Citation Nr: 18145323 Decision Date: 10/26/18 Archive Date: 10/26/18 DOCKET NO. 13-32 927 DATE: October 26, 2018 ORDER Entitlement to service connection for bilateral hearing loss is denied. From March 6, 2011, to June 4, 2015, entitlement to an initial rating in excess of 10 percent for left ankle sprain is denied. From March 6, 2011, to June 4, 2015, entitlement to an initial rating in excess of 10 percent for right ankle sprain is denied. From June 5, 2015, entitlement to a rating of 20 percent, but no greater, for left ankle sprain is granted, subject to the laws and regulations governing the payment of monetary benefits. From June 5, 2015, entitlement to a rating of 20 percent, but no greater, for right ankle sprain is granted, subject to the laws and regulations governing the payment of monetary benefits. From April 9, 2011, to April 9, 2018, entitlement to an initial rating in excess of 50 percent for PTSD is denied. From April 10, 2018, entitlement to a rating of 70 percent, but no greater, for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of bilateral hearing loss. 2. From March 6, 2011, to June 4, 2015, the Veteran’s left ankle sprain is characterized by moderate symptomatology. 3. From March 6, 2011, to June 4, 2015, the Veteran’s right ankle sprain is characterized by moderate symptomatology. 4. From June 5, 2015, the Veteran’s left ankle sprain is characterized by marked symptomatology. 5. From June 5, 2015, the Veteran’s right ankle sprain is characterized by marked symptomatology. 6. From April 9, 2011, to April 9, 2018, the Veteran’s PTSD is characterized by occupational and social impairment with reduced reliability and productivity due to such symptoms as panic attacks more than once a week, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, but is not characterized by occupational and social impairment with deficiencies in most areas; total social and occupational impairment is clearly not shown. 7. From April 10, 2018, the Veteran’s PTSD is characterized by occupational and social impairment with deficiencies in most areas; total social and occupational impairment is clearly not shown CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.385. 2. From March 6, 2011, to June 4, 2015, the criteria for a disability rating in excess of 10 percent for left ankle sprain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1–4.14, 4.71a, Diagnostic Code 5271. 3. From March 6, 2011, to June 4, 2015, the criteria for a disability rating in excess of 10 percent for right ankle sprain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1–4.14, 4.71a, Diagnostic Code 5271. 4. From June 5, 2015, the criteria for a disability rating of 20 percent, but no greater, for left ankle sprain have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1–4.14, 4.71a, Diagnostic Code 5271. 5. From June 5, 2015, the criteria for a disability rating of 20 percent, but no greater, for right ankle sprain have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1–4.14, 4.71a, Diagnostic Code 5271. 6. From April 9, 2011, to April 9, 2018, the criteria for a disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1–4.14, 4.130, Diagnostic Code 9411. 7. From April 10, 2018, the criteria for a disability rating of 70 percent, but no greater, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1–4.14, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 2003 to June 2006. In April 2018, the Veteran withdrew his prior request for a hearing. 1. Entitlement to service connection for bilateral hearing loss Service connection will be presumed for certain chronic diseases, including bilateral hearing loss, if manifest to a compensable degree within one year after discharge from service. See 38 C.F.R. §§ 3.307, 3.309. Because there is no indication that the Veteran’s hearing loss was manifested within one year of service, service connection is not available on a presumptive basis. Direct service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies at 500, 1000, 2000, 3000, or 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Even if disabling loss is not demonstrated at separation, a veteran may establish service connection for a current hearing disability by submitting evidence that a current disability is causally related to service. See Hensley v. Brown, 5 Vet. App. 155, 160 (1993). The Veteran’s January 2012 VA audiological examination does not provide for a diagnosis of bilateral hearing loss. Pure tone thresholds, in decibels, are as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 10 5 5 LEFT 10 5 5 0 5 Speech recognition ability using the Maryland CNC test is 96 percent in the right ear and 96 percent in the left ear. The Veteran has made no indication that his hearing has worsened since the time of the January 2012 examination. The pure tone thresholds and Maryland CNC scores contained in the January 2012 VA examination do not constitute a current diagnosis of hearing loss as defined by VA. Because there is no current diagnosis, the Veteran’s claim of entitlement to service connection for bilateral hearing loss must be denied. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R. Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to consider all regulations that are potentially applicable through the assertions and issues raised in the record. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings.” Hart v. Mansfield, 21 Vet. App. 505 (2007). When rating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating based on functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination, to include during flare-ups and with repeated use, when those factors are not contemplated in the relevant rating criteria. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59. The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the Diagnostic Codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Such inquiry is not to be limited to muscles or nerves. Limitation of motion determinations are, if feasible, to be expressed in terms of the degree of additional range of motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca, 8 Vet. App. at 207. By itself, pain throughout a joint’s range of motion does not constitute functional loss, but if there is additional pain, the examiner must address any additional loss of motion due to the DeLuca factors. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). If a claimant is already receiving the maximum disability rating available based on symptomatology that includes limitation of motion, it is not necessary to consider whether 38 C.F.R. §§ 4.40 and 4.45 are applicable. Spencer v. West, 13 Vet. App. 376, 382 (2000); Johnston v. Brown, 10 Vet. App. 80, 85 (1997). The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). A VA examination of the joints must, wherever possible, include range of motion testing for pain on active motion, passive motion, weight-bearing, nonweight-bearing, and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 169–70 (2016); 38 C.F.R. § 4.59. 2. From March 6, 2011, to June 4, 2015, entitlement to an initial rating in excess of 10 percent for left ankle sprain 3. From March 6, 2011, to June 4, 2015, entitlement to an initial rating in excess of 10 percent for right ankle sprain On March 6, 2011, the Veteran filed claims of entitlement to service connection for a right ankle disorder and a left ankle disorder. In February 2012, the RO granted service connection for these disorders at initial ratings of 10 percent under Diagnostic Code 5271 from March 6, 2011. The Veteran is appealing the rating aspects of that decision. Because the claims are initial claims, the Board will consider evidence of symptomatology from the date that the claims were filed. 38 C.F.R. § 3.400(o). Diagnostic Code 5271 provides compensation for ankle limitation of motion. 38 C.F.R. § 4.71. A 10 percent rating is provided for moderate limitation of motion. Id. A 20 percent rating is provided for marked limitation of motion. Id. The words “slight,” “mild,” “moderate” and “severe” as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The Veteran is entitled to initial ratings of 10 percent. The Veteran’s January 2012 VA ankle examination (pages 23–29 of 44) indicates discomfort using stairs, and “[d]aily pain 0 out of 1–10 pain scale.” Pain is 8 out of 10 during flare-ups, which are caused by using stairs, running, and softball. Right ankle plantar flexion is 40 degrees (45 degrees is normal). Right ankle dorsiflexion, left ankle plantar flexion, and left ankle dorsiflexion are all normal. The Veteran can perform repetitive-use testing without any loss in range of motion. Functional loss is reflected by less movement than is normal and pain on movement. Muscle strength is normal and there is no ankylosis. The examiner states that the Veteran’s ankle disorder does not currently impact the Veteran’s ability to work, but felt that he would not have been able to work as a policeman because of his ankle, back, and knee conditions. The Veteran wears ankle braces to alleviate flare-ups, but not “as a normal mode of locomotion.” A February 2013 VA medical record (received 9/27/13, page 1-2 of 7) indicates that bilateral ankle sprains are aggravated “with specific activity” and “bilateral full [range of motion] of ankles without tenderpoints.” In summary, prior to June 5, 2015, the Veteran displays slight limitation of range of motion with occasional flare-ups. He can perform repetitive-use testing without additional loss in range of motion. The Veteran occasionally wears ankle braces, but only for specific types of activity. While his ankle disorders prohibit him from working as a policeman, they do not prohibit him from all types of work. As will be explained in greater detail below, the Veteran has been gainfully employed at Colorado State University for at least the past five years, and was employed at Wall Mart prior thereto. Evidence of slight limitation of motion with occasional pain during certain activities, including as a result of flare-ups, with no apparent functional loss, supports the Veteran’s current ratings of 10 percent. Because there is no serious functional loss and minimal limitation of motion, the preponderance of the evidence is against the existence of marked limitation of motion so as to support a rating of 20 percent or greater. Rather, the evidence more nearly approximates a rating of 10 percent. Since this rating already contemplates painful motion and functional loss during flare-ups, any additional increased rating under DeLuca or Correia would constitute the prohibited practice of pyramiding, i.e., there is no additional non-compensated limitation of motion that can serve as a basis for a higher rating based on pain on functional use. 4. From June 5, 2015, entitlement to a rating of 20 percent, but no greater, for left ankle sprain 5. From June 5, 2015, entitlement to a rating of 20 percent, but no greater, for right ankle sprain From June 5, 2015, the Veteran is entitled to a rating of 20 percent. In a statement dated June 5, 2015, the Veteran’s wife states that the Veteran “comes home daily needing to rest while complaining of pain, weakness, and discomfort in both of his knees, his ankles, and back.” The Veteran’s wife is competent to testify regarding these symptoms because they are within the knowledge and personal observations of lay witnesses. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). There is no reason to doubt her credibility. For the left ankle only, a January 2017 private medical examination (received 2/6/17) indicates pain while running, wearing high-ankle shoes for stability, and pain severity of 0/10 at rest, which with certain activities can be as bad as 10/10. Range of motion is within normal limits. The Veteran’s gait is normal. An August 2017 VA ankle examination indicates increased ankle pain and that the Veteran now wears braces on both ankles for support. The Veteran denies physical limitations. He occasionally experiences flares when using stairs and when walking on uneven ground. The Veteran does not report any functional loss or impairment. Range of motion for both ankles is normal. For both ankles, the Veteran can perform repetitive-use testing with at least three repetitions and no additional loss of function or range of motion after three repetitions. Neither pain, weakness, fatigability, nor incoordination significantly limit functional ability with repeated use over time or during flare-ups. Muscle strength is normal for both ankles. The examiner states that the Veteran’s ankle disorder does not impact his ability to perform any type of occupational task. Regarding Correia, the examiner states that there is no pain with nonweight-bearing, weight bearing, or passive range of motion. In a May 2018 statement, the Veteran describes being unable to maintain any squatting position due to pain in his ankles and knees. He only wears high boots with custom orthotic insoles to provide support and help alleviate pain. The Veteran is considered competent to testify regarding these symptoms because they are within the knowledge and personal observations of lay witnesses. Barr, 21 Vet. App. at 309. There is no reason to question his credibility. Taken together, the Veteran regularly experiences flare-ups with pain and daily complains of weakness in his ankles. He wears shoes providing additional support, purchases custom insoles for pain, and is unable to maintain a squatting position. While he displays normal range of motion and denied functional loss in his August 2017 VA ankle examination, the evidence nevertheless more nearly approximates marked limitation of motion to support a rating of 20 percent. As the Veteran is not in receipt of the highest rating for limitation of ankle motion, a higher rating based on DeLuca or Correia is not for consideration. The evidence does not support additional staged ratings for any time period on appeal, and for no period would the Veteran be entitled to a higher rating under a different Diagnostic Code. 6. From April 9, 2011, to April 9, 2018, entitlement to an initial rating in excess of 50 percent for PTSD On April 9, 2011, the Veteran filed a claim of entitlement to service connection for PTSD. In February 2012, the RO granted service connection for PTSD at an initial noncompensable rating under Diagnostic Code 9411 from April 9, 2011. The Veteran is appealing the rating aspect of that decision. In September 2013, the RO increased the Veteran’s initial rating to 50 percent. Because the claim is an initial claim, the Board will consider evidence of symptomatology from the date that the claim was filed. 38 C.F.R. § 3.400(o). Diagnostic Code 9411 provides compensation for PTSD under the General Formula for Rating Mental Disabilities. 38 C.F.R. § 4.130. Under that code, a 50 percent rating is provided when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: Flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is provided for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: Suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. A 100 percent rating is provided for total occupational and social impairment, due to such symptoms as: Gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability of the veteran 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. 38 C.F.R. § 4.130. The symptoms associated with the rating criteria are not intended to constitute exhaustive lists, but rather 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 (2002). A Veteran may only qualify for a disability rating under 38 C.F.R. § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration that result in the levels of occupational and social impairment provided. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). To adequately evaluate and assign the appropriate disability rating to the Veteran’s service-connected psychiatric disability, the Board must analyze the evidence as a whole and the enumerated factors listed in 38 C.F.R. § 4.130. Mauerhan, 16 Vet. App. at 436. As this claim was certified to the Board after August 4, 2014, DSM-5 is applicable to the claim. The Veteran is service-connected for PTSD, but not for other mental disorders. The Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so. Mittleider v. West, 11 Vet. App. 181 (1998). Prior to April 10, 2018, the Veteran’s symptoms are consistent with a rating of 50 percent. Regarding any suicidal ideation, at no point during this time period does the Veteran indicate suicidal thoughts. He specifically denies suicidal ideation in medical records dated July 2012 (received 8/27/13, page 43 of 47) August 2012 (received 8/27/13, pages 4–12 of 47), and February 2013 (received 9/27/13, pages 1–2 of 7), and in the September 2013 and July 2017 VA PTSD examinations. Regarding speech, a February 2011 VA medical record (received 9/27/13, pages 1–2 of 7) indicates “normal response to questions” and no loose assoications. The September 2013 VA PTSD examination describes the Veteran as “alert, coherent, fully oriented, . . . polite and cooperative manner,” and with “no evidence of a formal thought disorder.” The July 2017 VA PTSD examination indicates normal speech and logical thought processes. Regarding near continuous panic or depression, a July 2012 private medical record (received 8/27/13, page 44 of 47) indicates anxiety in crowds. In an August 2012 private medical record, (received 8/27/13, pages 4–12 of 47) the Veteran indicates having anxiety in crowds and depression. In a January 2013 private medical record (received 8/27/13), the Veteran describes positive changes with his “attitude and mood.” A February 2013 VA medical record (received 9/27/13, pages 1–2 of 7) indicates hypervigilance, “short fuse,” and dysthymia. A June 2013 private medical record (received 8/27/13, page 17 of 47) states that the Veteran experiences anxiety and panic attacks at work. A July 2013 private medical record (received 8/27/13, page 17 of 47) indicates anxiety at work. The September 2013 VA PTSD examination indicates depressed mood, anxiety, suspiciousness, weekly panic attacks, and chronic sleep impairment. The July 2017 VA PTSD examination indicates “significant symptoms of depression” and panic attacks “occurring about once every six weeks.” Regarding impaired impulse control, a July 2012 private medical record (received 8/27/13, page 42 of 47) indicates anger and sleeplessness. In an August 2012 private medical record, (received 8/27/13, pages 4–12 of 47) the Veteran indicates depression, anxiety in crowds, and anger when driving. An October 2012 private treatment record (received 11/29/12) indicates “difficulty with anger, which manifests explosively when driving.” Regarding inability to establish and maintain effective relationships, a July 2012 private medical record (received 8/27/13, page 44 of 47) indicates self-isolation and hypervigilance when interacting with people he does not know. An August 2012 private medical record (received 8/27/13, pages 4–12 of 47) indicates social isolation and that the Veteran’s “relationship with his wife is doing better, that they are communicating more.” In a September 2012 private medical record (received 8/27/13, page 36 of 47), the Veteran indicates that “he is doing better in managing his reactions,” although he still experiences angry outbursts and difficulties in his relationship with his wife. An October 2012 private medical record (received 8/27/13, page 30 of 47) reads as follows: “He said that he is continually frustrated with the work environment, and that he experiences constant conflict with his supervisors. He said that he is nervous that he will be dismissed if things continue the way they are. He believes that his difficulties with posttraumatic stress are negatively impacting his job.” According to a different October 2012 private treatment record (received 11/29/12), the Veteran’s “pattern of emotional numbing, isolation, and irritability has contributed to him not being able to progress in his employment” and “[h]e has been formally reprimanded on many occasions and threatened with dismissal if his attitude and behavior do not change.” That record also describes “reduced contact with friends and family” with increasing isolation and “regularly participating in group counseling for the past two months.” He appears to have continued with group therapy until at least January 2013. See January 2013 group visit (received 8/27/13, page 25 of 47). In a January 2013 private medical record (received 8/27/13), the Veteran notes that while his relationship with his wife is somewhat strained but improving. An April 2013 private medical record (received 8/27/13, page 21 of 47) indicates that school is considered to be “going well,” but that the Veteran is experiencing increased conflict with his wife. A June 2013 private medical record, (received 8/27/13, page 17 of 47) states: “he continues to enjoy his job, and that he also enjoys the feeling of being in a work environment where he is able to apply his vocational training.” Also, he has “enjoyed the feeling of being able to make forward progress with his life.” A July 2013 private medical record (received 8/27/13, page 17 of 47) indicates a positive relationship with his wife and recently reconnecting with a fellow serviceman who was visiting from out of town. However, other private medical records consistently indicate marital difficulties. The September 2013 VA PTSD examination indicates some occupational impairment (limited advancement at work due to “not fitting in,” some interpersonal conflict at work) and social impairment (emotional detachment and irritability contributes to strained relationship with wife, no close friends, feels anxious and tense, panic attacks around crowds and avoids). The September 2013 VA PTSD examination contains specific findings of “[o]ccupational and social impairment with reduced reliability and productivity” and “[d]ifficulty in establishing and maintaining effective work and social relationships.” Furthermore, in that examination, the Veteran states that he “[p]reviously worked at Wal Mart but couldn’t get promoted because he was not a ‘yes man.’” The July 2017 VA PTSD examination notes “lack of closeness with his wife” but that “there is not a [lot] of time for he and his wife to do much together [because] ‘it is mostly a kid-[focused] family.’” Also in that examination, the Veteran states that at work “he gets good evaluations, although he only got a ‘2’ out of a possible ‘3’ on one, which was going to keep him from getting a raise . . . .” He also notes “irritability at work as well as at home” and avoidance behaviors regarding in-service events. An April 2018 lay statement from a co-worker (received 5/21/18) indicates that the Veteran has been working at Colorado State University for at least three years. A May 2018 statement from a different co-worker states that the Veteran has been working at Colorado State University for at least five years. The strongest evidence supporting a rating of 70 percent based on social and occupational impairment with deficiencies in most areas is the evidence of difficulties in the Veteran’s relationship with his wife, his tendency towards social isolation, conflicts at work, and intrusive memories of distressing in-service events. However, the Veteran has remained married for the entire period of the appeal, there are regular episodes of good relationships with his wife, and his relationships with his children appear to be strong. Regarding conflicts at work, the most severe difficulties appear to be related to his time working at Wal Mart, a position he left in 2013. Since that time, he has been working as an HVAC technician at Colorado State University and appears to sincerely enjoy applying his vocational training at that job. He seems to have good relationships with his co-workers, as reflected by the fact that in April 2018 and May 2018 a number of co-workers submitted lay statements in support of his pending musculoskeletal claims. There is evidence of depression and anxiety, such anxiety being part of his hypervigilance when meeting new people. However, based on his ability to complete technical training and apply that training at the same position over a period of five years, his depression and anxiety are not so near-continuous so as to affect the ability to function independently, appropriately, and effectively. Furthermore, there is no evidence of suicidal ideation, spatial disorientation, neglect of personal appearance and hygiene, or speech that is intermittently illogical, obscure, or irrelevant. Taken together, the Veteran’s symptoms more nearly approximate occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood and difficulty (not impossibility) in establishing and maintaining effective work and social relationships. The Veteran has maintained a relationship with his wife and children. He completed vocational training, worked at the same position for five years with good reviews, and has maintained sufficient relationships with his co-workers such that they were willing to help him with his appeal. Consistent with this, the September 2013 and July 2017 VA PTSD examinations contain specific findings of “[d]isturbances of motivation and mood” and “[d]ifficulty in establishing and maintaining effective work and social relationships.” The weight of this evidence is more consistent with a rating of 50 percent. The preponderance of the evidence is against a rating of 70 percent or higher because the Veteran has established a number of relationships, has maintained relationships, has completed vocational training, and has worked at the same position for five years without displaying suicidal ideation, intermittently illogical speech, spatial disorientation, neglect of hygiene, or near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively. 7. From April 10, 2018, entitlement to a rating of 70 percent, but no greater, for PTSD From April 10, 2018, the Veteran is entitled to a rating of 70 percent. A private medical opinion of that date (received 5/21/18) indicates that there is suicidal ideation and that the Veteran “has had severe episodes of depression, during which he has an inability to perform routine activities of daily living, neglects his personal appearance and hygiene, and is moody most of the day nearly every day.” According to the examiner, the Veteran “has suffered occupational and social impairment, with deficiencies in most domains of his life, including work, social relationships, thinking, and mood, due to near-continuous depression, panic episodes, and PTSD, that have had a significant impact on his ability to function independently, appropriately, and effectively.” The Veteran “avoids interpersonal interactions as much as possible.” At the same time, the Veteran is still able to work and “spoke in a clear voice using coherent grammatically correct sentences” during the examination. The weight of the evidence contained in the May 2018 private medical opinion supports a rating of 70 percent based on occupational and social impairment with deficiencies in most areas. Because the Veteran is still able to work and does not display gross impairment in thought processes or communication, the preponderance of the evidence is against a rating of 100 percent based on total occupational and social impairment. The evidence does not support additional staged ratings for any time period on appeal. For no period would the Veteran be entitled to a higher rating under a different Diagnostic Code. REASONS FOR REMAND 1. Entitlement to service connection for a back disorder is remanded. A September 2013 VA medical opinion concludes that the Veteran’s back disorder is less likely than not related to service. Part of the rationale for that opinion is that the Veteran’s service treatment records do not contain any medical complaints or treatment for a back disorder. That opinion does not consider the April 2011 statement from a fellow serviceman or the Veteran’s May 2018 statement, both of which describe in-service back pain that the Veteran did not report during service. An addendum opinion is required that addresses this evidence of in-service back pain. 2. Entitlement to service connection for a right knee disorder is remanded. An August 2017 VA medical examiner states: “Veteran had no right knee complaints in service. Right knee diagnosis of patella dislocation traumatic was due to playing softball in 2009, [three] years after service, and unrelated to service.” Regarding secondary service connection for the right knee, the same examiner states: “Veteran’s right knee patellar dislocation occurs 3 years after service while playing softball. There was no indication in notes by orthopedic doctor in 2009 for knee injury that veteran injured right knee due to his [service-connected] left ankle. There is no causal relationship between these two joints, these are separate joints with independent diagnosis with no interrelationship between the two.” There are two reasons that an addendum opinion is required. First, the August 2017 VA opinion does not address entitlement to service connection for a right knee disorder as secondary to the Veteran’s right ankle disorder. Second, the opinion does not address lay statements of record. In a June 2015 statement, the Veteran’s spouse states that the Veteran “has complained of pain and discomfort in his knees, ankles, and back” since she first met him in 2008, which was before his softball injury in 2009. Knee pain is also discussed in a fellow serviceman’s April 2011 statement and the Veteran’s May 2018 statement. For these reasons, an addendum opinion is required. In choosing to remand this claim, the Board has considered the January 2017 private medical opinion, which was submitted in February 2017 and June 2018. This opinion states the following: “Based off the subjective information provided and the objective information obtained, it is likely the patient has developed patella femoral pain syndrome. Because of the patient’s relatively normal strength and [range of motion], it is possible that this pain is a result of repetitive stress rather than a direct insult/trauma to the knee. This is further demonstrated by the fact that the patient only experiences pain when he is weight bearing with the knee bent at deeper angles. Further radiological tests may be required to definitively determine the integrity of the under surface, of the patella to rule out chondromalacia patella. Prognosis for the patient’s recovery with physical therapy is fair due to the chronicity of the pain.” At best, the January 2017 private medical opinion establishes that it is likely that the Veteran has a current right knee disorder that could possibly be the result of unspecified trauma. It does not opine that an actual current disorder is at least as likely as not related to service. By itself, the January 2017 private medical opinion does not satisfactorily support the nexus element of service connection. The matters are REMANDED for the following action: 1. After obtaining any additional records to the extent possible, an examiner should review the entire claims file and provide the following opinions: (a.) Whether the Veteran has any current or previously-diagnosed back disorder; and (b.) Whether it is at least as likely as not (a 50 percent or better probability) that any current or previously-diagnosed back disorder was incurred in the Veteran’s service. In reaching these opinions, the examiner should consider the April 2011 and May 2018 lay statements. For purposes of these opinions, the examiner should assume that these statements are credible. The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. 2. After obtaining any additional records to the extent possible, an examiner should review the entire claims file and provide the following opinions: (a.) Whether the Veteran has any current or previously-diagnosed right-knee disorder; (b.) Whether it is at least as likely as not (a 50 percent or better probability) that any current or previously-diagnosed right knee disorder was incurred in the Veteran’s service; and (c.) Whether the Veteran has any current or previously-diagnosed right knee disorder that (i) is proximately due to the Veteran’s service-connected right ankle disorder and/or left ankle disorder or (ii) was aggravated by the Veteran’s service-connected right ankle disorder and/or left ankle disorder. In reaching these opinions, the examiner should consider the April 2015 statement from the Veteran’s wife, indicating right knee pain prior to the Veteran’s 2009 softball injury. The examiner should also consider the April 2011 and May 2018 lay statements. For purposes of these opinions, the examiner should assume that these statements are credible. The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Cannon, Associate Counsel