Citation Nr: 1759932 Decision Date: 12/22/17 Archive Date: 01/02/18 DOCKET NO. 07-37 303 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to a rating in excess of 10 percent for left knee disability based on limitation of motion before January 29, 2013, and to a rating in excess of 30 percent from March 1, 2014, based on post-operative residuals of a left knee replacement. 3. Entitlement to a compensable rating for left knee instability before June 11, 2008, to a rating in excess of 10 percent from June 11, 2008, to January 29, 2013, and to a compensable rating from March 1, 2014. 4. Entitlement to a rating in excess of 30 percent for migraine headaches. 5. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 6. Entitlement to a total disability rating based on individual unemployability as the result of service-connected disability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J.A. Flynn, Counsel INTRODUCTION The Veteran served on active duty from June 1980 to June 1984, and from October 2003 to February 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the VA RO. An April 2007 rating decision denied the Veteran's claim for service connection for a hypertension disability. With respect to the claim of entitlement to greater ratings for a left knee disability, a November 2006 rating decision granted service connection for a left knee disability and assigned an initial 10 percent rating. An August 2008 rating decision granted a separate 10 percent rating for instability of the left knee effective June 11, 2008, and it denied a temporary total evaluation based on surgery requiring convalescence. A September 2009 rating decision granted a temporary total rating effective April 3, 2009, and a 10 percent rating effective September 1, 2009. An August 2012 rating decision granted a temporary total rating effective October 28, 2010, and a 10 percent rating effective March 1, 2011. A January 2014 rating decision granted a 100 percent rating based on left knee replacement effective January 29, 2013, and a 30 percent rating from March 1, 2014. With respect to the claim of entitlement to a greater rating for a migraine headache disability, a November 2006 rating decision granted service connection for migraine headaches and assigned an initial 10 percent rating; a December 2011 rating decision increased this rating to 30 percent. With respect to the claim of entitlement to a greater rating for PTSD, a March 2015 rating decision granted service connection for PTSD and assigned an initial 30 percent rating. This appeal has previously been before the Board, most recently in June 2016, when it remanded the Veteran's claims in order to obtain outstanding service treatment records, records from the Social Security Administration (SSA), and to provide additional examinations addressing the Veteran's migraine headaches and left knee disability. The Board finds that its remand instructions have been substantially complied with, and the Board will proceed in adjudicating the Veteran's claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that when the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Hypertension manifested to a compensable degree within one year of the Veteran's separation from service. 2. Before January 29, 2013, traumatic arthritis of the left knee was manifested by a range of motion functionally limited by pain to no less than 94 degrees of flexion and full extension; ankylosis, impairment of the tibia and fibula, and genu recurvatum were not shown. 3. Before June 11, 2008, even slight instability of the left knee was not shown. 4. From June 11, 2008, to January 29, 2013, no worse than slight instability of the left knee was shown. 5. The Veteran underwent a total left knee replacement in January 2013, and his left knee disability has since been manifested by no worse than intermediate symptoms with a full range of extension and slight joint instability. 6. Migraine headaches have not resulted in very frequent, completely prostrating and prolonged attacks that are productive of severe economic inadaptability. 7. The Veteran's PTSD has not resulted in symptoms of a greater severity than occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have been met. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.102, 3.303, 3.307, 3.309, 4.104, Diagnostic Code 7101 (2017). 2. Before January 29, 2013, the criteria for a rating in excess of 10 percent for a left knee disability based on limited motion due to traumatic arthritis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Code 5010-5260 (2017). 3. Before June 11, 2008, the criteria for a compensable rating for instability of the left knee have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Code 5257 (2017). 4. From June 11, 2008, to January 29, 2013, the criteria for a rating in excess of 10 percent for instability of the left knee have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Code 5257 (2017). 5. From March 1, 2014, the criteria for the award of a separate 10 percent rating, but no greater, for instability of the left knee have been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Code 5257 (2017). 6. From March 1, 2014, the criteria for a rating in excess of 30 percent for post-operative residuals of a left knee replacement have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Code 5055 (2017). 7. The criteria for a rating in excess of 30 percent for migraine headaches have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2017). 8. The criteria for a rating of 50 percent, but no greater, for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Board has granted the Veteran's claim of entitlement to service connection for a hypertension disability. As such, the Board finds that any error related to the Veterans Claims Assistance Act of 2000 (VCAA) is moot with respect to this claim. 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2017); Kent v. Nicholson, 20 Vet. App. 1 (2006); Mayfield v. Nicholson, 19 Vet. App. 103, (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Otherwise, VA has certain notice and assistance obligations to claimants. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. In the instant case, the Veteran was provided with all appropriate notification in February 2005 and August 2006, and neither the Veteran nor his representative has otherwise alleged or demonstrated any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders/Simmons, 556 U.S. 396 (2009); see also Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (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 duty to assist argument). Thus, adjudication of the Veteran's claim 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). The Veteran's post-service medical treatment records, including VA treatment records, private treatment records, and records from the Social Security Administration (SSA), have been obtained to the extent they were both identified and available. The duty to assist also includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). More specifically, a VA examination must be conducted when the evidence of record does not reflect the current state of the Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2017). To that end, when VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). When a claimant's medical history indicates that his condition undergoes periods of remission and recurrence, VA may be required to provide a medical examination during the period of recurrence in order to provide a proper disability rating. Ardison v. Brown, 6 Vet. App. 405, 407 (1994) (finding that an examination during the remission phase of the condition did not "accurately reflect the elements of the present disability"). In this case, the Veteran has reported, and the March 2017 examiner noted, that he experienced twice-weekly flare-ups of his left knee symptoms. In September 2017, the Veteran's representative argued that the Veteran was entitled to an additional examination during a flare-up of his left knee symptoms in order to properly rate the disability. With that said, upon review of the record, the Board finds no clinical evidence of periods of flare-up of the left knee disability. The Veteran has not otherwise reported any other specific or predictable periods during which flare-ups of symptoms occur. Given this history and the unpredictability of the flare-ups as specified by the Veteran, it would be difficult, if not impossible, to schedule an examination during a period of flare up. Voerth v. West, 13 Vet. App. (1999) (feasibility of scheduling an examination during an exacerbation is a factor in determining whether VA has a duty to provide such an examination). The Veteran was provided with examinations addressing his left knee in March 2005, November 2007, June 2008, and March 2017. The Veteran was provided with examinations addressing his migraine headache disability in March 2005, November 2007, and March 2007. The Veteran was provided with examinations addressing his PTSD in March 2015 and April 2017. The examination reports indicate that the examiners reviewed the Veteran's claims file and past medical history, recorded his current complaints, conducted appropriate evaluations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board, therefore, concludes that these examination reports are adequate for the purpose of rendering a decision in the instant appeal. 38 C.F.R. § 4.2 (2017); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran declined the opportunity to participate in a hearing before the Board. The Board finds that there is no indication that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Thus, the duties to notify and assist have been met, and the Board will proceed to a decision. Service Connection In order to establish service connection, there must be evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999). Hypertension is a chronic disease, and service incurrence will be presumed if such disability manifested to a compensable degree within the year after active service. 38 U.S.C. § 1112 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2017). A compensable (10 percent) rating for hypertension requires diastolic pressure that is predominantly 100 mmHg or greater or systolic pressure that is predominantly 160 mmHg or greater. A 10 percent rating is also the minimum rating for an individual with a history of diastolic pressure predominantly 100 or greater who requires continuous medication for control. 38 C.F.R. § 4.104, Diagnostic Code 7101. In this case, following the Veteran's separation from service in February 2005, the Veteran showed blood pressure of 142/100 mmHg, 140/100 mmHg, and 150/90 mmHg in March 2005. By October 2005, the Veteran had been prescribed Lisinopril, which is a medication that treats hypertension. Affording the Veteran with the benefit of the doubt, and acknowledging the repeated diastolic blood pressure readings of 100 mmHg, the Board finds that the evidence is at least in equipoise as to whether the Veteran demonstrated a compensable degree of hypertension within one year of his separation from service. Thus, the Board presumes that the Veteran's hypertension is connected to his service, and service connection for hypertension is granted. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Ratings Generally Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are appropriate for an increased rating claim, if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Separate disabilities arising from a single disease entity are to be rated separately. 38 C.F.R. § 4.25; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Pyramiding-the evaluation of the same disability or the same manifestations of a disability under different diagnostic codes-is to be avoided when rating a veteran's service-connected disabilities. See 38 C.F.R. § 4.14 (2017). Increased Rating for a Left Knee Disability 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. It is essential that the examination upon 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 the 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. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (2017). Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.40 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14 (2017). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and, (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45 (2017). The intent of the rating schedule is to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2017). Turning to the facts in this case, the Veteran filed his underlying claim of entitlement to service connection for a left knee disability in January 2005. In February 2005, a clinician noted that the Veteran had a full range of motion in the left knee and diagnosed the Veteran with internal derangement of the left knee. A February 2005 x-ray of the Veteran's left knee was normal. The Veteran underwent a VA examination in March 2005, at which time the Veteran indicated that he experienced pain in his left knee when kneeling. The left knee extended to 0 degrees and flexed to 94 degrees. Repetitive motion did not result in additional loss of motion, and no ankylosis was noted. The left knee was somewhat tender. The Veteran complained of left knee pain, weakness, stiffness, swelling, instability, giving way, locking, fatigability, and lack of endurance. The examiner did not note heat, redness, or subluxation. There were no flare-ups of symptoms, and the Veteran did not use assistive devices. On September 19, 2007, the Veteran underwent a surgical reconstruction of the anterior cruciate ligament (ACL) of the left knee. The Veteran was discharged on the same day as his surgery with an ACL brace for range of motion. The Veteran had a full range of flexion and extension, and Lachman's test showed a stable ACL. The Veteran underwent an additional examination in November 2007, at which time the Veteran indicated that he experienced swelling of the left knee. The Veteran denied experiencing symptoms of locking, giving way, subluxation, or dislocation; he indicated that his only symptoms were mild pain and minimal swelling. The Veteran had an increase in pain following his physical therapy sessions. The Veteran had extension to 0 degrees and flexion to 120 degrees; the examiner noted that the Veteran could move his left knee without significant difficulty. Repetitive motion did not result in additional limitation. Varus and valgus stress testing was normal, drawer testing was negative, and McMurray's sign was negative. The Veteran had 4/5 strength in the left knee, and there was no significant tenderness noted upon palpation. The Veteran's gait was normal. The examiner assessed the Veteran' with Osgood-Schlatter's deformity of the left knee, status post-revision, with residuals, status post-reconstruction of the left knee for a torn ACL and lateral collateral ligament. In February 2008, a clinician noted that the Veteran had no effusion or joint line tenderness of the left knee. Left knee flexion and extension were not limited. An April 2008 MRI examination of the Veteran's left knee showed postoperative changes of a prior ACL reconstruction. The ACL graft fibers appeared discontinuous and the findings were highly suspicious for a rupture of the ACL graft. In May 2008, the Veteran had no edema, effusion, or joint line tenderness. The Veteran had a full range of flexion and extension without restriction. The Veteran underwent an additional examination in June 2008, at which time the Veteran complained of constant left knee pain. The Veteran wore a brace, and he complained of difficulty ascending steps. The Veteran had received steroid injections, but such injections did not help. The Veteran could stand for up to 30 minutes, and he could walk up to 3 miles. The Veteran experienced pain, giving way, and weekly locking episodes of the left knee. The left knee had no deformity, instability, stiffness, weakness, effusion, flare-ups of joint disease, or inflammation. The Veteran had flexion to 140 degrees with pain, and extension to 0 degrees with pain. The Veteran had bumps consistent with Osgood-Schlatter's disease, grinding, and instability. There was no crepitation, mass behind the knee, clicking, or snapping. The examiner noted that the Veteran had abnormal medial collateral ligament stability in neutral position, but left knee stability testing was otherwise normal. No patellar or meniscal abnormalities were noted. The examiner diagnosed the Veteran with left knee degenerative arthritis with instability and a possible ACL tear. In a June 2008 clinical record, the Veteran complained of some instability and giving way in the left knee. No effusion was noted, and the Veteran had an "excellent" range of motion. No medial or lateral instability was noted, and there was no joint line tenderness. There was no patellofemoral abnormality. In a separate June 2008 record, Lachman's test showed minimal laxity. In November 2008, the Veteran was noted to have flexion to 125 degrees and extension to 0 degrees. The Veteran complained of instability, weakness, and pain. On April 3, 2009, the Veteran underwent a surgical revision of the reconstruction of the ACL of the left knee. The Veteran was granted a 100 percent rating from the date of this surgery until September 1, 2009. In August 2010, the Veteran was noted to have well-healed surgical wounds of the left knee with trace effusion. The Veteran had good extension and flexion, and 1-2+ Lachman's sign with a good endpoint and no pivot shift. No medial or lateral instability was noted, and McMurray's sign was negative. There was moderate medial joint line tenderness. In October 2010, the Veteran had mild medial joint line tenderness and trace effusion of the left knee. On October 28, 2010, the Veteran underwent an arthroscopic tricompartmental synovectomy and an arthroscopic shaving chondroplasty of the medial femoral condyle of the left knee. The Veteran was granted a 100 percent rating from the date of this surgery until March 1, 2011. In January 2013, the Veteran had flexion to 115 degrees with pain and extension to 0 degrees. There was no instability. The Veteran was diagnosed with tricompartmental degenerative joint disease. On January 29, 2013, the Veteran underwent a total surgical replacement of the left knee. The Veteran was granted a 100 percent rating for a 13-month period from the date of this surgery until March 1, 2014, at which time a 30 percent rating was granted. In April 2014, the Veteran stated that he had no significant joint pain, minimal morning stiffness, and no red, warm, or swollen joints. In March 2015, the Veteran indicated that he had experienced instability, pain, and giving way of the left knee over the past month. The Veteran indicated that in the week before, he fell on the stairs after his left knee gave out. The Veteran complained of popping. The clinician noted minimal varus and valgus laxity, and slightly more anterior drawer laxity than on the right. The Veteran was assessed with left knee pain and instability. In January 2017, the Veteran indicated that his left knee pain had been worsening over the past few months. The Veteran's left knee had a full range of motion, was non-tender to palpation, and it had no effusion. The Veteran was assessed with knee pain. The Veteran underwent an additional VA examination in March 2017, at which time the Veteran stated that he experienced constant pain in his left knee at a level of 2-3 out of 10. The Veteran complained of increased stiffness of awakening that improved after moving around. The Veteran reported that his left knee swelled with activity and buckled when walking on regular ground. The Veteran experienced pain when ascending stairs. The Veteran could squat, but he could not kneel. The Veteran could not stand or walk for longer than 15 minutes. The Veteran had flexion to 100 degrees with pain and extension to 0 degrees. There was no pain with weight-bearing, non-weight-bearing, or with a passive range of motion. Repetitive use testing did not result in additional loss of motion or other functional loss. There was localized tenderness or pain on palpation of the femoral area. There was no objective evidence of crepitus. The examiner found that pain and lack of endurance would significantly limit the Veteran's functional ability during flare-ups. The examiner noted edema and puffiness of the left medial patella and lower lateral patella. Muscle strength testing was normal, and there was no ankylosis. The examiner noted that the Veteran did not have a history of recurrent subluxation, lateral instability, or recurrent effusion. Medial instability testing was 2+ (5mm-10mm), and lateral instability testing was normal. The examiner noted that the Veteran had never had a meniscus (semilunar cartilage) disability. Following the Veteran's total left knee joint replacement, the examiner found that the Veteran had intermediate degrees of residual weakness, pain, or limitation of motion. A March 2017 x-ray examination showed a post total left knee arthroplasty with an intact prosthesis. There was no evidence of periprosthetic loosening or fracture. Turning to an analysis of this evidence, the Board will first address the appropriate rating for the Veteran's left knee before his January 29, 2013, total left knee replacement. The Veteran's left knee disability was rated 10 percent disabling during this time based on traumatic arthritis. 38 C.F.R. § 4.471a, Diagnostic Code 5010. The criteria applicable to rating traumatic arthritis provide for ratings based either on limitation of motion or x-ray findings. Id. A greater rating based on traumatic arthritis requires x-ray evidence of the involvement of two or more major joints, or two or more minor joint groups, with occasional incapacitating exacerbations. In this case, the Veteran's left knee disability involves a single major joint: the left knee joint. A greater rating based on x-ray evidence of traumatic arthritis is thus unavailable. The Board will next consider the applicability of each of the Diagnostic Codes applicable to the knees to determine whether the Veteran is entitled to a greater or separate disability rating. The Board will first discuss those Diagnostic Codes applicable to a limitation of motion of the knees, and it will then discuss those Diagnostic Codes applicable to instability of the knees. Diagnostic Code 5256 does not apply because the Veteran was not found to have ankylosis (or immobility and consolidation of a joint due to disease, injury, surgical procedure) in his left knee at any time before January 29, 2013, nor has it been contended otherwise. 38 C.F.R. § 4.71a (2017); Lewis v. Derwinski, 3 Vet. App. 259 (1992). With respect to Diagnostic Codes 5260 (limitation of flexion) and 5261 (limitation of extension, separate evaluations may be assigned for limitation of flexion and extension of the same joint. VAOPGCPREC 09-04 (September 17, 2004). Specifically, when a Veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Id. In pertinent part, limitation of flexion to 45 degrees warrants a 10 percent rating; to 30 degrees warrants a 20 percent rating, and; to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. In pertinent part, limitation of extension to 10 degrees warrants a 10 percent rating; to 15 degrees warrants a 20 percent rating; to 20 degrees warrants a 30 percent rating; to 30 degrees warrants a 40 percent rating, and; to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. With respect to an increased rating based on limitation of flexion, before January 29, 2013, the Veteran did not demonstrate flexion limited to 30 degrees or fewer, even when taking pain into consideration. Instead, at worst, the Veteran showed flexion of the left knee limited to 94 degrees in March 2005. The Board thus finds that a greater disability rating based on a limitation of flexion, which would require flexion limited to 30 degrees or fewer, is unavailable to the Veteran. 38 C.F.R. § 4.71a, Diagnostic Code 5260. With respect to an increased rating based on limitation of extension, before January 29, 2013, the Veteran did not demonstrate extension limited to 10 degrees or greater, even when taking pain into consideration. Indeed, during this time, clinicians did not note an impairment of extension of the left knee. The Board finds that a greater or separate disability rating based on a limitation of extension, which would require extension limited to 10 degrees or greater, is unavailable to the Veteran. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The Board must additionally consider functional loss due to pain and weakness that causes additional disability beyond that which is reflected on range of motion measurements. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board must consider the effects of weakened movement, excess fatigability and incoordination. 38 C.F.R. § 4.45. VA examiners and clinicians have noted the Veteran's complaints such as pain, and the Board has taken those complaints into consideration in its above discussion. The Board finds that the evidence does not support a finding that the Veteran's functional loss causes disability beyond the above-discussed range of motion testing. While the Board accepts the credible contentions of the Veteran that his left knee disability causes him to experience significant pain, the Board has taken that into account in its consideration of the range of motion of the Veteran's left knee. In fact, the complaints of left knee pain, coupled with the limitation motion of the left knee, provided the basis for the rating that has been assigned based on limited motion. 38 C.F.R. § 4.59. Turning to other potentially applicable Diagnostic Codes, Diagnostic Code 5262, applicable to impairment of the tibia and fibula, does not apply because the evidence does not show malunion of the tibia and fibula or symptoms approximating malunion of the tibia and fibula. 38 C.F.R. § 4.71a (2017). Diagnostic Code 5263 does not apply because the Veteran has not demonstrated symptoms approximating genu recurvatum at any time. Id. Having determined that the existing 10 percent rating is the maximum rating available to the Veteran before January 29, 2013, based on the Veteran's limitation of movement of the left knee, the Board next turns to the possibility of greater ratings based on instability of the left knee. The Veteran's left knee instability is rated 10 percent disabling effective June 11, 2008, and continuing until January 29, 2013, the date of the Veteran's left knee replacement. Limitation of motion and instability of a knee may be rated separately; in other words, evaluation of knee dysfunction based on both limitation of motion and instability does not amount to pyramiding under 38 C.F.R. § 4.14. See VAOPGCPREC 23-97 (July 1, 1997) and VAOPGCPREC 09-98 (August 14, 1998). Therefore, limitation of motion and instability of the knee may be rated separately, provided that any separate rating must be based upon additional disability. Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). Turning to an evaluation of this evidence of record, the Board notes that under Diagnostic Code 5257, recurrent subluxation or lateral instability is rated at 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71a. The words "slight," "moderate," and "severe" are not defined in the VA Schedule for Rating Disabilities. Clinicians' use of terms such as "moderate" and "severe," although an element that the Board will consider, is not dispositive of the issue. Rather than applying a mechanical formula, the Board must evaluate all of the evidence in order to ensure that its decisions are equitable and just. 38 C.F.R. § 4.6. In this case, the Board finds that the Veteran's symptoms of instability before the June 2008 effective date of his 10 percent rating, do not approach even the "slight" severity that would be required for a 10 percent disability rating. With that said, the Board acknowledges that in March 2005, the Veteran complained of symptoms such as instability, giving way, and locking. Upon physical examination, however, the examiner found that the Veteran did not have subluxation of the knee. In November 2007, the Veteran denied experiencing locking or giving way, and instability testing was normal. The evidence suggests that the Veteran wore a knee brace before June 2008, for example in August 2007 and November 2007. Upon consideration of this evidence, while the Board acknowledges the Veteran's March 2005 contentions that he experienced instability, the Board places greater weight on the narrative medical reports, which do not describe symptomatology of recurrent subluxation or lateral instability that the Board finds meets a "slight" level of severity. A compensable rating based on instability of the left knee is thus unwarranted before June 11, 2008. From June 11, 2008, until January 29, 2013, the Board finds that the Veteran's symptoms of instability do not approximate a moderate severity or worse that would be required for a rating in excess of the current 10 percent rating. In June 2008, an examiner noted that the Veteran had abnormal medial collateral ligament stability in neutral position; stability testing was otherwise normal. In a separate June 2008 record, Lachman's test showed minimal laxity. In August 2010, no medial or lateral instability was noted, and McMurray's sign was negative. In January 2013, the Veteran was noted not to have left knee instability. During this time, the Veteran subjectively complained of instability and giving way of the left knee. Upon consideration of this evidence, the Board finds that to the extent clinicians noted instability, such instability was not noted to be a "moderate" severity or greater. Instead, stability testing was largely normal, with clinicians noting only minimal instability in the left knee. In sum, the Board find that the symptom picture from June 11, 2008, until January 29, 2013 does not show moderate instability, as would be required for a rating in excess of the current 10 percent rating. Diagnostic Code 5258 does not apply because the Veteran's semilunar cartilage (that is, the meniscus) has not been dislocated with frequent episodes of locking, pain and effusion into the joint. 38 C.F.R. § 4.71a. Diagnostic Code 5259 does not apply because the Veteran's semilunar cartilage has not been removed. Id. The Board has also considered whether a temporary total disability evaluation is appropriate following the Veteran's September 2007 ACL surgery. In order to qualify for a total disability rating due to convalescence under 38 C.F.R. § 4.30, entitlement must be established by report at hospital discharge or outpatient release. With regard to the September 19, 2007, surgery, the Board notes that in November 2007, the Veteran stated that he stopped working in August 2007 in anticipation of his September 2007 surgery, and he had been told that he could not return to work until January 2008. As an initial matter, the Board notes that convalescence occurs after surgery and therefore is unavailable for the period before the surgical procedure. With regard to the period between the Veteran's surgery and January 2008, the Board notes that the September 2007 operative report does not mention a convalescence period. Instead, it reads, "Postoperatively, [the Veteran] will be covered with prophylactic antibiotic and anticoagulation treatment. He will be started on gait training with weight bearing as tolerated, range of movement and quadriceps and hamstring exercises." Thus, the need for a convalescence period is not shown in the discharge paperwork. The Veteran has not submitted additional private medical records pertaining to this time period. Moreover, when asked by his VA physician, for example in February 2008, for information regarding his post-surgical medical treatment, the Veteran did not bring any and could not recall the names of any of his medication. Thus, the medical evidence does not show a convalescence period following the September 2007 surgery. The Board turns now to the appropriate rating for the Veteran's left knee disability following his January 29, 2013, total left knee replacement. The Veteran is currently in receipt of a 100 percent rating for a 13-month period following his surgery, and a 30 percent rating from March 1, 2014, under Diagnostic Code 5055, applicable to knee prosthesis. Under the criteria applicable to knee replacement, a 100 percent rating applies during the one-year period following the implantation of a knee prosthesis. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Thereafter, the minimum rating following a knee replacement is 30 percent. A 60 percent rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain, or limitation of motion, adjudicators should rate Diagnostic Code 5055 by analogy to Diagnostic Codes 5256 (knee ankylosis), 5261 (limitation of leg extension), or 5262 (impairment of the tibia and fibula). 38 C.F.R. § 4.71a, Diagnostic Code 5055. The rating schedule does not define the terms "intermediate" or "severe" as they used in Diagnostic Code 5055. Instead, adjudicators must evaluate all of the evidence and render a decision that is equitable and just. 38 C.F.R. § 4.6. Clinicians' use of terminology such as "severe", although an element that the Board will consider, 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. Although Diagnostic Code 5055 covers a range of symptoms and manifestations of knee disability, it does not appear to contemplate subluxation or instability. Therefore, consideration of a separate rating under Diagnostic Code 5257 does not violate the rule against pyramiding set forth in 38 C.F.R. § 4.14. Turning to the possibility of a rating in excess of 30 percent for the Veteran's left knee disability from March 1, 2014, the Board first finds that the Veteran is not entitled to a 60 percent rating under Diagnostic Code 5055, which applies to chronic residuals consisting of severe painful motion or weakness in the affected extremity. The Board's review of the entirety of the evidence does not support a finding of severe symptoms associated with the Veteran's left knee condition. In April 2014, the Veteran had "no significant joint pain". In March 2015, the Veteran complained of pain. In January 2017, the Veteran complained of worsening left knee pain. In March 2017, the Veteran indicated that he experienced pain in his knee at a level of 2-3 out of 10. The March 2017 examiner found that the Veteran had intermediate degrees of residual weakness, pain, or limitation of motion, as a result of his left knee replacement. The Veteran has maintained full strength in his left knee. Thus, upon review of the evidence of record, the Board finds that the weight of the evidence does not support a finding that the Veteran suffers from severe painful motion or weakness in the left knee, and a 60 percent rating under Diagnostic Code 5055 is therefore unavailable. Diagnostic Code 5055 also allows for a rating greater than the existing 30 percent rating when the symptoms consist of intermediate degrees of residual weakness, pain or limitation of motion. VA may then rate the disability by analogy under Diagnostic Code 5256 (ankylosis of the knee), 5261 (limitation of extension), or 5262 (impairment of the tibia and fibula). As noted above, the March 2017 examiner characterized the Veteran's residuals as "intermediate" in severity, and the Board will thus address whether a rating in excess of 30 percent is available to the Veteran when rating by analogy. Diagnostic Code 5256 does not apply because the Veteran was not found to have ankylosis in his left knee at any time since March 1, 2014, nor has it been contended otherwise. 38 C.F.R. § 4.71a. With respect to Diagnostic Code 5261, applicable to limitation of extension, a rating in excess of the currently-assigned 30 percent rating would require extension limited to 30 degrees or greater. 38 C.F.R. § 4.71a. At no time since March 1, 2014, has the Veteran demonstrated such an impairment of left knee extension. Instead, in January 2017 and March 2017, the Veteran's left knee had a full range of extension. With respect to Diagnostic Code 5262, applicable to impairment of the tibia and fibula, the Veteran's left knee disability is not manifested by nonunion or malunion of the tibia and fibula. While a higher rating of 40 percent is available under that Diagnostic Code based on nonunion of the tibia and fibula with loose motion requiring a brace, no symptoms approximating nonunion are of record. Therefore, a higher rating is not warranted under any of the Diagnostic Codes 5256, 5261, or 5262. The Board must additionally consider functional loss due to pain and weakness that causes additional disability beyond that which is reflected on range of motion measurements. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board must consider the effects of weakened movement, excess fatigability and incoordination. 38 C.F.R. § 4.45. The Board acknowledges that in March 2017, an examiner found that the Veteran's pain and lack of endurance would significantly limit the Veteran's functional ability during flare-ups. With that said, the March 2017 examiner additionally noted that repetitive motion did not cause additional limitation of motion or other functional loss. Based on a review of the entirety of the record, the Board finds that the impairment described in the March 2017 examination report does not result in symptomatology that is in excess of the currently-assigned 30 percent rating. While the Board accepts the credible contentions of the Veteran that his left knee disability causes him to experience significant pain, the Board has taken this into account consideration of the range of motion of the Veteran's knee. The rating schedule does not require a separate rating for pain itself. Spurgeon v. Brown, 10 Vet. App. 194 (1997). Even if the Veteran's motion was 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) (emphasis added). 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. In this case, the Veteran's pain has not been shown to cause such impairment that the motion of the Veteran's left knee was functionally limited to a degree in excess of the currently-assigned 30 percent rating. Accordingly, a greater rating is not warranted based on functional loss. With regard to a separate rating based on instability, in March 2015, the Veteran complained of instability and giving way of the left knee. A clinician noted minimal varus laxity, valgus laxity, and slight anterior drawer laxity of the left knee. In March 2017, the Veteran complained of buckling in the left knee. The examiner found that the Veteran did not have a history of recurrent subluxation or lateral instability. Medial instability testing was 2+ (5mm-10mm), and lateral instability testing was normal. Upon review of this evidence, which includes clinicians' objective findings of slight instability in addition to the Veteran's subjective complaints, the Board finds that the evidence shows that the Veteran demonstrated slight instability of the left knee. The Board finds, however, that the Veteran's symptoms of instability have not been of a moderate severity or worse, nor has any clinician so found. Accordingly, the Board finds that a 10 percent rating for instability of the Veteran's left knee is warranted effective March 1, 2014. In sum, the Board finds that a rating in excess of 10 percent for the left knee disability before January 29, 2013, based on traumatic arthritis is unwarranted. A compensable rating based on instability is unwarranted before June 11, 2008, and a rating in excess of 10 percent based on instability is unwarranted from June 11, 2008, to January 29, 2013. Following the Veteran's total evaluation that began as of the date of his January 29, 2013, knee replacement, and which continued until March 1, 2014, a separate 10 percent rating for instability is warranted. Otherwise, a rating in excess of 30 percent for the Veteran's total knee replacement is unwarranted. Increased Rating for a Migraine Headache Disability The Veteran contends that his migraine headache disability warrants a rating in excess of 30 percent. The Veteran's headache disability has been evaluated under Diagnostic Code 8100, applicable to migraine headaches. Under these rating criteria, in pertinent part, migraines with characteristic prostrating attacks occurring on an average once a month over the last several months warrant a 30 percent rating; migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability warrant a 50 percent rating. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The term "prostrating attack" is not defined in regulation or case law. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999) (quoting Diagnostic Code 8100 verbatim but not specifically addressing the definition of a prostrating attack). The Board otherwise notes that prostration is defined as "extreme exhaustion or powerlessness." Dorland's Illustrated Medical Dictionary 1554 (31st ed. 2007). Turning to the facts in this case, the Veteran filed his underlying claim of entitlement to service connection for a migraine headache disability in January 2005. In February 2005, the Veteran stated that he had occasional migraine headaches, but he denied experiencing headaches at that time. The Veteran underwent a VA examination in March 2005, at which time the Veteran stated that he experienced headaches with sharp, throbbing pain three times a week, with each headache lasting about two hours. Physical examination of the Veteran was normal, and the examiner diagnosed him with migraine headaches. In September 2006, the Veteran stated that he had been experiencing more migraine headaches. In a September 2006 private psychiatric record, the Veteran reported that he experienced two to three "very disabling" migraine headaches weekly, and the "could not do anything" during such headache episodes. The Veteran underwent an additional examination in November 2007, at which time the Veteran stated that he experienced headaches with sharp pain two to three times a week, with each headache lasting two to three hours. The Veteran very rarely experienced a scotoma involving the left eye. Chemical odors, bright lights, and heat precipitated the Veteran's headaches. The Veteran had to wear sunglasses "pretty much all the time" when he was outdoors. Medications gave the Veteran occasional relief, and the medications were most effective when the Veteran took medications before the headaches started. The Veteran would lie down in a dark, quiet room, and such rest would alleviate the Veteran's headaches within two to three hours. The Veteran indicated that he was not allowed to drive during his headaches. The Veteran worked as a garbage truck driver, and he was normally excused from work with headaches. The Veteran stated that he had lost about 24 days from work in the past six months because of headache problems. The Veteran indicated that he could "do things" with headaches, but he was "not terribly effective". Physical examination of the Veteran was normal, and the examiner diagnosed him with migraine headaches. In April 2008, the Veteran was employed as a truck driver. Though the Veteran did not like his job, he was concerned about securing a different job due, in part, to his migraine headaches. In May 2009, the Veteran complained of once-weekly severe migraine headaches with associated dizziness and nausea. The Veteran took migraine medication, but he found such medication not to be effective. In February 2010, the Veteran complained of headaches. In August 2010, the Veteran denied headaches or visual changes. In October 2012, the Veteran's representative indicated that the Veteran experienced migraine headaches four to five times monthly. The Veteran had to rest in a completely dark, silent room for several hours in treatment of these migraines. The Veteran missed about 20 hours of work monthly as a result of his migraines. The Veteran's employer had informed him that his repeated absences due to migraines constituted an abuse of its sick leave policy. Thus, the representative argued that the Veteran experienced completely prostrating attacks that caused severe economic inadaptability. In February 2014, the Veteran denied having a headache. In association with the Veteran's claim for SSA disability benefits, in January 2013, it was determined that the Veteran's allegations of limitations due to migraines were not credible. In July 2014, the SSA found that the Veteran had not engaged in substantial gainful activity since December 26, 2012, as a result of rheumatoid arthritis, status-post left knee replacement, chronic rheumatic pericarditis, and anxiety. In August 2016, the Veteran denied having a headache, and he was assessed with stable migraine headaches. In January 2017, the Veteran stated that he continued to have migraine headaches, and he indicated that he had learned to take medications before the headaches began. The Veteran stated that he was bored at home and was looking for a part-time job. The Veteran underwent an additional VA examination in March 2017, at which time the Veteran stated that he experienced throbbing, aching, radiating headache pain three to four times a week over the preceding six months. The Veteran's headache pain typically lasted less than one day; the Veteran took medication, would lay down, and his headache would be relieved after three to four hours. The Veteran reported that he went to the hospital once in the past year. The Veteran experienced light and sound sensitivity and changes in vision associated with his migraines. The examiner found that the Veteran experienced characteristic prostrating attacks of headache pain once monthly. The examiner found that the Veteran did not have very prostrating and prolonged attacks of headache pain productive of severe economic inadaptability. The examiner indicated that when the Veteran was working, he would miss three to four days per month as a result of his headaches. Turning to an analysis of these facts, a greater rating for the Veteran's migraines requires that the Veteran's migraines produce very frequent, completely prostrating and prolonged attacks that are productive of severe economic inadaptability. The Board observes that no clinician has characterized the severity of the Veteran's migraine headaches in this way; indeed, the March 2017 examiner expressly found that the Veteran's symptoms were not of such severity. The Board finds that the Veteran's migraine headaches were not very frequent, completely prostrating, and prolonged. The Veteran has alleged that he experienced headache pain up to four times weekly, and that rest in a quiet, dark room alleviated his headache symptoms. The Board finds that the simple need to rest in order to alleviate headache symptoms is not consistent with a finding of "extreme exhaustion or powerlessness". The Board must also note that the symptom picture that the Veteran has described in his compensation and pension examinations, and the symptom picture that his representative has described, is of a far greater severity than the symptom picture otherwise shown in the Veteran's treatment records. This disparity detracts from the credibility of the Veteran's statements regarding the severity of his symptoms. The Veteran's treatment records show that while the Veteran generally received treatment and was prescribed acetaminophen for migraine pain, he often denied currently experiencing such pain. Furthermore, the Veteran rarely sought medical treatment specifically for headache pain. The Board finds that this infrequency of medical treatment for headache pain is inconsistent with a finding that the Veteran's migraine headaches were very frequent, completely prostrating, and prolonged. While the Board acknowledges the argument that the Veteran's headaches interfered with his previous work as a truck driver and were thus productive of severe economic inadaptability, the Board finds that the Veteran's existing 30 percent rating addresses the significant functional impairment presented by the Veteran's migraine headaches. A greater 50 percent rating requires symptoms of a severity that the Board cannot find in the record. Thus, upon review of the entirety of the medical evidence, the Board finds that the Veteran's migraines do not produce very frequent, completely prostrating and prolonged attacks that are productive of severe economic inadaptability. In sum, the Board finds that a rating in excess of 30 percent for migraine headaches is unwarranted at any time. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating for PTSD Under the General Rating Formula for Mental Disorders, in pertinent part, a 30 percent rating applies to 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, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating applies to 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 compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating applies to 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 psychiatric disorder 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 (2017). Furthermore, the specified factors for each incremental rating are examples, rather than requirements, for a particular rating. The Board will not limit its analysis solely to whether the Veteran exhibited the symptoms listed in the rating criteria. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Indeed, the symptoms listed under § 4.130 are not intended to serve as an exhaustive list of the symptoms that VA may consider but as examples of the type of degree of symptoms, or the effects, that would warrant a particular rating. Mauerhan, 16 Vet. App. at 442 (2002). The Veteran's actual symptomatology, and resulting social and occupational impairment, will be the primary focus when assigning a disability rating for a mental disorder, and the Veteran may qualify for a particular rating by demonstrating the particular symptoms associated with that percentage, or other symptoms of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). 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 (2017). While a GAF score is not itself determinative of the most appropriate disability rating, the Board must consider it when assigning a disability rating. VAOPGCPREC 10-95. GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). GAF scores ranging from 51 to 60 indicate 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). American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994); 38 C.F.R. § 4.130. Turning to the facts in this case, the Veteran filed his underlying claim of entitlement to service connection for PTSD in July 2006. In September 2006, a private clinician noted that the Veteran had been married for 21 years. The Veteran worked as a garbage truck driver, but he indicated that his job performance was suffering because it was difficult for the Veteran to "deal with people". The Veteran complained of restlessness, anxiety, uncertainty, anger, and difficulty sleeping. The Veteran was concerned about the future and he had nightmares. The Veteran had no hallucinations, delusions, psychosis, suicidal ideation, or homicidal ideation. The Veteran's thought process was normal, and his mood was depressed and anxious. The Veteran was oriented, his remote and recent memory were intact, and he had good judgment and insight. The clinician diagnosed the Veteran with PTSD and assigned a GAF score of 39. In a separate September 2006 record, a depression screen was negative. In March 2008, the Veteran was slightly anxious, and he complained of poor sleep and being easily startled. In April 2008, the Veteran indicated that he was married and had two children, one of whom lived with him. The Veteran enjoyed watching sports, and he worked as a truck driver. The Veteran was assessed with PTSD and assigned a GAF score of 57. In a separate record from April 2008, the Veteran stated that he did not like his job, but he was concerned about obtaining a different job because of his migraine headaches. In August 2009, the Veteran had been married to his current spouse for 24 years, and he denied experiencing any marital problems. The Veteran worked as a truck driver. The Veteran complained of sleep disturbance, a preference for staying at home where he was "happy", irritability, nervousness, and anger. The Veteran was assessed with depression not otherwise specified and assigned a GAF score of 75. In June 2010, the Veteran worked as a truck driver, and he indicated that his sleep was "great". The Veteran complained of a "snappy" mood and engaging in self-isolation. The Veteran heavily consumed alcohol. In October 2010, the Veteran was employed as a truck driver, but he did not like his job, and his coworkers annoyed him. The Veteran complained of nightmares and moodiness, and he consumed alcohol heavily. In May 2011, the Veteran denied experiencing unusual stress, anxiety, or depression. In July 2011, the Veteran indicated that he was experiencing difficulty in his relationship with his brother. The Veteran was employed, and he indicated that he was drinking an increased amount of alcohol. The Veteran planned to leave his job after a fall resulting in knee pain. The Veteran looked forward to vacationing with his spouse. In October 2011, the Veteran indicated that he felt frustration at work and engaged in heavy drinking on the weekends. In January 2012, the Veteran reported that he was consuming less alcohol and was sleeping better. While the Veteran's anger had improved, it remained an issue. The Veteran felt frustration at his job as a truck driver. In January 2013, the Veteran stopped working as a truck driver. In the Veteran's subsequent claim for SSA disability benefits, the Veteran claimed that he stopped working as a result of his rheumatoid arthritis, status-post left knee replacement, chronic rheumatic pericarditis, and anxiety. The Veteran underwent a VA examination in March 2015, at which time the examiner found that the Veteran's psychiatric symptoms resulted in occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran reported that his marriage was good, but sometimes he wished that he was not married. The Veteran had good relationships with his two adult children. The Veteran indicated that he was irritable and preferred to be by himself most of the time. The Veteran did not work, and he spent his days playing online poker and watching television. The Veteran worked as a truck driver until 2013, at which time he stated that he retired as a result of his knee disability. The Veteran indicated that he often experienced anger at work because he was asked to do jobs that others were meant to do. The Veteran received excellent evaluations at work but had a negative attitude. The examiner found that the Veteran's symptoms included a depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. The examiner found the Veteran to be capable of managing his financial affairs. In August 2016, the Veteran indicated that he had "good days and bad days", but he had been feeling worse following his mother's recent death. In October 2016, the Veteran described having panic attacks associated with his grief over his mother's death, with each panic attack lasting up to an hour. The Veteran had been heavily consuming alcohol. The Veteran complained of poor energy and motivation, poor sleep, and his mood was always sad and irritable. The Veteran reported experiencing episodes of crying. The Veteran's concentration and memory were significantly impaired. The Veteran isolated, and he had to force himself to leave his home. In November 2016, the Veteran reported that he had no energy or motivation, and the Veteran's mood was depressed with increased irritability. The Veteran indicated that he had begun experiencing auditory hallucinations, including hearing someone walking on his patio. The Veteran experienced paranoia associated with hearing such sounds. The Veteran's concentration and memory were significantly impaired. In December 2016, the Veteran reported experiencing increased anxiety, and a feeling that he was "hearing everything around the house". The Veteran experienced panic attacks. In January 2017, the Veteran stated that he experienced an anxiety attack on his way to his appointment, and he otherwise experienced several anxiety attacks weekly. The Veteran reported having little motivation to engage in the activities that he used to enjoy. The Veteran reported that he was bored at home and had been looking for a part-time job. The Veteran indicated that he slept poorly, with interrupted sleep and nightmares. The Veteran was married, and he lived with his spouse and daughter. The Veteran indicated that his spouse was supportive. The Veteran reported that he had started consuming alcohol again following his mother's July 2016 death. The Veteran underwent a VA examination in April 2017, at which time the examiner diagnosed the Veteran with PTSD, mild alcohol use disorder, and unspecified depressive disorder. The examiner found that the Veteran's psychiatric symptoms resulted in occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran stated that he was emotionally connected to his spouse of 31 years, his children, and his grandchildren. The Veteran remained socially active at church, where he served as a deacon. The Veteran attended his family's sporting events. The examiner found no evidence of gross impairment in social functioning. The Veteran remained unemployed since 2013 as a result of his knee injury. The Veteran stated that he had begun volunteering with meals on wheels, and he was active with church as a deacon. The Veteran provided lawn care services for the church every two weeks. The examiner noted that the Veteran's depression was characterized by bouts of depressed mood with difficulty with attention and memory, fatigue, increased irritability, decreased motivation, and decreased self-worth. The Veteran regularly consumed alcohol and had an associated tolerance, physiological dependence, and functional impairment. The Veteran's PTSD was characterized by a persistent re-experiencing of traumatic events, avoidance behavior, negative alterations in cognition, numbing behavior, and hyperarousal. The Veteran denied a history of suicide attempts, suicidal thinking, or psychiatric admissions. The examiner found that the Veteran's symptoms included a depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. The examiner found the Veteran to be capable of managing his financial affairs. The examiner found that the Veteran's psychiatric problems included chronic problems with nightmares, anxiety, depressed mood, and impaired sleep. The Veteran's difficulties with sleep could result in mental and physical fatigue, which could impact the veteran's ability to remain motivated to complete work tasks. The Veteran's difficulty sustaining motivation could result in problems with attendance and work performance, and his chronic irritability could result in poor social relations with coworkers and supervisors. In an August 2017 private psychiatric assessment, the Veteran complained of nightmares and flashbacks. The Veteran indicated that he experienced up to three panic attacks weekly, with each attack lasting up to three minutes. The Veteran slept four hours nightly. The Veteran startled easily, was hypervigilant, and had intrusive thoughts. The clinician found that the Veteran had a mild impairment of his ability to understand and remember very short and simple instructions. The Veteran had a moderate impairment in his ability to carry out very short and simple instructions and to sustain an ordinary routine without special supervision. The Veteran had a marked impairment of his ability to remember locations and work-like procedures and to work in coordination with or proximity to others without being distracted by others. The Veteran had an extreme impairment in his ability to understand and remember detailed instructions, to maintain attention and concentration for extended periods, to perform activities within a schedule, to maintain regular attendance, to be punctual within customary tolerances, to make simple work-related decisions, to complete a normal workday and workweek without interruptions, and to perform at a consistent pace without an unreasonable number of and length of rest periods. In terms of the Veteran's social interaction, the Veteran had a mild impairment in his ability to interact appropriately with the general public, to ask simple questions or request assistance, and to maintain socially appropriate behavior and adhere to basic standards of neatness and cleanliness. The Veteran had a marked impairment in his ability to accept instructions and respond appropriately to criticism from supervisors and to get along with coworkers or peers without distracting them or exhibiting behavioral extremes. In terms of the Veteran's adaptation, the Veteran's ability to be aware of normal hazards and take appropriate precautions was unimpaired. The Veteran had a moderate impairment in his ability to set realistic goals or make plans independently of others. The Veteran had an extreme impairment in his ability to respond appropriately to changes in the work setting, to travel in unfamiliar places or use public transportation, and his ability to tolerate normal levels of stress. The clinician found that the Veteran's impairment substantially interfered with his ability to work on a regular basis at least 20 percent of the time, and the Veteran would need to miss 30 days of work monthly as a result of his psychiatric impairment. The clinician found that the Veteran could not work on a regular and sustained basis because he was unable to sustain work relationships. The clinician assigned the Veteran a GAF score of 35. Turning now to an application of the relevant laws and regulations to the facts in the instant case, the Board concludes that the weight of the evidence demonstrates that the Veteran has shown occupational and social impairment with reduced reliability and productivity (particularly as the result of anxiety, depression, sleep impairment, and panic attacks) consistent with a 50 percent rating since the time of his July 2006 claim. Thus, the Board will afford the Veteran with the benefit of the doubt and find that a single 50 percent rating applies throughout the appeal period. The evidence does not, however, demonstrate a degree of occupational or social impairment consistent with a rating greater than 50 percent at any time. With regard to the Veteran's occupational impairment, the weight of the evidence does not show the total occupational impairment that is associated with a 100 percent disability rating or the occupational impairment with deficiencies in most areas that is associated with a 70 percent disability rating. In support of this finding, the Board notes that the Veteran worked as a truck driver until January 2013, at which time the Veteran stopped working as the combined result of both service-connected and non-service-connected disabilities. Before the Veteran stopped working, he consistently complained of experiencing anger at work, but he also stated that he received excellent work evaluations. After January 2013, the Veteran expressed an interest in working part-time in January 2017. The evidence, for example from April 2017, indicates that the Veteran engaged in volunteer work, served as a deacon at his church, and provided lawn care services for his church every two weeks. Clinicians during this time consistently found the Veteran to be able to handle money, pay bills, and manage his own financial affairs. In March 2015 and April 2017, clinicians found that the Veteran's symptoms resulted in occupational impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Board notes that this characterization of the Veteran's symptoms is consistent with a 30 percent disability rating. The Board finds that this occupational history is not consistent with a finding that the Veteran suffers from either total occupational impairment or impairment with deficiencies in most areas that would be associated with a 70 percent disability rating or greater. The Board acknowledges that the report of the August 2017 private clinician includes a checklist that described "extreme" levels of impairment in the Veteran's occupational functioning, such an in the Veteran's ability to understand and remember detailed instructions, to concentrate, to maintain a schedule, and to maintain attendance. The private clinician otherwise stated that the Veteran would need to miss 30 days of work a month as a result of his psychiatric symptoms. While the Board has considered these notations, the Board places relatively little probative weight on them. The checklist does not discuss facts contrary to its conclusions, for example, that the Veteran performed volunteer work, served as a deacon at his church, provided lawn services to his church, was consistently found to be competent to manage his financial affairs, and hoped to obtain part-time employment. The Board finds that such facts are inconsistent with the clinician's finding that the Veteran would essentially never be able to report to work as a result of his psychiatric impairment. Thus, despite the checklist of the August 2017 clinician, the Board finds that the weight of the evidence is against a finding that the Veteran suffered from either total occupational impairment or impairment with deficiencies in most areas that would be associated with a 70 percent disability rating or greater. With that said, the Board's determination does not diminish the seriousness of the occupational impairment that the Veteran has experienced as a result of his psychiatric symptoms. Indeed, the record shows that the Veteran often felt anger work as a result of psychiatric symptoms, and the Veteran has reported experiencing difficulties in motivation, mood, and concentration. The Veteran has additionally reported that his PTSD was a factor that led him to stop working in January 2013. The Veteran's PTSD symptoms doubtlessly have a significant impact on his occupational functioning, and it is because of these symptoms that the Board has awarded the Veteran a 50 percent rating. Of note, a 50 percent rating contemplates difficulty in establishing and maintaining effective work relationships. For the reasons set forth above, however, and even acknowledging the significance of the Veteran's symptoms, the Board finds that the Veteran's degree of occupational impairment does not approximate the symptoms associated with a 70 percent disability rating or greater. Similarly, with regard to the Veteran's social impairment, the Veteran has not shown the total social impairment that is associated with a 100 percent disability rating or the social impairment with deficiencies in most areas that is associated with a 70 percent disability rating. In support of this finding, the Board notes that during this time, the Veteran maintained good relationships with his spouse, children, and extended family. The Veteran maintained a decades-long marriage throughout the appeal, and he consistently described his spouse as supportive. The Veteran served as a deacon in his church. Furthermore, in March 2015 and April 2017, clinicians found that the Veteran's symptoms resulted in social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Board notes that this characterization of the Veteran's symptoms is consistent with a 30 percent disability rating. While the Board acknowledges the Veteran's descriptions of self-isolating and spending much of his time at home, the Board find that the Veteran's self-reported satisfaction with his familial relationships is not consistent with the inability to establish and maintain effective relationships that is associated with a rating of 70 percent or greater for the Veteran's PTSD. With that said, the Board's determination does not diminish the seriousness of the social impairment that the Veteran has experienced as a result of his psychiatric symptoms. Indeed, the record shows that the Veteran often felt anger as the result of psychiatric symptoms, and the Veteran has reported experiencing difficulties in motivation, mood, and concentration. Indeed, the Veteran's PTSD symptoms doubtlessly have a significant impact on his social functioning, and it is because of these symptoms that the Board has awarded the Veteran a 50 percent rating. Of note, a 50 percent rating contemplates difficulty in establishing and maintaining effective social relationships. For the reasons set forth above, however, and even acknowledging the significance of the Veteran's symptoms, the Board finds that the Veteran's degree of social impairment does not approximate the symptoms associated with a 70 percent disability rating or greater. In making this determination, the Veteran's GAF scores have been considered. The Board finds that these scores, when considered along with the symptoms contained in the associated clinical reports, are inconsistent with a disability rating in excess of the currently-assigned 50 percent rating. Accordingly, while the Board finds that PTSD warrants a 50 percent rating, it also finds that the weight of the evidence is against the assignment of a rating greater than 50 percent at any time. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a hypertension disability is granted. Before January 29, 2013, a rating in excess of 10 percent for a left knee disability based on limited motion is denied. Before June 11, 2008, a compensable rating for left knee instability is denied. From June 11, 2008, to January 29, 2013, a rating in excess of 10 percent for left knee instability is denied. From March 1, 2014, a rating in excess of 30 percent based on post-operative residuals of a left knee replacement is denied. From March 1, 2014, a separate 10 percent rating for left knee instability is granted, subject to the laws and regulations governing the award of monetary payments. A rating in excess of 30 percent for migraine headaches is denied. A rating of 50 percent, but no greater, for PTSD is granted, subject to the laws and regulations governing the award of monetary payments. REMAND A request for a TDIU is not a separate claim for benefits, but it can instead be part of any claim for increased compensation. See Rice v. Shinseki, 22 Vet. App. 447 (2009). If the claimant or the evidence of record reasonably raises the question of whether a veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue of whether a TDIU is warranted as a result of that disability. Id. In this case, the Veteran is unemployed, and he has claimed that he is prevented from working at least in part as a result of his service-connected disabilities. As such, the question of TDIU is raised by the record. Accordingly, the case is REMANDED for the following action: Adjudicate the issue of entitlement to a TDIU. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter that 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 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). ______________________________________________ THOMAS H. O'SHAY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs