Citation Nr: 1751206 Decision Date: 11/08/17 Archive Date: 11/17/17 DOCKET NO. 09-26 840 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to a rating in excess of 10 percent prior to November 26, 2013, and in excess of 60 percent afterwards, for a service-connected lumbar spine disability. 2. Entitlement to a rating in excess of 10 percent prior to November 26, 2013, and in excess of 60 percent afterwards, for a service-connected cervical spine disability. 3. Entitlement to a rating in excess of 10 percent prior to November 26, 2013, and in excess of 20 percent afterwards, for a service-connected left knee disability. 4. Entitlement to a rating in excess of 10 percent for a service-connected left ankle disability. 5. Entitlement to a rating in excess of 10 percent prior to November 26, 2013, and in excess of 20 percent afterwards, for service-connected left lower extremity peripheral neuropathy. 6. Entitlement to a rating in excess of 10 percent for service-connected gastroesophageal reflux disease (GERD). 7. Entitlement to a rating in excess of 30 percent prior to April 30, 2012, for service-connected posttraumatic stress disorder (PTSD). 8. Entitlement to a compensable rating for service-connected scars of residuals from breast reduction surgery. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD T. Berryman, Associate Counsel INTRODUCTION The Veteran had service in the Army National Guard and served on active duty from August 1982 to November 1982, September 1983 to November 1987, and June 1988 to July 2007. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. In connection with this appeal, the Veteran testified at a hearing before the undersigned Veterans Law Judge in June 2016. A transcript of that hearing is of record. In October 2016, the Board remanded the Veteran's claims for further development. The Board is satisfied that there was at the very least substantial compliance with its remand directives. See Dyment v. West, 13 Vet. App. 141, 146-157 (1999). FINDINGS OF FACT 1. Prior to November 26, 2013, range of motion testing, even contemplating functional limitation due to pain, weakness, stiffness, fatigability, lack of endurance, and repetitive motion etc., was not shown to functionally limit the forward flexion of the Veteran's lumbar spine to greater than 60 degrees or functionally limit the combined range of motion of the lumbar spine to greater than 120 degrees; muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour were not shown; ankylosis of the spine was not shown; and incapacitating episodes having a total duration of at least two weeks but less than four weeks during a 12 month period were not shown. 2. Prior to November 26, 2013, range of motion testing, even contemplating functional limitation due to pain, weakness, stiffness, fatigability, lack of endurance, and repetitive motion etc., was not shown to functionally limit the forward flexion of the Veteran's cervical spine to 30 degrees or less or functionally limit the combined range of motion of the cervical spine to 170 degrees or less; muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour were not shown; ankylosis of the spine was not shown; and incapacitating episodes having a total duration of at least two weeks during a 12 month period were not shown. 3. The Veteran's left knee disability has not been shown to result in ankylosis; dislocated or removed meniscus; flexion functionally limited to 45 degrees or less; extension functionally limited to 10 degrees or more; an impairment of the tibia and fibula; or genu recurvatum. 4. As of November 26, 2013, but not earlier, the Veteran's left knee disability was shown to result in lateral instability that is supportive of a separate compensable rating. 5. The Veteran's left ankle disability does not result in any ankylosis, malunion, astragalectomy, or marked limitation of motion. 6. Prior to November 26, 2013, the Veteran's left lower extremity peripheral neuropathy was characterized by mild incomplete paralysis of the femoral nerve; moderate incomplete paralysis, or worse, was not shown. 7. From November 26, 2013, the Veteran's left lower extremity peripheral neuropathy is characterized by moderate incomplete paralysis of the femoral nerve; severe incomplete paralysis, or worse, is not shown. 8. The Veteran's GERD does not result in persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain productive of considerable impairment of health. 9. Prior to February 23, 2012, the Veteran's PTSD was not shown to cause occupational and social impairment with reduced reliability and productivity or worse. 10. From February 23, 2012, the Veteran's PTSD resulted in total occupational and social impairment. 11. The Veteran's breast reduction surgery scars are painful. CONCLUSIONS OF LAW 1. The criteria for ratings in excess of those assigned for a lumbar spine disability have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5243 (2017). 2. The criteria for ratings in excess of those assigned for a cervical spine disability have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5243 (2017). 3. Prior to November 26, 2013, the criteria for ratings in excess of those assigned for the Veteran's left knee disability have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256-5263 (2017). 4. From November 26, 2013, the criteria for a separate compensable rating of 10 percent under Diagnostic Code 5257 for left knee instability have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2017). 5. The criteria for a rating in excess of 10 percent for a left ankle disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5270-74 (2017). 6. The criteria for ratings in excess of those assigned for left lower extremity peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.124a, Diagnostic Code 8521 (2017). 7. The criteria for a rating in excess of 10 percent for GERD have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.114, Diagnostic Code 7346 (2017). 8. Prior to February 23, 2012, the criteria for a rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). 9. From February 23, 2012, the criteria for a 100 percent rating for PTSD have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). 10. The criteria for a rating of 10 percent for breast reduction surgery scars have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.118, Diagnostic Codes 7801-7805 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). In this case, required notice was met, and neither the Veteran, nor her representative, has either alleged, or demonstrated, any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders, 129 U.S. 1696 (2009). Thus, adjudication of the claims at this time is warranted. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). VA treatment records, Social Security Administration (SSA) records, and private treatment records have been obtained. Additionally, the Veteran testified at a hearing before the Board in June 2016. The Veteran was also provided VA examinations and neither the Veteran, nor her representative, has objected to the adequacy of the examinations conducted during this appeal. See Sickels v. Shinseki, 643 F.3d, 1362, 1365-66 (Fed. Cir. 2011). As described, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Lumbar Spine Disability The Veteran was granted service connection for her lumbar spine disability by a June 2008 rating decision and initially rated at 10 percent under Diagnostic Code 5243 effective August 1, 2007, the day after her release from active service. A February 2014 rating decision granted an increased rating of 60 percent effective November 26, 2013. The Veteran disagrees with the assigned ratings and asserts she is entitled to higher ratings. Back disabilities are rated under either the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome (IVDS) based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a. Under the current Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, a 10 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least one week but less than two weeks during a 12 month period on appeal. A 20 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least two weeks but less than four weeks during a 12 month period on appeal. A 40 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least four weeks but less than six weeks during a 12 month period on appeal. A 60 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least six weeks during a 12 month period on appeal. 38 C.F.R. § 4.71a, Diagnostic Code 5243. An incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). Prior to November 26, 2013, the evidence of record does not show that the Veteran experienced IVDS for her lumbar spine disability. There is also no evidence showing that the Veteran had been prescribed bed rest to treat her lumbar spine disability prior to November 26, 2013. There is no contention to the contrary. From November 26, 2013, the Veteran is in receipt of the maximum 60 percent rating for IVDS. Prescribed bed rest is a fundamental element for an evaluation under this section of the rating schedule, the absence of any prescribed bed rest precludes a rating under these criteria. As such, a rating based on IVDS is not appropriate, and it is therefore more beneficial to evaluate the Veteran's lumbar spine disability under the General Rating Formula for Diseases and Injuries of the Spine for the period prior to November 26, 2013. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent evaluation is warranted if forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees, the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or if there is muscle spasm muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted if forward flexion of the thoracolumbar spine is 30 degrees or less or there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Normal ranges of motion of the thoracolumbar spine are flexion from 0 to 90 degrees, extension from 0 to 30 degrees, lateral flexion from 0 to 30 degrees, and lateral rotation from 0 to 30 degrees. 38 C.F.R. § 4.71, Plate V. The Veteran's clinical records show that she was treated for low back pain, but do not describe the results of any specific range of motion testing or findings consistent with muscle spasm or guarding, abnormal spinal contour, reversed lordosis, or abnormal kyphosis. In April 2008, the Veteran was afforded a VA examination. She reported that despite her back pain, she was able to get into and out of her bed and perform all her activities of daily living independently. She reported that every two or three years her back would go out for several days and she would be essentially bedridden; however, the last episode had occurred several years earlier, and not during the course of the appeal. On examination, she demonstrated flexion to 60 degrees, extension to 20 degrees, tilting to 20 degrees bilaterally, and left and right rotation to less than 10 degrees. Repetitive use testing resulted in no additional limitation or functional loss. She retained normal 5/5 strength. In November 2013, the Veteran was afforded a VA examination. She reported worsening of her lumbar spine symptoms. She reported flare-ups that resulted in increased back pain. On examination, she demonstrated flexion to 65 degrees, extension to 10 degrees, left and right lateral flexion to 20 degrees, and left and right rotation to 20 degrees, all with pain. Repetitive use testing resulted in reduced flexion to 60 degrees and right lateral flexion to 15 degrees. The examiner indicted that the Veteran had functional loss of the lumbar spine after repetitive use testing that consisted of less movement than normal, weakened movement, excess fatigability, pain on movement, disturbance of locomotion, interference with sitting, standing and/or weight-bearing, and lack of endurance. The examiner indicated that the Veteran had localized tenderness over the thoracic and lumbar spines and muscle spasms resulting in an abnormal gait or abnormal spinal contour. The examiner indicated that there was no ankylosis of the spine. The examiner indicated that the Veteran had IVDS with incapacitating episodes having a total duration of at least six weeks during the previous 12 months. Prior to November 26, 2013, the medical records show that the Veteran did not demonstrate either forward flexion or combined range of motion that was so functionally limited as to be consistent with a 20 percent rating. The medical record does not demonstrate findings consistent with a higher 20 percent evaluation. As such, a rating in excess of 10 percent is not warranted prior to November 26, 2013. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45 for the period prior to November 26, 2013. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40 (2017). Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Id.; see also 38 C.F.R. § 4.59 (2017) (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45 (2017). The Veteran reported that despite her back pain, she was able to get into and out of her bed and perform all her activities of daily living independently. She retained lumbar spine range of motion equivalent to the assigned 10 percent rating. In addition, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 43. While the Veteran reported pain, repetitive use testing did not reveal additional limitation that would warrant a 20 percent rating. Overall, the Veteran's treatment records do not demonstrate any additional functional limitations that would support the assignment of a higher rating for the period prior to November 26, 2013. Additionally, the evidence does not show an abnormal gait (as the Veteran's gait was symmetrical at the April 2008 VA examination) or abnormal spinal contour. After November 26, 2013, the Veteran is in receipt of a rating of 60 percent for her lumbar spine IVDS, which surpasses the maximum allowed based range of motion. The only rating available is a 100 percent rating for ankylosis of the entire spine. Where a musculoskeletal disability is evaluated at the highest rating available based upon limitation of motion, further DeLuca analysis is foreclosed. Johnston v. Brown, 10 Vet. App. 80 (1997). Accordingly, a schedular rating in excess of 10 percent prior to November 26, 2013, and in excess of 60 percent afterwards, for a lumbar spine disability is not warranted. As such, the claims are denied. Cervical Spine Disability The Veteran was granted service connection for her cervical spine disability by a June 2008 rating decision and initially rated at 10 percent under Diagnostic Code 5243 effective August 1, 2007, the day after her release from active service. A February 2014 rating decision granted an increased rating of 60 percent effective November 26, 2013. The Veteran disagrees with the assigned ratings and asserts she is entitled to higher ratings. Neck disabilities are rated under either the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome (IVDS) based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a. Under the current Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, a 10 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least one week but less than two weeks during a 12 month period on appeal. A 20 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least two weeks but less than four weeks during a 12 month period on appeal. A 40 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least four weeks but less than six weeks during a 12 month period on appeal. A 60 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least six weeks during a 12 month period on appeal. 38 C.F.R. § 4.71a, Diagnostic Code 5243. An incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). Prior to November 26, 2013, the evidence of record does not show that the Veteran experienced IVDS for her cervical spine disability. There is also no evidence showing that the Veteran had been prescribed bed rest to treat her cervical spine disability prior to November 26, 2013. There is no contention to the contrary. From November 26, 2013, the Veteran is in receipt of the maximum 60 percent rating for IVDS. Prescribed bed rest is a fundamental element for an evaluation under this section of the rating schedule, the absence of any prescribed bed rest precludes a rating under these criteria. As such, a rating based on IVDS is not appropriate, and it is therefore more beneficial to evaluate the Veteran's cervical spine disability under the General Rating Formula for Diseases and Injuries of the Spine for the period prior to November 26, 2013. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent evaluation is warranted if forward flexion of the cervical spine is greater than 30 degrees but not greater than 40 degrees, the combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or if there is muscle spasm muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted if forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees, the combined range of motion of the cervical spine not greater than 170 degrees; or if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent evaluation is warranted if forward flexion of the cervical spine is 15 degrees or less or there is favorable ankylosis of the entire cervical spine. A 40 percent evaluation is warranted if there is unfavorable ankylosis of the entire cervical spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Normal ranges of motion of the cervical spine are flexion from 0 to 45 degrees, extension from 0 to 45 degrees, lateral flexion from 0 to 45 degrees, and lateral rotation from 0 to 80 degrees. 38 C.F.R. § 4.71, Plate V. The Veteran's clinical records show that she was treated for neck pain, but do not describe the results of any specific range of motion testing or findings consistent with muscle spasm or guarding, abnormal spinal contour, reversed lordosis, or abnormal kyphosis. In April 2008, the Veteran was afforded a VA examination. She reported neck pain and asserted that she could not be on the phone if she had to tip her head in order to trap the headpiece against her shoulder. On examination, she demonstrated flexion to 45 degrees, extension to 45 degrees, left lateral flexion to 30 degrees, right lateral flexion to 40 degrees, left rotation to 60 degrees, and right rotation to 50 degrees. Repetitive use testing resulted in no additional limitation or functional loss. She retained normal 5/5 strength. In November 2013, the Veteran was afforded a VA examination. She reported worsening of her cervical spine symptoms. She reported that her pain spread to the shoulders. She reported flare-ups that resulted in increased neck pain. On examination, she demonstrated flexion to 40 degrees, extension to 5 degrees, left and right lateral flexion to 20 degrees, and left and right rotation to 45 degrees, all with pain. Repetitive use testing resulted in reduced flexion to 30 degrees, left lateral flexion to 10 degrees, left rotation to 35 degrees, and right rotation to 40 degrees. The examiner indicted that the Veteran had functional loss of the cervical spine after repetitive use testing that consisted of less movement than normal, weakened movement, excess fatigability, pain on movement, disturbance of locomotion, instability of station, and lack of endurance. The examiner indicated that the Veteran had localized tenderness over the cervical spine and muscle spasms resulting in an abnormal gait or abnormal spinal contour. The examiner indicated that there was no ankylosis of the spine. The examiner indicated that the Veteran had IVDS with incapacitating episodes having a total duration of at least six weeks during the previous 12 months. Prior to November 26, 2013, the medical records show that the Veteran did not demonstrate either forward flexion or combined range of motion that was so functionally limited as to be consistent with a 20 percent rating. There was also no showing that the Veteran's cervical spine caused any alteration in gait or abnormal spinal contour. The medical record does not demonstrate findings consistent with a higher 20 percent evaluation. As such, a rating in excess of 10 percent is not warranted prior to November 26, 2013. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45 for the period prior to November 26, 2013. See also DeLuca, 8 Vet. App. 202. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Id.; see also 38 C.F.R. § 4.59 (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. The Veteran reported neck pain and could not be on the phone if she had to tip her head in order to trap the headpiece against her shoulder. She retained cervical spine range of motion equivalent to the assigned 10 percent rating. In addition, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 43. While the Veteran reported pain, repetitive use testing did not reveal additional limitation that would warrant a 20 percent rating. Overall, the Veteran's treatment records do not demonstrate any additional functional limitations that would support the assignment of a higher rating for the period prior to November 26, 2013 After November 26, 2013, the Veteran is in receipt of a rating of 60 percent for her cervical spine IVDS, which surpasses the maximum allowed based range of motion. The only rating available is a 100 percent rating for ankylosis of the entire spine. Where a musculoskeletal disability is evaluated at the highest rating available based upon limitation of motion, further DeLuca analysis is foreclosed. Johnston, 10 Vet. App. 80. Accordingly, a schedular rating in excess of 10 percent prior to November 26, 2013, and in excess of 60 percent afterwards, for a cervical spine disability is not warranted. As such, the claims are denied. Left Knee Disability The Veteran was granted service connection for her left knee disability by a June 2008 rating decision and initially rated at 10 percent under Diagnostic Code 5299-5257 effective August 1, 2007, the date after her release from active service. A February 2014 rating decision granted an increased rating of 20 percent effective November 23, 2013, under Diagnostic Code 5258. The Veteran disagrees with the assigned ratings and asserts she is entitled to higher ratings. At the hearing, she testified that her left knee hurts after standing too long. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206 -07 (1995). Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5256 evaluates ankylosis of the knee. The record contains no evidence of knee ankylosis, and the Veteran has not described symptoms that are suggestive of ankylosis. Therefore, this Diagnostic Code is not applicable and will be discussed no further. Diagnostic Code 5257 evaluates recurrent subluxation or lateral instability of a knee. A 10 percent rating is assigned for a slight impairment, a 20 percent rating is assigned for a moderate impairment, and a 30 percent rating is assigned for a severe impairment. Diagnostic Code 5257 is not predicated on loss of range of motion. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Diagnostic Codes 5258 and 5259 evaluate semilunar cartilage, which is synonymous with the meniscus. A 10 percent rating is assigned under Diagnostic Code 5259 for removal of the meniscus. A 20 percent rating is assigned under Diagnostic Code 5258 for a dislocated meniscus with frequent episodes of "locking," pain, and effusion into the joint. Diagnostic Code 5260 evaluates limitation of knee flexion. A noncompensable rating is assigned for flexion limited to 60 degrees. A 10 percent rating is assigned for flexion limited to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees or extension limited to 15 degrees. A 30 percent rating is assigned for either flexion limited to 15 degrees or extension limited to 20 degrees. Diagnostic Code 5261 evaluates limitation of knee extension. A noncompensable rating is assigned for extension limited to 5 degrees. A 10 percent rating is assigned for extension limited to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. Of note, separate compensable ratings may be assigned for limitation of flexion and for limitation of extension, without violating the rule against pyramiding. See 38 C.F.R. § 4.14. Diagnostic Code 5262 evaluates impairment of the tibia and fibula. The December 2013 VA examiner indicated that the Veteran had shin splints during her active service, but currently had no symptoms. The record contains no evidence of a current impairment of the tibia and fibula, and the Veteran has not described symptoms that are suggestive of an impairment of the tibia and fibula. Therefore, this Diagnostic Code is not applicable and will be discussed no further. Diagnostic Code 5263 evaluates genu recurvatum. The record contains no evidence of left genu recurvatum, and the Veteran has not described symptoms that are suggestive of left genu recurvatum. Therefore, this Diagnostic Code is not applicable and will be discussed no further. Prior to November 26, 2013, the Veteran's left knee disability was rated under Diagnostic Code 5299-5257 for slight recurrent subluxation or lateral instability at 10 percent. From November 26, 2013, the Veteran's left knee disability was rated under Diagnostic Code 5258 for a dislocated meniscus. The Veteran's medical records show that she underwent anterior crucial ligament repair surgery in 2004 while in active service. After her separation from service, she continued to receive treatment for her knee symptoms. However, her treatment records do not show findings consistent with higher ratings. In April 2008, the Veteran was afforded a VA examination. She reported that she continues to have pain that increased with use. She also reported she could only walk a short distance due to a combination of her back and knee pain. On examination, she demonstrated left knee flexion to 120 degrees and extension to almost 0 degrees. Repetitive use testing resulted in no additional limitation of motion or discomfort. She had medial/lateral laxity at 30 degrees of flexion. In November 2013, the Veteran was afforded a VA examination. She reported that her left knee had worsened. She also reported flare-ups that resulted in additional pain. On examination, she demonstrated left knee flexion to 95 degrees with pain and extension to 0 degrees. Repetitive use resulted in flexion limited to 80 degrees. The examiner indicated that after repetitive use, the Veteran had less movement than normal, weakened movement, excess fatigability, incoordination and impaired ability to execute skilled movements smoothly, pain on movement, instability of station, disturbance of locomotion, and interference with sitting, standing, and weight bearing. She had reduced 4/5 strength and anterior, posterior, and medial-lateral left knee instability. The examiner indicated that the Veteran had no history of recurrent patellar subluxation/dislocation. The examiner indicated that the Veteran had a left knee meniscal condition that included a meniscal tear, frequent episodes of joint "locking," and frequent episodes of joint pain. The Board finds that the criteria to assign a rating in excess of 10 percent prior to November 26, 2013, under Diagnostic Code 5257 for the Veteran's left knee disability have not been met. At the April 2008 VA examination, the Veteran was noted to have medial/lateral laxity at 30 degrees of flexion, for which she was assigned a 10 percent rating for a slight impairment. At the November 2013 VA examination, the Veteran continued to show instability. A moderate impairment has not been demonstrated at any time during the course of the appeal. As such, a rating in excess of 10 percent prior to November 26, 2013, is not warranted. However, as the Veteran continued to show instability at the most recent VA examination, the 10 percent rating is continued. Accordingly, a separate 10 percent rating under Diagnostic Code 5257 from November 26, 2013, is granted. Regarding a meniscal condition, the Board finds that the criteria to assign a separate compensable rating under Diagnostic Codes 5258 or 5259 are not met prior to November 23, 2013. The April 2008 VA examiner did not indicate that the Veteran had a meniscal condition. From November 23, 2013, the Veteran is in receipt of the maximum rating permitted under these Diagnostic Codes. Turning to limitation of flexion, the Board finds the criteria to assign a separate compensable rating under Diagnostic Code 5260 have not been met. The Veteran demonstrated flexion, at worse, limited to 80 degrees even when considering pain, which exceeds the 60 degree limitation, equivalent to a noncompensable rating. As such, the Veteran is not found to meet even the criteria for a noncompensable rating under Diagnostic Code 5260, which requires flexion to be limited to 60 degrees. Turning to limitation of extension, the Board finds that the criteria to assign a separate compensable rating under Diagnostic Code 5261 have not been met. The Veteran consistently demonstrated extension in her left knee to almost 0 degrees, which exceeds the 5 degree limitation, equivalent to a noncompensable rating. As such, the Veteran is not found to meet even the criteria for a noncompensable rating under Diagnostic Code 5261, which requires extension to be limited to 5 degrees. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca, 8 Vet. App. 202. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Additionally, painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Here, while the November 2013 VA examiner indicated that repetitive use further limited the Veteran's flexion and resulted in less movement than normal, weakened movement, excess fatigability, incoordination and impaired ability to execute skilled movements smoothly, pain on movement, instability of station, disturbance of locomotion, and interference with sitting, standing, and weight bearing the Veteran nevertheless retained flexion and extension in excess of even compensable ratings. Furthermore, while the Veteran has been granted a separate rating for instability from November 23, 2013, the evidence simply does not support that the Veteran's left knee disability results in findings consistent with additional higher ratings. Thus, greater ratings for limitations of flexion and extension are not warranted under DeLuca. While the Veteran has been shown to experience knee pain, the Court of Appeals for Veterans Claims (Court) has held that even if range of motion was slightly limited by pain, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 43; see 38 C.F.R. § 4.40. Here, the Veteran consistently retained flexion and extension in excess of a noncompensable rating. As such, there is no basis for a compensable rating under Diagnostic Codes 5260 or 5261. To the extent that it is argued that the Veteran's range of motion is painful and therefore would merit a separate compensable rating under 38 C.F.R. § 4.59, that provision states that 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. However, here, the Veteran is currently assigned the minimum compensable rating based on instability prior to November 23, 2013, and multiple ratings from November 23, 2013. As such, 4.59 does not mandate a separate rating. Accordingly, a schedular rating in excess of those assigned prior to November 26, 2013, for a left knee disability is not warranted, and as such, the claim is denied. From November 26, 2013, a separate 10 percent rating is warranted for left knee instability, and to that extent, the claim is granted. Left Ankle Disability The Veteran was granted service connection for her left ankle disability by a June 2008 rating decision and initially rated at 10 percent under Diagnostic Code 5010-5271 effective August 1, 2007, the date after her release from active service. The Veteran disagrees with the assigned rating and asserts she is entitled to a higher rating. At the hearing, she testified that her left ankle hurts after standing too long. Ankle dorsiflexion is measured from 0 degrees to 20 degrees; plantar flexion is measured from 0 degrees to 45 degrees. 38 C.F.R. § 4.71a, Plate II. Diagnostic Code 5010 evaluates degenerative arthritis under Diagnostic Code 5003, which in turn evaluates disabilities based on the degree of limitation of motion under the appropriate Diagnostic Codes, in this case Diagnostic Code 5271. If the disability is noncompensable under the appropriate Diagnostic Code for the joint involved, a 10 percent rating will be for application for such major joint or group of minor joints affected by limitation of motion. Id. Limitation of motion needs to be objectively shown by findings such as swelling, muscle spasm, or painful motion. Id. Diagnostic Code 5270 evaluates ankylosis of the ankle and Diagnostic Code 5272 evaluates ankylosis of the subastragalar or tarsal joint. The record contains no evidence of ankle ankylosis, and the Veteran has not described symptoms that are suggestive of ankylosis. Therefore, these Diagnostic Codes are not applicable and will be discussed no further. Diagnostic Code 5273 evaluates malunion of the os calcis or astragalus. The medical record contains no evidence of malunion of the os calcis or astragalus of the left ankle, and the Veteran has not described symptoms that are suggestive of malunion of os calcis or astragalus of the left ankle. Therefore, this Diagnostic Code is not applicable and will not be discussed further. Diagnostic Code 5274 evaluates astragalectomy, or removal of the talus bone. The medical record contains no evidence of removal of the talus bone, and the Veteran has not described symptoms that are suggestive of malunion of removal of the talus bone. Therefore, this Diagnostic Code is not applicable and will not be discussed further. Diagnostic Code 5271 evaluates range of motion in the ankle. A 10 percent rating is assigned for moderate limitation of motion and a 20 percent rating is assigned for marked limitation of motion. The Board notes that words such as moderate and marked are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. The Veteran was assigned a 10 percent rating under Diagnostic Code 5010-5271, the minimum assignable rating. The evidence of record fails to establish that a higher disability rating is warranted as marked limitation of motion in her right ankle has not been shown. The Veteran's treatment records show that she receives treatment for her left ankle pain, but note no specific symptoms or limitations. In April 2008, the Veteran was afforded a VA examination. She reported that she did not use a brace and denied having undergone surgery for her left ankle. On examination, she demonstrated dorsiflexion to 5 degrees, but could be taken passively to 10 degrees, and plantar flexion to 25 degrees, but could be taken passively to 45 degrees. Repetitive use testing resulted in no additional limitation of motion or discomfort. In November 2013, the Veteran was afforded a VA examination. She reported that her left ankle had worsened. The examiner indicated that the Veteran had metatarsalgia, but did not have any other foot disability such as Morton's neuroma, hammer toe, hallux valgus, hallux rigidus, pes cavus, malunion or nonunion of tarsal or metatarsal bones, foot injures, or weak foot. She retained 4/5 strength in her left foot and toes. The examiner reported that standing more than 15 to 20 minutes resulted in left ankle pain and she reported being unable to tolerate being on her feet for long periods of time. The Veteran's left ankle range or motion was not indicated. Because the rating schedule offers no further guidance on the issue, the Board will rely on Webster's definitions of the terms used. "Marked" means noticeable, Webster's II New College Dictionary, 670 (1995). "Moderate" means of average or medium quantity. Id. at 704. Having reviewed the evidence of record, the Board concludes that the Veteran's left ankle findings are consistent with "moderate" limitation of motion. A finding of "marked" limitation is not appropriate as the Veteran retained half of normal ranges of motion and retained 4/5 strength. Moreover, in no record was the Veteran's limitation of motion so pronounced as to be noticeable. The Veteran's left ankle results in some limitations, but this is expected as the Veteran was provided with a compensable rating for moderate limitation of motion of the ankle. The clinical testing and observation of the Veteran's left ankle does not suggest that her left ankle is so functionally limited that it should be described as marked. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca, 8 Vet. App. 202. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Additionally, painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Here, while the November 2013 VA examiner indicated that the Veteran had left ankle pain after 15 to 20 minutes of standing and reported that she could not tolerate being on her feet for long periods of time, the Veteran nevertheless retained range of motion comparable to a moderate limitation of motion. The evidence simply does not support that the Veteran's left ankle disability results in findings consistent with a higher rating. Thus, a greater rating for limitation of motion is not warranted under DeLuca. While the Veteran has been shown to experience ankle pain, the Court of Appeals for Veterans Claims (Court) has held that even if range of motion was slightly limited by pain, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 43; see 38 C.F.R. § 4.40. Here, the Veteran consistently retained range of motion comparable to moderate limitations. To the extent that it is argued that the Veteran's range of motion is painful and therefore would merit a separate compensable rating under 38 C.F.R. § 4.59, that provision states that 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. However, here, the Veteran is currently assigned the minimum compensable rating based on limitation of motion. As such, 4.59 does not mandate a separate rating. Accordingly, a schedular rating in excess of 10 percent prior for a left ankle disability is not warranted. As such, the claim is denied. Left Lower Extremity Peripheral Neuropathy The Veteran was granted service connection for her left lower extremity peripheral neuropathy by a June 2008 rating decision and initially rated at 10 percent under Diagnostic Code 8521 effective August 1, 2007, the date after her release from active service. A February 2014 rating decision granted an increased rating of 20 percent effective November 23, 2013. The Veteran disagrees with the assigned ratings and asserts she is entitled to higher ratings. At the hearing, the Veteran testified that her left lower extremity hurts after standing too long. The Veteran's left lower extremity peripheral neuropathy is rated under Diagnostic Code 8521, which evaluates neuropathy of the external popliteal (common peroneal) nerve. A 10 percent rating is assigned for mild incomplete paralysis of the affected nerve. A 20 percent rating is assigned for moderate incomplete paralysis of the affected nerve. A 30 percent rating is assigned for severe incomplete paralysis of the affective nerve. A 40 percent rating is assigned for complete paralysis. 38 C.F.R. § 4.124a, Diagnostic Code 8521. The words "mild," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. In March 2008, the Veteran was afforded a VA examination. The examiner indicated that she had a history of numbness. In April 2008, the Veteran was afforded a VA examination. She had reduced left lower extremity reflexes, but retained normal sensation and normal strength. In November 2013, the Veteran was afforded a VA examination. She reported having numbness and tingling. On examination, she had reduced 4/5 strength in the left knee and ankle with no muscle atrophy. She had normal left lower extremity reflexes and decreased left lower extremity sensation. The examiner noted trophic changes over her left lower extremity. The examiner indicated that the Veteran had incomplete moderate left lower extremity paralysis. Thus, applying the regulations to the facts in the case, the Board finds that the criteria for a disability rating in excess of 10 percent prior to November 23, 2013, are not met for the Veteran's left lower extremity peripheral neuropathy. The evidence of record simply does not support a rating in excess of 10 percent rating under Diagnostic Code 8521, which would be warranted if moderate incomplete paralysis of the affected nerve was shown. As noted, the medical evidence of record prior to November 23, 2013, suggests that her left lower extremity incomplete paralysis was at most mild and does not show evidence of moderate, or higher, incomplete paralysis. Of note, there was no showing of symptoms other than sensory (for example atrophy was not observed to be present on physical examinations), and when the involvement is wholly sensory, VA regulations direct that the rating should be for the mild, or at most, the moderate degree. Here, as described, the Veteran's nerve impairment does not appear to rise to the level of moderate prior to November 23, 2013, when trophic changes were first seen. As such, a rating in excess of 10 percent is denied prior to November 23, 2013. Likewise, the Board finds that the criteria for a disability rating in excess of 20 percent from November 23, 2013, are not met for the Veteran's left lower extremity peripheral neuropathy. The evidence of record simply does not support a rating in excess of 20 percent rating under Diagnostic Code 8521, which would be warranted if severe incomplete paralysis of the affected nerve was shown. As noted, the medical evidence of record as of November 23, 2013, suggests that her left lower extremity incomplete paralysis was at most moderate and does not show evidence of severe incomplete paralysis or complete paralysis. Once again, no muscle atrophy was noted at any VA examination. The symptoms were generally sensory in nature. While trophic changes support a moderate rating, their presence without atrophy does not suggest the presence of severe peripheral neuropathy. As noted, the examiner who performed the physical examination in November 2013, considering all of the neurologic symptomatology in the left lower extremity, concluded that the peripheral neuropathy was moderate. As such, a rating in excess of 20 percent is denied from November 23, 2013. While the Veteran asserted that her condition had progressed, objective clinical testing and examination did not reveal symptomatology that would support a rating in excess of the ratings assigned. The Veteran is certainly competent to report the symptoms that she experiences, but her statements and the medical evidence of record must be reviewed together to determine the appropriate disability level. There is no doubt that the Veteran's left lower extremity is symptomatic and causes discomfort, but it is for that reason that she has been assigned the compensable ratings. The objective medical evidence simply does not identify symptoms that would support higher ratings. The Board has considered all other potentially applicable Diagnostic Codes, but has found that no other Diagnostic Codes would result in more favorable findings. Accordingly, a schedular rating in excess of 10 percent prior to November 23, 2013, and in excess of 20 percent from November 23, 2013, for the Veteran's left lower extremity peripheral neuropathy have not been met and her claim is denied. GERD The Veteran was granted service connection for her GERD by a June 2008 rating decision and initially rated at 10 percent under Diagnostic Code 7399-7304 effective August 1, 2007, the date after her release from active service. The Veteran disagrees with the assigned rating and asserts she is entitled to a higher rating. At the hearing, she testified that she takes over-the-counter medications and sleeps with extra pillows. Diagnostic Code 7399 indicates the disability is not listed in the Schedule for Rating Disabilities and it has been rated by analogy under a closely related disease or injury. 38 C.F.R. §§ 4.20, 4.27. The RO rated the claim under Diagnostic Code 7304, which evaluates gastric ulcer. Under Diagnostic Code 7304, a rating of 10 percent is warranted for mild GERD with recurring symptoms once or twice yearly. A 20 percent is warranted for moderate GERD with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration; or with continuous moderate manifestation. A 40 percent is warranted for moderately severe GERD, which is less than severe, but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year . A 60 percent rating is warranted for severe GERD with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7304. The Veteran's clinical records show that she was treated for GERD symptoms, but do not describe the results of any specific findings consistent of moderate GERD with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration or with continuous moderate manifestation. At a March 2008 VA examination, the Veteran reported that she had GERD symptoms off and on. She reported that she managed her symptoms with diet and positioning. In November 2013, the Veteran was afforded a VA examination. She reported that her GERD was a little bit better. The examiner indicated that the Veteran's symptoms were mild and included pyrosis, reflux, regurgitation, and nausea. The examiner indicated that the Veteran's GERD did not result in an esophageal stricture, esophagus spasms, an acquired diverticulum of the esophagus, or any other pertinent physical findings, complication, conditions, signs, or symptoms related to her GERD. The Board is sympathetic to the concerns that have been voiced, and notes that the Veteran's GERD undoubtedly causes some impairment as is suggested by the 10 percent rating that is assigned. However, the record does not show that her GERD rises to the level of assignment of a rating in excess of 10 percent. The rating schedule was created as a guide to evaluating disability resulting from all types of diseases and injuries encountered, and the percentage ratings that are assigned represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Here, the Veteran has not specifically identified any GERD symptoms which would merit a higher schedular rating. The claims files fails to establish that the Veteran's GERD causes recurring episodes of severe symptoms two or three times a year averaging 10 days in duration or continuous moderate manifestation. Likewise the GERD was not shown to result in persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation that is accompanied by substernal arm or shoulder pain. Of note, the VA examiner in November 2013 specifically found the Veteran's GERD symptoms to be mild. Accordingly, a schedular rating in excess of 10 percent for the Veteran's GERD has not been met. As such, the claim is denied. PTSD The Veteran was granted service connection for her PTSD by a June 2008 rating decision and initially rated at 30 percent under Diagnostic Code 9411 effective August 1, 2007, the date after her release from active service. The Veteran's PTSD was increased to 100 percent effective April 30, 2012. The Veteran disagrees with the assigned rating prior to April 30, 2012, and asserts she is entitled to a higher rating. Under the General Rating Formula for Mental Disorders, a 30 percent evaluation is assigned when a veteran's mental disability causes 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). 38 C.F.R. § 4.130, Diagnostic Code 9433. A 50 percent evaluation is assigned when a veteran's mental disability causes 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; or difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is assigned when a veteran's mental disability causes 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); or an inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned when a veteran's mental disability causes total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; danger of hurting self or others; intermittent inability to perform activities of living (including maintenance of minimal hygiene); disorientation to time or place; or, memory loss for names of close relatives, occupation, or own name. Id. When rating a mental disorder, VA must consider the frequency, severity, and duration of the Veteran's psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency must assign a rating based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When rating the level of disability from a mental disorder, the rating agency must consider the extent of social impairment, but cannot assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. When determining the appropriate disability evaluation to assign, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact the Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 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. Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-IV. The amendments replace those references with references to the recently updated "DSM-5." As the Veteran's claim was certified to the Board before August 4, 2014, the DSM-5 is not applicable to this case. Also relevant to the Board's analysis is the Global Assessment of Functioning (GAF) score assigned to the Veteran, which is a scale that indicates the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Carpenter v. Brown, 8 Vet. App. 240 (1995); Richard v. Brown, 9 Vet. App. 266 (1996); American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV); 38 C.F.R. § 4.130. While the veteran's GAF score is not itself determinative of the most appropriate disability rating, the Board must consider it when assigning the appropriate disability rating for the veteran. VAOPGCPREC 10-95 (1995), 60 Fed. Reg. 43186 (1995). GAF scores ranging from 31 to 40 indicate 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 adult avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). GAF scores ranging from 41 to 50 indicate 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, cannot work). American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994); 38 C.F.R. § 4.130. The competent evidence of record, to include the Veteran's treatment records, VA examination reports, and private medical opinions do not establish findings consistent with a higher rating prior to February 23, 2012. In March 2008, the Veteran was afforded a VA examination. She reported being married and living with her children and grandchildren. The Veteran continued to work. The examiner reviewed the Veteran's claims file, interviewed her, and conducted an examination. The examiner assessed the Veteran with a GAF of 40. However, the Veteran's treatment records show that in July 2009 and August 2009, she was alert and cooperative with a normal mood and affect. Later in October 2010, she was cooperative and fully alert and oriented. On February 23, 2012, the Veteran was psychiatrically hospitalized. She reported having suicidal and homicidal ideation. She was assessed with a GAF of 45. Afterwards, SSA found the Veteran disabled due to her acquired psychiatric disability. In March 2012, the Veteran's Vocational Rehabilitation Counselor reported that as of February 23, 2012, the Veteran was no longer able to continue with her daily activities or work. As described, the Veteran has clearly experienced psychiatric symptomatology as a result of her PTSD. However, prior to February 23, 2012, the record does not establish that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. The March 2008 VA examiner assessed the Veteran with a GAF of 40. However, at the time, the Veteran continued to work and lived with her extended family. Later treatment records show that she had a normal mood and remained alert and cooperative. As such, prior to February 23, 2012, the Veteran's treatment records do not show psychiatric findings consistent with a higher rating. As such, it cannot be concluded that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity prior to February 23, 2012. On February 23, 2012, the Veteran was psychiatrically hospitalized for her acquired psychiatric disorder. Her Vocational Rehabilitation Counselor reported that as of February 23, 2012, the Veteran was no longer able to continue with her daily activities or work. She was subsequently granted SSA disability due to her acquired psychiatric disability. As such, as of February 23, 2012, the Veteran's medical records demonstrate that she had total social and occupational impairment. Accordingly, a rating in excess of 30 percent prior to February 23, 2012, is denied. From February 23, 2012, the Veteran is granted a 100 percent rating for her PTSD. Scars from Residuals of Breast Reduction Surgery The Veteran was granted service connection for her scars from residuals of breast reduction surgery by a June 2008 rating decision and initially rated at a noncompensable rate under Diagnostic Code 7802 effective August 1, 2007, the date after her release from active service. The Veteran disagrees with the assigned rating and asserts she is entitled to a higher rating. During the course of the Veteran's appeal, on September 23, 2008, VA amended the criteria for evaluating scars. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). However, the amendments specifically provide that the revised regulations are only effective for claims filed on or after October 23, 2008, unless a claimant requests consideration under the amended criteria. In this case, neither the Veteran, nor her representative, has requested such consideration. As such, the criteria in effect at the time the Veteran's claim was received are applicable. Under Diagnostic Code 7804, scars that are painful on examination are rated at 10 percent disabling. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2007) At the June 2016 hearing, the Veteran credibly testified that her scars of residuals from breast reduction surgery were painful, and lay testimony is competent to establish the presence of observable symptomatology, such as the pain. Layno v. Brown, 6 Vet. App. 465, 469 (1994). As such, a 10 percent rating for her scars of residuals from breast reduction surgery is granted. ORDER A rating in excess of 10 percent prior to November 26, 2013, and in excess of 60 percent afterwards, for a lumbar spine disability is denied. A rating in excess of 10 percent prior to November 26, 2013, and in excess of 60 percent afterwards, for a cervical spine disability is denied. Prior to November 26, 2013, ratings in excess of those assigned for the Veteran's left knee disability is denied. From November 26, 2013, a separate 10 percent rating for left knee lateral instability is granted, subject to the laws and regulations governing the award of monetary benefits. A rating in excess of 10 percent for GERD is denied. Prior to February 23, 2012, a rating in excess of 30 percent for PTSD is denied. From February 23, 2012, a rating of 100 percent for PTSD is granted, subject to the provision governing the award of monetary benefits. A 10 percent rating for scars of residuals from breast reduction surgery is granted, subject to the laws and regulations governing the award of monetary benefits. ______________________________________________ MATTHEW W. BLACKWELDER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs