Citation Nr: 1422900 Decision Date: 05/20/14 Archive Date: 05/29/14 DOCKET NO. 05-41 289 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for headaches. 2. Entitlement to a disability evaluation in excess of 10 percent (prior to August 3, 2005 and from November 1, 2005) for a left knee disability. 3. Entitlement to an initial disability evaluation in excess of 10 percent for a right knee disability. 4. Entitlement to a separate disability evaluation for left knee arthritis. 5. Entitlement to a separate disability evaluation for right knee arthritis. 6. Entitlement to a compensable initial disability evaluation for residuals of a crush injury to the right great toe. 7. Entitlement to a compensable initial disability evaluation for tinea versicolor. 8. Entitlement to an initial disability evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD). 9. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU), prior to July 31, 2009. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and J.N. (observer) ATTORNEY FOR THE BOARD K. Curameng, Counsel INTRODUCTION The Veteran had active duty service from December 2000 to January 2003. This matter came to the Board of Veterans' Appeals (Board) from a March 2004 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was remanded in September 2012 for further development. The Veteran testified at a hearing before the Board at the RO (Travel Board) in March 2012. Although the appeal also originally included the issue of service connection for a left shoulder disability, this benefit was granted by rating decision in September 2013 and is therefore no longer in appellate status. The service connection claim for headaches and a TDIU claim prior to July 31, 2009 are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to August 3, 2005, the Veteran's service-connected left knee disability was not manifested by moderate recurrent subluxation or lateral instability. 2. From November 1, 2005, the Veteran's service-connected left knee disability was not manifested by moderate recurrent subluxation or lateral instability. 3. The Veteran's service-connected right knee disability is not manifested by moderate recurrent subluxation or lateral instability. 4. There is x-ray evidence of degenerative disease of the knees bilaterally with painful motion. 6. The Veteran's service-connected crush injury to the right great toe is manifested by moderate symptoms. 7. The Veteran's service-connected tinea versicolor is manifested by intermittent systemic therapy for a total duration of less than six weeks during the past 12-month period. 8. The Veteran's service-connected PTSD is not manifested by total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability evaluation in excess of 10 percent, prior to August 3, 2005, for the Veteran's service-connected left knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a and Diagnostic Code (DC) 5257 (2013). 2. The criteria for entitlement to a disability evaluation in excess of 10 percent, from November 1, 2005, for the Veteran's service-connected left knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a and Diagnostic Code (DC) 5257 (2013). 3. The criteria for entitlement to a separate 10 percent disability evaluation for left knee arthritis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a and Diagnostic Code (DC) 5003 (2013). 4. The criteria for entitlement to a separate 10 percent disability evaluation for right knee arthritis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a and Diagnostic Code (DC) 5003 (2013). 5. The criteria for entitlement to a disability evaluation in excess of 10 percent for the Veteran's service-connected right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code (DC) 5257 (2013). 6. The criteria for entitlement to a disability evaluation of 10 percent (but no higher) for the Veteran's service-connected crush injury to the right great toe have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R §§ 4.7, 4.71a, Diagnostic Code (DC) 5284 (2013). 7. The criteria for entitlement to a disability evaluation of 10 percent (but no higher) for the Veteran's service-connected tinea versicolor have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code (DC) 7806 (2013). 8. The criteria for entitlement to a disability evaluation in excess of 70 percent for the Veteran's service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130 Diagnostic Code (DC) 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Duty to Notify Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant with notice in September 2006 and February 2009, subsequent to the initial adjudication. The notification substantially complied with the specificity requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006) identifying the five elements of a service connection claim; and Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. While the notices were not provided prior to the initial adjudication, the claimant has had the opportunity to submit additional argument and evidence, and to meaningfully participate in the adjudication process. The claims were subsequently readjudicated in August 2011 and September 2013 supplemental statements of the case, following the provision of notice. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of her claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist VA has obtained service, private and VA treatment records; obtained Social Security Administration (SSA) records; obtained Vocational Rehabilitation Records; reviewed the Veteran's electronic files; assisted the Veteran in obtaining evidence; afforded the Veteran VA examinations; and afforded the Veteran a March 2012 Travel Board hearing. By form received in September 2013, the Veteran and her representative stated that they had no additional evidence and requested that the claim be forwarded to the Board immediately. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran and her representative have not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the increased rating claims at this time. Increased Ratings The present appeal involves the Veteran's claim that the severity of her service-connected knee disabilities, a crush injury to the right great toe, tinea versicolor and PTSD warrant higher disability ratings. Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. at 126. I. Knees Since two of the increased rating issues in this case involve the knees, the Board notes at this point that normal flexion of the knee is to 140 degrees, and normal extension of the knee is to 0 degrees. 38 C.F.R. § 4.71, Plate II. The Veteran's service-connected bilateral knee disabilities have been rated by the RO under the provisions of Diagnostic Code 5257. A rating of 10 percent is warranted when there is slight recurrent subluxation or lateral instability; a 20 percent rating is warranted when there is moderate recurrent subluxation or lateral instability of the knee; and a 30 percent rating is warranted when there is severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, DC 5257. Arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint or joints involved. Separate ratings may be assigned for knee disability under Diagnostic Codes 5257 and 5003 where there is x-ray evidence of arthritis in addition to recurrent subluxation or lateral instability. See generally VAOPGCPREC 23-97 and VAOPGCREC 9-98. Factual Background A June 2003 VA treatment record shows pain and use of a brace for walking. Range of motion (ROM) for the right knee was from 5 degrees of hyperextension to 130 degrees, and for the left knee 0 to 130 degrees. A July 2003 VA MRI of the right knee shows small joint effusion; degenerative change of the anterior and posterior horns of the lateral meniscus with small posterior and possible small anterior tear. A somewhat larger oblique horizontal tear of the posterior horn of the medial meniscus was noted. A February 2004 VA orthopedic consultation shows knee pain and occasional instability. ROM was from -5 to 120 with no varus/valgus instability bilaterally. X-ray was negative for osteoarthritis and patellar subluxation. An April 2004 VA treatment record from the ER shows reports of swelling and constant dull with occasional sharp shooting pains in her knee joint that woke her up at night. Upon physical examination instability was noted around the patella more on the left than on the right. An April 2004 VA physical therapy progress note shows that she said that she quit her job due to painful and swollen knees. She was waiting for knee braces. A June 2004 VA treatment record shows complaints of pain, giving out frequently and locking. Bilaterally, there was no effusion and no valgus/varus instability. Range of motion was from 0 to 120 in the left knee, and -5 to 120 in the right knee. A July 2004 VA treatment record shows complaints of pain and use of knee braces and medication did not help. Range of motion bilaterally was from 0 to 120 with no pain. There was also no effusion and no instability. A September 2004 VA treatment record shows patella-femoral syndrome with meniscus tear and worsening of symptoms. The July 2003 MRI was noted. A September 2004 VA radiology report showed no evidence of fracture, dislocation or osteoarthritis of the left knee. A December 2004 VA treatment record shows no effusion with range of motion from 0 to 130 degrees bilaterally. January 2006 VA treatment record shows chondromalacia of the right knee that "appears mild at this time...." An October 2006 VA examination shows complaints of weakness, stiffness, and swelling, giving way, lack of endurance and locking. She had constant pain in the right knee, which was relieved with medication. Functional impairment consisted of being unable to perform any sports and having difficulty exercising. Upon physical examination, there was no evidence of joint effusion or locking pain. Range of motion was from 0 to 90 degrees and was limited secondary to pain after repetitive movement to the aforementioned degrees. It was not additionally limited secondary to fatigue, weakness, lack of endurance or incoordination. A July 2007 VA radiology report shows no evidence of acute bilateral knee osseous injury or significant degenerative disease, and left small subpatellar joint effusion. An April 2009 VA radiological report shows no evidence of fracture or dislocation. Visualized joint spaces are unremarkable. The impression was normal bilateral knees. An October 2009 VA examination report chondromalacia shows no deformity, instability, stiffness, weakness, incoordination, and episodes of dislocation or subluxation, effusions. However, there was giving way, pain, swelling and locking episodes (daily or more often). Range of motion was 0 to 130 degrees bilaterally with objective evidence of pain following repetitive motion. There were no additional limitations after three repetitions of range of motion. The examiner noted no joint ankylosis. A January 2011 VA treatment record shows complaints of left knee pain. A June 2011 VA treatment report shows refitting for a knee brace. Various VA treatment reports from December 2004 to April 2012 list knee arthralgia as an active problem. Records all the way to July 2012 show that the Veteran had been repeatedly seen for pain. An August 2012 VA Orthopedic Surgery Outpatient Note shows complaints of increase in symptoms bilaterally. It was noted that an MRI is not suggestive of a mechanical lesion at this time. Analysis The Veteran has been rated under DC 5257 for recurrent subluxation/lateral instability. The evidence shows that the Veteran's symptoms of the left knee (prior to August 3, 2005, and from November 1, 2005) and right knee were slight and not moderate. A February 2004 VA treatment records shows occasional instability, but no varus/valgus instability laterally upon testing. A September 2004 VA x-ray report shows no dislocation. An April 2009 VA x-ray report shows no evidence of dislocation. An October 2009 VA examination report notes no episodes of dislocation or subluxation. Overall, the Veteran's symptoms of the left knee (prior to August 3, 2005, and from November 1, 2005) and right were slight as there was occasionally instability and no evidence of subluxation. Turning to alternate DC's for the knees, a higher rating is not warranted under DC 5256 for ankylosis of the left knee (prior to August 3, 2005, and from November 1, 2005) and right knee since there is ROM bilaterally(and thus no ankylosis). Additionally, the highest available rating under DC 5259 for symptomatic removal of semilunar cartilage; or genu recurvatum under DC 5263 is 10 percent and therefore are not for application for the left knee and right knee. Even though the Veteran reported locking and pain for the left, DC 5258 is not for application as there is no evidence of dislocated semilunar cartilage. While the Veteran uses a knee brace, DC 5262 is not for application for the left knee (prior to August 3, 2005, and from November 1, 2005) and right knee since there is no impairment of the tibia and fibula. Ranges of motion of the left knee (prior to August 3, 2005, and from November 1, 2005) and right knee are not compensable under DC's 5260 and 5261 for flexion and extension, respectively. However, a July 2007 VA radiology report shows no evidence of "significant degenerative disease" which indicates to the Board that there is some degeneration. With x-ray evidence of arthritis and evidence of painful motion, separate ratings of 10 percent (but no higher) are warranted. See 38 C.F.R. § 4.71a, DC 5003. II. Great Toe The Veteran's service-connected crush injury to the right great toe has been rated by the RO under the provisions of Diagnostic Code 5284. Under this regulatory provision, a rating of 10 percent is warranted for moderate foot injuries. A 20 percent rating of 20 percent is warranted for moderately severe foot injuries. A maximum rating of 30 percent is warranted for severe injuries of the foot. 38 C.F.R. § 4.72, Diagnostic Code 5284. A March 2004 VA treatment record shows 5/5 strength in the great toe. A May 2006 VA treatment record shows that she was able to perform toe walking. An October 2009 VA examination shows that her symptoms were stable and that she had pain and other symptoms (which were not specified) while standing, walking and at rest. The examiner noted that the following symptoms were not identified: swelling, heat, redness, stiffness, fatigability, weakness and lack of endurance. There were no flare-ups. There were functional limitations on standing and walking. Upon physical examination, it was noted that the great toe was tender to palpation. X-ray showed mild degenerative joint disease (DJD) at the first MTP joint, and was otherwise negative. The examiner noted that the DJD affected her daily activities. A September 2011 VA treatment record noted that the Veteran was able to do the toe walk easily. Upon physical examination, there were normal toe raises 10 to 20 times without the loss of plantar flexion. At the March 2012 Travel Board hearing, the Veteran said her toes "pop in and out of joint" and have been this way since a car ran over her foot. She complained that the whole side of her foot (specifically, "farther up the foot") was in pain Based on the foregoing, a rating of 10 percent (but no higher) is warranted. Here, the Veteran complained of pain and competently testified under oath that her toes would dislocate from the joint. Additionally, treatment records show tenderness to palpation. Overall, these symptoms approximate a 10 percent rating for a moderate foot injury. A rating of 20 percent is not warranted as there was full strength in her toe, and she was able to perform the toe walk. The examiner noted no swelling, heat, redness, stiffness, fatigability, weakness, lack of endurance or flare-ups. Thus her symptoms were not moderately severe. Staged ratings are not of application since the Veteran's right great toe is adequately contemplated by the grant of a 10 percent rating during the entire time period in question. III. Tinea Versicolor The Veteran's service-connected tinea versicolor has been rated by the RO under the provisions of Diagnostic Code 7806 for dermatitis or eczema. Under this regulatory provision, a noncompensable rating is warranted for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period. A 10 percent rating is warranted for at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted for 20 to 40 percent of the exposed areas affected or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A maximum rating of 60 percent is warranted for more than 40 percent of the exposed areas affected, or more than 40 percent of exposed areas affected, or; constant, or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. A May 2003 VA treatment record shows multiple spots across the arms/shoulder/chest, which was treated with selsun. An April 2008 VA treatment record shows that she was taking pills and used selenium sulfide shampoo but it is still a recurrent issue. The plan of treatment included taking fluconazole and using nizoral shampoo 2-3 times per week and the Veteran was to follow up in two months. An October 2009 VA examination report shows that there was no exposed areas (head, face, neck and hands) affected. There was less than 5 percent of total body area affected. The examiner diagnosed tinea versicolor-in remission. The examiner noted treatment in the past year with ketoconazole that was used for less than a week (specifically, 5 days). The examiner noted that treatment was systemic but is neither a corticosteroid nor an immunosuppressive. At the March 2012 Travel Board hearing, the Veteran testified that with the use of Selsun Blue, she kept her symptoms under control. However, every once in a while one will flare up. A September 2012 VA dermatology consultation shows that her symptoms manifested along her chin and jawline. She occasionally used Benx Peroxide, but not Minocin. She had frequent bouts of tinea versicolor sometimes on her face and trunk. She used Selsun Blue frequently. The doctor diagnosed intermittent tinea versicolor. The plan was to use Ketocon shampoo for three days and then on an as needed bases. For severe and extensive outbreaks, the Veteran was to orally take Ketocon once and repeat in two weeks. Based on the foregoing, a compensable rating is warranted. Specifically, a rating of 10 percent (but no higher) is warranted. Here, treatment consisted of intermittent systemic therapy--taking ketoconazole orally. The October 2009 VA examination report showed use for less than a week; and the September 2012 VA dermatology consultation showed use only once and was to be repeated two weeks later. Overall, there was intermittent systemic therapy required for a total duration of less than six weeks during the past 12-month period to warrant the next higher rating of 10 percent. A rating of 30 percent is not warranted as the tinea versicolor does not cover 20 to 40 percent of the entire body/exposed areas affected, or; require systemic therapy for a total duration of six weeks or more, but not constantly, during the past 12-month period. Staged ratings are not of application since the Veteran's tinea versicolor is adequately contemplated by the 10 percent rating during the entire time period in question. IV. PTSD Under the criteria for PTSD (set forth at 38 C.F.R. § 4.130, Diagnostic Code 9411), a 70 percent rating is assigned when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent schedular rating is warranted when there is 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 relative, own occupation or own name. The Global Assessment of Functioning (GAF) scale reflects the psychological, social and occupational functioning under a hypothetical continuum of mental illness. See American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See also Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). According to the DSM-IV, a GAF score between 31 to 40 is indicative of some impairment in reality testing or communication (e.g., speech is at times illogical, obscure or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work); a GAF score between 41 and 50 is indicative of 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); a GAF score between 51 and 60 is indicative of 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 coworkers). A Veteran "may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114 (Fed. Cir. 2013). Factual Background A May 2003 VA treatment record shows that she was alert and cooperative and showed no signs of psychosis or cognitive impairment. She was assigned a GAF score of 65. An October 2003 VA treatment record shows she was pleasant, cooperative and well-groomed. Speech had normal rate and rhythm. Thought process was coherent and logical. There were no delusions and no hallucinations. She denied suicidal ideation, except for a past attempt in service. She denied homicidal ideation. An October 2004 VA treatment records show that she was oriented in all four spheres. Thought processes were liner and goal directed. There were no delusions paranoid or hallucinations. There was also no suicidal/homicidal ideation. Insight/judgment were poor. Speech was normal for rate, rhythm and volume. The record shows a GAF score of 50. A September 2005 VA treatment record shows she was dressed casually, appropriately, neatly, engaged, good eye contact, cooperative and agitated. Her mood was described as fearful, very depressed, and angry. There was no suicidal/homicidal ideation. There was mild to moderate paranoia, no acute psychosis. She was alert and oriented in all four spheres. Insight and judgment were intact. It was noted that the PTSD was severe and disabling, and "warrants 70-100% SC for PTSD- permanent and unemployable." A November 2005 private treatment record from C.M. LCSW showed that she was referred by VSO since VA will not see her in an individual or group setting. "She enjoys the group process, however, she things she needs individual therapy as well." She had difficulty sleeping and had nightmares. She had difficulty with interpersonal relationships and had a few friends. "She is relatively socially isolated and has a tendency to get into relationship so that she will not be alone...." She has active fear about the one how assaulted her and avoids reminders of her military experience. The examiner noted that she was dressed casually and well groomed. She was alert and oriented in all three spheres. Thoughts were logical presented in normal speech. There was good eye contact and no apparent perceptual disturbances. There was no suicidal or homicidal ideation. She noted chronic and prolonged PTSD and assigned a GAF score of 38. A Counseling Record certified in June 2006 indicates that the Veteran's limitations affect her ability to engage in competitive employment due to her "inability to be up and around on her feet for prolonged periods of time, perform bending, crouching, squatting, kneeling, and heavy lifting." It was additionally noted that she had difficulty managing relationships and dealing with coworkers and supervisors. A September 2006 VA examination report shows appearance, hygiene and behavior were appropriate. Affect and mood were abnormal with findings of depression, anxiety and angry outbursts. Communication, speech and concentration were within normal limits. Panic attacks occurred every couple of weeks. She had flashbacks. There were no delusions. Hallucination history was present occasionally. Obsessional rituals were absent. Thought process was appropriate. Judgment was impaired with occasional misperceptions of male behaviors. Abstract thinking was normal. Memory was within normal limits. Suicidal and homicidal ideation were absent. The examiner assigned a GAF score of 57. An April 2008 VA treatment record shows she was open in conversation, friendly and cooperative. There were no delusions or hallucinations. Insight and judgment were fair to good. She denied suicidal/homicidal ideation. Speech was normal in rate and rhythm. Thoughts were organized, goal-oriented, rational, reliant and coherent. The Veteran was assigned a GAF score of 48. June 2009 and August 2009 VA treatment records show she was appropriately groomed and was cooperative. She was oriented to all spheres. Speech was of normal rate, rhythm and volume and not pressured. Thought process was coherent and goal-directed. There were no fixed delusion of paranoia, grandiosity or reference. There was no specific obsessions or preoccupations. There were no suicidal and homicidal thoughts. Memory and concentration were good. A July 2010 VA social work group note showed she listened attentively, made helpful suggestions, shared concerns and welcomed a new member to a women's support group. A November 2010 VA treatment record shows that she was dressed appropriately, clean and neat. Thoughts were logical and clear. She denied suicidal and homicidal ideation. She was alert and oriented. Memory for recent and remote events were intact. Insight was good, and judgment was fair. A January 2011 VA treatment record shows she was "cooperative, open, pleasant, likable"; and she was well groomed with good eye contact. Thought process was linear. She denied suicidal and homicidal ideation and psychotic symptoms. Insight was fair to good. Judgment was "currently good." It was noted that she endorses prior suicidal thoughts when she was a teenager and in service; and denied any more recent suicidal thoughts. She noted one episode of homicidal thought in service; and she denied making any attempt to kill someone, either recently or by history. A February 2012 Counseling Record shows that the Veteran cannot tolerate physically demanding jobs and needs accommodations in light to sedentary duty jobs. It was noted that she will enroll in an education program to qualify her for work in human services. A February 2012 VA treatment record shows that she was alert and oriented in all spheres. She was cooperative, appropriate and pleasant. She was well groomed, had good eye contact and her speech was normal in tone, rate and volume. Thought process was linear and thought content was appropriate. There were no delusions or hallucinations. Insight and judgment were intact. Her GAF score was 50. In a March 2012 statement, the Veteran indicated that for Spring 2012, she was taking 11 units of classes after dropping 4 units due to pneumonia and PTSD. She noted that in Spring 2011, she took four classes, but dropped the personal finance classes "due to a clash with the teacher, I was unable to learn with her style of teaching, I did not want to fail ....". A June 2012 VA treatment record notes that she was not accepted to the Women's Trauma Recover Program and recommended that she participate in anger management. An April 2010 note was cited in which the Veteran reported no control of her anger when she had "blackouts" and noted a playful situation that had gone out of control when she attended her boyfriend "and wanted to kill him." In a July 2012 statement, the Veteran representative noted her depressed mood, problems sleeping, problems interacting, distrust of others, (especially men), intrusive thoughts, problem with motivation, panic attacks and emotional outburst. She reported flashback and nightmares. At the September 2012 Travel Board hearing, the Veteran testified to quitting school in 2006/2007, working until up until recently, and being in VA vocational rehabilitation. At the time of the hearing, she worked part-time and had a boss that let her call in sick. She testified to suicidal/harmful thoughts, flashbacks. She noted inappropriate behavior in that she lashes out at others since she did not like being bossed. She reported going three to four days without showering "because it hurts too much to get in the tub, because you have to step over the tub, and I have to raise my arms over my head just to wash my hair." She testified to lack of memory, focus and concentration. She reported not remembering dates. Analysis Based on the evidence of record, the Veteran's PTSD is characterized by difficulty with interpersonal relationships, anger and depressed mood, sleep problems, intrusive thoughts, problems with motivation, panic attacks and emotional outburst. It is also characterized by flashbacks and nightmares. Overall, the Board finds that these symptoms are similar to many of those contemplated by the currently assigned 70 percent rating and even lower. Her reports of lashing out at others who boss her around, wanting to kill her boyfriend, and not trusting of others demonstrates impaired impulse control, difficulty in adapting in a work setting, and inability to establish and maintain effective relationships, which are reflected in a 70 percent rating. Significantly, her GAF score was no lower than 38, which is indicative of some impairment in reality testing or communication or major impairment in several areas reflected in a 70 percent rating. Moreover, her panic attacks, and disturbances of motivation and difficulty with men are among the types of symptoms associated with the 50 percent rating. Her trouble remembering dates, and having depressed mood and chronic sleep problems are contemplated by the 30 percent rating. Based on the evidence of record, there is no total occupational and social impairment when considering the severity, frequency and duration of her symptoms. Here, the Veteran was able to clearly convey her symptoms during treatment and throughout her claim both through testimony and through written correspondence. Additionally, at the Travel Board hearing, she testified that she worked part time and was allowed to call in sick, which exemplifies her ability to judge whether she could handle work on certain days. Moreover, she was appropriate and cooperative at her medical appointments and provided competent testimony before the Board, which demonstrates that she is not totally impaired. Moreover, treatment over the years included not only individual therapy, but also group therapy in which she was an active participant. Additional symptoms that cause total and occupational and social impairment are enumerated in DC 9411. There was no gross impairment in thought processes or communication. Again, she was able to communicate the symptoms she experienced and reasons why she should be awarded a higher rating. One report noted hallucinations; but there were no indications that they were persistent. There was also no grossly inappropriate behavior. While the Veteran testified at the Travel Board hearing that she lashes out at others, it appears to occur when she is bossed around. Overall, at her appointments, she made good eye contact; and at one group treatment, she listened attentively, provided suggestions, shared concerns and welcomed a new participant to the group. Even though she had as a teenager and during service contemplated suicide, and had a homicidal thought in service and at one point she wanted to kill her ex-boyfriend, there was no persistent danger of hurting self or others as she denied suicidal and homicidal ideation as she continually denied both. There was no intermittent inability to perform activities of daily living as she was well groomed for her appointments. She testified at the Travel Board hearing that she would go for days without a shower, but that appears to be due to physical limitations. Furthermore, she was oriented in all spheres. While she reported not remembering dates, there was no evidence of memory loss for names of close relative, own occupation or own name. The Board acknowledges that the presence of absence of specific symptoms enumerated in the regulations is not necessarily dispositive. The Veteran's PTSD causes occupational and social impairment to some degrees. Given the frequency, nature and duration of those symptoms, however, the Board finds that they result in no more than occupational and social impairment, with deficiency in most areas such as work, school, family relations, or mood. They do not more closely approximate the types of symptom contemplated by the maximum rating. Therefore, a 100 percent rating is not warranted. Staged ratings are not of application since the Veteran's PTSD is adequately contemplated by the 70 percent rating during the entire time period in question. Should the severity of the PTSD increase in the future, the Veteran may always file a claim for an increased rating. IV. Extraschedular Considerations Finally, the Board has considered whether extraschedular consideration is warranted. Regarding her knees and right toe, the Veteran has reported pain and swelling, which the Board notes is already contemplated by DC 5257 that considers the severity (from slight to severe) of subluxation/instability of the knee; and DC 5284 which rate the level of severity of symptoms from moderate to severe of the foot. As for tinea versicolor, the Veteran reported flare ups around her body and the use of Selsun Blue on a frequent basis. However, while the DC does not specifically discuss flare-ups, the area covered by the disorder and the type and frequency of treatment are contemplated by the regulation. As for her symptoms of PTSD, the severity of her occupational and social impairment are considered by DC 9411. The discussion above reflects that the rating criteria reasonably describes and contemplates the severity and symptomatology of the Veteran's service-connected disabilities. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). Even if the Board were to find that the rating criteria were not adequate, referral for extraschedular would still not be warranted because the Board also finds that Thun step two is not satisfied. See Johnson v. Shinseki, 26 Vet. App. 237, 247 (2013) (en banc) (error in Thun step one analysis is harmless were Board makes an adequate finding that Thun step two is not satisfied). The Veteran's disability does not present an exceptional disability picture with related factors such as marked interference with employment or frequent hospitalization. 38 C.F.R. § 3.321(b)(1). The Veteran has not been hospitalized for the left knee (prior to August 3, 2005, and from November 1, 2005), right knees, right great toe, tinea versicolor and PTSD. As to employment, she has not asserted that her right great toe and tinea versicolor has affected her employment and the evidence does not show that either disability impacts her ability to work. The Board acknowledges the Veteran's reports of quitting her job because of her knee. However, Vocational Rehabilitation records show that the condition of her knees alone is not the sole reason why she is unemployable. Likewise, PTSD alone does not affect her employment. Thus, referral is not warranted. ORDER Entitlement to a disability evaluation in excess of 10 percent (prior to August 3, 2005 and from November 1, 2005) for a left knee disability is denied. Entitlement to an initial disability evaluation in excess of 10 percent for a right knee disability is denied. Entitlement to a separate 10 percent disability evaluation for left knee arthritis is granted, subject to laws and regulations applicable to payment of VA benefits. Entitlement to a separate 10 percent disability evaluation for right knee arthritis is granted, subject to laws and regulations applicable to payment of VA benefits. Entitlement to a disability evaluation of 10 percent (but no higher) for residuals of a crush injury to the right great toe is granted, subject to laws and regulations applicable to payment of VA benefits. Entitlement to a disability evaluation of 10 percent (but no higher) for tinea versicolor is granted, subject to laws and regulations applicable to payment of VA benefits. Entitlement to an initial disability evaluation in excess of 70 percent for PTSD is denied. REMAND The other issue before the Board includes a service connection claim for headaches. Pursuant to the September 2012 Board remand, the Veteran was provided a VA examination in September 2013. Nevertheless, the Board finds that the opinion provided is inadequate as it is based on incorrect factual findings. The examiner noted "one episode of headache during service. No other supporting records after 2001 show the Veteran having headaches through the years." However, as noted in the remand, various service treatment records show complaints of headaches. Furthermore, post service treatment records show assessments of migraine headaches on VA examinations in October 2003 and October 2005. Thus, there is more than one episode in service and post service treatment record show headaches. As for the remaining claim, by rating decision in September 2013, the RO granted TDIU effective July 31, 2009 noting that that was the date of receipt of claim. However, a review of the record shows that a TDIU claim was received as early as May 2009. Thus, whether a TDIU claim is warranted prior to the effective date needs to be determined. As the issue of TDIU prior to July 31, 2009 is inextricably intertwined with the service connection issue on appeal, the RO should reconsider this issue after development and reconsideration of the services connection claim. In light of the remand reasons above, updated/outstanding private and VA treatment records should be obtained, if any. Accordingly, the case is REMANDED for the following action: 1. Obtain any updated/outstanding private treatment records (identified by the Veteran) that reflect treatment for headaches. After securing the necessary release, obtain these records and any updated VA treatment records. 2. The claims file should then be forwarded to the September 2013 VA examiner for review and an addendum opinion addressing the questions posed. If the September 2013 VA examiner is no longer available or determines that the opinion cannot be provided without an examination, the Veteran should also be afforded an appropriate VA examination to determine the nature, extent and etiology of any current headaches. It is imperative that the claims file be made available to the examiner for review in connection with the examination. Any medically indicated special tests should be accomplished. After reviewing the claims file and examining the Veteran, the examiner should respond to the following: a) On the basis of the clinical record, can it be clearly and unmistakably concluded that the Veteran's headaches preexisted her entry into active military service? b) If it is found that the headaches did clearly and unmistakably preexist service, can it also be clearly and unmistakably concluded that they were not aggravated to a permanent degree in service beyond that which would be due to the natural progression of the disease? c) If the headaches are not found to have so preexisted service, did they have their onset during active military service? The examiner should offer a rationale for any opinion. If an opinion cannot be provided without resorting to mere speculation, the VA examiner should discuss why an opinion is not possible. 3. After completion of the above and any additional development which the RO may deem necessary, the RO should then review the expanded record and readjudicate the service connection claim and determine whether TDIU prior to July 31, 2009 is warranted. The RO should issue an appropriate supplemental statement of the case, and give the Veteran and her representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs