopathy of the right knee is granted. REMAND The Board acknowledges that the Veteran was previously afforded VA examinations in January 2008, January 2010 and April 2012. Nevertheless, these examinations are insufficient. In this regard, the Board notes that the Veteran alleges that he has a disorder manifested by pain and stiffness of multiple joints, including his hands, knees, back, and feet, including as due to an undiagnosed illness. However, while these examination reports considered some of the Veteran's joints independently (his back and right knee), none of these examination reports addressed whether the Veteran has a disorder manifested by pain and stiffness of multiple joints, including as due to an undiagnosed illness, and if so, whether it was causally or etiologically related to the Veteran's military service. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a). See Barr, supra. See also McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination in order to assist in determining the current nature and likely etiology of the Veteran's pain and stiffness of the multiple joints, including whether this is a manifestation of an undiagnosed illness. Based on the examination and review of the record, the examiner is requested to opine whether the Veteran has a disorder manifested by pain and stiffness of the multiple joints and if so, whether it is at least as likely as not (whether there is at least a 50 percent probability) related to the Veteran's service, including as due to an undiagnosed illness. A rationale for all opinions expressed should be provided. The relevant documents in the claims file should be made available to and be reviewed by the examiner in conjunction with the examination. All tests deemed necessary should be conducted and the results reported in detail. 3. Readjudicate the claims for service connection. If, upon completion of the above action, the benefits sought remain denied, the case should be returned to the Board after compliance with requisite appellate procedures. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs