Citation Nr: 1824294 Decision Date: 04/24/18 Archive Date: 05/03/18 DOCKET NO. 14-28 181A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona THE ISSUES 1. Entitlement to a compensable rating for a bilateral hearing loss disability. 2. Entitlement to a rating in excess of 10 percent for a back disability. 3. Entitlement to a rating in excess of 10 percent for a left knee disability. 4. Entitlement to a rating in excess of 10 percent for a right knee disability. 5. Entitlement to a rating in excess of 10 percent for a left wrist disability. 6. Entitlement to a rating in excess of 10 percent for a right wrist disability. 7. Entitlement to a rating in excess of 50 percent for anxiety disorder. ATTORNEY FOR THE BOARD J.A. Flynn, Counsel INTRODUCTION The Veteran served on active duty from June 1983 to October 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2011 rating decision of the VA RO. The veteran was issued statements of the case in January 2018 concerning the issues of entitlement to a higher rating for left shoulder disability, and entitlement to service connection for a vertigo disorder (the former disorder originated from an August 2015 rating action, and the latter from an August 2014 rating action). To date, the veteran has not submitted a substantive appeal as to either issue. Consequently, the Board will not further address either issue. The issue of entitlement to a compensable rating for bilateral hearing loss is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's back disability is not manifested by ankylosis, forward flexion functionally limited to 60 degrees or less, a combined range of motion functionally limited to 120 degrees or less, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or incapacitating episodes of intervertebral disc disease (IVDS). 2. The Veteran's bilateral knee disability is manifested by a range of motion functionally limited by pain to no less than 130 degrees of flexion and full extension; instability, meniscus impairment, ankylosis, impairment of the tibia and fibula, and genu recurvatum are not shown. 3. The Veteran's bilateral wrist disability is not manifested by ankylosis. 4. The Veteran's anxiety disorder 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 a rating in excess of 10 percent for back disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Code 5237 (2017). 2. The criteria for a rating in excess of 10 percent for right knee disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Codes 5256-63 (2017). 3. The criteria for a rating in excess of 10 percent for left knee disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Codes 5256-63 (2017). 4. The criteria for a rating in excess of 10 percent for right wrist disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Codes 5214-15 (2017). 5. The criteria for a rating in excess of 10 percent for left wrist disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Codes 5214-15 (2017). 6. The criteria for a rating in excess of 50 percent for anxiety disorder have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9413 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA provided the Veteran with 38 U.S.C. §§ 5103(a)-compliant notice in October 2010. 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 service treatment records and post-service medical treatment records 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 experiencing flare-ups of his back disability, knee disability, and wrist disability. With that said, the Veteran has not reported any 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 back and knees in August 2011, July 2014, and September 2017. The Veteran was provided with examinations addressing his wrists in August 2011, February 2014, April 2014, and September 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 at a hearing before the Board. Thus, 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. Increased Ratings Generally Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. 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. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, staged ratings have been assigned, and as discussed below, the evidence does not support the assignment of any additional staged rating periods other than those discussed herein. 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. 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 (2017); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Pyramiding-the evaluation of the same manifestation of a disability under different diagnostic codes-is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2017). 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). Increased Rating for a Back Disability The Veteran's back disability is evaluated as 10 percent disabling under Diagnostic Code 5237, applicable to lumbosacral strain. The Veteran is seeking a higher rating. Spine disabilities are evaluated under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever results in the higher evaluation when all disabilities are combined. 38 C.F.R § 4.71a, Diagnostic Code 5243 (2017). The General Rating Formula for Diseases and Injuries of the Spine rates lumbar spine disabilities as follows, in pertinent part: 20 percent: Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 40 percent: Forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. 50 percent: Unfavorable ankylosis of the entire thoracolumbar spine. 100 percent: Unfavorable ankylosis of the entire spine. 38 C.F.R § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (2017). "Ankylosis" is immobility and consolidation of a joint due to a disease, injury, or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992). The Formula for Rating IVDS Based on Incapacitating Episodes rates lumbar spine disabilities as follows, in pertinent part: 20 percent: Incapacitating episodes having a total duration of at least two weeks but fewer than four weeks during the past 12 months. 40 percent: Incapacitating episodes having a total duration of at least four weeks but fewer than six weeks during the past 12 months. 60 percent: Incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R § 4.71a, Diagnostic Code 5243 (2017). An "incapacitating episode" is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. When evaluating diseases and injuries of the spine, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. 38 C.F.R § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (2017). Turning to the facts in this case, the Veteran filed his claim of entitlement to an increased rating in September 2010. In May 2011, a clinician noted that the Veteran had tenderness and spasm of the lumbosacral spine. The clinician noted that the Veteran had "restricted" extension, bilateral lateral flexion, and bilateral lateral rotation. The Veteran underwent a VA examination of his back in August 2011, at which time the examiner diagnosed the Veteran with lumbosacral strain with mild levoscoliosis and degenerative disc disease. The Veteran reported that he experienced flare-ups twice yearly, during which time he suddenly experienced back spasms and was unable to get up. The Veteran had forward flexion to 90 degrees or greater without pain, extension to 30 degrees or greater without pain, bilateral lateral flexion to 30 degrees or greater with pain, and bilateral lateral rotation to 30 degrees or greater without pain. Repetitive use testing did not result in additional loss of motion or other functional loss. The Veteran did not have localized tenderness or pain to palpation, guarding, or muscle spasm. The examiner found that the Veteran did not have IVDS. The Veteran underwent an additional VA examination in July 2014, at which time the examiner diagnosed the Veteran with lumbosacral strain. The Veteran reported that his back hurt with prolonged sitting, and his pain increased during the day. The Veteran denied experiencing flare-ups. The Veteran had forward flexion to 80 degrees with pain, extension to 30 degrees or greater with pain, bilateral lateral flexion to 30 degrees or greater with pain, and bilateral lateral rotation to 30 degrees or greater without pain. Repetitive use testing did not result in additional loss of motion or other functional loss. The examiner noted that the Veteran had functional impairment in the form of less movement than normal and painful movement. The Veteran did not have localized tenderness or pain to palpation, guarding, or muscle spasm. The examiner found that the Veteran did not have IVDS. The Veteran underwent an additional VA examination in September 2017, at which time the examiner diagnosed the Veteran with lumbosacral strain. The Veteran reported experiencing intermittent daily low back pain up to twice weekly. The Veteran's pain was aggravated by awakening, prolonged sitting, prolonged standing, and prolonged walking. When the Veteran experienced pain, he indicated that he could not bend until it resolved. The Veteran denied experiencing flare-ups. Range of motion testing was normal, and it was noted that while the Veteran experienced pain upon examination, the pain did not result in functional loss. The Veteran showed pain with weight bearing. Repetitive use testing did not result in additional loss of motion or other functional loss. The examiner noted that the Veteran had functional impairment in the form of less movement than normal and painful movement. The Veteran did not have localized tenderness or pain to palpation, guarding, or muscle spasm. The examiner found that the Veteran did not have IVDS. Turning to an analysis of these facts, the Veteran's back disability has been rated 10 percent disabling throughout his appeal. With regard to a rating in excess of 10 percent, the Veteran's back has not been ankylosed, or immobile, at any time. Furthermore, the Veteran's back has not shown forward flexion limited to 30 degrees or fewer at any time, even when taking pain into consideration. Without ankylosis or such a limitation of motion, a rating of 40 percent or greater for the Veteran's back disability is unwarranted at any time. With regard to a 20 percent rating, the Veteran has not shown forward flexion limited to 60 degrees or fewer, even when taking pain into consideration. The combined range of motion of the thoracolumbar spine has not been limited to 120 degrees or fewer, even when taking pain into consideration. The Veteran has not shown muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 20 percent rating for the Veteran's back disability is unwarranted at any time. In reaching this conclusion, the Board considered 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 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board has considered the effects of weakened movement, excess fatigability, and incoordination. 38 C.F.R. § 4.45 (2017). Although the Board accepts the Veteran's assertions that his back disability causes him to experience pain, the Board has taken this into account in its above discussion of range of motion. The rating schedule does not require a separate rating for pain itself. Spurgeon v. Brown, 10 Vet. App. 194 (1997). Pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). Furthermore, even when the Veteran's complaints of pain are considered, the Board concludes that the overall manifestations of his spine disability generally do not demonstrate a degree of functional loss so as to warrant higher ratings for the period on appeal. Ratings in excess of those currently assigned are similarly unavailable under the formula for rating IVDS. A rating in excess of 10 percent based on IVDS would require incapacitating episodes with a total duration of at least two weeks during a 12-month period. In this case, there has been no showing that the Veteran actually has IVDS, nor has it been demonstrated that bed rest has been prescribed at any time during the course of the appeal. In sum, the criteria for a rating in excess of 10 percent based on IVDS have not been met. Turning now to an evaluation of the neurological manifestations of the Veteran's back disability, a compensable evaluation of the Veteran's neurological symptoms would require a finding that such symptoms approximate at least mild incomplete paralysis. See 38 C.F.R. § 4.124a, Diagnostic Code 8520. Turning to the facts in this case, in December 2010, the Veteran complained of back pain that radiated into the right leg every couple of months. In May 2011, the Veteran complained of back pain that radiated to both thighs. In August 2011, muscle strength, reflex, and sensory testing were normal. The Veteran had no radicular pain or other signs or symptoms of radiculopathy. In July 2013, a clinician noted that the Veteran had no weakness of the bilateral knees or ankles. In April 2014, the Veteran denied experiencing radiating back pain, and muscle strength, sensory, and reflex testing were normal. In July 2014, muscle strength, reflex, and sensory testing were normal. The Veteran had no radicular pain or other signs or symptoms of radiculopathy. In September 2017, the Veteran indicated that he experienced pain that radiated to his left knee up to twice weekly. Muscle strength, reflex, and sensory testing were all normal. The Veteran had no radicular pain or other signs or symptoms of radiculopathy. Upon review of these facts, the Board finds that to the extent the Veteran suffers from neurological symptoms, such symptoms are no more than slight. The Veteran himself has not alleged that he experiences neurological symptoms as a result of his back disability. Clinicians have not indicated that the Veteran experiences neurological manifestations of a back disability. Accordingly, the Board finds that the Veteran's neurological symptoms do not rise to the level of mild incomplete paralysis, and a compensable rating addressing neurological manifestations of the Veteran's back disability is unwarranted. In making these determinations, the Board has also considered the statements that the Veteran has submitted in support of his claim. The Veteran has described a symptom picture showing that his back disability causes him symptoms of pain, spasm, and stiffness, and he has been awarded the current 10 percent rating in acknowledgement of such symptoms. While the Board is sympathetic to the Veteran, it cannot award greater ratings for the Veteran's back disability because the Veteran's symptoms simply do not meet the criteria associated with a rating in excess of 10 percent. Increased Ratings for Bilateral Knee Disabilities The Veteran's bilateral knee disabilities are evaluated 10 percent disabling under Diagnostic Code 5260, applicable to limitation of flexion of the legs. The Veteran is seeking higher ratings. The Board will first address the issue of entitlement to greater ratings based on limitation of motion of the bilateral knees. Separate evaluations may be assigned for limitation of flexion and extension of the same knee 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 30 degrees warrants a 20 percent rating, and limitation of flexion 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. Turning to the facts in this case, the Veteran filed his claim of entitlement to an increased rating in September 2010. In December 2010, the Veteran complained of left knee pain that increased with prolonged walking. The Veteran was noted to have mild tricompartmental degenerative changes of the bilateral knees. In August 2011, a clinician noted that the Veteran's active range of motion was within normal limits. The Veteran underwent a VA examination of his knees in August 2011, at which time the examiner diagnosed the Veteran with degenerative joint disease of the bilateral knees. The Veteran complained of swelling and pain in the knees with prolonged walking. The Veteran indicated that he experienced flare-ups of pain in the right knee during the winter. The Veteran had bilateral flexion to 130 degrees with pain and extension to 0 degrees without pain. Repetitive use testing did not result in additional limitation of motion or other functional loss. The Veteran did not have tenderness or pain to palpation of the knees. The Veteran underwent an additional VA examination in July 2014, at which time the examiner diagnosed the Veteran with bilateral knee enthesopathy. The Veteran indicated that he experienced pain in both knees that increased during the winter. The Veteran denied experiencing flare-ups. The Veteran had flexion to 130 degrees bilaterally without pain and extension to 0 degrees without pain. Repetitive use testing did not result in additional loss of motion or other functional loss. The Veteran had tenderness or pain to palpation bilaterally. The Veteran underwent an additional VA examination in September 2017, at which time the examiner diagnosed the Veteran with degenerative arthritis of the bilateral knees. The Veteran complained of intermittent pain in the bilateral knees, with the pain on the left greater than the right. The Veteran denied experiencing swelling or paresthesias in the knees. The Veteran indicated that he experienced flare-ups during cold weather, during which time it was hard for the Veteran to walk, stand, or sit for too long. The Veteran indicated that he could not run or turn without his knee braces. The Veteran could not stand or sit for long periods of time without changing positions. The Veteran could walk his dog and jog without problems. Range of motion testing was normal for both knees. While the Veteran complained of pain on examination, the examiner noted that the pain did not result in a functional loss. There was pain with weight-bearing. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. Repetitive use testing did not result in an additional loss of motion or other functional loss. The examiner noted that the Veteran was being examined immediately after repetitive use over time, and pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. Muscle strength testing was normal. Turning to an analysis of this evidence, with respect to an increased rating based on limitation of flexion, the evidence does not demonstrate flexion of the bilateral knees limited to 30 degrees or fewer, even when taking pain into consideration. The Board thus finds that greater ratings based on a limitation of flexion, which would require flexion limited to 30 degrees or fewer, are unavailable to the Veteran. 38 C.F.R. § 4.71a, Diagnostic Code 5260. With respect to an increased rating based on limitation of extension, the evidence does not demonstrate a limitation of extension at any time, even when taking pain into consideration. The Board thus finds that a separate 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 bilateral knee disability causes him to experience pain, the Board has taken that into account in its consideration of the range of motion of the Veteran's bilateral knees. Having determined that the existing 10 percent ratings are the maximum ratings available based on limitation of movement of the bilateral knees, the Board next turns to the possibility of greater ratings based on instability. 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). 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. Turning to the facts in this case, in February 2011, the Veteran indicated that his right knee had been swollen for a week and a half, and he reported hearing a popping sound. In July 2011, the Veteran denied experiencing swelling, heat, or erythema. In August 2011, the Veteran complained of his patellae popping and one episode of his right knee locking. The Veteran's patellar movement was within normal limits bilaterally with guarding when the patella was mobilized. The Veteran's strength was normal. In August 2011, a VA examiner indicated that joint stability testing of the bilateral knees was normal. There was no evidence or history of recurrent patellar subluxation or dislocation. The Veteran had never had any meniscal conditions. In July 2014, the Veteran wore sleeve braces on his knees. Muscle strength testing and joint stability testing was normal bilaterally, and there was no evidence or history of recurrent patellar subluxation or dislocation. The Veteran had never had any meniscal conditions. In September 2017, the examiner noted objective evidence of crepitus with movement testing. The Veteran did not have a history of recurrent subluxation, instability, or recurrent effusion. Joint stability testing was normal. The Veteran had not ever had a meniscus condition. The Veteran reported that he regularly wore knee braces. In this case, the Board finds that the Veteran's symptoms of instability do not approximate the "slight" severity that is required for a 10 percent rating. While the Veteran complained on a few occasions of knee popping and locking, clinicians have consistently found the Veteran's knees to be stable. The Board thus finds that the Veteran's symptom picture is inconsistent with a finding that he suffered from even slight instability of the knees at any time. Furthermore, when semilunar cartilage (that is, the meniscus) is dislocated with frequent episodes of locking, pain and effusion into the joint a 20 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5258. When semilunar cartilage has been removed, but remains symptomatic, a 10 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5259. In this case, the evidence does not show, nor does the Veteran contend, that he has ever suffered from an impairment of the meniscus of the knees; greater evaluations under Diagnostic Codes 5258 and 5259 are thus unavailable. In making these determinations, the Board has also considered the statements that the Veteran has submitted in support of his claim. The Veteran has described a symptom picture showing that his bilateral knee disability causes him to experience pain and requires him to wear braces, and he has been awarded 10 percent ratings in acknowledgement of such symptoms. While the Board is sympathetic to the Veteran, it cannot award greater ratings for the Veteran's bilateral knee disability because the Veteran's symptoms simply do not meet the criteria associated with ratings in excess of 10 percent. Increased Ratings for Bilateral Wrist Disabilities The Veteran's bilateral wrist disabilities are evaluated 10 percent disabling under Diagnostic Code 5215, applicable to limitation of motion of the wrists. The Veteran is seeking higher ratings. A normal range of motion in the wrist is dorsiflexion (extension) to 70 degrees, palmar flexion to 80 degrees, ulnar deviation to 45 degrees, and radial deviation to 20 degrees. 38 C.F.R. § 4.71, Plate I. Handedness for the purpose of a dominance rating is determined by the evidence of record, or by testing on VA examination. 38 C.F.R. § 4.69. Only one hand is considered dominant. The evidence of record establishes that the Veteran is left-handed, and as such, the left arm is the Veteran's major extremity, and the right arm is the Veteran's minor extremity. A limitation of motion of the wrist, whether the major or minor extremity, is rated 10 percent disabling when palmar flexion is limited to a position in line with the forearm, or when dorsiflexion is less than 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5215. Favorable ankylosis in 20 degrees to 30 degrees dorsiflexion warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5214. Ankylosis of the wrist in any other position, except favorable, warrants a 30 percent rating for the minor extremity and a 40 percent rating for the major extremity. Id. Unfavorable ankylosis in any degree of palmar flexion or with ulnar or radial deviation warrants a 40 percent rating for the minor extremity and a 50 percent rating for the major extremity. Id. Extremely unfavorable ankylosis is rated on the basis of a loss of use of the hands. Id. Turning to the facts in this case, the Veteran filed his claim for an increased rating in September 2010. In November 2010, the Veteran was assessed with carpal tunnel syndrome (CTS) following his complaints of bilateral wrist pain. In May 2011, the Veteran complained of stiffness in the wrists. The Veteran underwent a VA examination in August 2011, at which time the examiner diagnosed the Veteran with normal bilateral wrists. The Veteran denied experiencing pain in the wrists, and he indicated that he wore wrist braces at night. The Veteran denied experiencing flare-ups. The Veteran had bilateral palmar flexion to 80 degrees without pain and dorsiflexion (extension) to 70 degrees or greater without pain. Repetitive use testing did not result in additional limitation of motion or other functional loss. The Veteran did not have tenderness or pain to palpation of the wrists. Muscle strength testing was normal. The Veteran underwent a VA examination in February 2014, at which time the examiner diagnosed the Veteran with ulnar nerve entrapment at the wrists. The Veteran reported that he experienced a "pricking feeling" and numbness in both hands at night. The Veteran reported that he experienced flare-ups, and he wore wrist braces when the pain became unbearable and when he had to drive. The Veteran had palmar flexion of the right wrist to 20 degrees with pain at 10 degrees and dorsiflexion (extension) to 0 degrees with pain. The Veteran had palmar flexion of the left wrist to 30 degrees with pain at 10 degrees and dorsiflexion (extension) to 5 degrees with pain at 0 degrees. The Veteran could not perform repetitive use testing as a result of pain. The examiner noted that the Veteran had additional limitations of movement and functional ability following repetitive use testing in the form of weakened movement, excess fatigability, incoordination, pain on movement, and, on the right side, atrophy of disuse. The examiner indicated that the Veteran had extremely unfavorable ankylosis of both wrists and localized tenderness or pain on palpation of both wrists. Muscle strength testing showed that the Veteran's right wrist had active movement with gravity eliminated for both flexion and extension; the left wrist had active movement against some resistance for both flexion and extension. The examiner noted that the Veteran had muscle atrophy of both hands and wrists, more severely in the right than left. The examiner found that pain, weakness, fatigability, or incoordination could significantly limit functional ability either during flare-ups of when the joint was used repeatedly over a period of time. The examiner estimated the reduction to be 30 degrees on the left and 20 degrees on the right. In April 2014, a different examiner from the one who conducted the February 2014 examination opined that the February 2014 examination did not accurately address the Veteran's symptoms. The April 2014 examiner noted that the record did not contain nerve conduction studies or other data to support a diagnosis with CTS. Furthermore, the April 2014 examiner noted that the notation of the February 2014 examiner that the Veteran had essentially no motion of the wrists was incompatible with the absence of such symptoms in the Veteran's clinical records. Thus, while the Board has included the findings of the February 2014 examiner for the sake of completeness, it places little probative value on these findings for the reasons expressed by the April 2014 examiner. The Board will thus not use the findings of the February 2014 examiner in its below analysis of the proper rating for the Veteran's bilateral wrist disability. Accordingly, the Veteran underwent an additional examination in April 2014, at which time the examiner diagnosed the Veteran with a bilateral wrist strain. The Veteran complained of numbness and tingling in both hands. The Veteran denied experiencing flare-ups. The Veteran had palmar flexion of the right wrist to 45 degrees without pain and extension (dorsiflexion) of the right wrist to 65 degrees without pain. The Veteran had palmar flexion of the left wrist to 50 degrees without pain and extension (dorsiflexion) of the right wrist to 55 degrees without pain. Repetitive motion testing resulted in less movement than normal. The Veteran did not have localized tenderness or pain on palpation of the joints or soft tissue of either wrist. Muscle strength testing of the wrists was normal, no muscle atrophy was noted, and the Veteran did not have ankylosis of either wrist joint. Diagnostic testing showed no significant findings. The examiner noted that the Veteran was not wearing braces, and he moved his hands and wrists easily. Sensory examination to light touch and scratch was normal bilaterally, and the Veteran subjectively complained of tingling bilaterally. The examiner found "essentially none" of the symptoms noted during the February 2014 examination. The Veteran was scheduled to undergo EMG testing to determine whether he had carpal tunnel syndrome, but in May 2014, the examiner noted that the Veteran had cancelled his EMG examination. The Veteran underwent an additional VA examination in September 2017, at which time the Veteran denied experiencing joint pain in his wrists. The examiner noted that the Veteran's left hand was dominant, and the Veteran denied experiencing flare-ups. The Veteran indicated that he occasionally dropped items when holding them for too long. Range of motion testing in both wrists was normal, with no pain noted on examination. The Veteran's wrists were not ankylosed. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. Repetitive use testing did not result in an additional loss of motion or other functional loss. Muscle strength testing was normal. The Veteran subjectively complained of tingling and pain. Turning to an analysis of these facts, the Board notes that the Veteran's bilateral wrist disability is currently rated on the basis of impaired motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5215. With that said, the Veteran has subjectively complained of neurological symptoms such as tingling and weakness associated with his bilateral wrist disability, and certain clinicians, for example in November 2010, have assessed the Veteran with CTS. The April 2014 and September 2017 examiners found, however, that such a diagnosis was inappropriate because the Veteran had declined to undergo the nerve conduction studies that would establish a diagnosis with CTS, nor did the medical evidence otherwise contain data supporting such a diagnosis. Furthermore, even accepting the Veteran's complaints of subjective symptoms such as numbness, pain, and weakness, the Board finds that such complaints do not approximate the mild incomplete paralysis that would be associated with a compensable rating of the Veteran's wrist disability based on his claimed neurological symptoms. See 38 C.F.R. § 4.124a, Diagnostic Code 8515. The Veteran is otherwise currently in receipt of 10 percent ratings for his bilateral wrist disability as an acknowledgement of the Veteran's complaints of painful motion. The Board notes that 10 percent is the maximum rating available to the rating on the basis of impaired motion of the wrists. See 38 C.F.R. § 4.71a, Diagnostic Code 5215. A greater rating of the Veteran's bilateral wrist disability would require a finding that the Veteran's wrists were ankylosed, or immobile. With the exception of the February 2014 examiner, who found, contradictorily, both that the Veteran's wrists were extremely unfavorably ankylosed and that the Veteran indeed retained motion in the wrists, no clinician has found the Veteran's wrists to be ankylosed at any time, nor has the Veteran sought clinical treatment for immobility of the wrists. The Board finds that the weight of the evidence does not support a finding that the Veteran's wrists were immobile at any time. A greater rating based upon ankylosis of the wrists is therefore unavailable. See 38 C.F.R. § 4.71a, Diagnostic Code 5214 (2017). In making these determinations, the Board has also considered the statements that the Veteran has submitted in support of his claim. The Veteran has described a symptom picture showing that his bilateral wrist disability causes him to experience pain and requires him to wear braces, and he has been awarded 10 percent ratings in acknowledgement of such symptoms. While the Board is sympathetic to the Veteran, it cannot award greater ratings for the Veteran's bilateral wrist disability because the Veteran's symptoms simply do not meet the criteria associated with ratings in excess of 10 percent. Increased Rating for Anxiety Disorder 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 9413. 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. 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 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 claim of entitlement to an increased rating for anxiety disorder in September 2010. The Veteran underwent a VA examination in August 2011, at which time the examiner found that the Veteran had occupational or social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although the Veteran generally functioned satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran was married to his spouse, and he had two children whom he visited every weekend. The Veteran reported having a good relationship with his spouse. The Veteran indicated that he did not have friends. The Veteran went to the gym with his spouse on the weekends, and he took culinary classes four days each week. The Veteran reported that he was "selective" in the kinds of work that he wanted to do. The Veteran took an international vacation once yearly to see family. The Veteran cared for his dog and engaged in housework. The Veteran reported that he was unemployed, and he last interviewed for a job six months before. The Veteran had no history of suicide attempts or violence. The examiner noted that the Veteran had anxiety, panic attacks that occurred once weekly or less often, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner found the Veteran to be capable of managing his financial affairs. The examiner assigned the Veteran a GAF score of 60. The Veteran underwent an additional VA examination in July 2014, at which time the examiner found that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran reported that he had been married for over 30 years, and he indicated that his marriage was "just okay". The Veteran indicated that he only left the house when it was essential. The Veteran indicated that he had an "okay" relationship with his son and a "not so good" relationship with his daughter. The Veteran had not seen his siblings in about 10 years, but he engaged in phone conversations with them. The Veteran reported having few friends, but he indicated that he had fewer than he used to because he was quick to anger. The Veteran indicated that he was unemployed, but he hoped to find a job. The Veteran reported that he had stopped taking classes because he struggled with them. The Veteran had participated in volunteer work for over a year and a half and was hired as an employee, but he stopped working as a result of symptoms of vertigo. The examiner noted that the Veteran's capacity to carry out short and simple instructions was intact, but he had moderate difficulty following more complex instructions. The Veteran struggled in getting along in group situations. The Veteran indicated that he struggled with concentration and forgetfulness. The examiner found the Veteran to be capable of managing his financial affairs. The examiner found that the Veteran suffered from anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. In February 2016, the Veteran reported that he did not sleep well as a result of anxiety. The Veteran further indicated that he occasionally became verbally aggressive with his wife. The Veteran's dog calmed him. In December 2015, the Veteran indicated that he resided with his wife, and traveled to live with his son for a week each month. The Veteran indicated that when he had panic attacks, he was "paralyzed" two to three times weekly. The Veteran indicated that his spouse said that he was "moody". The Veteran complained of difficulty with concentration and memory. In March 2016, a clinician noted that the Veteran resided with his spouse and had a "difficult time staying by himself". The Veteran intended to travel to visit his sister for several months. The Veteran denied symptoms of depression, and he indicated that his dog helped him. The Veteran underwent an additional VA examination in October 2017, at which time the examiner found that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran remained married to his spouse, but he indicated that his marriage was "not that good" because of the anger that he experienced as a result of his anxiety. The Veteran reported that he usually wished to be alone, and he did not have regularly scheduled activities with his spouse. The Veteran reported that he sometimes saw his children, and he spoke with his son. The Veteran did not see his grandchildren often. The remainder of the Veteran's family lived in another part of the country, and he did not keep in regular contact with them. The Veteran did not often spend time with friends; instead, the Veteran enjoyed spending time with his dog. The Veteran was unemployed, and he reported that he had not looked for work. The Veteran reported that he showered every day, spent time outside, and took his dog for walks. The Veteran prepared small meals, dressed himself, and groomed himself. The Veteran ran errands and helped with chores around the house. The examiner found the Veteran to be capable of comprehending short and simple instructions, but he had difficulty in following more complex instructions. The examiner found that the Veteran could struggle in group situations. The Veteran had the ability to complete activities of daily living without assistance. The Veteran complained of difficulty sleeping at night as a result of worry. The examiner found that the Veteran had anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. 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 does not 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. While the Veteran has not worked since filing his claim in September 2010, the Veteran took classes and engaged in volunteer work, which he stopped as a result of symptoms not relevant to this appeal. Clinicians have consistently found the Veteran to be able to handle money, pay bills, and manage his own financial affairs. Furthermore, in August 2011, an examiner found that the Veteran had impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although the Veteran generally functioned 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. In July 2014 and October 2017, examiners found that the Veteran's symptoms resulted in impairment with reduced reliability and productivity. The Board notes that this characterization of the Veteran's symptoms is consistent with a 50 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's determination does not, however, diminish the seriousness of the occupational impairment that the Veteran has experienced as a result of his psychiatric symptoms. Examiners have indeed noted symptoms such as an impaired ability to follow complex instructions and difficulty in appropriately behaving in group situations. The record otherwise shows that the Veteran has reported experiencing difficulties in sleep, motivation, mood, and concentration. The Veteran's anxiety 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 since filing his claim of entitlement to service connection, the Veteran maintained a decades-long marriage with his spouse, and he had relationships with his children, though he reported a closer relationship with his son than with his daughter. The Veteran reported travelling internationally to see his extended family, and he reported having plans to travel across the country to see his sister. The Veteran consistently reported that his relationship with his dog brought him social fulfillment. Furthermore, in August 2011, an examiner found that the Veteran had impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although the Veteran generally functioned 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. In July 2014 and October 2017, examiners found that the Veteran's symptoms resulted in impairment with reduced reliability and productivity. The Board notes that this characterization of the Veteran's symptoms is consistent with a 50 percent disability rating. While the Board acknowledges the Veteran's descriptions of self-isolating, spending much of his time at home, and experiencing anger, the Board finds 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 anxiety. 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 Veteran has reported experiencing difficulties in sleep, motivation, mood, and concentration. The Veteran has indicated that his relationship with his daughter was strained, and he indicated that his outbursts of anger had an impact on his marriage. The Board acknowledges that the Veteran's anxiety symptoms 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, the Board finds that the weight of the evidence is against the assignment of a rating in excess of 50 percent at any time. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER A rating in excess of 10 percent for back disability is denied. A rating in excess of 10 percent for left knee disability is denied. A rating in excess of 10 percent for right knee disability is denied. A rating in excess of 10 percent for left wrist disability is denied. A rating in excess of 10 percent for right wrist disability is denied. A rating in excess of 50 percent for anxiety disorder is denied. REMAND The Veteran received audiological consultations at the VA Medical Center (VAMC) in Phoenix, Arizona on April 23, 2012, and December 2, 2015. The notes associated with these consultations refer to audiograms that are not otherwise of record. The AOJ should undertake all appropriate efforts to associate the April 2012 and December 2015 audiograms with the record. Accordingly, the case is REMANDED for the following actions: 1. Undertake all appropriate efforts to associate the April 2012 and December 2015 audiograms with the record. 2. Then, after ensuring any other necessary development has been completed, readjudicate the remaining claim on appeal. If any action remains adverse to the Veteran, provide the Veteran and his representative with a supplemental statement of the case, allow an appropriate opportunity to respond, and thereafter 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. §§ 5109B, 7112 (2012). ______________________________________________ THOMAS H. O'SHAY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs