Citation Nr: 1751037 Decision Date: 11/08/17 Archive Date: 11/17/17 DOCKET NO. 12-27 039 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an increased rating for posttraumatic stress disorder (PTSD) in excess of 10 percent prior to June 29, 2015, and in excess of 70 percent therefrom. 2. Entitlement to an initial compensable disability rating for right shoulder instability with recurrent dislocation prior to January 25, 2011, and in excess of 20 percent from January 26, 2011 (exclusive of the period from October 21, 2011 until January 31, 2012, during which time a temporary 100 percent rating was assigned under 38 C.F.R. § 4.30. 3. Entitlement to an initial compensable disability rating for right wrist strain status post triangular fibrocartilage complex repair. 4. Entitlement to an initial compensable rating for right knee pes tendonitis. 5. Entitlement to a total disability rating due to individual unemployability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Z. Sahraie, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1997 to September 1998 and from July 2006 to June 2010. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The matter was previously before the Board in January 2015, at which time it was remanded for additional development. It has been returned to the Board for appellate review. This appeal was processed using the Virtual VA paperless claims processing system and the Veterans Benefits Management System (VBMS). Accordingly, any future consideration of this case should take into consideration the existence of these records. FINDINGS OF FACT 1. Prior to June 29, 2015, the Veteran's PTSD was productive of occupational and social impairment with occasional decrease in work efficiency. 2. From June 29, 2015, the Veteran's PTSD was productive of total occupational and social impairment. 3. Prior to January 26, 2011, the Veteran's right shoulder disability was manifested by forward flexion to 160 degrees, abduction to 165 degrees, external rotation to 60 degrees, and internal rotation to 65 degrees, all without pain. 4. From January 26, 2011, the Veteran's right shoulder disability was manifested by periodic subluxation of the scapulohumeral head, and guarding with all movements of the right arm. 5. The probative medical evidence shows the Veteran's right wrist disability has not been productive of palmar flexion limited in line with the forearm, or of dorsiflexion of less than 15 degrees. 6. Throughout the rating period on appeal, the Veteran's right knee disability was manifested flexion to no worse than 140 degrees, and extension to no worse than 0 degrees, even following repetition, with no evidence of instability, subluxation, joint "locking," or ankylosis. 7. Prior to June 29, 2015, the Veteran was not rendered incapable of securing and maintaining substantially gainful employment as a consequence of service-connected disability. CONCLUSION OF LAW 1. Prior to June 29, 2015, the criteria for a 30 percent disability rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2015); 38 C.F.R. §§ 4.1 4.3, 4.7, DC 9411 (2016). 2. From June 29, 2015, the criteria for a total disability rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2015); 38 C.F.R. §§ 4.1 4.3, 4.7, DC 9411 (2016). 3. Prior to January 26, 2011, the criteria for a compensable rating for a right shoulder disability have not been shown. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2015); 38 C.F.R. §§ 4.1 4.3, 4.7, DC 5201 (2016). 4. From January 26, 2011, the criteria for a 30 percent rating for a right shoulder disability have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2015); 38 C.F.R. §§ 4.1 4.3, 4.7, DC 5201 (2016). 5. The criteria for a compensable rating for a right wrist disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2015); 38 C.F.R. §§ 4.1 4.3, 4.7, DC 5215 (2016). 6. The criteria for a compensable rating for a right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2015); 38 C.F.R. §§ 4.1 4.3, 4.7, DC 5260 5215 (2016). 7. Prior to June 29, 2015, the criteria for the assignment of a total disability rating based on individual unemployability were not met, including on an extraschedular basis. 38 U.S.C.A. § 1155, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 3.340, 3.341, 4.16, 4.19 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to notify and assist In claims for increase, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vasquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VA has sent the Veteran letters throughout the appeal process which set out the type of evidence needed to substantiate the claim. There has been no allegation of notice error in this case. The Board has also satisfied its duty to assist. 38 U.S.C.A. § 5103A; 38 C.F.R. 3.159. VA has obtained all identified and available treatment records for the Veteran. In addition, the Veteran has undergone VA examinations in connection with his increased rating claims. The Board finds the examinations adequate, because they include reviews of the medical file, interviews of the Veteran, and examination findings supported by rationale. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In light of the foregoing, the Board finds that VA has provided the Veteran with every opportunity to submit evidence and arguments in support of his appeal. The Veteran has not identified any outstanding evidence that needs to be obtained. Entitlement to an increased rating for posttraumatic stress disorder (PTSD) in excess of 10 percent prior to June 29, 2015, and in excess of 70 percent therefrom. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service connected disorder. 38 U.S.C.A. § 1155. The evaluation of a service-connected disorder requires a review of a veteran's entire medical history regarding that disorder. 38 U.S.C.A. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Evidence to be considered in an appeal from an initial disability rating is not limited to that reflecting the then current severity of the disorder. Fenderson v. West, 12 Vet. App. 119 (1999). In cases where an initially assigned disability evaluation has been disagreed with, it is possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Fenderson, 12 Vet. App. at 126-27; Hart v. Mansfield, 21 Vet. App. 505 (2007). Such separate disability ratings are known as staged ratings. The Veteran's service connected PTSD has been evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411; however, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. A 30 percent rating contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when there is 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- 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. A 70 percent rating is assigned for 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 rating is assigned 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; and memory loss for names of close relatives, or for the Veteran's own occupation or name. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact occupational and social impairment. Vasquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 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; 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 the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vasquez-Claudio, 713 F.3d at 118. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which must provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). The Board also notes that the GAF scale was removed from the more recent DSM-V for several reasons, including its conceptual lack of clarity, and questionable psychometrics in routine practice. See DSM-V, Introduction, The Multiaxial System (2013). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the frequency and severity of his current symptomatology that is observable to the senses. See Layno v Brown, 6 Vet. App. 465, 470 (1994). Additionally, the Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998). Turning to the evidence of record, notes from the Veteran's October 2010 VA psychiatric examination show no more than mild symptoms, the Veteran indicating treatment with psychotropic medications had helped him manage his PTSD symptoms. The Veteran stated he was "less moody," adding he "[didn't] feel as down," and "actually [felt] a little motivated." He described his marriage as "great," adding that he enjoyed "great" relationships with his children. He noted that he frequently partook of hobbies, including riding his 4-wheeler on a weekly basis with his friends, and attending bar-b-ques. The Veteran acknowledged that he cared for multiple animals. The examiner with whom he met characterized the Veteran as cooperative and attentive, with congruent affect, linear thought processes, and good hygiene. The Veteran's mood was, however, noted to be dysphoric, and he endorsed a degree of social avoidance. Overall, the examiner found the Veteran's PTSD to be mild, assigned a GAF score of 70, indicative of minimal functional impairment, and indicated the Veteran was not beset by any occupational impairment at the time. February 2012 VA psychiatric treatment notes do not indicate any significant deterioration in the Veteran's condition. They show that although the Veteran had been attending therapy, he ceased attending between April 2011 and January 2012. Treatment records from late 2013 also fail to show a significant exacerbation of the Veteran's condition; he reported in December of that year that he was "doing well," and had recently returned home after travelling to visit family in New Jersey. These notes show the Veteran was not receiving psychotherapy at the time, but was able to manage his symptoms. Records from early 2014 confirm the Veteran continued to endorse "doing well," albeit with occasional periods of anxiety, irritability, and "boredom during the day when [his] children [were] at school." VA treatment records from May 2014 show periodic insomnia, irritability and anxiety. However, as of March 2015, the Veteran reported "working two jobs to help cover bills," and he had been absent from therapy for several months. He reported marginally worsening symptoms at this time, including intrusive thoughts, nightmares, flashbacks, frequent anger, depression, and poor sleep. Nevertheless, the Veteran missed an appointment for psychiatric treatment in May 2015, indicating he "forgot," and adding he was generally doing "okay...[albeit with] some anxiety and moodiness." However, VA treatment notes from May 2015 confirm the Veteran was "using his coping skills...and [was] generally stable." Overall, the evidence covering that portion of the appeal period prior to June 29, 2015, demonstrates occupational and social impairment with occasional decrease in work efficiency and no more than intermittent periods of inability to perform occupational tasks. The Veteran consistently endorsed depressed mood during this period, as well as periodic bouts of anxiety and irritability. Further, the record reveals a degree of social avoidance. These symptoms indicate a disability picture that most closely approximates the 30 percent rating criteria described above. However, the Veteran did not demonstrate a level of impairment consistent with a 50 percent rating during the earlier portion of the appeal period. Treatment notes do not characterize the Veteran's affect as "flattened," nor do they show circumstantial, circumlocutory, or stereotyped speech. The Veteran did not report panic attacks during this portion of the appeal period, and there is no indication of memory loss or impaired thinking. Further, as noted above, the Veteran's relationships with his wife and children are frequently described in positive terms, and he noted he enjoys other friendships and partakes of hobbies. The Veteran's symptoms did not equate in severity, frequency, and duration to occupational and social impairment with reduced reliability and productivity. Nor did the Veteran demonstrate a level of impairment consistent with a 70 percent rating during the earlier portion of the appeal period. The evidence does not suggest the presence of obsessional rituals that interfere with routine activities. Nor is there evidence in the treatment or examination records of depressive symptoms rising to such a level as to interfere with routine activities. No treating provider or examining source noted difficulty adapting to stressful circumstances. Further, the record does not reflect complaints of suicidal ideation, nor is there evidence of a formal thought disorder, or of intermittently illogical, obscure, or irrelevant speech, spatial disorientation, neglect of personal hygiene, or outright inability to establish and maintain effective relationships. He showed no psychotic symptoms, and the record does not reveal any violent outbursts during the earlier portion of the appeal period. The Veteran's hygiene was consistently noted as within normal limits. The Veteran's symptoms did not equate in severity, frequency, and duration to occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Finally, there was no significant evidence that the Veteran's symptoms conferred upon him the total occupational and social functioning referenced by the 100 percent evaluation criteria during the earlier portion of the appeal period. As discussed above, the record contains no evidence of impairment in thought processes or communication; the Veteran did not report delusions or hallucinations, nor is there evidence of grossly inappropriate behavior during this period. Although the Veteran indicated periodic anger and violent urges, there is no evidence of any acts of violence during the period at issue, and the medical evidence does not suggest the presence of any suicidal or homicidal ideation; hence, the Board concludes the Veteran was not in persistent danger of hurting himself or others during the earlier portion of the appeal period. Moreover, there is no evidence of even intermittent inability to perform activities of daily living; no evidence of disorientation to time or place; and no more than mild memory loss. Accordingly, the Board finds the Veteran's symptoms did not rise to the level of severity contemplated by the 100 percent evaluation criteria. See C.F.R. § 4.130, Diagnostic Code 9411. However, the evidence of record shows a rapid and marked decline in the Veteran's overall level of function, on or around the time of his June 2015 VA examination. Notes from that examination reveal the Veteran had stopped working due to his psychiatric symptoms, while showing increasingly limited socialization and extreme discomfort around others. The Veteran's mood was depressed, his concentration "very limited," and his memory impaired. Further, the Veteran endorsed severe anxiety, as well as increasingly frequent bouts of anger, irritability, and impulsivity, as well as low motivation and poor judgment. VA treatment records following that examination confirm the trend of decline. By mid-2016 the Veteran was faithfully attending biweekly psychotherapy sessions, but to little avail. The record shows frequent and significant family-related problems, including severe marital discord, along with crippling anxiety and increased reliance on alcohol to cope. Records from January 2017 show worsening insomnia, depression, anxiety, anger, and impaired self-control. In June 2017, the Veteran was involved in an altercation with a friend during which he brandished a firearm, leading to a charge of reckless endangerment with a deadly weapon. By July 2017, he was meeting weekly with his clinician, the record revealing little in the way of symptom improvement, even with a growing list of psychotropic medications. The Veteran endorsed severe anxiety and agitation, and had withdrawn further from any kind of socialization. The evidence establishes that the Veteran is unemployable from June 2015 forward. The record reveals severe relationship problems, lack of judgment, and extremely dangerous and reckless behavior. While the Veteran does not have all the criteria listed in the 100 percent rating, considering the overall disability picture, the Board finds that the Veteran's symptomatology for this period equates in frequency, duration and severity to total social and occupational impairment. Accordingly, a total rating is assigned for the Veteran's PTSD for the period beginning on June 29, 2015. Entitlement to an initial compensable disability rating for right shoulder instability with recurrent dislocation prior to January 25, 2011, and in excess of 20 percent from January 26, 2011 (exclusive of the period from October 21, 2011 until January 31, 2012, during which time a temporary 100 percent rating was assigned under 38 C.F.R. § 4.30). The Veteran is currently service-connected under DC 5201 for a right shoulder disability with a noncompensable rating prior to January 25, 2011, and a 20 percent rating from January 26, 2011 (excepting a temporary total disability rating from October 21, 2011 until January 31, 2012.) Ratings furnished under DC 5201 are based on limitation of motion and associated functional limitations. The diagnostic codes applicable to a rating of the shoulder are between DCs 5200-5203. Ratings vary depending on whether the impairment is to the major or minor arm. In this case, the Veteran is right hand dominant, so only the ratings for impairments to the "major" arm are applicable and will be set forth below. Normal shoulder flexion and abduction is from 0 to 180 degrees (90 degrees at shoulder level), and normal internal and external rotation is from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. Under DC 5200 for ankylosis of the scapulohumeral articulation (the scapula and humerus move as one piece), a 30 percent rating is assigned when the ankylosis is favorable with abduction to 60 degrees such that a person can reach his mouth and head, a 40 percent rating is assigned the arm when the ankylosis is considered to be intermediate that is between favorable and unfavorable, and a 50 percent rating is assigned when the ankylosis is considered to be unfavorable, such that abduction is limited to 25 degrees from the side. Under DC 5201 for limitation of motion of the minor arm, a 30 percent rating is assigned when the range of motion is limited to shoulder level, or when the maximum range of motion is limited to midway between side and shoulder level, and a 40 percent rating is assigned when range of motion of the arm is limited to 25 degrees from the side. Under DC 5202 for other impairment of the humerus, when there is malunion of the humerus, a 20 percent rating is assigned with moderate deformity or marked deformity. A 30 percent rating is also assigned when there is recurrent dislocation of the humerus at the scapulohumeral joint, with either infrequent episodes, and guarding of movement only at shoulder level, or with frequent episodes and guarding of all arm movements. A 50 percent rating is assigned when there is fibrous union of the arm; a 60 percent rating is assigned when there is nonunion of (false flail joint) the humerus in the arm; and an 80 percent rating is assigned when there is loss of head of (flail shoulder) the humerus in the arm. Under DC 5203 for impairment of the clavicle or scapula, a 10 percent rating is assigned for malunion or for nonunion without loose movement. When there is nonunion with loose movement, a 20 percent rating is assigned. A 20 percent rating is also assigned when there is dislocation of the clavicle or scapula. The Board also notes that degenerative arthritis is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200, etc.). 38 C.F.R. § 4.71a, DC 5003. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable Diagnostic Code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40 (2016); Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Moreover, with respect to musculoskeletal disabilities, the law recognizes that "[p]ainful motion is an important factor of disability, and it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint." See 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). In determining the actual degree of disability with respect to the Veteran's right shoulder disability, contemporaneous medical records and an objective examination by a medical professional are more probative of the degree of the impairment than his lay opinions. This is particularly so where the rating criteria require analysis of the clinical significance of medical symptoms, even if the existence of symptoms is observable by a lay person. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); King v. Shinseki, 700 F.3d 1339, 1344-45 (Fed. Cir. 2012). The Veteran underwent a VA examination of his right shoulder in July 2010. Range of motion testing revealed forward flexion to 160 degrees, abduction to 165 degrees, external rotation to 60 degrees, and internal rotation to 65 degrees, all without pain. There was no change in range of motion after three repetitions of testing. The Board notes that although the Veteran has since contended that he has experienced shoulder pain throughout the appeal period, notes accompanying the July 2010 shoulder examination do not reflect complaints of pain on motion, or any objective manifestations of pain. Further, treatment records prior to January 26, 2011, do not reflect significant treatment for shoulder pain. Based on this testing, the Board finds assignment of a compensable rating unwarranted for the earlier portion of the appeal period. Prior to January 26, 2011, the Veteran did not demonstrate compensable limitation of motion. Given that his range of motion is not limited to a compensable degree, and testing did not reveal any degree of pain on motion or loss of function after repeated testing, the Board finds that a compensable rating is not warranted prior to January 26, 2011. In so finding, the Board has given due consideration to the Court's holding in Burton, noted above, but finds that, absent objective manifestations of pain in the record, the criteria for even the minimum rating are not met for the earlier portion of the appeal period. October 2011 VA treatment records show that following Bankart repair of his right shoulder, the Veteran experienced residual symptomatology characterized by stiffness and decreased range of motion. Treatment notes from February 2012 show the Veteran was undergoing rehabilitative physical therapy, and reporting that "he ha[d] improved significantly." The Veteran was afforded a VA shoulder examination in June 2012. Range of motion testing showed flexion to 130 degrees, with pain at 90 degrees, and abduction to 90 degrees, with pain at 80 degrees. There was additional loss of range of motion after 3 repetitions, leading the examiner to conclude that the Veteran would be expected to lose function with repeated use over time or during flare-ups. Further, Hawkins' impingement test was positive, as was empty-can testing, external rotation/infraspinatus strength testing, and lift-off sucscapularis testing. Moreover, the Veteran showed guarding with all arm movements, and endorsed episodes of dislocation. He was tender to palpation of the acromioclavicular joint. The examiner commented: "[t]o address the DeLuca provision, there is decreased range of motion after repetitive motions due to pain and muscle fatigue and [the Veteran] is status post Bankart repair...for instability/shoulder dislocation due to torn labrum per MRI. Considering these finding it is conceivable that this [Veteran's] shoulder pain further limits his activities of daily living...as he describes. It is not feasible however to attempt to express any of this in terms of additional limitation of motion as these matters cannot be determined with any degree of medical certainty." Another VA examination was conducted in December 2015. This examination revealed a degree of improvement; range of motion testing was normal, although the Veteran reported pain on examination. The examiner indicated, however, that pain did not rise to such a level as to cause functional loss, adding there was no evidence of pain with weight bearing, no tenderness, no crepitus, and no loss of range of motion after three repetitions of testing. The Veteran demonstrated full 5/5 strength in the right arm, but endorsed infrequent episodes of subluxation of the glenohumeral joint. Crank apprehension and relocation testing were negative, and the examiner confirmed there was no loss of head, nonunion, fibrous union or malunion of the humerus. In reviewing the evidence of record, the Veteran's demonstrated range of motion, at its most severe during his June 2012 VA examination, does not warrant assignment of a rating in excess of 20 percent. However, at that examination, and again at his December 2015 examination, the Veteran confirmed periodic subluxation of the scapulohumeral head. Further, notes accompanying the June 2012 examination reveal guarding with all arm movements. Accordingly, and construing the evidence in the light most favorable to the Veteran, the Board finds assignment of a 30 percent rating warranted under DC 5202 for recurrent dislocation of the scapulohumeral joint with frequent episodes and guarding of movement at the shoulder level. However, there is no basis for a higher rating. There is no evidence of loss, malunion, or fibrous union of the humerus, nor of ankylosis of the shoulder joint. As such, a higher rating would be unavailable under DC 5202, or under any other DC applicable to the shoulder. Hence, while the evidence does not support assignment of a compensable rating for the earlier portion of the appeal period, a 30 percent rating is appropriate from January 26, 2011 (excepting the aforementioned temporary total disability period.) Entitlement to an initial compensable disability rating for right wrist strain status post triangular fibrocartilage complex repair. The Veteran seeks a compensable rating for a right wrist disability, status post triangular fibrocartilage complex repair. The disability is rated under DC 5215 for limitation of motion of the wrist, which provides at maximum a 10 percent evaluation where the wrist manifests palmar flexion limited in line with the forearm, or dorsiflexion of less than 15 degrees. 38 C.F.R. § 4.71a, DC 5215 (2016). Normal palmar flexion is to 80 degrees and normal dorsiflexion is to 70 degrees. 38 C.F.R. § 4.71, Plate I. Testing conducted at the Veteran's July 2010 VA examination showed supination to 75 degrees, pronation to 80 degrees, dorsiflexion to 60 degrees, palmar flexion to 65 degrees, radial deviation to 20 degrees, and ulnar deviation to 45 degrees, all repeatable after three repetitions of testing, and all without pain. The Veteran evinced no tenderness around his wrist. The Veteran underwent surgery on the right wrist in May 2014, and a second VA examination was conducted the following month. Notes from that examination show the Veteran's wrist was healing well; he was nontender, and was able to abduct his fingers and oppose his thumb. He was sensate to radial, median and ulnar nerves. He demonstrated 60 degrees of wrist extension, 45 degrees of flexion, and full pronation and supination. A final VA examination was conducted in December 2015. The Veteran demonstrated palmar flexion to 80 degrees, dorsiflexion to 70 degrees, ulnar deviation to 45 degrees, radial deviation to 20 degrees, all of which were characterized as normal. Although the Veteran complained of pain on examination, the examiner indicated it did not appear to be of such severity as to cause functional loss. There was no evidence of pain with weight bearing, no tenderness to palpation, and no crepitus. The Veteran demonstrated full strength in the wrist, with no atrophy. The examiner opined the Veteran would not be expected to experience any loss of movement or function due to pain, weakness, fatigability or incoordination with repetitive use over time. A review of the evidence shows the Veteran has never demonstrated any compensable limitation of range of motion in the right wrist. Further, the December 2015 VA examiner indicated there was no evidence on examination that suggested any degree of functional loss due to pain. As such, the Board finds that, even in consideration of the Deluca factors, there is no basis in the record for assignment of a compensable rating for a right wrist disability. Entitlement to an initial compensable rating for right knee pes tendonitis. The Veteran's right knee disability is currently rated under Diagnostic Code 5260, for limitation of flexion of the knee. Diagnostic Codes 5260 and 5261 pertain to limitation of knee motion. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. In this regard, a normal range of knee motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. A limitation of leg flexion allows for a 10 percent evaluation when it is limited to 45 degrees and a 20 percent evaluation when it is limited to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. A limitation of leg extension is assigned a 10 percent evaluation when it is limited to 10 degrees and a 20 percent evaluation when it is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Separate ratings for knee disabilities may be assigned for disability of the same joint, if none of the symptomatology on which each rating is based is duplicative or overlapping. See VAOPGCPREC 9-04 (2004); 69 Fed. Reg. 59,990 (2004); 38 C.F.R. § 4.14. Under Diagnostic Code 5259, a 10 percent rating can be assigned for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a. Under Diagnostic Code 5258, a 20 percent evaluation can be assigned for cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. Id. Recurrent subluxation or lateral instability can be rated as slight (10 percent), moderate (20 percent), or severe (30 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5257. Evaluations for knee impairment can also be assigned based on ankylosis or genu recurvatum, but as the Veteran has not at any time been found to have ankylosis or genu recurvatum, these diagnostic codes are not applicable and will not be further discussed. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5263 (2016). The Veteran underwent a VA knee examination in July 2010. Range of motion testing revealed flexion to 140 degrees, extension to 0 degrees, with no loss of range of motion after 3 repetitions of testing. All movement was without pain, and the right knee was stable in all plains, albeit with mild tenderness. The record does not reveal a great deal of treatment sought or received for knee problems during the current appeal period, and the Veteran's gait has consistently been noted to be normal. A second VA knee examination was conducted in December 2015. Range of motion testing was entirely normal, and although the Veteran complained of pain on testing, the examiner opined it did not rise to such a level as to cause functional loss. There was no loss of range of motion after 3 repetitions, and the examiner opined that there was no evidence that the Veteran would experience functional loss with repeated use over time. There were no reports of "flare-ups." Finally, diagnostic imaging revealed no arthritis, and the Veteran demonstrated full strength in the right lower extremity, with no instability and no joint effusion. The testing detailed above shows the Veteran has no compensable limitation of range of motion. Moreover, although the Veteran complained of pain on testing at his December 2015 VA examination, notes from that examination do not reflect objective manifestations of pain, the record is otherwise bare of complaints of ongoing right knee pain or treatment therefor, knee-related treatment has been conservative, and knee problems do not appear to have caused significant limitations of activity. Hence, while the Board has considered Burton, it finds that with respect to the Veteran's right knee, the record lacks sufficient objective evidence of chronic right knee pain to warrant assignment of the minimum rating. Further, the December 2015 VA examiner indicated there was no indication on examination to suggest any degree of functional loss due to pain. Hence, while the Board has considered Burton and Deluca, it finds that with respect to the Veteran's right knee, the record lacks sufficient objective evidence of chronic right knee pain or functional loss to warrant assignment of a compensable rating. Entitlement to a total disability rating due to individual unemployability prior to June 29, 2015. VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that a veteran is precluded, by reason of service-connected disability, from obtaining and maintaining any form of gainful employment consistent with his or her education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2015). Under the applicable regulations, benefits based on individual unemployability are granted only when it is established that the service-connected disability or disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. Under 38 C.F.R. § 4.16, if there is only one such disability, it must be rated at least 60 percent disabling to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a) (2016). As discussed above, the instant decision grants a total rating for PTSD from June 29, 2015, thereby mooting the issue of TDIU as of that date. Prior to June 29, 2015, the Veteran was service-connected for PTSD, a right shoulder disability, cervical and lumbar spine disabilities, residuals of a neck scar, right testicle hydrocele, tinea unguium of both toenails, a right wrist disability, a right knee disability, and hemorrhoids. The threshold criteria for a total disability rating under the provisions of 38 C.F.R. § 4.16(a) were not met. Consequently, the only remaining question in this case is whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities, for purposes of a possible extra-schedular evaluation pursuant to 38 C.F.R. § 4.16(b). Under 38 C.F.R. § 4.16(b), referral to the Director of Compensation Service for extra-schedular consideration requires a determination that a particular Veteran is currently rendered unable to secure or follow a substantially gainful occupation by reason of his or her service-connected disabilities. See VAOPGCPREC 6-96. The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed under 38 C.F.R. § 4.16(b). Individual unemployability must be determined without regard to any non-service connected disabilities or a Veteran's advancing age. 38 C.F.R. §§ 3.341(a), 4.19 (2016); see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in a Veteran's favor. 38 C.F.R. § 4.3 (2016). While the regulations do not provide a definition of "substantially gainful employment," VA Adjudication Procedure Manual, M21-1 MR, Part IV, Subpart ii, Chapter 2 (Dec. 13, 2005) (previously cited at M21-1, Part IV, paragraph 7.09), defines the term as that "at which non-disabled individuals earn their livelihood with earnings comparable to the particular occupation in the community where the veteran resides." Also, in Faust v. West, 13 Vet. App. 342 (2000), the Court defined "substantially gainful employment" as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to a Veteran's earned annual income. In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a veteran is entitled to TDIU is whether his or her service-connected disabilities alone are of sufficient severity to produce unemployability. The determination as to whether a total disability is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). The Veteran claims that his psychiatric and musculoskeletal disabilities rendered him unable to secure or maintain gainful employment prior to June 29, 2015. The record shows that the Veteran has reported that he has not worked since separation. He filed his TDIU claim in November 2011. The medical evidence regarding the Veteran's employability consists of VA treatment records and examination reports. These pieces of medical evidence show consistent treatment for PTSD, as well as treatment for musculoskeletal disabilities. No treating provider has suggested that the Veteran's disabilities, individually or in combination, rendered him altogether incapable of gainful employment on an indefinite basis prior to June 29, 2015. The examination reports treating with the Veteran's musculoskeletal disabilities, many of which are discussed above, similarly do not show symptoms of indefinite duration that approach a debilitating level. The crux of the Veteran's contentions with respect to unemployability have related to his psychiatric problems owing to PTSD. As discussed in that section of this decision dealing with the Veteran's PTSD prior to June 29, 2015, while the record shows significant limitation, symptoms did not render the Veteran unemployable. Moreover, the Board notes in particular a March 2015 VA psychiatric treatment note which reflects the Veteran was "working two jobs to help cover bills." Additionally, treatment records consistently show the Veteran confirmed he was "doing well" during the earlier portion of the appeal period. December 2013 VA treatment notes, January 2014 notes, and May 2014 notes all suggest the Veteran was able to manage his symptoms. December 2013 notes show the Veteran was able to travel independently to visit family in New Jersey. The Veteran appears to have been able to manage his psychiatric symptoms without psychotherapy for long portions of the appeal period; for instance, February 2012 VA treatment records show the Veteran ceased therapy altogether between April 2011 and January 2012. Finally, no treating or examining provider characterized the Veteran's mental symptoms as severe during the period at issue. A provider described the Veteran's PTSD as "moderate" in February 2012, while a VA examiner described it as mild in October 2010. The Board does not doubt that the Veteran's service-connected disabilities have caused him significant difficulties throughout the current appeal period, and have had an effect on his employability. However, the Board finds that the weight of the evidence does not support the Veteran's contention that his service-connected disabilities were of such severity as to preclude his participation in any form of substantially gainful employment, warranting referral for extraschedular consideration, prior to June 29, 2015. Thus, the Board finds that the evidence does not demonstrate that the Veteran was unemployable due to his service-connected disabilities during that portion of the appeal period. Accordingly, a basis for referral to the Veteran's TDIU claim prior to June 29, 2015, for consideration on an extraschedular basis has not been presented, and referral to the Director is not warranted. ORDER Entitlement to a rating of 30 percent for PTSD is granted for the period prior to June 29, 2015. Entitlement to a 100 percent schedular disability rating for PTSD is granted from June 29, 2015. Prior to January 26, 2011, entitlement to a compensable rating for a right shoulder disability is denied. From January 26, 2011, exclusive of the period from October 21, 2011 until January 31, 2012, entitlement to a 30 percent rating for a right shoulder disability is granted. Entitlement to a compensable rating for a right wrist disability is denied. Entitlement to a compensable rating for a right knee disability is denied. Prior to June 29, 2015, entitlement to a TDIU is denied. ____________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs