Citation Nr: 1754022 Decision Date: 11/27/17 Archive Date: 12/07/17 DOCKET NO. 10-48 441 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased initial rating in for posttraumatic stress disorder (PTSD) with depressive disorder, rated 30 percent disabling from June 5, 2008, to May 17, 2016, and rated 50 percent disabling thereafter. 2. Entitlement to a rating in excess of 10 percent for bilateral plantar fasciitis status post left Achilles lengthening. 3. Entitlement to a rating in excess of 10 percent for right knee patellofemoral pain syndrome. 4. Entitlement to a rating in excess of 10 percent for left knee patellofemoral pain syndrome. 5. Entitlement to a total disability evaluation based on individual unemployability due to service connected disabilities (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran and TW ATTORNEY FOR THE BOARD Steve Ginski, Associate Counsel INTRODUCTION The Veteran served on active duty from September 2001 to June 2005. These matters are before the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in July 2009 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In November 2010 the RO granted a temporary total rating for service-connected bilateral plantar fasciitis status post left Achilles lengthening based on the need for convalescence after surgery for the period from May 6, 2009, to July 31, 2009. The currently appealed 10 percent rating was resumed effective from August 1, 2009. The Veteran provided testimony at a November 2014 hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. Thereafter, the Board remanded this claim in January 2015 for additional development. The claims have been returned to the Board for appellate consideration. This appeal was processed using the Veterans Benefits Management System (VBMS) and the Legacy Content Manager (LCM) system. LCM contains complete VA treatment records and a December 2016 Social and Industrial Survey. Otherwise, LCM contains documents that are either duplicative of the evidence in the VBMS electronic claims file or not relevant to the issue on appeal. The issues of entitlement to ratings in excess of 10 percent for bilateral knee patellofemoral pain syndrome are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Resolving all doubt in favor of the Veteran, the Veteran's PTSD and depression more nearly approximates deficiencies in most areas due to an inability to adapt to stressful situations and maintain effective relationships. 2. Prior to May 6, 2009, and beginning August 1, 2009, the Veteran's bilateral foot disability due to bilateral plantar fasciitis was manifested by a moderately severe disability of each foot, with resulting pain. 3. The Veteran's service-connected disabilities render him unable to secure or follow substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating, of 70 percent, but no more, for service-connected PTSD and depression are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code (DC) 9411 (2017). 2. The criteria for a separate disability rating of 20 percent, but no higher, for a left foot disability, have been met prior to May 6, 2009, and beginning August 1, 2009. 38 U.S.C.A. § 1155 (West 2014); 38 U.S.C.A. §§ 4.1, 4.3, 4.7, 4.14, 4.21, 4.71a, DCs 5276, 5280, 5284 (2017). 3. The criteria for a separate disability rating of 20 percent, but no higher, for a right foot disability, have been met prior to May 6, 2009, and beginning August 1, 2009. 38 U.S.C.A. § 1155 (West 2014); 38 U.S.C.A. §§ 4.1, 4.3, 4.7, 4.14, 4.21, 4.71a, DCs 5276, 5280, 5284 (2017). 4. The criteria for TDIU have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Neither the Veteran nor his attorney has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The Veteran also offered testimony before the undersigned Veterans Law Judge at a Board hearing in November 2014. The Board finds that all requirements for hearing officers have been met. 38 C.F.R. § 3.103(c)(2) (2017); Bryant v. Shinseki, 23 Vet. App. 488 (2010). To the extent that any evidentiary deficiency was noted, the Board finds that it has been cured on remand. Finally, the Board also finds that there has been compliance with the prior January 2015 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). II. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2017). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2017). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3 (2017). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2017). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev'd in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). A. PTSD with Depressive Disorder The Veteran is in receipt of a 30 percent disability rating for PTSD from March 2008 to May 17, 2016. From May 16, 2016, he is in receipt of a 50 percent disability rating for PTSD. The Veteran's PTSD has been evaluated under 38 C.F.R. § 4.130, DC 9411. Under this code, a 50 percent evaluation contemplates 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 warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood, due to such symptoms as: suicidal ideations; 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 worklike setting); and the inability to establish and maintain effective relationships. A 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. However, the symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). "[A] veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The symptoms shall have caused occupational and social impairment in most of the referenced areas. Vazquez-Claudio, 713 F.3d 112. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 3 8 C.F.R. § 4.126. In addition, the evaluation must be 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. 38 C.F.R. § 4.126. 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). Notwithstanding the use of the newer manual, the DSM-IV is the governing manual in the instant case. The Secretary of VA has specifically indicated that DSM-IV is still to be applied to claims pending before the Board. 79 Fed. Reg. 45094 (Aug. 4, 2014). GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect 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). See 38 C.F.R. § 4.130 (2014). The Veteran has been diagnosed with PTSD and major depressive disorder throughout the appeal period. Depression has been linked on a secondary basis to service-connected PTSD, migraines, bilateral foot, and bilateral knee disorders. Therefore, all psychiatric symptoms will be considered in deciding the Veteran's increased rating claim. Factual History The Veteran submitted a claim of entitlement to service connection for PTSD in June 2008. Of record is an October 2008 VA initial psychology consultation. On presentation, the Veteran reported feelings of depression, anxiety, tension, anhedonia, decreased concentration, insomnia, fatigue, social aversion and isolation, poor angry control with verbal outburst, suicidal ideation, low self-esteem, decreased appetite, and weight gain. Symptoms of PTSD identified by the Veteran at that time were a history of combat trauma, combat-related intrusive thoughts and nightly nightmares, avoidance of trauma-related cues, hypervigilance, hyper-startle response, crowd avoidance, and anxiety while driving. In describing his medical history, the Veteran indicated that he had attempted suicide in December 2007 by taking a "handful" of Tramadol and drinking beers. He had vomited at that time but had recurring suicidal ideation since then. He had not acted on his ideation because he was a father and wanted to be present for his son. He had last experienced passive suicidal ideation two weeks prior with no intent or plan. The attending psychiatrist noted that the Veteran was future oriented, had responsibility to his family, had a supportive girlfriend and mother, and was dedicated to his son. He had plans for the future, including attending college. He utilized positive skills such as distraction or reaching out to significant others. The Veteran also indicated that he was hopeful about treatment. The Veteran was provided with the National VA Suicide hotline number. The attending psychiatrist diagnosed PTSD and major depressive disorder and assigned a GAF score of 51. A January 2009 VA treatment note documents the Veteran reporting a history of depressed mood, irritability, frequent isolation, very limited trips out of the house, past panic attacks, nightmares, flashbacks and intrusive memories, and hypervigilance with some symptoms of general paranoia without fixed delusions. The Veteran was suffering from severe insomnia, getting only about three hours of fragmented sleep per night. The Veteran denied current suicidal ideation but acknowledged that he has had passive suicidal ideation without a clear plan or intent in the past, aside from his one suicidal attempt in 2007. Another January 2009 VA treatment note shows an assessment of combat-related PTSD with major depressive disorder and a GAF score of 55. In May 2009, VA received a letter from Dr. TH and DR. MET, who had provided the October 2008 initial psychology consultation. As a result of the Veteran's PTSD, he felt a general affective numbing, markedly diminished interest or participation in significant activities, and avoidance of thoughts, feelings, or conversations associated with his trauma. The Veteran also complained of symptoms of increased arousal such as difficulty falling and staying asleep, restlessness, irritability, tension, anxiety, difficulty concentrating, excessive jumpiness, and hypervigilance. These symptoms caused significant distress. In addition to his PTSD symptoms, the Veteran also appeared to be suffering from a major depressive disorder. He reported and endorsed a depressed mood, anhedonia, fatigue, insomnia, feelings of worthlessness, and a diminished ability to think or concentrate. Regarding functional impairment, the Veteran's anxiety, distress, and hyperarousal made it difficult for him to focus and attend in social or professional settings. VA provided an examination in June 2009. At that time, the Veteran was receiving VA treatment for PTSD and depression and taking anti-depressants, zolpidem and citalopram hydrobromide. The Veteran reported being in a depressed mood, irritable daily, isolative, pessimistic, and sleep-deprived. Depressive symptoms would occur daily with moderate severity. During the clinical interview, the Veteran described having a girlfriend and a son, but no family support. Intercurrent stressors included his difficulties with pain, which negatively impacted his mood and participation in activities. He reported enjoying staying in the house. The examiner also noted that the Veteran had an overdose attempt in 2007. An examination revealed normal appearance. The Veteran was using crutches. His speech was unremarkable. Affect was appropriate, and mood was dysphoric. The mental status examination was normal other than the Veteran's report of sleep impairment. The Veteran reported having initial insomnia some days and intermittent awakenings. The pattern was different daily, and he was not always tired. PTSD symptoms were identified as recurrent and intrusive distressing recollections of his in-service traumatic event. He also had persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness. The examiner identified persistent symptoms of increased arousal, such as difficulty falling or staying asleep, irritability or outburst of anger, hypervigilance, and exaggerated startle response. These disturbances caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. Regarding frequency, the Veteran reported having nightmares about one to two times per week, but not always awakening from a dream. He reported ruminating about his experiences daily. He also reported avoidance and numbing symptoms daily. Hyperarousal symptoms were daily or according to cues. Depression symptoms were identified as mood symptoms such as being down, sad, or depressed. The Veteran would also have appetite changes, psychomotor retardation or agitation, fatigue, feelings of worthlessness, and possible suicidal thoughts. Symptoms of depression that may overlap with PTSD included insomnia, impaired concentration, social withdrawal, and diminished interest. The examiner provided a GAF score of 65, which was for PTSD only. The examiner found that PTSD resulted in signs and symptoms that are transient or mild and decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. The examiner iterated that the Veteran was not unemployable due to PTSD. Based on PTSD alone, his social and interpersonal problems may be mildly impacted by irritability. The examiner opined, however, that his mood was impacted by his coping style and in reaction to his perceived physical problems, rather than PTSD. In his October 2010 substantive appeal, the Veteran asserted that his PTSD prevented him from being around groups of people, caused disturbances of motivation of mood, and resulted in major difficulty in establishing and maintaining effective work and social relationships. He was experiencing difficulty in keeping a relationship with his significant other, having to rent an apartment because of the issues that he would have with anger, depression, and high levels of stress. He reported doing what he could to work on his issues but having episodes of harming himself in the past and troubles with sleeping well. In December 2010, VA received a buddy statement from TM. She noted that their relationship had suffered as a result of the Veteran's PTSD. Intervening VA treatment notes document regular psychiatric treatment up until June 2015. During this time, the Veteran regularly complained of difficulty sleeping due to pain and nightmares. The Veteran was diagnosed with PTSD and depression. GAF scores throughout this period of the appeal were predominantly below 50, ranging from 45 to 49. Some GAF values in 2013 and 2014 were 50 and above. For example, in March 2015, the Veteran presented at the VA medical center for a mental health visit. A mental status examination did not yield abnormal findings. The Veteran was diagnosed with PTSD and depression, and the psychiatrist assigned a GAF score of 47. The Veteran was again evaluated in June 2015. Since his last mental health clinic in March 2015, the Veteran had continued to be in pain with periods of depression. At that time, a mental status examination was normal, though the Veteran's mood was described as anxious and dysphoric. His affect was also described as tense. The psychiatrist diagnosed PTSD, chronic, and assigned a GAF score of 47. VA provided an examination in May 2016. The examiner diagnosed PTSD and depressive disorder due to chronic pain as a result of migraines, bilateral plantar fasciitis and bilateral knee pain, all conditions service-connected. The examiner noted that the Veteran's psychiatric disability resulted in occupational and social impairment with reduced reliability and productivity. The examiner made it clear that he was describing the impairment caused by both PTSD and depressive disorder. The Veteran reported that he had married his girlfriend in January 2012. They had been together several years prior to that. The Veteran completed an on-line degree in Business and proceeded to obtain his BA in business. He then completed his MBA. Following his MBA, the Veteran applied for jobs with VA, for management jobs in human resources, and for a series of sports team management positions. After not receiving any interviews, he gave up, thinking that no one would give him reasonable accommodations for his disabilities. The Veteran reported that he would remain at home. Next, the Veteran described having lack of motivation and having to deal with his physical limitations. He described his main mental health problem as his attitude. He also mentioned his motivation, mood, and forgetfulness. He described always thinking about his time in military, in Iraq specifically. He next reported that he was only able to get three to four hours of sleep per night, awakening with night sweats. He indicated that he would have two to three nightmares per week. He also described having "day mares", or being "zoned out and kinda in la la land". During such episodes, he would imagine scenarios that did not occur during his military service, but would involve witnessing the death of a friend. He described having such episodes two to three times per week. The Veteran next described that he was on medications for his psychiatric disorders. However, the VA examiner reviewed the file and noted in the report that medication refills were not noted. The Veteran indicated that he filled his medications one week earlier. The Veteran was not in active treatment for his psychiatric symptoms with VA at that time. The examiner identified depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, and disturbances of motivation and mood as the symptoms attributable to the Veteran's diagnoses. A mental status examination was normal. Regarding panic attacks, the Veteran indicated that his most recent attack was there weeks earlier. He reported that he would go to bed at 9 PM, but it would take up to two hours to fall asleep due to pain. After falling asleep, he would awaken with night sweats. The Veteran indicated that he had suicidal ideations when he first got out of the military. However, he denied having such thoughts in the previous 10 years, noting that he wanted to be present for his son. The examiner noted that the Veteran tended to focus on medical issues that caused him to be unemployable. While the Veteran's mental health issues had increased since his last VA examination, the VA examiner noted that the Veteran appeared cognitively capable of processing work. The examiner noted that the Veteran would work best if he was able to work from home from his computer, as he did for college. The Veteran was not in any active treatment for mental health issues, which the Veteran had attributed to migraines. The Veteran had reported the ongoing use of mental health medications for PTSD, depression, and sleep. The examiner noted that the medications were last refilled in June 2015 when the Veteran was in Florida. The Board notes that VA treatment records show May 2016 correspondences between the Veteran and the VA medical center in Northern Indiana. The Veteran received a refill on his psychiatric medications. Analysis The Board resolves reasonable doubt in the Veteran's favor and finds that the evidence of record reflects that the Veteran's symptoms more nearly approximate a 70 percent evaluation. Throughout the appeal the Veteran has suffered from chronic sleeping difficulty, isolative tendencies, anxiety, depression, and avoidance. In May 2009, the Veteran's VA psychiatrist noted that the Veteran's anxiety, distress, and hyperarousal made it difficult for him to focus and attend in social or professional settings. At the June 2009 VA examination, the examiner only identified the functional limitations attributable to the Veteran's PTSD. However, since then, depression has been service-connected, and it is clear that the examiner in June 2009 believed that depression resulted in clinically significant symptoms such as appetite changes, psychomotor retardation or agitation, fatigue, feelings of worthlessness, and possible suicidal thoughts. Though denying such thoughts later in the appeal, the Veteran in 2009 clearly identified recurring suicidal ideation, though without intent or plan. In December 2010, the Veteran and his future-spouse indicated that his PTSD was affecting their relationship. This is supported by an examination for the Veteran's TDIU claim in December 2016 where the Veteran indicated that his wife had left him due to his psychiatric condition. Although the examiner in May 2016 noted that the Veteran's depression and PTSD resulted in occupational and social impairment with reduced reliability and productivity, the Board finds that the examination reflects more serious symptomatology. The Veteran reported having nightmares, but he also described having events called daymares, where he would enter a state of mind where he would envision harm being brought upon his friends. Most pertinent, the Veteran's symptoms and clinical history throughout the appeal period demonstrate significant difficulty in his ability to adapt to stressful situations and to maintain effective relationships. Supporting this are the Veteran's GAF scores, which have been provided as in the 40s and 50s throughout the appeal period. As noted above, GAF values in the 40s are reflected of more serious symptomatology. Although he does not have many of the symptoms identified in the criteria for a 70 percent rating, he has reported difficulty in adapting to stressful situations and the inability to maintain effective relationships. Accordingly, the Board resolves doubt in the Veteran's favor and finds that a 70 percent evaluation is warranted. A 100 percent evaluation, however, is not for assignment. The evidence of record does not demonstrate total social and occupational impairment. The Veteran could adequately care for himself and hygiene was not noted to be an issue at any point during the time period. Furthermore, he did not exhibit inappropriate behavior, persistent delusions or hallucinations, a danger to self or others, or disorientation to time or place, or memory loss for names of close relatives, or his own name. Finally, the Veteran's thought processes and communication were not noted to be grossly impaired. He has not demonstrated total social impairment, as he has consistently maintained a good relationship with his son. As such, the Veteran's PTSD and depression does not warrant a 100 percent evaluation. In short, the Board finds that there is not such an approximate balance of the positive evidence and the negative evidence to permit more favorable determinations. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The evidence does not support the award of a higher rating for the Veteran's service-connected PTSD and depression. Neither the Veteran nor his/her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). B. Bilateral Plantar Fasciitis The Veteran's bilateral plantar fasciitis is currently rated under DC 5276, which rates pes planus. He is in receipt of a 10 percent rating until May 5, 2009, and in receipt of a 10 percent rating beginning August 1, 2009. In a September 2017 brief, the Veteran's representative argued that the Veterans' bilateral foot disorder should be rated under DC 5284, which rates other foot injuries. The Board will consider all relevant diagnostic codes. DC 5276 provides ratings for acquired flat foot (pes planus). A 30 percent rating is warranted for severe bilateral acquired flatfoot manifested by marked deformity (pronation, abduction, etc.), accentuated pain on manipulation and use of the feet, indications of swelling on use of the feet, and characteristic callosities. A 50 percent evaluation is warranted for pronounced bilateral acquired flatfoot manifested by marked pronation, extreme tenderness of the plantar surfaces of the feet, and marked inward displacement and severe spasm of the tendo achilles on manipulation which is not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a (2017). As noted above, the Board will consider all relevant diagnostic codes. One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. See 38 C.F.R. § 4.20 (2017) (providing for consideration of functions affected, anatomical localization, and symptomatology in assigning a diagnostic code). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case" and the Board can choose the diagnostic code to apply so long as it is supported by reasons and bases as well as the evidence. Butts v. Brown, 5 Vet. App. 532, 538 (1993). Accordingly, the Board has considered whether DC 5284, for other foot injuries, would be more appropriate to rate the service-connected bilateral plantar fasciitis. DC 5284 provides a 10 percent rating for impairment of moderate degree, a 20 percent rating for moderately severe impairment, and a 30 percent rating for severe impairment. 38 C.F.R. § 4.71a, DC 5284. Words such as "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. 4.6 (2017). Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2017). In Copeland v. McDonald, the Court explained that it is improper to rate a disability by analogy where VA's rating schedule includes criteria for the service-connected condition. 27 Vet. App. 333, 338 (2017). The Court did so in the context of a case involving hallux valgus and pes planus and specifically rejected the argument that the conditions could be rated by analogy to foot injuries under DC 5284. Id. However, the Veteran has only received diagnoses of plantar fasciitis during the instant appeal. This condition is not enumerated or discussed in any of the diagnostic codes for rating disabilities of the foot. 38 C.F.R. § 4.71a, DCs 7256-5283. Based on the symptomatology, diagnoses, and relevant medical history discussed below, the Board finds that in this case, application of DC 5284 is more appropriate than DC 5276 or any other applicable DC to rate the service-connected bilateral plantar fasciitis because it incorporates all symptoms related to the Veteran's foot injuries and is more favorable to the Veteran in this case. Factual History The date of the Veteran's claim for an increased rating for bilateral plantar fasciitis has been set in June 2008. Of record is a December 2008 treatment note from Dr. ALC, the Veteran's podiatrist. The Veteran had presented for treatment with complaints of continued pain and functional disability to both feet, but left greater than right. Having reviewed the Veteran's medical records, Dr. ALC noted a long history of plantar fasciitis for approximately six years with treatment such as injections, physical therapy, night splints, nonweightbearing casting, orthotics, and sneakers. The doctor noted that the Veteran had significant pain and functional disability to the left foot, and the Veteran walked with an antalgic gait favoring his left foot despite him having bilateral plantar fasciitis. X-ray images taken at that time showed normal skeletal structure and calcaneal inclination angle bilaterally. No lytic or blastic lesions were noted on either foot. The Veteran did not have pes planus. On examination, there was no equinus deformity. The Veteran could actively dorsiflex to 20 degrees and he had approximately 40 degrees of plantar flexion. Dr. ALC noted no ecchymosis or edema to either heel. Dr. ALC noted that the Veteran had the same symptoms of Baster's nerve to the left and right foot. He had discomfort with dorsiflexion of the hallux or more tightness. These findings essentially echo the findings of an earlier November 2008 visit. VA provided an examination in June 2009. The Veteran's diagnosis was identified as bilateral plantar fasciitis. The Veteran reported having surgery to release his left achilles tendon to help with plantar fasciitis. The examiner saw no objective evidence regarding this surgery for review. The Veteran reported that his surgery occurred on May 6, 2009. Bilaterally, symptoms identified included pain, stiffness, and fatigability while standing, walking and at rest. The symptoms were located bilaterally from the arch of the foot to the heel. The Veteran was able to stand for 15 to 30 minutes and walk for one quarter of a mile. The Veteran's left foot was in a cast at that time, and he was using crutches, the surgery only occurring during the previous two months. Because the Veteran's left foot was in a cast the examiner was unable to evaluate that extremity. A right foot examination was normal, and X-ray images from August 2008 and February 2009 were negative for any abnormalities. The examiner diagnosed bilateral plantar fasciitis, and noted that the condition resulted in significant occupational effects. The Veteran had decreased mobility and pain. As a result, the Veteran had to be assigned different duties and increased absenteeism from work. Daily activities such as chores, shopping, and driving were moderately impacted. Exercise, sports, recreation, and traveling were severely impacted. The examiner noted that the Veteran's service-connected bilateral fasciitis should not preclude light duty or sedentary employment. However, strenuous physical employment was limited given the Veteran's bilateral foot disorder. The examiner noted that the Veteran was unemployed but was currently a full-time student. VA provided another examination in October 2010. Then, the Veteran described his bilateral plantar fasciitis as exquisitely painful with a daily occurrence. The pain was worse on the first steps of morning, but it would also affect him with prolonged standing. The examiner noted the Veteran's left achilles tendon lengthening procedure to relax the plantar fascia. The surgery had reportedly not helped. The Veteran claimed he was experiencing a significant amount of bilateral pain in the plantar fascia. In both feet, the examiner identified pain and stiffness while standing, walking, and while at rest. The Veteran denied having flare-ups. However, he was unable to stand for more than a few minutes, and his walking was limited to a few yards to a couple of blocks. The Veteran used a cane for bilateral foot and knee pain, but there was a fair amount of efficacy from the use of corrective shoes, inserts, or braces. An examination showed tenderness along the bilateral plantar fascia. The examiner diagnosed bilateral plantar fasciitis, noting that a more precise diagnosis could not be rendered as there was no objective data to support a more definitive diagnosis. The examiner also diagnosed status-post left achilles tendon lengthening procedure, indicating that this procedure was most likely caused by or a result of the Veteran's service-connected left plantar fasciitis. Regarding functional impact, the examiner noted that bilateral plantar fasciitis resulted in decreased mobility, problems with lifting and carrying, and pain. The examiner found that plantar fasciitis had a severe effect on the Veteran's ability to perform chores, shopping, exercise, recreation, traveling, and driving. The bilateral foot disorder prevented sports, had a moderate effect on bathing, dressing, and toileting, and had a mild effect on feeding and grooming. The examiner indicated that the Veteran avoided many social, recreational, and physical activities due to the pain in his feet. In his December 2010 VA Form 9, the Veteran asserted that he had been restricted to the point of not being able to sit or stand for long periods of time due to his knees and feet. He had received numerous steroid injections, heel supports, physical therapy, shock wave therapy, and achilles lengthening surgery to relieve the pressure and pain from the plantar fasciitis of his left foot. He indicated that the evaluation assigned for his bilateral plantar fasciitis did not consider the issues that affected him on a daily basis. In December 2010, VA received a buddy statement from TM, who noted that she had massaged and iced the Veteran's feet because his plantar fasciitis was in so much pain. VA provided an examination for the Veteran's claim in May 2016. The examiner diagnosed bilateral plantar fasciitis. During the clinical interview, the Veteran indicated that he had a sharp, poking-type, excruciating pain in his arches. The pain on daily average was a nine out of 10, and he had to use a cane to walk due to his pain. The Veteran indicated that he could walk, but slowly and with the use of a cane. He indicated that he could walk a half to full city block. He took tramadol and ibuprofen daily for his feet. The Veteran used arch supports and built-up shoes for his plantar fasciitis. He also had extreme tenderness on the plantar surface of both feet. The examiner noted that the Veteran did not have pes planus. Regarding functional impact, the examiner noted that the Veteran appeared to have a very hard time walking, despite imaging not corroborating this. The examiner noted that the Veteran's functional impairment may be due to plantar fasciitis alone. VA treatment records during the appeal period are significant for complaints of significant pain in the feet as a result of bilateral plantar fasciitis. He has been provided plantar fasciitis night splints, braces, arch supports, a cane, among other assistive devices. He and his wife have submitted statements describing extensive efforts to massage, ice, and rehabilitate his feet on a regular basis to enable limited function during his daily activities. Analysis After a thorough review of the record, the Board finds that rating the Veteran's bilateral plantar fasciitis under DC 5284 is appropriate and that separate 20 percent disability ratings are warranted for each foot for the entire appeal period. The evidence shows that the Veteran's bilateral plantar fasciitis has resulted in moderately severe impairment of each foot. In June 2009, a VA examiner noted that daily activities such as chores, shopping, and driving were moderately impacted. Exercise, sports, recreation, and traveling were severely impacted. The examiner noted that the Veteran's service-connected bilateral fasciitis should not preclude light duty or sedentary employment. However, strenuous physical employment was limited given the Veteran's bilateral foot disorder. In October 2010, the VA examiner found that plantar fasciitis had a severe effect on the Veteran's ability to perform chores, shopping, exercise, recreation, traveling, and driving. The bilateral foot disorder prevented sports, had a moderate effect on bathing, dressing, and toileting, and had a mild effect on feeding and grooming. The examiner indicated that the Veteran avoided many social, recreational, and physical activities due to the pain in his feet. Finally, in May 2016, regarding functional impact, the VA examiner noted that the Veteran appeared to have a very hard time walking, despite imaging not corroborating this. The examiner noted that the Veteran's functional impairment may be due to plantar fasciitis alone. The Board concludes that ratings in excess of 20 percent for each foot are not warranted, as severe disability is not shown. The medical evidence and the Veteran's assertions indicate that he complains of daily pain, and examinations have shown tenderness. He uses a cane on a regular basis and uses assistive devices. However, the cane use has been attributed to the Veteran's bilateral knee disability, which has been manifested as instability. Therefore, the evidence shows that, for all periods relevant to this appeal, the Veteran has bilateral foot disability manifested as plantar fasciitis, which has been productive of pain. Moreover, the Veteran has competently reported his pain as being severe on numerous occasions over the course of the claim and appeal period. Therefore, based on the foregoing, the Board finds that separate ratings of 20 percent for each foot under DC 5284 are warranted because the Veteran's bilateral foot disabilities most closely approximate moderately severe disability. However, the Board finds that there is not such an approximate balance of the positive evidence and the negative evidence to permit more favorable determinations. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. TDIU A TDIU is governed by 38 C.F.R. § 4.16, providing that such a rating may be assigned where the schedular rating is less than total, and when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more 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 (2017). The Veteran's occupational history includes employment with the US Postal Service until 2007. He was granted disability retirement in October 2010. The Veteran has obtained his Master's Degree in business, though multiple attempts in gaining employment have not resulted in full-time employment. Here, the Veteran meets the schedular criteria for a TDIU. He is service-connected for PTSD and depression, now rated as 70 percent disabling for the appeal period, which alone meets the schedular criteria for a TDIU. He is also service-connected for headaches, rated as 30 percent disabling, which contemplates characteristic prostrating attacks occurring on an average once a month over last several months; radiculopathy at 20 percent disabling, which contemplates moderate imcomplete paralysis; lumbar spine disability, rated as 20 percent disabling, which contemplates forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 degrees. or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; and a left ankle disability, rated as 20 percent disabling, which contemplates marked limitation of motion. The Board notes that the Veteran and other medical providers have attributed significant functional impairment to his other service-connected disorders, including bilateral plantar fasciitis, bilateral knee patellofemoral syndrome, migraine headaches, lumbosacral strain, radiculopathy of the left lower extremity, and limited left ankle motion. Further, as noted above, the Board finds that the Veteran's PTSD and depression has resulted in deficiencies in most areas due to the Veteran's inability to adapt to stressful situations including work or a worklike setting. A December 2016 VA social and industrial survey was conducted. After reviewing the Veteran's record and briefly discussing the Veteran's mental and physical status, the examiner noted that the Veteran ceased work in 2007 as a result of physical pain and after a conflict at work with a supervisor. He was informed that he was not allowed to return to work, but he indicated that his physical ailments were the main reason for his cessation. The Veteran described having chronic back, knee, and foot pain, as well as migraines, which he related were incapacitating five to six times per week such that he would stay in bed. Regarding the effects of the Veteran's disabilities and their impact on social functioning, the examiner noted that the Veteran had good social skills, basically, but he lacked access to his usual support system due to geographical location. She noted that the Veteran's spouse had left him recently, which the Veteran had indicated was the result of his physical and mental disabilities affecting his ability to be active around the home and his motivation to interact socially. The examiner noted that these acute social stressors had increased the Veteran's depressed mood, decreasing his interest and activity level regarding social interaction. Incorporating the previous examinations discussed for the issues above into the current analysis, the Board finds that the Veteran's service-connected disabilities render him unable to secure and follow substantially gainful employment. VA examinations conducted for the Veteran's knees and feet show an inability or severe limitation in occupations involving non-sedentary activities. The May 2016 VA examiner for the Veteran's service-connected psychiatric disorders noted that the Veteran would work best if he was able to work from home from his computer, as he did for college. However, this opinion does not reflect consideration of the Veteran's competent statements and disability rating reflecting numerous migraine headaches that would often necessitate bed rest. In short, the Board finds that the Veteran's service-connected disabilities render him unable to secure or follow substantially gainful employment. The December 2016 industrial and social survey, though not conclusively showing unemployability, was highly suggestive of a level of impairment that impacted the Veteran's ability to function in substantially gainful employment. That, in conjunction with the Veteran's credible statements and the VA examinations and treatment records, shows a level of disability resulting from the combined effect of the Veteran's service-connected disorders that prevents the Veteran' from securing or following substantially gainful employment. Thus, a TDIU is warranted. ORDER Entitlement to an initial disability rating of 70 percent, but no higher, for PTSD and depression, is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a disability rating of 20 percent, but not higher, for a left foot disability prior to May 6, 2009, and beginning August 1, 2009, is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a disability rating of 20 percent, but not higher, for a right foot disability prior to May 6, 2009, and beginning August 1, 2009, is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a TDIU is granted, subject to the applicable law governing the award of monetary benefits. REMAND For the increased ratings claims for the Veteran's knees, remand is required to obtain an additional VA examination. VA examinations for musculoskeletal conditions must include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59 (2017); Correia v. McDonald, 28 Vet.App. 158 (2016). A VA examination for the knees was recently conducted in May 2016. The examiner provided range of motion measurements for knee flexion and extension without commenting on pain for passive, active, weight-bearing, or nonweight-bearing motion. The examiner did indicate that the Veteran had no with weight bearing. However, this does not meet the criteria noted in Correia. On remand, a new examination must provide the necessary findings or explains why these findings are not necessary. Recent VA treatment records should also be obtained on remand. Accordingly, the case is REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 2. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected bilateral knee disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must utilize the appropriate Disability Benefits Questionnaire. The examiner must test the range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. 3. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2017). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 4. Ensure compliance with the directives of this remand. If a report is deficient in any manner, implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 5. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim must be readjudicated. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ K. MILLIKAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs