Citation Nr: 19106905 Decision Date: 01/29/19 Archive Date: 01/29/19 DOCKET NO. 16-54 044 DATE: January 29, 2019 ORDER New and material evidence has not been presented, and the claim to reopen entitlement to service connection for a bone disability is denied. New and material evidence has not been presented, and the claim to reopen entitlement to service connection for skin cancer is denied. Service connection for erectile dysfunction is denied. A rating in excess of 40 percent for ankylosis of left ankle (previously rated as degenerative arthritis left talonavicular joint) is denied. A rating in excess of 10 percent for arthritis of the left foot is denied. A rating in excess of 10 percent for shell fragment wound residuals of the right scapular area is denied. A rating in excess of 10 percent for a right shoulder shell fragment (muscle group I) wound is denied. A rating in excess of 20 percent for a right shoulder shell fragment (muscle group II) wound is denied. A rating in excess of 20 percent for a right shoulder shell fragment (muscle group III) wound is denied. A rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to May 4, 2017 is denied. A rating in excess of 70 percent for PTSD from May 4, 2017 is denied. FINDINGS OF FACTS 1. In a May 2012 rating decision, the Veteran’s claim for service connection for a bone disability was denied and the Veteran neither filed a Notice of Disagreement, nor submitted new and material evidence within a year of the rating decision. 2. The evidence received since the May 2012 rating decision includes evidence that is cumulative or redundant of the evidence previously of record and is not sufficient to raise a reasonable possibility of substantiating the claim of entitlement to service connection for a bone condition. 3. In a December 2009 rating decision, the Veteran’s claim for service connection for skin cancer was denied and the Veteran neither filed a Notice of Disagreement, nor submitted new and material evidence within a year of the rating decision. 4. The evidence received since the December 2009 rating decision includes evidence that is cumulative or redundant of the evidence previously of record and is not sufficient to raise a reasonable possibility of substantiating the claim of entitlement to service connection for skin cancer. 5. The weight of the evidence is against finding that the Veteran has a diagnosis of erectile dysfunction. 6. The Veteran’s shell fragment scar on the right scapular is painful and measures 5 cm by 1.5 cm. 7. The Veteran’s right shoulder disability of muscle group I is productive of a moderate impairment. 8. The Veteran’s right shoulder disability of muscle group II is productive of a moderate impairment. 9. The Veteran’s right shoulder disability of muscle group III is productive of a moderate impairment. 10. The Veteran’s left ankle ankylosis with degenerative arthritis has been assigned the maximum 40 percent rating for a disability of the ankle under the regular schedular criteria. 11. The Veteran’s left foot disability has been manifested by moderate impairment. 12. Prior to May 4, 2017, the Veteran’s PTSD was productive of no more than occupational and social impairment with reduced reliability and productivity due to symptoms such as difficulty in establishing and maintaining effective work and social relationships. 13. At no time has the Veteran’s PTSD caused total social and occupational impairment. CONCLUSIONS OF LAW 1. The May 2012 rating decision denying service connection for a bone disability is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. The criteria to reopen a previously denied claim for service connection for a bone disability have not been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The December 2009 rating decision denying service connection for skin cancer is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 4. The criteria to reopen a previously denied claim for service connection for skin cancer have not been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. The criteria for service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1110, 1131, 5013, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 6. The criteria for a rating in excess of 10 percent for a right scapular scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7804. 7. The criteria for an initial rating in excess of 10 percent for right shoulder (muscle group I) have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.73 Diagnostic Code (DC) 5301. 8. The criteria for an initial rating in excess of 20 percent for a right shoulder disability (muscle group II) have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. § 4.73 Diagnostic Code (DC) 5302. 9. The criteria for an initial rating in excess of 20 percent for a right shoulder disability (muscle group III) have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.73 Diagnostic Code (DC) 5303. 10. The criteria for a rating in excess of 40 percent for residuals of a left ankle ankylosis with degenerative arthritis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.27, 4.68, 4.71a, Diagnostic Codes 5010-5270. 11. The criteria for an evaluation in excess of 10 percent for a left foot disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Code 5271. 12. The criteria for an initial rating in excess of 50 percent for PTSD prior to May 4, 2017, and in excess of 70 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.21, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1967 to March 1970. This matter is on appeal from a December 2014 rating decision. Reopening a Claim Generally, a claim that has been finally denied in an unappealed RO decision or a Board decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104 (b), 7105(c). The exception is that if new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. 38 U.S.C.§ 5108. New evidence means evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). When determining whether the submitted evidence meets the definition of new and material evidence, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). Pursuant to Shade, evidence is considered new if it has not been previously submitted to agency decision makers, and it is material if, when considered with the evidence of record, it would at least trigger VA’s duty to assist by providing a medical opinion, which might raise a reasonable possibility of substantiating the claim. Id. The Court interprets the language of 38 C.F.R. § 3.156 (a) as creating a low threshold, and views the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” 1. Bone disease The last final denial of this claim was a May 2012 rating decision which found that the probative medical evidence failed to relate the Veteran’s bone disability to his military service. Since the Veteran failed to file a Notice of Disagreement or submit additional evidence within a year of that rating decision, that rating decision became final. See 38 U.S.C. § 7105(c). The Veteran then filed to reopen his claim in February 2014. At the time of the May 2012 rating decision, the record consisted of VA treatment records, which showed no bone abnormalities, deformities, or disease. Evidence since the May 2012 rating decision includes new VA treatment records. July and December 2017 treatment records noted complaints of “bone pain” and the Veteran was recommended for clinical correlation, although there is no indication that such was ever completed. An August 2017 report noted that the Veteran complained that his pain was due to osteoporosis. Other than a note that indicated that the Veteran has a history of chronic low bone density, which was previously considered by the May 2012 rating decision, the record fails to reflect a diagnosis of a bone disorder. The Board finds that the evidence received since the May 2012 rating decision is not new as it is cumulative of the evidence of record. Moreover, it is not material as it does not raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. Even considering the holding in Shade v. Shinseki, 24 Vet. App. 110, to the effect that the VA regulation as to reopening a claim “must be read as creating a low threshold,” there is still a minimum threshold. However, the new evidence does not reach that threshold. As such, the claim is not reopened. 2. Skin disease The last final denial of the Veteran’s claim for service connection for a skin disease is a December 2009 rating decision. RO denied that claim because the evidence of record failed to reflect of a skin condition, specifically cancer. Since the Veteran failed to file a Notice of Disagreement or submit additional evidence within a year of that rating decision, that rating decision became final. See 38 U.S.C. § 7105 (c). At the time of the December 2009 rating decision, the record consisted of service treatment records, which showed treatment for urticaria, hivers, and poison ivy. There was no indication of skin cancer. The record also included a 2009 VA examination report, which concluded that the skin conditions the Veteran experienced during service had resolved in service. While the VA examination noted actinic keratosis, it was felt that such was unrelated to his service. Evidence since the December 2009 rating decision include new VA treatment records, which failed to reflect a diagnosis of skin cancer. The Board finds that the evidence received since the December 2009 rating decision is not new, nor is it material to the evidence already of record. Even considering the holding in Shade, 24 Vet. App. 110, to the effect that the VA regulation as to reopening a claim “must be read as creating a low threshold,” there is still a minimum threshold. However, the new evidence does not reach that threshold. As such, the claim is not reopened. Service Connection Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). In general, service connection requires (1) 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) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran contends that he developed erectile dysfunction as a result of his military service. However, service treatment records were silent for complaints or diagnosis relating to erectile dysfunction, and post-service treatments also fail to document a diagnosis. Other than the Veteran’s own statement, the record in this case lacks any competent evidence to establish the presence of erectile dysfunction. While the Veteran is uniquely positioned to observe his penile functioning, there is no indication that, to the extent the Veteran has erectile dysfunction, that it actually began during service, or is otherwise the result of any service connected disability. Here there is no suggestion from any medical professional that the Veteran has erectile dysfunction that either began during or was otherwise caused by his military service, and no evidence aside from the Veteran filing for service connection supports this claim. As such, the evidence of record is insufficient to support the grant of service connection and the claim is denied. Increased Rating 1. Right shoulder shell fragment wound The Veteran’s shell fragment wound to his right scapular area has been rated based on both the scar that is present and based on injuries to several muscle groups in the shoulder area. In February 2014, the Veteran filed a claim seeking an increased rating for his shoulder. The Board will first consider whether a rating in excess of 10 percent is warranted for the Veteran’s right shoulder scar which is rated under Diagnostic Code 7804, which provides a 10 percent rating for one or two scars that are unstable or painful; a 20 percent rating for three or four scars that are unstable of painful; and 30 percent rating for five or more scars that are unstable or painful. Alternatively, a compensable rating may be assigned under several other Diagnostic Codes. For scars that do not affect the head, face or neck, a 10 percent rating may be assigned if a scar is deep and nonlinear and covers an area of at least 6 square inches (39 sq. cm.) (a deep scar is one associated with underlying soft tissue damage) (38 C.F.R. § 4.118, Diagnostic Code 7801); or 2) superficial (meaning that it is not associated with underlying soft tissue damage) and nonlinear and covers an area of at least 144 square inches (929 sq. cm), (38 C.F.R. § 4.118, Diagnostic Code 7802). A May 2014 VA examination show that the Veteran’s shrapnel scar on the right scapular area measured 4 cm by 1.5 cm. The Veteran denied that the superficial non-linear scar was either painful or unstable. At a February 2017 VA examination, his shrapnel scar was measured at 5 cm by 1.5 cm. There was no objective evidence that the scar was unstable or painful. The scar was evaluated again at a March 2017 VA examination, where it was again measured at 5 cm by 1.5 cm. However, it was noted that motion in the right arm causes pain and numbness down the arm to his fingers. He explained that this sensation limited the amount of mobility and function in his right arm, such that he could not throw a ball overhanded with any accuracy. In review of the record, the Board finds that a rating in excess of 10 percent for a right scapular scar is not warranted. While objective medical evidence shows complaints of pain, but the Veteran only has 1 scar in his right scapular, which has already been compensated at a 10 percent rating. 2. Evaluation of residuals, shell fragment would, right shoulder (muscle groups I, II, III) Pursuant to the Veteran’s claim for increase rating for a right shoulder shell fragment wound, he was granted three separate ratings by a January 2018 rating decision at 10 percent under Diagnostic Codes 5301, 20 percent under Diagnostic Code 5302, and 20 percent under Diagnostic Code 5303, all effective as of the date his claim for an increase was received. Under DC 5301, muscle group I involves the extrinsic muscles of the shoulder girdle: the trapezius, levator scapulae, and serratus magnus. For a dominant arm, a slight disability warrants a noncompensable rating, a moderate disability warrants 10 percent rating, severely moderate disability warrants a 30 percent rating, and a severe disability warrants a 40 percent rating. Pursuant to DC 5302, Muscle Group II involves the extrinsic muscles of the shoulder girdle: pectoralis major II, the latissimus dorsi and teres major, pectoralis minor, and rhomboid muscles. Under DC 5302, for a dominant arm, a slight disability warrants a noncompensable rating, a moderate disability warrants a 20 percent rating, a moderately severe disability warrants a 30 percent rating, and a severe disability warrants a 40 percent rating, the highest rating available under the DC. 38 C.F.R. § 4.73. Pursuant to DC 5303, Muscle Group III involves the intrinsic muscles of the shoulder girdle, including the pectoralis major I (clavicular) and the deltoid. For a dominant arm, a slight disability warrants a noncompensable rating, a moderate disability warrants a 20 percent rating, a moderately severe disability warrants a 30 percent rating, and a severe disability warrants a 40 percent rating. At a February 2017 examination conducted on behalf of VA, the Veteran reported that he feels pain and a pulling sensation when he lifts his arm due to scarring. His scar was measured at 5 cm by 1.5 cm. Then, in May 2017, the Veteran underwent another examination where he reported sharp pain with motion that causes numbness down the right arm and fingers of the right hand. A July 2017 radiology report revealed normal alignment of the glenohumeral joint. There was no evidence of fracture or other acute osseous abnormality. The AC joint was normal in appearance, without significant degenerative spurring. That same month, an examination conducted on behalf of VA noted a penetrating muscle injury which causes a pulling feeling and difficulty in reaching or holding objects. The injury affected group I (extrinsic muscles of the shoulder girdle), group II (muscles of the shoulder girdle), and group III (intrinsic muscles of the shoulder girdle). Symptoms included weakness, fatigue and pain in all three muscle groups. A muscle strength test revealed less than normal strength, scoring 4 out of 5. It was also noted that the Veteran underwent an arthroscopic surgery in July 2017. The Veteran reported difficulty reaching over head, carrying or lifting objects, or throwing things overhead. The applicable provisions of the rating schedule at 38 C.F.R. § 4.73, Diagnostic Codes 5301 to 5323 prescribe the evaluation of disabilities manifested by muscle injuries based upon the classifications of slight, moderate, moderately severe, or severe. 38 C.F.R. § 4.56(d)(1)-(4). The corresponding level of severity of a service-connected muscle injury is determined to a significant extent by the presence or absence of cardinal signs and symptoms of muscle disability, which consist of loss of power, lowered threshold of fatigue, weakness, pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c). Under Diagnostic Codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe as follows: (1) Slight disability of muscles: (i) Type of injury: Simple wound of muscle without debridement or infection; (ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56 (c). (iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue. (2) Moderate disability of muscles: (i) Type of injury: Through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. (ii) History and complaint: Service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56 (c), particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. (iii) Objective findings. Entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. (3) Moderately severe disability of muscles: (i) Type of injury: Through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56 (c) and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. (4) Severe disability of muscles (i) Type of injury: Through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56 (c), worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56 (d). Turning first to the muscle injury itself, service treatment records show that the Veteran incurred a shrapnel wound to right scapula in March 1968, but do not contain much description of the injury itself. On a medical history survey completed in conjunction with his separation physical in 1970 the Veteran reported occasional stiffness in the shoulder. After review of the record, the Board finds a rating in excess of 10 percent under Diagnostic Code 5301 is not warranted because the evidence fails to indicate a moderately severe muscle disability. The Veteran’s shoulder symptoms include weakness, numbness, and fatigue. While he complains of a pulling sensation when reaching for objects overhead, he is still capable of reach. There is no indication that the Veteran required a prolonged hospitalization or that the shoulder caused an inability to keep up with work requirements. Additionally, the examiner in July 2017 stated that the was no fascial injury and the shell fragment wound did not impact the muscle functioning or substance. Thus, without a showing of at least a moderately severe disability in muscle group I, a rating in excess of 10 percent is not warranted. Under Diagnostic Code 5302, a rating in excess of 20 percent is not warranted for muscles group II. The record indicates that the Veteran’s right shoulder disability causes difficulty in reaching, lifting and holding objects. Other than some difficulty in lifting, the Veteran’s symptomatology does not demonstrate moderately severe impairment of Group II muscle group. The Board is cognizant of the Veteran’s statements over the course of the appeal. However, the evidence shows that the 20 percent evaluation presently assigned for DC 5302, which contemplates moderately severe impairment of the group II muscle group, is appropriate. Finally, under Diagnostic Code 5303, a rating in excess of 20 percent is not warranted as the Veteran’s muscle group III did not equate to a moderately severe disability. A muscle strength test showed a slight reduction in strength (with a score of 4/5), which does not equate to moderately severe impairment. Other than weakness and fatigue, there is no evidence of impairment of coordination, uncertainty movement, lowered threshold of fatigue, or loss of power. Moreover, there is no sign of fascial impairment or loss or impairment of muscle substance, which would be consistent with a moderately severe muscle injury. Thus, a claim for a rating in excess of 20 percent is denied. 3. Ankylosis of left ankle (previously rated as degenerative arthritis left talonavicular joint) The Veteran contends that he is entitled a higher rating for his left ankle disability. The Veteran’s left ankle disability, characterized as a left ankle disability with ankylosis, has been assigned a 40 percent rating under Diagnostic Code 5010-5270, 38 C.F.R. § 4.71a. Thus, his disability has been evaluated as residuals under Diagnostic Code 5270. 38 C.F.R. § 4.27. As 40 percent is the maximum rating allowed under that code, the Board will consider whether any alternative or separate Diagnostic Code may enable a higher rating. Butts v. Brown, 5 Vet. App. 532 (1993). Diagnostic Code 5010 addresses arthritis due to trauma, substantiated by X-ray findings; it is to be rated as degenerative arthritis. 38 C.F.R. § 4.71a. Diagnostic Code 5270 addresses ankylosis of the ankle. Generally, ankylosis is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). A 30 percent rating is assigned when ankylosis is present in plantar flexion between 30 and 40 degrees; or in dorsiflexion between 0 and 10 degrees. The maximum 40 percent rating is assigned when ankylosis is present in plantar flexion at more than 40 degrees; or in dorsiflexion at more than 10 degrees; or with abduction, adduction, inversion or eversion deformity. 38 C.F.R. § 4.71a, Diagnostic Code 5270. By way of history, the Veteran was granted service connection for his left ankle disability at an October 2009 rating. He was ultimately granted the maximum schedular rating of 40 percent by an October 2014 rating decision, effective March 4, 2014. Then, a June 2017 rating decision assigned that the rating of 40 percent be effective from February 19, 2014, the date his claim was received. In support of his claim, the Veteran’s representative challenged the adequacy of the February 2017 examination, alleging that the physician did not provide sufficient responses relating to the Veteran’s claim for increased rating. In response to the Veteran’s representative letter dated April 2017, a new examination was conducted on behalf of VA in May 2017. There, an evaluation showed that the Veteran suffers from osteoarthritis and degenerative arthritis of the left ankle. It was also noted that there is ankylosis with inversion deformity. The Veteran reported flare ups of the ankle and reported swelling and stiffening, along with sharp pain when in use. He also reported functional loss, which includes limitation in walking, standing, climbing stairs, and mobility in the left ankle. The Veteran demonstrated abnormal range of motion, with dorsiflexion at 20 degrees and plantar flexion at 35 degrees. After a repetitive use testing, there was additional loss of motion, with plantar flexion to 30 degrees. A muscle strength test show reduced strength, scoring 3 out of 5. There is also objective evidence of pain with weight bearing. Given the objective evidence of record, the Board finds that a rating in excess of the maximum 40 percent rating for the left ankle disability is not warranted. Evidence shows that the Veteran has a limited range of motion, with pain and functional loss. These symptoms have been adequately compensated under the 40 percent rating under Diagnostic Code 5270. The Veteran has not submitted any additional evidence to warrant the consideration of an extra-schedular evaluation. In conclusion, an increased rating for the Veteran’s residuals of left ankle disability is not warranted. As the preponderance of the evidence is against the claim, the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Left foot arthritis By way of history, the Veteran was granted service connection for a left foot arthritis (secondary to his left ankle disability) by an October 2014 rating decision at a 10 percent rating, effective March 4, 2014. The Veteran contends that he is entitled to a higher rating. His left ankle disability was previously rated under Diagnostic Codes 5010-5271, however, when the rating for ankle ankylosis was granted, a separate 10 percent rating was awarded under Diagnostic Code 5284. Under DC 5284, residuals of foot injuries are rated as 10 percent disabling for moderate disability, 20 percent for moderately severe disability, and 30 percent for severe disability. 38 C.F.R. § 4.71a. The words “moderate,” “moderately severe,” and “severe” are not defined in the VA Schedule for Rating Disabilities. Furthermore, the use of terminology such as “severe” by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. Rather, all evidence must be evaluated in arriving at an appropriate rating that would compensate the veteran for losses such as impairment in earning capacity and functional impairment. 38 C.F.R. §§ 4.2, 4.6. Based on his June 2016 statement, the Veteran stated that he can no longer drive for extended period of time due to the pain in his foot. He also experiences difficulty climbing up and down stairs. In an October 2016 vocational assessment, the Veteran reported that he has to sit with his foot propped up to decrease the swelling and pain. He also stated that he is unable to drive for extended lengths of time due to the pain. At his February 2017 VA examination, the Veteran reported increased pain and limited mobility. He denied functional loss or flare ups of the foot. The examiner found a moderate level severity of the left foot. There was however no objective evidence of pain with weight bearing and the Veteran did not require any foot support. Foot x-rays showed plantar and dorsal calcaneus spurs, degenerative changes of the intertarsal joints, with prominent osteophytes extending cephalad from the superior surface of the navicular bone, minimal involvement of the remaining tarsal bones is noted. Mild degenerative changes of the first metatarsophalangeal joint were also noted. Through his representative, the Veteran asserted in an April 2017 letter that the February 2017 examination was inadequate as the examiner failed to provide information as to the extent of the Veteran’s pain or functional effects. The Veteran was afforded a new VA examination in May 2017. There, the VA physician found no evidence of ankylosis of the foot. The Veteran reported experiencing sharp pain in his foot with stiffness due to humidity. He also reported flare ups with swelling and sharp pain with movement, especially with standing, walking, squatting, and bending. Upon examination, the physician found evidence of less movement than normal, weakened movement, incoordination, pain, pain on weight bearing, swelling, interference with standing, and lack of endurance. However, the physician was unable to determine whether pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare ups. While the evidence is clear that the Veteran experiences pain in his foot, a rating in excess of 10 percent is not warranted as the showing of moderately severe foot disability would be necessary under Diagnostic Code 5284. There was no indication of muscle atrophy, edema, heat, redness, instability, callosities, or loss of use of his foot. The objective medical evidence found pain, weakness, swelling, and limited mobility, which most proximate a moderate disability under both Diagnostic Code 5284. 5. PTSD with depression By way of history, the Veteran was granted service connection for PTSD (with depression) at 30 percent, effective May 7, 2009 by an October 2009 rating decision. It was increased to 50 percent by an June 2017 rating decision, effective February 19, 2014, the day the current appeal was received. It was subsequently increased to 70 percent, as of May 5, 2017. Under the Diagnostic code 9411, a 50 percent disability rating is assigned where a psychiatric disability causes occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is assigned where a psychiatric disability causes occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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); and inability to establish and maintain effective relationships. The maximum schedular disability rating of 100 percent is assigned where a psychiatric disability causes total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is the Veteran’s symptoms, but it must also make findings as to how those symptoms impact the Veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Rating of PTSD (with depression) in excess of 50 percent prior to May 5, 2017 Prior to May 5, 2017, the Veteran was assigned a 50 percent rating for his PTSD. At a May 2014 VA examination, the Veteran reported having sleep problems due to nightmares about his Vietnam deployment. He also reported having decreased in appetite, which caused weight loss. He denied hallucinations, delusions, and paranoia, suicidal or homicidal ideations. The examiner documented symptoms which included hypervigilance, exaggerated startled response, problems with concentration, and sleep disturbance. The Veteran also reported depressed mood, anxiety, near-continuous panic, chronic sleep impairment, and mild memory loss. At the examination, the Veteran was alert, oriented, and made good eye contact throughout the session. His mood was somewhat depressed and his affect was constricted. This thought process was logical and goal oriented. The Veteran reported living with his wife along with their daughter and grandchildren. He described the relationship with his wife as “strained,” due to her health problems and his irritability and impatience. However, he reported maintaining a good relationship with his daughter and grandchildren. On a typical day, he completes chores around the house and pursues his hobby of building an operating model trains. The Veteran used to work at a wastewater treatment facility. However, due to his constant argument with his superior and his physical ailments, the Veteran retired earlier than expected. When asked which set of criteria best described the Veteran’s psychiatric symptomatology, the examiner indicated that his symptomatology caused social and occupational impairment with reduced reliability and productivity. That is, the examiner found his symptomatology to be most consistent with a 50 percent rating. February to August 2015 therapy session notes showed that the Veteran complained of pain and depressive symptoms. He was oriented to time, place, and person. His affect and speech were within normal limits. While his insight was limited, his judgment was adequate. He denied delusions, hallucinations, suicidal and homicidal ideations. In his June 2016 affidavit, the Veteran reported complaints of nightmares that caused sleep disturbances. Because of this, he complained that he was not well rested and would become irritable and tired during daytime. He also reported struggling with anger issues which have caused problems in his family. Additionally, given his hypervigilance, he avoided crowds of people and preferred not to leave his home, unless necessary. Treatment notes from April to August 2016 show the Veteran attended multiple counselling sessions. There, the Veteran shared his concerns about retired life and chronic pain. He was well-oriented and presented good hygiene. His affect was within normal limits even though there was indication of depressed mood and irritability. His speech was normal and his thoughts were linear and logical. His insight was limited and just judgment was fair. The Veteran denied hallucinations, suicidal or homicidal ideations. In an October 2016 vocational assessment, it was noted that the Veteran preferred to work independently, preferring to work on the weekends and holidays. He reported to the counselor that in the past, his anger and irritability had affected his interpersonal relationships with both his family and co-workers. The Board finds that prior to May 2017, a rating in excess of 50 percent is not warranted. The evidence does not show illogical or obscure speech, impaired impulse control, spatial disorientation, or neglect of personal hygiene. The Veteran consistently denied suicidal ideations throughout all his therapy sessions, and while he has retired early because of his conflicts at work, the record does not reflect difficulty in adapting to stressful circumstances consistent with a 70 percent rating. While the absence of these symptoms is not always determinative, the Veteran failed to show other symptoms of similar severity, frequency, and duration. Moreover, at his examination, the examiner found the Veteran’s psychiatric symptomatology to be most consistent with a 50 percent rating. The examiner did note that the Veteran experienced near-continuous panic or depression that affected his ability to function independently, appropriately and effectively. However, while this symptom can be indicative of a 70 percent rating, its presence alone does not mandate the assignment of a 70 percent rating. Here, the totality of the Veteran’s symptoms suggests that a 50 percent rating was appropriate prior to May 2017. Additionally, a 70 percent rating contemplates an inability to establish and maintain effective relationships, yet the Veteran was clearly able to maintain strong family relationships. While these relationships were likely not without difficulty, a 50 percent rating contemplates difficulty in establishing and maintaining effective work and social relationships. The Veteran is also not entitled to a 100 percent disability rating during this time period. The evidence does indicate a total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, suicidal or homicidal ideations, grossly inappropriate behavior, and persistent delusions or hallucinations. The Board notes that while he reports conflicts in his relationship with his wife, he maintains a good relationship with his daughter and grandchildren. There is also no indication that the Veteran is a persistent danger to himself or others. Evaluation of PTSD (with depression) in excess of 70 percent from May 5, 2017 As noted, the Veteran’s PTSD is currently rated at 70 percent. To obtain total schedular rating for his PTSD, the evidence must show that the Veteran’s PTSD causes total social impairment and total occupational impairment. The use of total suggests complete impairment both socially and occupationally. After review of the Veteran’s new medical evidence, the Board finds that the Veteran’s PTSD symptomatology most closely approximated the criteria for the 70 percent rating. Here, there is no question that the Veteran is impacted by his PTSD. He reported continued nightmares about his service and loss in appetite. His symptoms also include sleep disturbance, depressed mood, anxiety, irritability, and concentration problems. However, the evidence does not show total social impairment. For example, the May 2017 examination reported that the Veteran still maintains a familial relationship. While he does admit that his anger and irritability have caused conflicts in the family, he denied significant concerns such as potential divorce or separation. He continues to live with his wife, daughter, and grandchildren. At the examination, the Veteran appeared on time and was casually dressed. His grooming and hygiene was marginal. His speech was logical and goal directed. His attention and concentration was impaired. There was no indication of homicidal or suicidal ideations, auditory or visual hallucinations. In a previous examination in February 2017, the Veteran reported being irritated and impatient with his wife and daughter, but did admit to being able to relate to his grandchildren with greater ease. While he reported to losing patience, he still attempted to participate with his local VFW. Furthermore, VA psychology therapy records in 2016 show that the Veteran denied suicidal and homicidal ideations. The Board does not doubt that the Veteran’s PTSD causes some social and occupational impairment, but the fact remains that a 70 percent rating contemplates an inability to establish and maintain effective relationships. As such, the aforementioned social contacts and his ability to manage his daily life clearly preclude the assignment of a total schedular rating. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N.Yeh, Associate Counsel